Lpn Flashcards
Pressure injuries
The pressure collapses bl. Vessels. 2 hours=tissue necrosis
Causes=shearing, friction, boney prominences
Prevention=reposition q 2 hours. Teach pt to shift q15 min
NO DONUTS NO MASSGE TO RED AREA
Life span considerations
Room environment considerations
OOBas much as possible
Temperature, ventilation, noise, odors, lighting. Create therapeutic environment
Room equipment
Semi-Fowler for bed bath and to prevent aspiration
Trendelenburg=feet up head down
Pressure injuries
Stage 1-intact skin w/nonblanchable redness
Stage 2-partial thickness loss of dermis. Shiny or dry, blisters, shallow, open, red-pink
Stage 3-full thickness tissue loss, subcutaneous fat is sometimes visible.
No bone, Tendo or Muscle
Stage 4- Full thickness tissue loss w/exposed bone tendon muscle
Unstagable-full thickness tissue loss wound base covered by slough and Escher
Suspected deep tissue injury-appears purple or maroon area of intact skin
Droplet precaution for deseases
Must use mask
Deseases=flu, diphtheria, whooping cough aka pertussis (highly contagious)
Vascular reaction
Delivers blood nutrient and fluids to injured area
Culture sensitivity testing
Test for the bacterias sensitivity and resistance in order to know which antibiotics are effective to stop bacterial growth
Contact precautions
PPE- gown and gloves
Deseases- C-diff, MRSA (resistant to many antibiotics
Surgical asepsis
Destruction of microorganisms and their spores
Invasive procedures
Pathogenic
Causing specific deseases/infections
When must hands be washes
Before and after pt care. Between pt contact. After touhing body fluids excretions secretions, touching contaminated equipment. *Immediately after removing gloves
Name 5 pathogens
Bacteria, Protozoa, viruses,fungi, parasites
Chain of infection
Pathogen-germ, Reservoir- place where it can grow, Exit- feces blood urine secretions, Method of transmission- contaminated food air droplets hands contaminated needle Entrance - mucous membranes mouth break in skin. Another person or animal
Tell me something about needle sticks
Must be reported immediately. Most commonly transmitted infection from needle sticks is hep b and serum hepatitis
Asepsis
Clean technique. Decrease the growth and transmission of microorganisms. Normal routine
Stages of infection
Prodromal- may be contagious , malaise , low grade fever generally unwell
Acute-most contagious sore throat sinus congestion high fever swollen glands/lymph nodes pain w/swallowing
How are Bacterial infection
Transmitted from person to person by direct contact, by inhalation, and w/ articles contaminated by the pathogen
Aerobic
Anaerobic
W/ oxygen
W/o oxygen
No antibiotics for viruses
Cold, flu, hiv, hepatitis and herpes
Localized infections
Single part/organ
Inflammatory, edema/swelling, erythema/redness, pain n tenderness
Systemic infections
Entire body. Fever. Increased wh bl cells, can be fatal
Inflammatory response
Protection, bodies response to injury or infection
Vascular reaction
Delivers fluid blood and nutrition to injured area
Alcohol based sanitizer
More effective than soap and water
NOT effective against spores, anthrax and c-diff
Deadly bacteria
Streptococcus is responsible for more deseases than any other bacteria
MRSA-serious/ can be fatal
Airborne precautions
Pt should wear surgical mask outside of isolation room. Limit lt movement to only what is medically necessary
Hand hygiene and PPE
Diabetic foot care
Do not trim nails
Do not soak too long
For poor circulation, refer to podiatrist
Negative air flow
Room air is vented to the outside, 6-12 air exchange per hour, door should be closed. Used for airborne precautions
Reducing risk of infection
Hand hygiene and sterile supplies when appropriate
Baths
Complete bed bath- pts who are totally dependent,
Partial bed bath-pt needs help w/ areas he cannot reach
Tepid sponge bath-helps to reduce temp
Medicated bath- addresses skin problems
Hot water tub bath- relieves muscle soreness and stiffness
Moisture, sweating, and Incontinence
Can cause skin breakdown, change linen regularly.
30 degree lateral position
Pt lies in lateral position w/ pillow between legs removing pressure from knees and ankles
Oral hygiene
Stimulates appetite, moistens mouth and lips, prevents periodontal deseases, improves pts feelings of well being
Shaving
Use electric razor for pt. On bl thinner
Always move from dirty to clean!!!
UAPs
Can assist w/ambulatory pt, can shower stable pt
No oral care w/o gag reflex
Perineal careuncircumcised penis
Retract clean and RETURN foreskin
Catheter care
Remove exudate (drainage), clean from meatus out, clean entire catheter
Skin care
Skin ferments physical condition changes, always consider pt preferences. Back care/ rub provides relaxation, relieves muscle tension, stimlates circulation unless contraindicated
Incubation period
No symptoms may be contagious based on the pathogen
Convalescence
Recovery
Best time for bedmaking
Mornings, after bath, when unoccupied, occupied when necessary
