Misc. Fundamentals Flashcards
Airborne
Isolation Precautions
Protect against droplet infections smaller than 5mcg and that remain airborne (larger droplets fall).
“My Chicken Hez TB” & VRSA
- Measles
- Chicken Pox
- Herpes zoster
- TB
- VRSA
Management
- Standard precautions
- Negative pressure room (private)
- Mask (n-95 for TB)
- VRSA includes contact precautions
Cane Walking
- *C** - Cane
- *O** - Opposite
- *A** - Affected
- *L** - Leg
Contact
Isolation Precautions
Contact precautions protect visitors and caregivers (when they are within 3ft of the client) against direct client and environmental contact infections
“MRS WEE”
- MRSA (VRSA requires airborne precautions)
- RSV
- Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies, staph)
- Wound infections
- Enteric infections (C-Diff)
- Eye infections (conjunctivitis)
Management
- Gown, gloves, goggles, private room
Crutch Walking
“Step Up”
When going up stairs, the good leg goes first, followed by crutches, then affected leg. (The opposite when going down stairs.)
Delegation
RNs do not delegate what they can EAT
- *E** - Evaluate
- *A** - Assess
- *T** - Teach
Considerations include:
- Predictability of outcome
- Potential for harm
- Complexity of care
- Need for problem-solving and innovation
- Level of interaction with client (need for psychosocial support or education)
Droplet
Isolation Precautions
Droplet precautions protect against droplets larger than 5mcg and travel 3 to 6 ft from the client.
“SPIDERMAn”
- Sepsis
- Scarlet Fever
- Strep
- Pertussis
- Pneumonia
- Parvovirus
- Influenza
- Diphtheria
- Epiglottitis
- Rubella
- Mumps
- Adenovirus
Management
- Private room, mask
Lateral
or
Side-Lying Position
- Pt lies on side with most of the weight on the dependent hip and shoulder.
- Good sleeping position, but the client must be turned regularly to prevent development of pressure ulcers on the dependent areas.
- A 30o lateral position is recommended for clients at risk for pressure ulcers.
Modified Trendelenburg Position
- Client remains flat with legs elevated above the level of the heart.
- This position is used to prevent and treat hypovolemia and facilitates venous return.
Fowler’s Position
- Pt is supine with HOB at 45o
- Frequently used during procedures such as NG tube insertion and suctioning
- Allows for better chest expansion and ventilation
Order of Assessment
I - Inspect
P - Palpate
P - Percuss
A - Auscultate
EXCEPT with the abdomen:
I - Inspect
A - Auscultate
P - Percuss
P - Palpate
High Fowler’s Position
- Pt is supine with HOB at 90o
- Promotes lung expansion by lowering diaphragm; used for clients experiencing dyspnea
Orthopneic Position
- Pt sits in the bed or at the bedside. A pillow is placed on the over-bed table, which is placed across the client’s lap. The client rests his arms on the over-bed table.
- Position allows for chest expansion and is especially beneficial to clients who have COPD.
Prone Position
- Pt lies flat on abdomen with head to one side
- Position promotes drainage from the mouth but inhibits chest expansion
Latex Allergies
Clients that are allergic to the following may be at risk for a latex allergy:
Bananas, Apricots, Cherries, Grapes, Kiwis, Passion Fruit, Avocados, Chestnuts, Tomatoes, and/or Peaches
Reverse Trendelenburg
- The entire bed is tilted with the foot of the bed lower than the head of the bed.
- This position promotes gastric emptying and prevents esophageal reflux.
