Module 2 Flashcards
1
Q
define local infection
A
limited to the specific part of the body where microorganisms remain
2
Q
define systemic infection
A
microorganism that spreads and damages different parts of the body
3
Q
define bacteremia
A
microorganisms in the blood
4
Q
define septicemia
A
body systems that are affected by bacteremia
5
Q
how long does an acute infection last?
A
3-5 days
6
Q
how long does a chronic infection last?
A
months-years (occurs slowly)
7
Q
define endogenous HAI
A
infection developing from the patients
8
Q
define exogenous HAI
A
infection developing from outside sources
9
Q
define iatrogenic HAI
A
infections that are a direct result of diagnostic/therapeutic procedures
10
Q
4 types of microorganisms that cause infection
A
- bacteria
- viruses
- fungi
- parasites
11
Q
difference between medical vs. surgical asepsis
A
- medical - limits the number and transmission of pathogens
* surgical - kills all microorganisms
12
Q
an improper catheterization technique causes
A
escherichia coli
13
Q
contamination of closed drainage systems cause
A
enteorcoccus species
14
Q
inadequate hand hygiene causes (3)
A
- pseudomonas aeruginosa
- staphylococcus aureus (MRSA)
- coagulase-negative staphylococci
15
Q
improper dressing change technique causes
A
enterococcus species (VRE)
16
Q
improper IV fluid, tubing, and site care technique cause (2)
A
- staphylococcus aureus
- enterococcus species
17
Q
improper suctioning technique causes (2)
A
- pseudomonas aeruginosa
- enterobacter species
18
Q
what is the body’s first line of defense?
A
SKIN
19
Q
6 links of chain of infection
A
- etiologic agent
- reservoir
- portal of exit from reservoir
- mode of transmission
- portal of entry to a host
- susceptibility of a host
20
Q
signs and symptoms of local infection (5)
A
- localized swelling,
- redness,
- pain/ tenderness with palpation/movement,
- palpable heat,
- loss of function
21
Q
signs of systemic infection (6)
A
- fever,
- increased pulse,
- Increases resp,
- malaise/loss of energy,
- anorexia,
- enlargement/tenderness of lymph nodes
22
Q
nonspecific defenses as a barrier to microorganisms
A
protect the person against all microorganisms, regardless of prior exposure
23
Q
other mucous membranes that protect against microorganisms (7)
A
- mucous membranes have cilia,
- lungs have alveolar macrophages,
- oral cavity sheds mucosal epithelium,
- eye with tears,
- acidity of the stomach,
- resident flora of large intestine,
- peristalsis moves microbes
24
Q
define inflammatory response
A
a local and nonspecific defensive response of the tissues to an injurious or infectious agent;
25
goal of inflammatory response
destroys or dilutes injurious agent, prevents further spread of the injury, and promotes repair of damaged tissue
26
5 stages of inflammatory response
- pain
- swelling
- redness
- heat
- impaired function
27
3 stages of inflammatory response
1. vascular and cellular responses
2. exudate production
3. reparative phase
28
what occurs during 1st stage of inflammatory response
-blood vessels go to the site of injury and constrict
-blood vessels then dilate
-histamine is released
-more blood flows to the injured area
(responsible for hyperemia and signs of redness and heat)
29
what occurs during the 2nd stage of inflammatory response
- exudate (fluid that escaped from blood vessels, dead phagocytic cells, and dead tissue cells and products they release)
- plasma protein, thromboplastin, and platelets form together an interlacing network to wall off area to prevent spread of injurious agent
30
3 types of exudate
- serous
- purulent
- hemorrhagic (sanguineous)
31
what occurs in the 3rd stage of inflammatory response
- scar tissue formation
- damaged cells are replaced by regeneration one by one
- organized in a way that pattern and function of the tissue is restored
- granulation tissue- when damaged tissues are replaced with conective tissues of collagen, blood capillaries, lymphatics
32
name some Specific (immune) defenses
directed against identifiable bacteria, viruses, fungi, or other agents
33
antigen
substance that induces a state of sensitivity or immune responsiveness
34
auto antigen
if the proteins originate in a person’s own body
35
Antibody-mediated defenses (humoral immunity)
defenses reside ultimately in the B lymphocytes and are mediated by antibodies produced by B cells; defend against extracellylar phases of bacterial and viral infections
36
antibody (immunoglobulin)
part of body’s plasma proteins
37
active immunity
host produces antibodies in response to natural antigens (infectious MO) or artificial antigens (vaccines)
38
passive (acquired) immunity
the host receives natural or artificial antibodies produced by another source
39
Cell-mediated defenses/cellular immunity: T cell system (3)
- Helper T cells: help in function of immune system
- cytotoxic cells- attack and kill mo and sometimes bodys own cells
- suppressor T cells: syuppressfunctions of helper T cells and cytotocix cells
40
supporting defenses of a susceptible host (methods to decrease the risk of infection) (6)
- hygiene
- nutrition
- fluid
- sleep
- stress
- immunization
41
if infections cannot be prevented, what is the nurses goal?
to prevent the spread of the infection within and between persons, and to treat the existing infection
42
disinfecting
chemical preparation used on inanimate objects
43
antiseptics
agents that inhibit the growth of some microorganisms
44
disinfectants
agents that destroy pathogens other than spores by sterilization
45
sterilizing
the process that destroys all MO
46
4 methods of sterilizing
- moist heat: autoclave
- gas: ethylene oxide gas,
- boiling water: most practical for in home sterilizing
- radiation
47
Goal of sterile Technique
free from all MO
48
sterile field (3)
* a microorganism free area
* establish a field by using the innermost side of a sterile wrapper or by using a sterile drape
* sterile supplies and solution can be placed on it
49
steps to follow with an exposure at work
1. report immediately
2. complete injury/accident report
3. seek evaluation and follow up
50
describe serous fluid and example
clear to pale yellow
| blister from a burn
51
describe purulent fluid and example
contains pus (suppuration)
color dependent on causative organism
(on edge of wound on unstageable)
52
describe sanguineous fluid
bloody, contains large amounts of RBC's
53
describe serosanguineous
bloody and clear to pale yellow
54
describe purosanguineous
bloody and pus mixture
55
standard precautions (tier 1)
- blood, all body fluids, excretions, secretions
- hand hygiene,
- PPE- gowns, gloves, masks, protective eye wear
- safe injection procedures,
- safe handling of potentially contaminated equipment or surfaces
- respiratory hygiene/cough etiquette
56
purpose of placing patients in isolation
to prevent the spread of infections or potentially infectious MO to health personnel, clients, visitors
57
tier 2 - transmission based precautions (3)
1. airborne
2. droplet
3. contact
58
airborne isolation is used when... (and examples-3)
-clients known to have orsuspected of having serious illness transmitted by airborn drolet nuclei smaller than 5 microns
(measles, varicella, TB)
59
droplet isolation is used when...(and examples-7)
-patients known to have or suspected of having serious illess transmittied by particle droplets larger than 5 microns
(Diphtheria, mycoplasma pneumonia, ertussis, mumps, rubella, strep oharyngitis, scarlet fever)
60
contact isolation is used when...(and examples-4)
-patients known to have or suspected of having serious illnesses easily transmitted by direct client contact or contact with item in the clients environment
(C diff, shigella, hepatitis A, MRSA)
61
Risk for infection is the diagnostic label because...
problems assocaited with the transmission of MO; MUST identify risk factors
62
risk for inadequate primary defenses R/T...5
- broken skin,
- traumatized tissue,
- decreased ciliary action,
- stasis of body fluids,
- change in pH of secretions
63
risk for inadequate secondary defenses R/T...4
- leukopenia
- immunosuppression
- decreased hemoglobin
- suppressed inflammatory response
64
PPE and delegation to the tech
Health care members are accountable for proper implementation of these procedures
65
ways bacteria can cause infection
most common infection causing microorganisms;
| transported through air, water, food, soil, body tissues, fluids
66
ways viruses can cause infection
consist primarily of nucleic acid and must enter living cells in order to reproduce
67
types of fungi that can cause infection
yeast and molds; low pH of the vagina inhibits growth of many MO
68
1 normal flora in the vagina
candida albicans
69
types of parasites that can pass infections
live on other living organisms; ticks, fleas, mites
70
goal of Therapeutic sitz bath
soothe irritated skin or treat an area such as the perineum; taken in a tub 1/3 or ½ full of water; client remains in the bath for designated time (normally 20-30 min)
71
Foot care for the diabetic patient
diabetic pts have extremely dry skin; tell them to use a nonperfumed lotion and to avoid putting lotion between the toes; advise to not soak their feet in water because it is drying to the skin
72
Hearing aide care
remove the hearing aide, turn it off, remove the earmold, soak it in mild soapy solution, rise and dry well, check to make sure the ear mold is open and remove any moisture, reattach earmold to hearing aide and reinsert
73
Shaving a patient
wear gloves, apply shaving cream, hold skin taut, hold razor at 45 degree angle and shave in firm strokes in the direction of hair growth, after its all shaved wipe the cleints face with wet washcloth, dry the face well, put lotion on if client desires
74
Handling dentures
clean them 1 time a day; remove them from the mouth, scrub them with a toothbrush , rinse them and then reinsert into pt mouth
75
Contact lenses care
make sure the correct lenses gets placed into the right slot on contact case and use a new solution every time you soak contacts
76
when handling patients with abrasions
Keep wound clean
Don’t wear rings
Lift do not pull client across bed
Use two or more people for assistance
77
when handling patients with excessive dryness
Prone to infection; provide alcohol free lotions
Bathe client less frequently use no soap and rinse thoroughly
Encourage increased fluid intake
78
when handling patients with ammonia dermatitis (diaper rash)
keep skin dry and clean by applying protective ointment
| Boil an infants diapers or wash them with antibacterial detergent
79
when handing a patient with acne
Keep skin clean
| treatments vary
80
when handling patients with Erythema
Wash area carefully to remove excess micros
| Apply antiseptic spray or lotion to prevent itching
81
when handling patients with hirsutism
Remove unwanted hair (because of excessive growth of body hair)
Enhance clients self concept
82
define Alopecia
hair loss
83
Ticks that are found in hair are...
small gray brown parasites that bite into tissue and suck blood and transmit several disease to people in particular Rocky Mountain fever , Lyme disease and tularemia
84
Pediculosis
infestation of lice
85
Pediculus capitis
found on scalp and tends to stay hidden in hairs
86
Pediculus corporis
- tends to cling to clothing so that when a client undressed --the lice may not be evidence on the body
- The person habitually scratches
- There are scratches on the skin
- There are hemorrhagic spots on the skin where the lice have sucked blood.
87
Scabies
a contagious skin infestation by the itch mite.
88
Self care deficit R/T (4)
- Bathing self care deficit
- Dressing self care deficit
- Toileting self care deficit
- Feeding self care deficit
89
Deficient knowledge R/T (4)
- Lack of experience with skin condition and need to prevent secondary infection
- New therapeutic regimen and manage skin problems
- Lack of experience in providing hygiene care to dependent person
- Unfamiliarity with devices available to facilitate sitting on or rising from toilet
90
Situational low self esteem R/T (6)
- developmental changes
- functional impairment
- loss (body part, memory, cognitive impairment)
- social role changes
- failures, rejections, lack of recognition
- behavior inconsistent with values
91
Bathing self care deficit (foot care) R/T (3)
- Visual impairment
- Impaired hand coordination
- Other related or contributing factors
92
Risk for impaired skin integrity R/T (2)
- Altered tissue perfusion; peripheral (associated with edema, inadequate arterial circulation)
- Poorly fitting shoes
93
Risk for infection [on feet] (2)
- Impaired skin integrity (ingrown toenail, corn, trauma)
| - Deficit nail or foot care
94
Deficient knowledge (diabetic foot care) (2)
- Lack of teaching/ learning activities about diabetic foot care
- Newly established medical diagnosis and necessary foot hygiene practices
95
Risk for infection around the nail bed R/T (2)
Impaired skin integrity of cuticles
| Altered peripheral circulation
96
Impaired oral mucous membrane R/T
Deficient knowledge
97
Dressing self care deficit R/T (5)
- Activity intolerance
- Imposed immobility (bed rest(
- Pain in upper extremities
- Altered level of consciousness
- Lack of motivation associated with depression
98
Impaired skin integrity R/T (3)
- Pruritus secondary to scabies
- Pruritus secondary to head lice
- Insect bite
99
Risk for infection [on the head] R/T (2)
Scalp laceration
| Insect bite
100
Disturbed body image R/T (5)
- biophysical (illness, trauma, injury)
- illness treatment, dependence on machine
- psychosocial
- cultural/spiritual
- cognitive/perceptual
- developmental changes
101
Risk for infection [in the eyes] R/T (2)
Improper contact lens hygiene
| Accumulation of secretions on eyelids
102
Risk for injury [in the eyes] R/T (2)
Prolonged wearing of contact lenses
| Absence of blink reflex associated with unconsciousness
103
the RN can delegate hygiene tasks EXCEPT
diabetic foot care
104
3 diagnostic testing phases
1. pretest - focus is client preparation
2. intratest - focus is specimen collection and performing/assisting with diagnostic tests
3. post-test - focus is nursing care of the client, monitoring, follow-up, and observations (compare results with previous tests, report results to team members)
105
lab tests for heart failure (4)
- CK (creatine kinase)-enzyme found in heart and skeletal muscles
- Myoglobin- early marker for muscle damage in MI
- Troponin I- detects small infarct, myocardial injury
- Troponin T- detects acute MI, unstable angina, myocarditis
106
what kind of technique is used to collect specimens?
aseptic technique
107
guaiac test is used for...
occult blood; aka; can be readily performed by the nurse in the clinical area; guaiac paper is used in the test is sensitive to fecal blood content
108
steatorrhea
excessive amount of fat in the stool
109
when handling bedpan and transferring specimen—use _______ technique
aseptic
110
2 types of fecal occult blood testing
```
guiac test (hemoccult)
flushable reagent pads-detect presymptomatic occult bleeding caused by gastrointestinal diseases; no handling of stool
```
111
3 purposes of time urine
- assess the ability of the kidney to concentrate and dilute urine
- determine disorders of glucose metabolism—diabetes
- determine levels of specific constituents
112
echocardiogram
a noninvasive test that uses ultrasound to visualize structures of the heart and evaluate left ventricular function; let client know that the test causes no discomfort
113
cystoscopy
bladder, ureteral orifices, and urethra can be directly visualized using a cystoscope, a lighted instrument inserted through the urethra
114
Lumbar Puncture: (LP, spinal tap)
cerebrospinal fluid is withdrawn through a needle inserted into the subrachnoid space of the spinal canal between the edge of the bed or examining table; the back is arched increasing the spaces between the vertebrae so that the spinal needle can be inserted readily
115
manometer
a glass or plastic tube calibrated in millimeters; doctors use this when taking a reading or pressure
116
Abdominal Paracentesis
carried out to obtain a fluid specimen for lab study and to relieve pressure on the abdominal organs due to the presence of excess fluid; use sterile technique; common site is midway between the umbilicus and the symphysis pubis on the midline;
117
ascites
a large amount of fluid accumulates in the abdominal cavity; normal ascetic fluid is serous clear and light yellow in color
118
magnetic resonance imaging: aka MRI
noninvasive diagnostic scanning technique in which the client is place in a magnetic field; provides a better contrast between normal and abnormal tissue than the CT scan; used for visualization of the brain, spine, limbs and joints, heart, blood vessels, abdomen, and pelvis
119
barium enema
when examing the lower GI tract, client is given this enema
120
risk factors for pressure ulcers (9)
- friction/shearing
- immobility
- inadequate nutrition
- fecal/urinary incontinence
- decreased mental status
- diminished sensation
- excessive body heat
- advanced age
- chronic medical conditions
121
characteristics of STAGE 1 pressure ulcer
nonblanchable erythema
localized area of redness over a bony prominence
area may be painful, firm, soft, warmer, or cooler
122
characteristics of STAGE 2 pressure ulcer
partial thickness loss of dermis
shallow open ulcer
red-pink wound bed NO slough
intact open/ruptured, serum-filled blister
shiny/dry shallow ulcer
(NOT used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation)
123
characteristics of STAGE 3 pressure ulcer
```
full thickness tissue loss
subcutaneous fat may be visible
bone, tendon, or muscle NOT exposed
slough may be present but NOT obscure the depth of tissue loss
*depth varies on anatomical location
```
124
characteristics of STAGE 4 pressure ulcer
```
full thickness tissue loss
EXPOSED bone, tendon, or muscle
slough, ESCHAR may be present on some parts of wound bed
undermining and tunneling
*depth varies on anatomical location
```
125
characteristics of an UNSTAGEABLE pressure ulcer
full thickness tissue loss
base of ulcer is COVERED by slough/eschar in wound bed
***UNTIL enough slough and/or eschar is removed to expose the base of the wound, true depth and stage CANNOT be determined
126
National patient safety goal regarding pressure ulcers
patient safety in prevention of health care associated pressure ulcers
127
Etiology of pressure ulcers
Due to localized ischemia which is a deficiency of blood supply to the tissue
128
reactive hyperemia
skin takes on a bright red flush
129
3 types of would healing
- primary - tissue surfaces/edges are approximated and minimal or no tissue loss (closed surgical incision, use of a liquid glue to seal clean laceration)
- secondary - extensive tissue loss and tissue edges CANNOT or should not be approximated (greater scarring)
- tertiary - AKA delayed primary intention - wounds remain 3-5 days open for purpose of draining exudate, resolution of infection or edema, then closed/approximated with sutures
130
prolonged use of ___ may make a person susceptible to wound infection by resistant organisms
antibiotics
131
2 drugs that interfere with healing
Anti-inflammatory drugs (steroids and aspirin)
| antineoplastic agents
132
dehiscence
partial or total rupturing of a sutured wound (4 to 5 days postop);
involves an ab wound in which the layer below the skin separate;
Need to support with a large sterile dressing soaked with sterile normal saline;
sudden straining such as coughing or sneezing causes this to happen
133
evisceration
(organs protruding from open wound):
| protrusion of the internal viscera through an incision
134
3 phases of would healing
1. inflammatory (begins immediately after injury and continues for 3-6 days) involves hemostasis and phagocytosis
2. proliferative (begins 3rd/4th day and continues through 21st day) collagen forms, granulation tissue forms
3. maturation (begins 21st day and may continue up to 2 years) collagen organizes, strengthening the scar
135
3 different colors of wounds
1. red (protecting)
2. yellow (skin is broken-needs dressing)
3. black(needs debridement)
136
3 phases of perioperative nursing
1. preoperative - assessing client
Identifying potential or actual health problems
Planning specific care based on the individual needs
Providing preoperative teaching
2. intraoperative - Safety
Maintaining an aseptic environment
Ensuring proper functioning of equipment
Providing surgical team with instruments and supplies needed
3. postoperative - Assessing clients response to surgery
Performing interventions to facilitate healing and prevent complicating
Teaching and providing support to the client
Planning for home care
137
The client is a chronic carrier of infection. To prevent the spread of infection to other clients or other health care providers, the nurse emphasizes interventions that...
Block the portal of exit from the reservoir
138
The most effective nursing action for controlling the spread of infection
Thorough hand hygiene
139
When caring for a single client during one shift, it is appropriate for the nurse to reuse only the PPE
Goggles
140
The nurse determines that a field remains sterile if...
Sterile items are 2 inches from the edge of the field
141
The client is unresponsive and requires total care by the nursing staff. The assessment of ___ does the nurse check first before providing special oral care to the client?
Gag reflex
142
The client is in surgery and will be returning to his bed via stretcher. The ___ bed option reflects that the nurse approximately planned ahead for this client?
Surgical bed in high position
143
The nurse is observing the UAP perform peri care for a client. ___ indicates that the nurse need to discuss additional teaching?
Does not retract the foreskin
144
The nurse is discussing foot care with a client who was recently diagnosed with diabetes. The statement ___ by the client indicates a need for further teaching?
"I enjoy walking barefoot around the house"
145
The client is complaining of SOB. Respirations are 28 and labored. The bed is currently in the flat position. The tech puts the bed in ___ position
Fowlers
146
A 78 year old make needs to compete w 24 hour urine specimen. In planning his care, the nurse realizes that ___ measure is important?
Place a sign stating "save all urine" in the bathroom
147
The noninvasive procedure that provides information about the physiology or function of an organ
Nuclear scan
148
When assisting with a bone marrow biopsy, the nurse should take __ action
Assess for bleeding and hematoma formation for several days after the procedure
149
The NP requests a blood test to determine how well a client has controlled her diabetes the past 3 months this. What blood test proves this?
Glycosylated hemoglobin
150
A primary care provider is going to perform a thoracentesis. The nurses role will include
Position the client in a seated position with elbows on the overhead table
151
Your client has a Braden score scale of 17. What is an appropriate nursing action?
Implement a turning schedule; the client is at increased risk of skin breakdown
152
Proper technique for performing a wound culture includes ___
Cleansing the wound prior to obtaining the specimen
153
A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with ___ dressing
Hydrocolloid
154
What is false about this statement:
| If a person cannot turn themselves in bed, someone should help the person change position q4 hours.
Should be q2 hours
155
An appropriate RN Dx for a client with large areas of skin exocriation resulting from scratching an allergic rash is
Impaired skin integrity
156
A client who is having a mastectomy expresses sadness about losing her breast. Based on this info, the RN would identify that the client is at risk for __ RN Dx
Grieving
157
The RN assesses a postOP client who has a rapid, weak pulse; urine output is less than 30 mL/hr; and decreased BP. The clients skin is cool and clammy. What complication should the RN suspect
Hypovolemic shock
158
The client is most likely to require the greatest amount of analgesia for pain during ___ period
12-36 hours post surgery
159
A semi-conscious client in the PACU is experiencing dyspnea. What action should the RN perform first
Reposition the client to keep the tongue forward
