Mod 2 Test Flashcards
What common resident microorganisms can you find on the skin?
Staphylococcus epidermidis Propionibacterium acnes Staphylococcus aureus Corynebacterium xerosis Pittosporum aureus
What common resident microorganisms can you find on the nasal passages?
Staphylococcus aureus
Staphylococcus epidermidis
What common resident microorganisms can you find on the oropharynx?
Streptococcus pneumoniae
What common resident microorganisms can you find in the mouth?
Streptococcus mutans
Lactobacillus
Bacteroides
Actinomyces
What common resident microorganisms can you find in the intestine?
Bacteroides Fusobacterium Eubacterium Lactobacillus Streptococcus Enterobacteriaceaes Shingella Escherichia coli
What common resident microorganisms can you find on the urethral orifice?
Staphylococcus epidermidis
What common resident microorganisms can you find in the urethra?
Proteus
What common resident microorganisms can you find in the vagina?
Lactobacillus
Bacteroides
Clostridium
Candida albicans
What is a communicable disease?
If an infectious agent can be transmitted to an individual by direct or indirect contact or as an airborne infection.
What is pathogenicity?
It is the ability to produce disease; thus a pathogen is a microorganisms that can cause a disease
What is an opportunistic pathogen?
Causes disease only in a susceptible individual
What is asepsis?
Is the freedom from disease causing microorganisms
What is used to decrease the possibility of transferring microorganisms from one place to another?
Aseptic technique
What are the two basic types of asepsis?
Medical and surgical
What is medical asepsis?
Practices intended to confine a specific microorganisms to a specific area limiting the number, growth and transmission
In Medical asepsis, objects are referred to as what?
Clean- absent of most microorganisms
Dirty- likely to have microorganisms
Surgical asepsis or sterile technique is referred to as what?
Practices that keep an area or object free of all microorganisms
What is sepsis?
Is condition in which acute organ dysfunction occurs secondary to infection
What types of microorganisms cause infection?
Bacteria- most common
Viruses- must enter a living cell
Fungi- include yeast and mold
Parasites- live on other organisms
What is colonization?
It is the process by which strains of microorganisms become resident flora
What is a local infection?
It is limited to the specific part of the body where the microorganisms remain
What is a systemic infection
It is when the microorganisms spread and damage different parts of the body
What is it called when a culture of the persons blood reveals microorganisms?
Bacteremia
When bacteremia result in systemic infection it is called what?
Septicemia
What happens durning an acute infection?
It appears suddenly or last a short time
What happens durning a chronic infection?
It occur slowly over a very long period and may last years or months
Infections that originate in the hospital are called what?
Nosocomial infections
What is a subgroup of health care- associated infections?
Nosocomial infections
What accounts for 2/3 of all HAIs?
Central intravenous lines- associated bloodstream infections
Catheter associated urinary tract infections
Ventilator-associated pneumonia
Nosocomial infections that originate from the client are called what?
Endogenous
Nosocomial infection that originated from the hospital environment are called what?
Exogenous
Urinary tract infections are caused by what?
Escherichia coli - improper catheterization technique
Enterococcus species- contamination of closed drainage system
Pseudomonas aeruginosa- inadequate hand hygiene
What causes infection in surgical sites?
Staphylococcus aureus/ MRSA- inadequate hand hygiene
Enterococcus species/ VRE- improper dressing change technique
Pseudomonas aeruginosa
What causes infection in the bloodstream?
Coagulase- negative staphylococci inadequate hand hygiene
Staphylococcus aureus- improper intravenous fluid, tubing, and site care technique
Enterococcus species
What is a latrogenic infection a direct result of?
Diagnostic or therapeutic procedures
How many links make up the chain of infection?
6
In the chain of infection the place where the organism naturally resides is what?
The etiologic agent or microorganisms
The reservoir in the chain of infection does what?
Is the source of the microorganisms (carrier)
Before an infection can establish itself in a host it must leave what?
Portal of exit from the reservoir
After the microorganisms leaves the reservoir via a portal of exit it requires what?
A method of transmission
What are the three methods of transmission for a microorganisms?
Direct transmission- kissing, bitting, sex
Indirect transmission
* vehicle- borne- handkerchief, toys, clothes
* vector borne - insect
Airborne transmission- droplets, dust
What serves as a portal of entry for a microorganisms?
Break in skin, respiratory tract, gastrointestinal tract, urinary tract, reproductive tract, blood, tissue
What is a susceptible host?
A susceptible host is any person who is at risk for infection
How does the chain of infection work?
Etiologic agent Reservoir Portal of exit Mode of transmission Portal of entry Susceptible host
What is infection?
It is the growth of microorganisms in the body tissue where they are not usually found
What is the body’s first line of defense against microorganisms?
Intact skin and mucous membranes
Where is bacteria most plentiful on the body?
Perineum and axillae
How does resident bacteria keep other bacteria from multiplying?
They use up all the available nourishment and the end products of their metabolism inhibits bacterial growth
What role do the mucous membrane and cilia play in the defense function of the nasal passages?
They trap microorganisms, dust, and foreign particles
What protective mechanisms does the oral cavity have?
It sheds mucosal epithelium to rid the moth of colonizers and saliva contain microbial inhibitors such as lactoferrin, lysozyme, and secretory IgA
Eye are protected by what?
Tears
The GI tract is protected by what?
The high acidity of the stomach and the resident flora in the large intestine
What are the natural defenses of the vagina?
Low PH levels inhibit the growth of of many disease producing microorganisms
What is the defense of the urethra?
Urine flow and intact mucosal surface
What is inflammation?
It is a local and nonspecific defensive response of the tissues to an injurious or infectious agent
What are the five characteristics of an inflammatory response?
Pain Swelling Redness Heat Impaired fiction of the part of the injury is severe
What are the three stages of an inflammatory response?
First stage: vascular and cellular responses
Second stage: exudate production
Third stage: reparative phase
What happens durning the first stage of inflammatory response?
Blood vessels at the site constrict followed by dilation of small blood vessels causing more blood to flow the the site this is called hyperemia and is responsible for heat and redness eventually releasing leukocyte causing inflammation creating pressure on the nerve endings causing pain.
Normal leukocyte count is 4500 to 11000 and can rise to 20000 when inflammation occurs
What happens durning the second stage of inflammatory response?
Inflammatory exudate is produced consisting of fluid that escaped the blood vessels. The plasma protein fibrinogen is released into the tissues and thrombophlebitin is released by the injured tissue which form a wall to prevent spread of injurious agent and exudate is cleared away by lymphatic drainage.
Major types of exudate are serous, purelent, and sanguineous
What happens durning the third stage of the inflammatory response?
Regeneration is the replacement of destroyed tissue cell by cell. The ability to regenerate cells varies considerably by the type of tissue digestive and respiratory tracts have good regenerative capacity and the nervous, muscular, and elastic tissues so not. When regeneration is not possible repair occurs by fibrous tissue/ scar tissue
What are the two immune response components?
Anti body defenses and cell mediation defenses
What are the two major types of immunity?
Active immunity- the host produces a antibodies in response natural antigens or artificial antigens ( infectious microorganisms of vaccine)
Passive immunity- the host receives it natural or artificial ( nursing mother or anti venom)
What are the three main groups of T cells?
Helper T- helps the functions of the immune system
Cytotoxic T cells- which attack and kill the microorganisms and sometimes the bodies own cells
Suppressor T cells- which can suppress the fictions of the helper T cells and cytotoxic t cell
What are factors increasing susceptibility to infection?
Age, heredity, level of stress, nutritional status, current medical therapy and preexisting disease processes
Durning an assessment if you found localized swelling, redness, pain or tenderness with palpation or movement, palpable heat, loss of fiction in the body part affected it would be a sign of what?
Local infection in the skin or mucous membranes
What are the signs of a systemic infection?
Fever
Increased pulse and respiratory rate
Malaise/ loss of energy
Anorexia and, in some situations nausea and vomiting
Enlargement and tenderness of lymph nodes that drain the area of infection
What lab data would indicate the presence of an infection?
Elevated leukocyte
Increased in specific types of leukocyte sad revealed in the differential WBC
Elevated erythrocytes sedimentation rate ESR
Urine blood sputum or other drainage
What measures can be taken to avoid susceptibility to infection?
Hygiene Nutrition Fluid Sleep Stress Immunization
What is disinfectants?
Agents that destroy pathogens other than spores
When breaking the chain of infection what can you use on the first links in the chain? ( etiologic all agent and reservoir)
Antiseptic and disinfectants
What do standard precautions apply to?
Blood
All bodily fluids except sweat
Nonintact or broke skin
Mucous membranes
What do standard precautions include?
Hand hygiene
Use of personal protective equipment-gloves goggles, mask, gowns
Safe injection practices
Safe handling of potentially contaminated equipment or surfaces in the clients environment
Respiratory hygiene/ cough etiquette
What are the three types of transmission based precautions?
Airborne precaution
Droplet precaution
Contact precautions
What is the largest organ of the body?
skin
What are the skins 5 major function?
Protects underlying tissues Regulates body temp Secretes sebum Transmits sensation through nerve receptors Produces and absorbs vitamin D
What is the oily substance that has a bactericidal on the skin called
Sebum
What are some common skin problems?
Abrasion Excessive dryness Ammonia dermatitis (diaper rash) Acne Erythema(rash,sun exposure, temp) Hirsutism (excessive hair)
Where are the apocrine glands located?
Azillae and anogenital
Where are the eccrine glands found?
Palms of the hand soles of the feet and forehead
What are the different function level ratings used when assessing client self care abilities?
0 completely independent
+1 requires use of equipment or device
+2 semi dependent requires help from another person for assistance, supervision,teaching
+3 dependent requires help from another person and equipment or device
+4 totally dependent does not participate in activity
What are the purpose of a bath?
To remove transient microorganisms, secretions, excretions, and dead skin cells To stimulate circulation Promote sense of well being Produce relaxation and comfort Prevent body odors
What diagnoses would you use for a client having problems performing hygiene care?
Bathing Self- care deficit, dressing Self- care deficit, toileting Self- care deficit,
What are the two categories of baths given?
Cleaning and therapeutic
What are the different types of cleansing baths?
Complete bed bath Self- help bed bath Partial bath Bag bath Towel bath Tub bath Shower
Why are therapeutic baths given and for how long?
Are given for physical effects to soothe irritated ski or treat an area. Medication may be placed in the bath and often last for 20-30 mins temp is 100-115 for adults
What should you do if a person with dementia become agitated?
You should stop and change the approach it is also helpful if you wait and try again in 30 min
What are common foot problems?
Callus Corns Planter wart Fissures Tinea pedis (athletes foot)
What virus is a plantar wart caused by?
Papovavirus honinis virus
When assessing the nail you notice a spoon shape in which the nail curves upward from the nail bed what it this called?
Koilonychia and is seen in clients with iron deficiency anemia
Clubbing is a condition in which the angle between the nail and the nail bed is 180 degrees or greater what causes this
Long term lack of oxygen
Beau’s lines in the nails are cause by what?
Injury or severe illness
What is reason for loss of teeth?
Periodontal disease
What are common problem of the mouth?
Halitosis- bad breath
Glossitis- inflammation of the tounge
Gingivitis- inflammation of the gum
Periodontal disease- spongy, bleeding gums
Reddened or excoriated mucosa
Excessive dryness of the buccal mucosa
Cheilosis- cracked lips
Dental caries- cavities
Sordes-accumulation of foul matter
Stomatitis- inflammation of the oral mucosa
Parotitis- inflammation of the parotid salivary glands
What do you need to before providing oral care on a unconscious client?
Check for a gag reflex
How do you grade edema?
1+ is 2 mm
2+ is 4 mm
3+ is 6 mm
4+ is 8 mm
When describing the skin pallor describes what?
Paleness
Cyanosis describe what
A blush tinge of skin color
Jaundice describes what?
A yellowish tinge to skin color
Erythema describes what?
A redness tinge of skin color associated with a variety of skin rashes
What causes alopecia?
Chemotherapeutic agents
What are the three types of pediculosis?
Pediculus capitis (the head louse) Pediculosis corporis(the body louse) Pediculus pubis (the crab louse)
What is hirsutism?
Excessive body hair
What are nursing diagnoses related to eye problems?
Risk for infection
Risk for injury
If a hearing aid is not to be use for a few days what should you do?
Remove the battery
How long should a first time wearer wear hard contact lenses?
12-14 hours
Soft contact lenses can be wire for how long?
1-30 days
What are the different types of hearing aids?
Behind the ear BTE open fit Behind the ear BTE In the ear ITE aid In the canal ITC aid Completely in the canal CIC aid Eye glasses aid Body hearing aid
What common bed position is the mattress completely horizontal?
Flat
Spinal injury
What common bed position is the mattress semi sitting position between 45-60 degrees knee possibly bent?
Fowler a position
Promotes lung expansion
What common bed position is the head of the bed is raised 15-45 degrees?
Semi fowler’s position
Relief from lying position
What common bed position is the head of the bed is lower and the foot is raised at a straight incline?
Trendelenburg’s position
Circulation and drainage of basal lung lobes
What common bed position is the foot of the bed is lower and the head is raised at a straight incline?
Reverse trendelenburg’s
Stomach emptying and prevent reflex
What are the phases of diagnostic testing?
Protest- focus on client preparation
Intratest- focus on specimen collection
Post test- the focus is follow up activities and observation
What are nursing diagnoses related to diagnostic testing?
Anxiety or fear
Impaired physical mobility
Deficient knowledge
Durning blood testing what is it called when a vain is pictured for collection of a specimen?
Venipunture
What is a phlebotomist?
A person from a laboratory who performs venipuncture
What are normal RBC and what would increase or decrease them?
Men 4.6-6 million
Women 4-5 million
Increased: dyhdration, polycythemia Vera, high altitude, cardiovascular diseases
Decreased: blood loss, anemias over hydration, leukemias, chronic renal failure, pregnancy
What are normal Hemoglobin and what would increase or decrease them?
Men 13.5-18g/dl
Women 12-15g/dl
Increased: polycythemia, dehydration, chronic obstructive, pulmonary disease, heart failure
Decreased: blood loss, anemias, kidney disease, cancers
What are normal hematocrit and what would increase or decrease them?
Men: 40-54%
Women: 36-46%
Increased: dehydration, burns, hypovolemia
Decreased: acute blood loss, pregnancy, dietary deficiencies, anemias
What are normal WBC and what would increase or decrease them?
4,500-11,000
Increased: acute infection, tissue necrosis, myocardial infarction, collagens disease
Decreased: viral infection, hematopoietic disease, rheumatoid arthritis
What are normal Platelet count and what would increase or decrease them?
150,000-400,000
Increased: infection,polycythemia Vera, acute blood loss, splenectomy
Decreased: idiopathic ( unknown causes), thrombocytopenia purpura, cancer, systematic lupus erythematosus, some types of anemias
What are the most commonly order serum electrolytes?
Sodium, potassium,chloride and bicarbonate ions
What is serum osmolality?
The measure of solute concentration of the blood
What makes up plasma?
Water,salt, sodium, potassium, calcium, magnesium, chloride, bicarbonate, plasma proteins, albumin, fibrinogen, globulin,
Substance transported by the blood
Nutrients, waste products of metabolism, respiratory gases
What are the formed elements(cells) of blood?
Erythrocytes (RBC)
Leukocyte ( WBC)- basophils, eosinophils, neutrophils, lymphocytes, monocytes
Platelets
Is obtaining a capillary blood specimen to measure blood glucose considered invasive?
Yes
How does the injector have to be place when obtaining a capillary blood specimen?
Perpendicular
When doing a guaiac test what color indicates positive for blood?
Blue
How is sputum different from saliva?
Sputum is the mucous from the lungs, bronchi, and trachea and saliva is clear liquid created by the salivary glands in the mouth
When should a sputum sample be collected?
First thing in the morning so the client can cough up secretions that have accumulated in the night
Can the client use mouthwash before a sputum sample collection?
Yes so that the sample is not contaminated with microorganisms from the mouth
What is a barium enema?
An enema containing barium. Used to view the flow of the intestines during a x-Ray for continuous observation
A cystoscopy is done to do what?
View the bladder, ureter and urethra by inserting a lighted through the urethra
What does a electrocardiogram do?
Detects dysthymia a and alterations in conduction indicative of myocardial damage, enlargement of the heart, or drug effects
What does a echocardiogram do?
It is a noninvasive test that uses ultrasound to visualize structure of the heart
Durning a lumbar puncture would the needle be placed?
In the subarachnoid space of the spine between the fourth and fifth lumber vertebrae
How does the client need to be placed durning a lumbar puncture?
Client is placed laterally with their head bent toward the cheats and knees flex to the abdomen
What is abdominal paracentesis used for?
To obtain fluid for the lab and relieve pressure off the organs
What to positions are use for thoracentesis?
The sitting position with the arm forward and when the client leans over pillow
What is the difference between an open and close wound?
Open wounds must have broken the skin or mucous membranes and close the skin is not broken
What is a clean wound?
Are uninfected wounds primarily closed wounds
Clean contaminated wound are what?
Wounds that are surgical in which the respiratory, gastrointestinal, genital urinary tract has been entered but show no signs of infections
What are contaminated wound?
These include open fresh accidental wounds and surgical wounds involving a major break in sterile technique. Often show signs of inflammation
What are dirty or infected wounds?
Wounds containing dead tissue signs of infection such as purulent drainage
Where do pressure ulcers occur?
Over bony prominence
What are pressure ulcers due to?
Localized Ischemia, a deficiency in the blood flow to the tissue
A closed wound were the skin appears ecchymotic because of damaged blood vessels is what type of wound?
Contusion
A wound caused by a sharp instrument is what type of wound?
Incision
An open wound involving the skin is what type of wound?
Abrasion
Penetration of the skin and often underlying tissues causes what type of wound?
Puncture
An open wound where the edges are jagged are what kind of wounds?
Lacerations
A wound from a bullet is what kind of wound
Penetrating
What are the different types of wound exudate?
Serous exudate- consist of serum
Watery and has a few cells ex. Blister
Purulent exudate- is thicker has a presence of pus consist of leukocyte tinge of green, blue, yellow
Saguineouse exudate- large amount of red blood cells often seen in open wounds
What are risk factors of pressure ulcers?
Friction/ shearing Immobility Inadequate nutrition Fecal and urinary incontinece Deceased mental status Diminishing sensation Excessive body heat Advanced age Chronic medical conditions
A nonblanchable erythema potential for ulceration is what stage?
Stage I
Partial-thickness skin loss injury to epidermidis possible dermis ( blister abrasion) is what stage of a pressure ulcers?
Stage II
Full- thickness skin loss, injury or necrosis of subcutaneous tissue, deep crater is what stage pressure ulcers?
Stage III
Full thickness skin loss and damage to muscle or bone or support structures, injury or necrosis to muscle, bone or tendons is what stage of pressure ulcers?
Stage VI
Primary intention healing occurs where?
The tissue surfaces have been approximated (closed) and there is a minimal or no tissue loss, minimal scarring
A wound with considerable tissue loss and should not be approximated is a ?
Secondary wound
Wounds that are left open for 3-5 days to allow edema or infection to resolve/exudate/drain and are then closed with sutures are what?
Tertiary intention
How long does the inflammatory phase of wound healing last?
3-6 days
The proliferative phase of wound healing extends for how long?
From day 3-4 to about day 21 post injury
The maturation phase of wound healing begins when and last how long?
Begins about day 21 and can extend 1 or 2 years after the injury
When using the RYB color code what phase is a red wound and how does it need to be taken care of?
Red is usually in the late regeneration phase of tissue repair and needs to be protected to avoid disturbance to regenerating tissue. Gently cleans with nontoxic wound cleanser protect with a alcohol free barrier film, fill dead space with hydrogel or alginate, cover with transparent film, hydrocolloid dressing, or clear absorbent acrylic dressing,change dressing the least possible amount
When using the RYB color code what characteristics do yellow wounds have and how does it need to be taken care of?
Yellow wounds are characterized primarily by liquid to semiliquid “slough” that is often accompanied by purulent drainage or previous infection. Clean wound to remove nonviable tissue by applying damp-to- damp dressing or irrigating by using absorbent material such as impregnated hydrogel or alginate dressing
When using the RYB color code what characteristics do black wounds have and how does it need to be taken care of?
Are covered with thick necrotic tissue or Escobar and require debridement and this can be accomplished four different ways sharp, mechanical,chemical,and autolytic then treat it like a yellow wound
