Health Assessment 2220 Exam 1 Flashcards

1
Q

What does health assessment include?

A

encompasses the entire person such as physical, intellectual, spiritual, environmental, sociocultural, and emotional

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2
Q

How to conduct health assessment

A

gathering information about health status of pt current and past history, health history subjective, and physical assessment objective

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3
Q

types of health assessments

A

initial/comprehensive, focused/episodic, emergency, and time lapsed

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4
Q

initial/comprehensive assessment

A

full head to toes exam conducted on admission

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5
Q

focused/episodic assessment

A

specific to injury/complain of pt and is conducted after comprehensive exam focused on pt chief complaint (ex: ABD pain requires ABD exam)

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6
Q

Emergency Assessment

A

life threatening problems need to be noted and solved immediately; focused on ABCs then secondary complaints; rapid head to toe exam/trauma assessment conducted (ex: stabbings, anaphylaxis, SOB)

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7
Q

Time lapsed

A

interval assessment such as taking vital signs every 4 hours or every so many days a pt requires a check up

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8
Q

Types of assessment techniques in order

A

Inspection, palpation, percussion, and auscultation

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9
Q

Order of assessment for abdominal exam

A

Inspection, auscultation, percussion, palpation (palpating prior to auscultation can create abnormal bowel sounds)

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10
Q

inspection assessment

A

what do you see, hear, smell? what size, color, shape, position, symmetrical?

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11
Q

palpation assessment

A

feeling of the pt body using palmar surface and fingers for sensitivity, ulnar surface for vibration, dorsal surface for temperature; whats the temp., skin turgor, texture, moisture, vibration, shape?

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12
Q

light palpation

A

1cm (0.5”)

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13
Q

moderate palpation

A

1cm-2cm (0.5-0.75”)

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14
Q

deep palpation

A

2cm (1”)

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15
Q

percussion assessment

A

tapping of pt body listening for different sounds that are produced (hollow vs. dense)

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16
Q

direct percussion

A

directly tapping on surface of pt

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17
Q

blunt percussion

A

using the ulnar surface of fist and thumping your own other hand against pt

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18
Q

indirect percussion

A

tapping finger on own other finger/hand against pt

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19
Q

auscultation assessment

A

listening to pt organs and bodily systems with stethoscope

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20
Q

use for diaphragm

A

to hear higher pitched sounds such as lung sounds, bowel sounds, and normal heart sounds

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21
Q

use for bell

A

listen to lower pitched sounds such as murmurs or bruits

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22
Q

is bell pressed lightly or firmly when auscultating

A

lightly

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23
Q

diaphragm pressed lightly or firmly when auscultating?

A

firmly

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24
Q

what are you listening for when auscultating?

A

quality of sounds such as pitch (high or low), loudness (soft or loud), duration (short,medium, or long), quality (description of sound)

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25
Q

tips for ausculation

A

examine from the right of pt, warm stethoscope, close eyes for better attention, auscultate on bare skin

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26
Q

general survey importance

A

begins moment of contact, provides clues to overall health, first impression give cues for what needs attention, establishes pt baseline, includes vitals, H&W

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27
Q

What to observe for in general survey

A

(11) 1. signs of distress, 2. stature/build, 3. speech patterns, 4. Significant others accompanying, 5. Dressing/grooming, 6. posture/gait/coordination, 7. LOC, 8. Eye contact, 9. vision/hearing problems, 10. nutritional state, 11. affect

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28
Q

example general survey

A

pt is 56 Y male construction worker appears healthy and stated age
pt AOx4, cooperative and shwoing no signs of distress
HT 6’1” Wt 202lbs
T- 97.6 P-82bpm RR 16/min BP 122/78 R arm sitting

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29
Q

The importance of an interview

A

establishes trust

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30
Q

Health history

A

biographical data, reason for seeking care, present health or history of present illness, past health, family history, functional assessment & ADLs/psychosocial

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31
Q

chief complaint

A

reason pt is seeking care in their own words

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32
Q

present health or HPI

A

location, character/quality, severity/quantity, timing, setting, aggravating/relieving factors, associated/radiating factors, pt perception; OPQRSTI

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33
Q

Past health

A

childhood illnesses, accidents/injuries, serious/chronic illnesses, hospitalizations, operations, OB history, immunizations, last exam, allergies, current meds

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34
Q

family history

A

age and health/cause of death of blood relatives; presence of heart disease, cancer, HTN, CVA, diabetes, cancer, blood disorders, obesity, psychiatric

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35
Q

subjective data

A

symptoms that pt describes; clinician cannot see these and relies on pt word (pain, health history

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36
Q

objective data

A

what can be seen through a general survey and physical examination

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37
Q

interviewing techniques

A

(5) validating- validates correctness of what nurse heard, clarifying- using question to decipher the truth or if something is unclear, reflecting- repeating what pt has said or describing feelings to elaborate, sequencing- used to place events in chronological order to identify cause and effect, directing- obtain more information or introduce something new

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38
Q

open ended questions

A

used to start conversation and obtain information (ex; what concerns do you have about treatment?)

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39
Q

close-ended questions

A

helpful for seeking specific information or clarification (ex: how many times do you take this medication?)

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40
Q

communicating with children

A

be responsive to nonverbal communication, get at eye level, be gentle and calm, use understandable language, use structured play

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41
Q

communicating with critically ill

A

assume they can hear you, explain what you are doing and provide cues about day/night, call bell within reach

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42
Q

sources for assessment

A

reviewing medical records, patient interview, family interview, other providers

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43
Q

phases of interview

A

introduction-purpose of interview, how long it will take, expectations, ensure confidentiality, working- open-ended questions for obtaining info and close-ended for direct questions, closing- summary of the interview

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44
Q

functional assessment

A

self esteem/self-concept: personal identity, body image, role-performance, activity: are they active or sedentary, sleep/rest: adequate sleep, nutrition/elim.: good diet and bowels, stress/adaptations: stressors in life d/t job or family and what coping skills, intimate partner violence: safe at home or stating domestic violence

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45
Q

older adult assessment tool

A

SPICES: sleep disorders, problems with eating, incontinence, confusion, evidence of falls, skin breakdown

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46
Q

non-verbal communication

A

physical appearance and facial expressions (how you present to the pt), posture (get at eye level), gestures, tone of voice and touch (be careful with touch)

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47
Q

equipment used for assessments

A

opthalmoscope for eyes, odoscope for ears, stethothscope for lungs, hear, BP, heart sounds, bowel sounds, pulse ox for sat

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48
Q

when are vital signs taken?

A

admissions, discharge, change in status, every 1-4-8 hours (depending on floor)

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49
Q

normal ranges

A

BP- 120/80, HR-60-100, RR- 12-20, Sat. 95-100 , Core temp. 35.9-38 C or 96.7-100.4F

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50
Q

What can affect vitals

A

pain

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51
Q

most accurate temp.

A

rectal (98.7-100.5)

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52
Q

least accurate temp.

A

axillary

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53
Q

ways to measure core temp

A

tympanic and rectal (rectal usually 1 degree F higher than oral)

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54
Q

how to take BP

A

using sphygmomanometer and stethescope, aneroid (calibrated 2mmHg), needle at 0

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55
Q

incorrect BP readings

A

too small of cuff = higher reading and too large cuff= lower reading; pt has not rester (5 min), consumption of caffeine, smoked, arm not at heart level, pt not quiet

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56
Q

factors affecting temperature

A

circadian rhythm (lowest temp in AM and peak around 4-8PM), age (older = lower core temp.), sex progesterone during ovulation increases temp. (~0.5-1F), environmental temp or consuming warm drink (wait 15 min), increase in metabolic rate (exercise, stress, illness)

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57
Q

oral route temp

A

most common; blue one for mouth; wait 15-30 minutes after iced or hot drink

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58
Q

contraindications to oral temp

A

kids <5 years, confused/unconscious pt, comatose pt, pt with seizure disorders, pt after oral/nasal surgery, pt receiving O2

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59
Q

tympanic membrane route

A

measures core temp (usually 1F higher than oral), good for young, confused/unconscious pt

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60
Q

contraindication for tympanic membrane temp.

A

pt with ear drainage, external ear infection (middle ear infect. is fine), or scars on tympanic membrane

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61
Q

temporal

A

non-inasive, quick, reliable

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62
Q

contraindications to temporal artery route temp.

A

do not measure over scar tissue, open lesions, or abrasions

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63
Q

axillary route

A

used when both oral and rectal are contraindicated, not used when accuracy required, usually 1 F lower than oral

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64
Q

core temp measurements

A

tympanic membrane and rectal

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65
Q

rectal temp. route

A

measures core temp., the most accurate, 1 degree higher than oral, use lubricant, insert in direction of umbilicus 1.5 inch

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66
Q

contraindication of rectal temp

A

pt with diarrhea, bowel surgery, rectal diseases, heart disease or after cardiac surgery, neutropenic pt, pt with spinal cord injury, throbocytopenia

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67
Q

factors that afect respirations

A

(12 factors) age (d/t lung capacity), sex (males lower RR d/t capacity), altitude (increased elevation = increased RR), stree/anxiety (stimulates SNS increasing R), exercise (increase O2 demand increasing RR), medications (narcs depress Resp. drive and stimulants increase), acid-base balance (hyperventilate to release CO2), brain lesions (cheyne stokes), respiratory disease (can affect rate, depth, pattern), pain (incease RR but decreases depth), anemia (decreased O2 carrying which increases RR), fever (increases metabolic rate which increases RR)

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68
Q

when counting respirations

A

do not announce, count to 15 sec and multiply by 4; if irregular count for 1 minute

69
Q

Pulse factors

A

W>M, pulse decreases with age (infant pulse varies with breathing), SNS increases HR and PNS decreases HR, fever stress, disease, activity increase HR, beta blocker slow down HR, atropine increase HR

70
Q

pulse sites

A

superficial temporal (forehead), external maxillary (in front of ear), carotid ( at a time), brachial, ulnar, radial, femoral (groin), popliteal (behind knee), posterior tibial (medial posterior to ankle), dorsalis pedis (top of foot)

71
Q

where to palpate on unresponsive

A

carotid

72
Q

pulse deficit

A

difference between apical and pulse rates (femoral or radial); not every beat is generating enough blood flow for peripheral pulse

73
Q

when count pulse for 60 seconds

A

irregular rhythm

74
Q

factors affecting BP

A

age (increase with age d/t decreased elasticity; wider pulse pressure with age), circadian rhythm (lowest in AM; varies 5-10), sex (w lower than M until menopause), food intake (increases after food), exercise 9increases during exercise), weight (increased BP with increased weight), emotional state (anxiety, pain, fear, excitement, increases BP by stim. SNS), body position (lower in prone/supine), race (higher in African Americans), meds (diuretics decrease BP, oral contraceptives increase BP)

75
Q

Normal BP

A

120/80 and below

76
Q

Prehypertension

A

120-129/80

77
Q

stage 1 HTN

A

130-139/80-89

78
Q

stage 2 HTN

A

140+/90+

79
Q

HTN crisis

A

180+/and or 120+

80
Q

Why is normal BP important

A

HTN is one of leading causes for cardiovascular disorders like MI, stroke, renal failure,\; end organ damage of brain, heart, kidneys

81
Q

orthostatic hypotension

A

decrease in SBP of 20 or more and decrease of DBP of 10 or more within 3 minutes of standing compared to supine/sitting; d/t vasodilation (HR compensates by increasing)

82
Q

need for O2

A

less than or equal to 90%

83
Q

inaccurate sat readings

A

HGB too low, poor Peripheral circ. movement, CO (higher affinity for binding), thick nails, dark nail polish

84
Q

Valves of heart and location

A

Tricuspid valve (from right atria to right ventricle, pulmonary valve (right ventricle to right pulmonary artery), mitral valve (left atrium to left ventricle), aortic valve (left ventricle to aorta)

85
Q

auscultate aorta

A

2nd intercostal space, RSB

86
Q

auscultate pulmonary artery

A

2nd intercostal space, LSB

87
Q

auscultate Erbs point

A

3rd intercostal space, LST

88
Q

auscultate tricuspid valve

A

4th intercostal space, LSB

89
Q

auscultate mitral valve

A

5th intercostal space, mid clavicular line

90
Q

PMI

A

point of maximal impulse is 5th intercostal space mid clavicular line; apical pulse

91
Q

S1 sounds

A

closing of AV valves (mitral and Tricuspid); ventricular systole begins

92
Q

S2 sounds

A

closing of Semilunar valves (pulmonary and aortic); diastole begins

93
Q

diastole

A

period between S2 and S1

94
Q

systole

A

area between S1 and S2

95
Q

what are you feeling at the PMI

A

ventricular recoil

96
Q

documenting pulses

A

rate, rhythm, and quality; location; amplitude (0-+3)

97
Q

pulse amplitudes

A

0- absent pulse, unable to palpate, +1- diminished pulse, +2- brisk, normal pulse, +3- bounding pulse

98
Q

how to find/auscultated weak or difficult pulses

A

use a doppler

99
Q

pack years documenting

A

15 years of smoking 2.5 packs a day = 37.5 pack year

100
Q

BMI

A

ratio of weight to height

101
Q

underweight

A

less than 18.5 BMI

102
Q

normal weight

A

18.5-24.9 BMI

103
Q

overweight

A

25-29.9 BMI

104
Q

obese

A

30-39.9 BMI

105
Q

extreme obesity

A

40+ BMI

106
Q

Cardiovascular exam

A

signs and symptoms, lifestyle habits, medications, family history, smoking history

107
Q

signs and symptoms of CV

A

fatigue, dyspnea, chest pain, SOB, leg cramping, foot sensation (pins and needles), wound healing (slow), edema, arrythmias or palpitations

108
Q

lifestyle habits for CV

A

alcohol consumption, smoking, exercise, diet

109
Q

family history for CV

A

HTN, DM, murmurs, CHD, CVD (cardiovascular disease), dyslipidemia (dysfunctional lipids), obesity, LQTS (long QT syndrome)

110
Q

smoking history

A

type of tobacco or nicotine, when started and stopped, pack years, smoking cessation

111
Q

risk of lung cancer for former smokers

A

risk is back to those of non smokers after 15 years

112
Q

HDL vs. LDL

A

HDL keeps arteries clear of plaques; LDL forms plaques causing hardening and narrowing

113
Q

Lipid lab numbers

A

triglycerides <150mg/dL
Total CHOL <200mg/dL
LDL <100mg/dL
HDL >60mg/dL

114
Q

Cardiopulmonary Inspection

A

skin color (general, lips, nailbeds); body position (upright or tripod); finger clubbing (from chronic hypoxia); nasal flaring (hypoxia sign); anxiousness or restlessness

115
Q

Central cyanosis

A

blue lips and due to low arterial O2, cap refill < 3 sec (normal)

116
Q

peripheral cyanosis

A

normal arterial O2, prolonged cap refill > 3 sec

117
Q

edema

A

caused by capillaries leaking fluid; scale is +1-+4 (2mm, 4mm, 6mm, 8mm (pitting))

118
Q

causes for edema

A

hear failure, kidney failure, liver failure, weakness/damage to veins in legs, inadequate lymphatic system, long term protein deficiency, increased cell membrane permeability

119
Q

skin turgor

A

hydration status; pinched skin should return to normal otherwise it results in tenting

120
Q

location for turgor test

A

forearm, sternum, sub-clavicular, abdomen In children (do not use back of hands for older adults)

121
Q

types of pain

A

acute vs chronic

122
Q

acute pain

A

last less than 6 months (rapid onset), mild - severe, triggers autonomic nervous system (increase HR, BP, and RR), disappears after underlying cause is resolved

123
Q

chronic pain

A

lasts beyond normal healing period, minimum of 6 months, can be unrelenting and severe or consistent or comes and goes

124
Q

sources of pain

A

cutaneous/ superficial (skin wound), somatic (tendon, ligament, nerve, bone, blood), visceral (organ pain), referred pain (originates somewhere but is felt elsewhere), neuropathic (pins and needles; disease/lesion of CNS or PNS), intractable pain (resistant to interventions) psychogenic pain (no reason for pain)

125
Q

pain assessment

A

COLD ERA and OLDCARTS

126
Q

COLD ERA

A

character of complaint/ pain, onset of symptoms, location, duration or pain, exacerbated by what, relieved by what, associated symptoms

127
Q

OLDCARTS

A

onset, location, duration, character, aggravating factors/associated symptoms, relieving factors, treatment, severity

128
Q

pain rating scales

A

Wong baker (faces), 0-10 distress scale, abbey pain scale, nonverbal pain scales (dementia pain scales), FLACC pain scale (2 months-7 years)

129
Q

medical asepsis

A

hand hygiene and wearing gloves; reduce number of pathogens; keeping clean

130
Q

types of PPE

A

gloves, gowns, masks, eyewear

131
Q

gowns

A

prevent soiling of blood/bodily fluids

132
Q

masks

A

prevent inhalation of large particle aerosols and small droplet nuclei; discourage touching eyes, nose, mouth

133
Q

eyewear

A

protect eye membrane from splash contamination

134
Q

N95

A

filtering facepiece respirator; filters out 95% of particles; needs to be fit-tested, can reuse for 5 days

135
Q

donning PPE

A

wash hands, put on gown, put on mask, put on goggles/face shield, put on gloves (outside of pt room)

136
Q

doffing PPE

A

(untie gown ties if fasten in front then…), remove gloves, then goggles/face shield, then gown, then mask, then wash hands

137
Q

HAI

A

healthcare associated infections

138
Q

Types of HAIs

A

CAUTI, SSI, VAP, CLABSI, MRSA, C-Diff, VRE, CRE

139
Q

CAUTI

A

catheter associated UTI

140
Q

SSI

A

surgical site infections

141
Q

VAP

A

ventilator associated pneumonia

142
Q

CLABSI

A

central line associated bloodstream infections

143
Q

MRSA

A

methicillin resist and staphylococcus aureus

144
Q

C-diff

A

gram pos. bacillus (anaerobic); diarrhea; contact enteric precautions (gloves and gowns); use soap d/t spores

145
Q

types of precautions

A

contact (direct or indirect), airborne, droplet

146
Q

types of indirect contact

A

vector (living creature ex: insect) and fomite (inanimate object)

147
Q

how to create correct precaution measures

A

standard precautions + transmission based

148
Q

standard precautions

A

blood, all bodily fluids EXCEPT sweat, non-intact skin, mucous membrane

149
Q

contact/contact enteric (intestines) definition and PPE

A

gown, gloves, handwashing before, disposable equip or clean with chlorhexidine;

150
Q

contact and contact enteric precautions

A

private room if possible, dedicated equip., door can be open, disposable cleaning supplies, transport- protect surfaces, instructions to visitors are susceptibility and PPE

151
Q

droplet precautions definition and PPE

A

mask, gown, gloves; infections spread by large particle droplets (ex: rubella, mumps, diptheria)

152
Q

droplet precautions

A

private room if possible, dedicated equipment, door can be open, transport of pt- mask and tissue receptacle, instructions of visitors- susceptibility and PPE

153
Q

airborne precautions defintion and PPE

A

TB, varicells, rubeola; resppirator, gown, and gloves (room may have HEPA

154
Q

airborne precautions

A

private room (neg. pressure and sealed), dedicated equipment, door closed, pt transport requires mask, instruct visitors susceptibility and PPE

155
Q

Reverse (neutropenic) isolastion

A

private room, dedicated equip., door closed, no standing water in room, no plants/flowers, healthy providers. transport of pt needs mask, visitors should not visit if sick, where proper PPE

156
Q

5 steps of infection prevention

A

stop at the source, block portal of exit (cover motuh when cough), interrupt mode of transportation (wash hands), protect portal of entry (mucous mebranes), increase defense (vaccines)

157
Q

infectious agent

A

BACTERIA, fungi, virus, parasite

158
Q

reservoir/host

A

natural habitat of organism (human, animal, inanimate object)

159
Q

portal of exit

A

sputum, emesis, stool, blood

160
Q

means of transmission

A

aerosol, droplet, contact

161
Q

portal of entry

A

mucous membranes, nonintact skin, GI tract, GU tract, respiratory tract

162
Q

susceptible host

A

immunosuppressed, elderly, chronically ill, trauma/surgery

163
Q

stages of infections

A

incubation (pathogen proliferating), prodromal (person is most infectious with vague and nonspecific symptoms), full stage (specific signs and symptoms of disease), convalescent (recovery from infection)

164
Q

gram positive bacteria

A

1 large cell wall that does stain; easier to kill

165
Q

gram negative bacteria

A

double phospholipid cell membrane; harder to kill; does not stain

166
Q

broad spectrum vs. narrow spectrum antibiotic

A

broad kills both whereas narrow kills 1

167
Q

exogenous transmission

A

entering body from environment

168
Q

endogenous transmission

A

become infected with own bacteria (micoflora)

169
Q

fungal infections

A

spread by direct skin contact or indirectly from contaminated floors or soils