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nurs 113 > MIDTERM > Flashcards

MIDTERM Flashcards

1
Q

Chain of infection

A
  1. pathogen i.e., common cold virus
  2. reservoir i.e., people
  3. exit of reservoir i.e., out of mouth via saliva
  4. transportation i.e., sneeze/cough, speech, hands…
  5. portal of entry i.e., eyes, mucous membranes …
  6. susceptible host i.e., anyone
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2
Q

routine precaution “standard” and PPE

A

For ALL patients regardless of diagnosis or presumed infectiousness when handling:
* All body fluids, secretions and excretions except sweat
* Blood
* Non-intact skin
* Mucous membranes
PPE: gloves, gown, mask; eyewear as needed

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3
Q

isolation precaution - contact

A

germs are on surface of patient
PPE: gloves and gown

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4
Q

isolation precaution - droplet

A

germs are in large droplets in air within 1-2 m of patient. germs can survive in environment away from patient.
PPE: gown, gloves, mask, eyewear within 2m of patient

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5
Q

isolation precaution - airborne

A

germs are suspended in tiny air particles
PPE: N95 mask

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6
Q

donning

A
  1. hand hygiene
  2. gown
  3. mask
  4. eyewear
  5. gloves
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7
Q

doffing

A
  1. gloves
  2. hand hygiene
  3. gown
  4. hand hygiene (2m away from patient)
  5. eyewear
  6. hand hygiene
  7. mask
  8. exit room and hand hygiene
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8
Q

10 risk factors for falls (older adults)

A
  1. change in vision
  2. change in hearing
  3. change in mobility
  4. changes in reflexes
  5. genitourinary changes
  6. unfamiliar environment
  7. uneven/broken pavement
  8. medications
  9. dizziness and vertigo
  10. postural instability
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9
Q

Henrich II Fall Risk Model

A

used to determine potential risks.
score greater than 5 = high risk of falling

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10
Q

10 ways to prevent falls as a nurse

A
  1. using Henrich II Fall Risk Model
  2. call bell instruction
  3. fitted shoes for patient
  4. uniform stair sizes
  5. proper lighting
  6. proper handrails
  7. elevated toilet seat with armrests
  8. secure power cords along baseboard
  9. supervising patients who are confused
  10. placing tables near patients to avoid reaching over
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11
Q

5 SAFTEY CHECKS

A
  1. braked are on
  2. bed is in lowest position
  3. call bell is in reach
  4. side bars/ rails are up as needed
  5. personal belongings are in reach
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12
Q

seizure

A
  • close curtain for privacy
    before : pillows on bed and available,
    position bed low, 2 side rails up, padded
    side-rails and headboard (if possible)
    during : ensure safety of environment, put
    pillow under head, do not put anything in
    their mouth, put bed rails up with padding,
    provide privacy, if able – turn patient to
    side-lying position, loosen tight clothing
    (ties, strings etc.), time the seizure
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13
Q

sleep protocol

A
  1. reduce the amount of noise i.e., close doors/ windows
  2. dim lights
  3. announcement on PA that sleep will commence soon and minimize noise
  4. turn on white noise machine
  5. round for quietness - ask patient if they would like eye mask/ earplugs
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14
Q

deconditioning - metabolic/ gastrointestinal

A
  • peristalsis decreases, fluid intake and appetite decrease
  • difficulty passing stool
  • edema
  • electrolyte imbalance - calcium
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15
Q

respiratory

A
  • decreased lung expansion and a decrease in gas exchange
  • pulmonary secretions begin to pool
  • atelectasis = collapse of alveoli
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16
Q

cardiovascular

A
  • decreased cardiac output
  • orthostatic hypotension = drop in BP
  • heart works faster and less efficiently
  • thrombus = materials attach to the inside of a vein
  • embolus = a dislodged thrombus that travels through the circulatory/ respiratory system
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17
Q

musculoskeletal

A
  • reduced muscle mass and impaired joint mobility
  • decreased endurance as the patient
    osteoporosis = loss of bone mass
    joint contracture = fixation of a joint
    foot drop = inability to dorsiflex due to nerve damage
18
Q

urinary elimination

A

kidneys and ureters are at a level position, urine must enter ureters unassisted by gravity
- increased rate of UTIs and renal calculi

19
Q

intergumentary

A

increased risk for pressure injuries
- prolonged ischemia (decreased flood flow) can result in a pressure injury
- inflammation over a bony prominence ex. scapulae, elbows, coccyx, heels

20
Q

ROM

A

done to prevent joint contracture and reducing hazards of immobility
- active = patient does it
- passive = nurse moves each joint

21
Q

pressure ulcer development - pressure intensity

A

minimal pressure required to collapse capillary. tissue ischemia or reduction of blood flow can occur when there is a prolonged period

22
Q

pressure ulcer development - pressure duration

A

low pressure over a long period of time and high intensity pressures over short periods of times both cause tissue damage
- extended periods of time can occlude blood flow and nutrients, contributes to cell death

23
Q

pressure ulcer development - tissue intolerance

A

the ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structure
- factor of shear, friction, and moisture affect the skins ability to tolerate pressure

24
Q

why are older adults at risk for pressure injuries (4)

A
  1. impaired mobility
  2. impaired sensory perception
  3. alteration in level of consciousness
  4. nutrition
25
Q

5 classic signs of wound infection

A
  1. erythema (redness) or edema (swelling)
  2. warmth in surrounding tissue
  3. pain/tenderness
  4. purulent discharge
  5. fever/chills
26
Q

body mechanics

A
  1. tighten abdominal muscles. keep back , neck, pelvis, and feet aligned. avoid twisting
  2. bend at knees and keep feet apart, lower center of gravity
  3. use your arms and legs, NOT your back
  4. slide patient toward your body
  5. person with heaviest load coordinates the effort by counting to three
27
Q

Braden Risk Assessment

A

to determine the patients level of pressure injury risk
- smaller the number = the more at risk

28
Q

fowler’s

A

head of bed raised to 45* or more
- semi-sitting position, foot of bed raised at knee
used: when patient eats or nasogastric tube insertion and nasotracheal suction\
promotes lung expansion

29
Q

semi-fowler’s

A

head raised approx. 30*, foot of bed raised at knee
- promotes lung expansion
Use: patient receives gastric feedings to reduce regurgitation and aspiration

30
Q

trendelenburg’s

A

entire bed frame tilted downward
use : postural drainage
facilitates venous return in patients who have poor peripheral perfusion

31
Q

reverse trandelenburg’s

A

entire bed frame is tiled up
used infrequently
- promotes gastric emptying (gravity) and prevents esophageal reflux

32
Q

flat

A

horizontally parallel with floor
use : patients with vertebral injuries and in cervical traction. if patients are hypotensive (low BP) and for sleeping

33
Q

body mechanics in bed making

A
  1. bed should be raised to appropriate height
  2. nurse should move back and forth to opposite sides of the bed, no reaching over
  3. turning or repositioning the patient, side rails up on the side the patient will face
34
Q

supported supine position

A
  • rolled towel in lumbar area to support the spine
  • pillow under patients upper shoulders, neck, or head to retain proper alignment
  • trochanter rolls or sandbags parallel to the lateral surface of the patients thighs if immobile
  • heel boots to prevent foot drop
  • pillows under pronated forearms, keeping upper arms parallel to body
  • hand roles in patients hands to prevent extension of fingers and abduction of thumb
35
Q

Sabina

A

sit to stand to sit
orange sling = medium
unlock brakes on sabina
-make sure brakes are locked on commode or wheelchair
step 1 : position sling around hips/lower back, secure buckle and tighten waist belt.
step 2 : feet flat on foot step (shoes), position elbows around the sling
patients arms either flat against body or holding onto straps

36
Q

golvo

A

patient is non weight bearing
supine to sitting
- Place the sling under the client – ensure
shoulders are supported and the lower edge of the sling is at the top of the sacrum /buttocks and top of sling (with head support) covers client’s head.

37
Q

ceiling lift - universal

A

supine to sitting
- transfer patient from bed to wheelchair/ commode/ OR bedside chair
neck support - good for patients with poor neck control
bar is perpendicular

38
Q

ceiling lift - positioning sling

A

moves in supine
bar is parallel
move pillow to head to bed to prevent bonking

39
Q

hygiene sling

A

used to lower patient directly into bathtub
supine to 90*

40
Q

escar

A

unstageable
- can’t see what’s under it

nurs 113 (7 decks)

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