FUNDAMENTALS FINAL EXAM Flashcards
standard precautions
Prevent and control transmission of diseases that can be acquired by contact it with blood, body fluids, non-intact skin, and mucous membranes.
isolation precautions
Protect patients, their families, other visitors, and healthcare workers from spreading germs across a healthcare setting.
Contact isolation
Direct and indirect contact with patients and environment.
Droplet isolation
Diseases that are transmitted by large droplets expelled into the air.
airborne isolation
transmitted by smaller droplets. 3 ft, and can remain in air for a longer amount of time.
Gowns
prevent soiling clothes (infected material, blood or bodily fluid)
Masks
Respiratory protections (blood, bodily fluids) airborne.
Protective eyewear
when performing procedures that splash or splatter (large abdomen wound or insertion)
Gloves
help prevent transmission of pathogens by indirect or direct contact.
What is the chain of infection
- Infectious agent or pathogen.
- Reservoir
- Portal of exit
- Mode of transmission
- Portal of entry
- Host
Infectious agent or pathogen
bacteria, viruses, fungi, and protozoa.
Reservoir
places in the environment where the pathogen lives. (people, animals, insects, medical equipment).
Break the chain by sterilizing, cleaning, pest control.
Portal of exit
after microorganisms grow they find the portal of exit, so they are able to enter another host and cause disease (mucus, gi tract) You can break this chain by washing your hands, personal protective equipment, control of splatter, and waste disposal.
Mode of transmission
direct, indirect, droplet, airborne, vehicles, vector. You can break the chain by hand hygiene, PPE, food safety, isolation.
Portal of entry
enter the body in the same route as exiting (hand hygiene, PPE, personal hygiene, first aid)
Host
susceptible host to spread disease (immunizations, treatment of underlying disease, health insurance, patient education)
Risk factors for developing infections
Age, nutritional status, stress, and disease process.
Medical asepsis
(clean technique) reduces number of organisms present and prevent transfer
Surgical asepsis
(sterile technique) prevents contamination of an open wound. Maintains sterile field for surgery.
Community acquired disease
diseases developed outside the hospital. Patient acquires disease within 2 days of admission.
Hospital acquired disease
Diseases developed from the hospital. Lower respiratory tract infections. Patient acquires disease two day after discharge.
Localized infections
wound infection.
symptoms include: pain, tenderness, warmth, redness.
Systemic infections
affects entire body. Can become fatal if undetected and untreated.
Fowler Position.
45-60 degrees, patient head slightly elevated.
High fowlers
When head of bed needs to be elevated as possible. Ideal for excretion, help patient breathe, swallowing of food.
Semi Fowlers
During labor, receiving food through a tube.
Low fowlers
optimal for patients rest.
Supine position
resting on back. used in surgeries.
Prone position
used in surgeries. Laying on stomach.
Side lying
Patient rests on side (weight on hip and shoulder)
Sims position
places weight on anterior illeum, humerus, and clavicle.
Therapeutic effects and complications of bed rest
-theraputic effects: lots of rest, decrease cardiac and oxygen
Complications: SKIN BREAKDOWN, PRESSURE ULCERS. collapse of alveoli, decreased metabolism rate, fluid, electrolyte and calcium imbalance, inflammation of the lung from stasis and pooling of secretions, drop of bp greater than 20mmhg in systolic, muscle effects, skeletal effects, disuse, osteoporosis, joint contracture, footdrop,
Safety interventions when transferring and using a lift:
-make sure patient is secured
-if patient is too heavy get another nurse in there with you
-if patient starts to fall, slowly take them to the ground
Make sure breaks are on
Interventions to prevent complications of immobility
- constantly rotate patient to lessen the chance of skin breakdown
- keep them entertained so they don’t go into depression
- perform assessments of body alignment
- excersise in bed
different types of exercise
isotonic, isometric, aerobic
isotonic
muscles shorten to produce a muscle contraction to have movement (walking)
Isometric
change in muscle tension but no change in muscle length and no movement (gluteal setting, quad setting; squeeze and relax glutes)
aerobic
using oxygen to do an activity (running)
Isokinetic
includes variable resistance to movement (machines provide resistance to movement as joint goes through full ROM)
Complete bed bath
bath administered to totally dependent patient in bed
Partial bath
bed bath that only bathes parts that would be uncomfortable if unbathed. Face, hands, armpits, perineal area. Could be back rub too.
bag bath
has moistened towels with cleaning solution, easy, reduced time bathing, and patient comfort is better.
oral care
brush teeth if needed or use swabs.
clean dentures on a regular basis, remove and night and make sure to keep them covered in water.
Perineal care
male- inner to outer meatus. Move inner to outer.
Female- outer (2) Then inner (2). swipe down middle
eye care
wash with clean moistened wash cloth.
different section of washcloth each time.
principles of making an occupied bed
-patient is not able to move out of the bed so therefore you have to change the linens while patient is in bed. Especially if linens are soiled.
Potential cause of pressure ulcers
skin breakdown (patient needs to be turned every two hours). -pressure, friction, shearing.
stage I pressure ulcer
area is red and there may be a little pain but no open wound
stage II pressure ulcer
Skin breaks open, wears away, and forms an ulcer between dermis and epidermis. Shallow crater.
Stage III pressure ulcer
Check for undermining. ulcer gets bigger and extends to fat.
stage IV pressure ulcer
Pressure sore is very deep, reaches muscle tissue and bones. Extensive damage may occur.
Primary intention
healing occurs when the wound edges are approximate. Example: sutures, staples, or glue.
Secondary intention
takes place when the wound edges cannot be approximated and the wound needs to heal from the bottom. too wide to close up.
tertiary intention
combination of both primary and secondary intention. Would cannot be stitched up immediately but it can after a while. Does not need to be closed, skin graft or burn.
Skin assessment
constantly assess skin for breakdown, temp, moisture, etcetera.
serous wound drainage
plasma thats thin, clear and watery. normal to experience this during wound healing, but an excessive amount of this could lead to bacteria living on the wound.
sanguineous wound drainage
fresh blood that is prevalent among deep wounds or full and partial thickness.
serosanguineous wound drainage
thin and watery and color is pink. Most common. red blood cells in the fluid which is sign that it is damaged.
purulent wound drainage
milky looking. (green and yellow, sometimes grey). Wound is infected.
dehiscence
a splitting wound moist sterile dressing. surgical wound breaks open after surgery is finished.
eviscaration
extrusion of viscera outside of the body. (organs out of the body)
safety issues for nurses in the workplace
back, injuries, exposure to radiation, and puncture injuries.
Guidelines for restraits
- follow agency policies, state laws, and professional guidelines
- use less restrictive interventions first, document their use and patients response.
- secure the restraint using a quick release knot.
- release restraints at least every 2 hours.
- document all interventions and the patient responsse to it.
Safety interventions that can be used instead of restraints
orienting the patient to the environment, planning nursing care with the patient and explaining all procedures, monitoring the patient frequently, keeping the bed in the lowest position, one-to-one monitoring, using a weight or position sensitive device to alert the caregiver of a patient’s attempt to ambulate
Different routes of med administration
oral, rectal, vaginal, eye installations
potential assessments needed prior to administering each route
alwasys assess the patient prior to giving medication.
-swallowing
proper administration technique and what needs to be included in a medication order?
6 rights
- right time
- right patient
- right dose
- right medication
- right documentation
- right route
Also frequency, any special instructions, signature of prescriber
Safety considerations
choking hazard. Raise bed up. Have water ready.
Stages of infection: Incubation period
entrance of pathogen into body and the time it takes for an appearance of first symptom.
Stages of infection: Prodromal stage
interval from onset of nonspecific signs and symptoms to more specific symptoms
Stages of infection: Illness stage
interval when client manifests signs and symptoms specific to type of infection.
-common cold by sore throat, fever, congestion.
Stages of infection: Convalescence
interval when acute symptoms of infection disappear
Technique for positioning in bed
orienting the patient to the environment, planning nursing care with the patient and explaining all procedures, monitoring the patient frequently, keeping the bed in the lowest position, one-to-one monitoring, using a weight or position sensitive device to alert the caregiver of a patient’s attempt to ambulate
steps to the nursing process
- assessment
- diagnosis
- planning
- implementing
- evaluation
Recognize correct formatting nursing diagnoses statements
Nursing diagnosis…related to…as evidenced by…
Understand how to prioritize nursinig problems
A-airway
B-breathing
C-circulation
What type of information is needed to obtain during the assessment phase
- collection of information from a primary source (patient) and secondary sources (family friends, health care professionals, medical records)
- interpretation and validation of data to ensure a complete data base
Enuresis
bedwetting
dysuria
difficult, painful urination
frequency
urinating more frequently, without increase in amount
nocturia
voiding during sleeping hours
urgency
sudden, forceful urge to urinate
hesistancy
delay in starting stream of urine
oliguria
less than 30 ml/hr
polyuria
excess urine
anuria
absence of urine
stress incontinence
leakage of small volumes due to urethral hypermobility or incomopetent sphincter. (laughing too hard)
urge incontinence
involuntary passage of urine, sense of urgency
Signs/symptoms, assessment, complications, and teaching needs for diarrhea
S&S: stomach pain, abdominal cramps, bloating, thirst, weight loss, fever
Assessment: ask when problem started, stool frequency, type, and volume, whether there is blood in the stool or vomiting, check for dehydration, check for five, puss in stool, ask if lasted for more than a week
Complications: dehydrated, dry mouth
Teaching needs: probiotics intake, antibiotics, drink lots of water
Signs/symptoms, assessment, complications, and teaching needs for constipation
Signs: infrequent bowel movements and hard, dry stools that are difficult to pass
Laboratory tests for stool
- Occult blood test
- hemoglobin
- hematocrit (anemia from GI bleeding)
- liver function tests
- serum Amylase and serum lipase (assess for hepatobiliary disease and pancreatitis)
SBAR report
situation, background, assessment, recommendation
Signs and symptoms of UTI’s
Dysuria Cystisi Urgency Frequency Inctonience Supra pubic tenderness Foul smelling urine
teaching needed for prevention of UTIs
go pee right after sexual intercourse.
drink lots of liquids
wipe front to back
clean voided or midstream urine sample
-use a sterile specimen cup
-women- clean labia with cotton ball or gauze (front to back) let patient void and then collect, remove before done.
Male- sterile gloves, hold penis and use wipes to clean
-collect urine specimen remove before done
sterile testing
Clamp the tubing below the port to allow fresh urine to collect in tube. Wipe with an antimicrobial wipe and insert syringe and withdraw 3-5 ml, transfer urine to sterile container using aseptic technique
timed urine test
2-12 or 24 hour collects. Begins after patient urinates and ends with a final voiding at the end of the time period. Patient voids into clean receptacle and the urine is transferred to the special preservatives. Must be free of feces and toilet tissue
urinalysis
Analyze values of PH, protein, glucose, ketones, blood, specific gravity, and microscopic values for RBCS, bacteria , casts, and crystals.
Procedure for enemas and impaction removal
- remove wrapping
- squat or lie on one side with one leg bent and the other out straight
- lubrication added if needed
- gently but firmly place the suppository into the rectum with the pointed end first (digit length or 3-4 inches)
- close legs and sit still for a few minutes
therapeutic techniques
silence, accepting, giving recognition, offering self, giving broad opinions, encouraging comparisons, reflecting, restating, focusing, exploring, clarifying.
non-therapeutic techniques
overloading, value judgements, incongruence, under loading, false reassurance/agreement, invalidation, focusing on self, changing the subject, giving advice.
Internal locus of control vs. external locus of control
Internal: a person believes that he or she can influence events and their outcomes
External: someone blames outside forces for everything
cognitive learning
Deals with acquiring, storing, and recalling information.
-lecture, written materials, case studies, care plans, programmed instruction
affective learning
(Feeling Domain) deals with changes in feelings, beliefs, attitudes, and values.
- role modeling
- one to one counseling
- support groups
- evaluate learning by observing
psychomotor learning
(Skill domain) deals with learning a new skill that requires both mental and physical activity.
-demonstration
-return demonstration
Audiovisual materials
behaviors of an altered self concept
Self care deficit, emotional & behavioral changes, anxiety & depression, and self destructive behavior
Erickson’s stages of development
- trust vs mistrust
- autonomy vs shame
- initiative vs guilt
- industry vs inferiority
- identity vs role confusion
- intimacy vs role confusion
- generativity vs stagnation
- ego integrity vs despair
trust vs. mistrust
Feeding- children will develop trust when caregivers provide reliability, care, and affection. A lack of this will lead to mistrust.
autonomy vs. shame
Toilet training: Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure leads to feelings of shame and doubt.
initiative vs. guilt
Exploration: Children need to begin asserting control and power over the environment. Succes in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt.
industry vs. inferiority
School: children need to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority.
identity vs. role confusion
social relationships: teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self
intimacy vs. isolation
Relationships: Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure leads to loneliness and isolation.
generativity vs. self-absoption
Work and parenthood: Adults need to create or nurture tings that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishments, while failure results in shallow involvement in the world.
ego integrity vs. despair
Reflection of life: older adults need to look back own life and feel a sense of fulfillment. Success at this stage leads to wisdom, while failure results in regret, bitterness, and despair.
nursing interventions that can be implemented to support a patients self esteem.
- reachable goals
- help patient discover strengths
- listen attentively ??
compensation
non athlete joins debate team
rationalization
“he needs to learn to be sufficient himself”
denial
fails to seek medical help when needed
displacement
patient yells at another person after being diagnosed with cancer
intellectualization
patients discusses all test results but avoids focusing on fear or feelings
projection
preoperative patient says to wife “dont be scared.”
Examples of stressors
work, family, daily hassles, trauma, crisis, life long illness.
situational factors
personal job, or family changes (divorce, laid off, pregnancy)
maturational factors
stressors that vary with age and maturity
sociocultural factors
environmental and social stressors (poverty and physically handicapped)
hospice ver palliative care
Hospice: system of family-centered care designed to help terminally ill people be comfortable and maintain a satisfactory lifestyle throughout the terminal ill phase of their illness
Palliative: level of care that is designed to relieve or reduce intensity of uncomfortable symptoms but not to produce a cure. Palliative care relies on comfort measures and use of alternative therapies to help individuals become more at peace during end of life
acual loss and percieved loss
Actual: loss of an object person, body part, or function, or emotion that is overt and easily identifiable
Perceived: loss that is less obvious to the individual experiencing it. Although easily overlooked or misunderstood, a perceived loss results in the same grief process as an actual loss
