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N321: Nursing Assessment of Clients > Module 3 > Flashcards

Module 3 Flashcards

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1
Q

Difference between Aspesis and Sterile

A

Asepsis means free of harmful microorganisms, but Sterile means free of ALL microorganisms

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2
Q

Chain of Infection

A

-infection steps that can be interrupted to significantly minimize infection chance

Infectious Agent –> Reservoir –> Portal of Exit –> Mean of Transmission–> Portals of Entry –> Susceptible Host

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3
Q

3 Means of Transmission

A
  1. contact
  2. Inhalation
  3. Ingestion
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4
Q

The smallest infectious agents capable of causing an infection are …

A

virus

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5
Q

Stages of Infection

A
  1. Incubation Period
  2. Prodromal Stage
  3. Full Stage of Illness
  4. Covalescenct Period
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6
Q

Incubation Period

A
  • time between invasion and appearance of symptoms of infection (ex: cold is 2 day incubation)
  • does not necessarily mean they are contagious but often are
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7
Q

Prodromal Stage

A
  • persons most infectious stage where they do not realize they are contagious, but early signs and symptoms are present that are vague/nonspecific
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8
Q

Full Stage of Illness

A
  • Also called Acute Phase
  • specific S/S present indicative of local or system infection
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9
Q

Covalescenct Period

A

-recovery period
-still can be infectious

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10
Q

Most infectious stage ?

A

Prodromal

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11
Q

Local infection

A

occurring in one body area

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12
Q

Systemic infection

A

symptoms manifested throughout the entire body

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13
Q

Most contagious infectious disease?

A

Measles

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14
Q

Information on Measles

A

-Agent - Paramyxovirus
-Reservoir - Human
-Portal of Exit - Aerosol
-Mode of transmission - inhalation
-portals of entry - respiratory
-susceptible host - non-immunized persons
-Incubation - 10 to 12 dats with rash in 14 days
- Prodromal - 2-4 days (fever, cough, rash, on mucus membranes)
-full Stage - rash at 14 days post exposure lasting 5-6 days
-Covalescence - recovery 10-14 days after rash develops

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15
Q

Nosocomial Infections

A
  • infection occuring while client is getting health care (ex: UTI from catheter)
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16
Q

Types of Nosocomial infections?

A
  1. Exogenous
  2. Endogenous
  3. Iatrogenic
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17
Q

Exogenous Nosocomial infection

A

causative organism is from people / outside

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18
Q

Endogenous Nosocomial infection

A

causative organism comes from microbial life within the person (natural flora)

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19
Q

Iatrogenic Nosocomial infection

A

results from a treatment or diagnostic procedure (IV line, urinary catheter)

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20
Q

Most common sites of Nosocomial infections

A

-urinary tract
-respiratory tract
-surgical wounds
-traumatic wounds (like burns)
-bloodstream

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21
Q

The Most effective prevention method of nosocomial infections?

A

Hand Washing

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22
Q

Information to remember when washing hands

A

-no fake nails/polish
-clean under nails, between fingers, back of hands, 1 inch above wrist
-keep skin intact and moisturized to prevent drying out and breaking allowing infection
-you can use gel based hand hygiene agents EXCEPT when hands are soiled or dealing with C Diff spores

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23
Q

Information to keep in mind when using PPE

A

-Assess the risk of exposure outside the room to choose PPE, and do it before health care activity
- practice respiratory hygiene/cough etiquette and hand hygiene alongside PPE

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24
Q

Isolation and Barrier Techniques Used in Practice

A
  1. OHSA regulations (legally binding)
  2. CDC guidelines (not legally binding)
  3. Precautions (Standard/Universal, body substance/contact, airborne, droplet)
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25
Q

Universal Precautions

A

used with everyone, person is not necessarily infectious, but every health care worker associated with their care must treat all body fluids as though they are infectious

also called standard precautions

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26
Q

Body Substance/Contact Precautions

A
  • OHSA regulation
    -extension of universal precautions
    -includes blood, blood tinged fluids, and not necessarily infectious things, feces, urine, oral secretions, wound secretions, emesis (vomit), and other body substances
  1. Do not bring gloves into the hallway
  2. wash hands BEFORE leaving patient room
  3. if you might have fluid contact, wear a gown or other PPE
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27
Q

MDRO

A

Multi drug Resistant Organism (MRSA,VRE,VRSA,ESBL)

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28
Q

Airborne Precautions

A

-small size infections spread through the air (like rubeola, varicella, and TB)
-patient goes into a pressure negative room
-staff use N95 respirators
-patients only leave rooms if absolutely necessarily
-patient needs to wear surgical mask if possible

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29
Q

Droplet Precautions

A

-large (>5 microns) particle droplets like rubeolla, mumps, diptheria, adenovirus, child/infant infections
-transport REQUIRES patient to wear mask
-social distancing (3 feet to 6 feet)
-mouth, nose, eye protection may be needed

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30
Q

Disturbing Discovered on Fabric Sanitation (Uniforms)

A
  • 33% of staff do not launder at the correct temp
  • tumble drying recommended
  • some dont clean uniforms after each shift
    -some clean uniforms with other clothing!!
    -pockets and sleeves often are contaminated
    -scrubs with antimicrobial properties DONT help
  • ACS urges no public scrub wearing
  • white coats give a professional look but harbor tons of pathogens
    -white coats are rarely if ever washed
    -MDRO is often carried back into patient care areas
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31
Q

1 in ___ Hospitalized Patients has at least 1 HAI

A

31

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32
Q

__% of patients had one or more HAI

A

3

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33
Q

What parts of worker uniforms increase rate of HAI?

A

-clothing (improper care/sanitation)
-jewelry (rings hold a very large bacterial load)
-watches (significantly higher (3x the amount) of bacteria is found on watches)

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34
Q

____ HAIs a year, ____ deaths due to HAIs

A

687,000 ; 72,000

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35
Q

Joint Commissions main safety goal?

A
  1. patient safety through reduction of HAIs
  2. this will also relieve financial impact (9.8 billion due to HAIs is spent annually)
36
Q

There is a push to leave what parts of healthcare uniforms?

A

-Rings/Jewelry/Neckties/Hair Bands
-White Lab Coats
-Long Sleeve Shirts
-Wrist Watches

37
Q

Clostridioides difficile (C-diff) causes how many illnesses a year in the US? Deaths?

A

half a million illnesses, 100,000 illnesses alone in nursing homes, and 14,000 deaths

38
Q

Who is most susceptible to C. Diff infection?

A

older clients and those taking antibiotics

39
Q

C. difficile colitis

A

infection of C. diff causing scarring in the intestinal tract and decreasing absorption (leading to fluid/electrolyte/nutrient loss)

40
Q

C. diff is a ___

A

spore (commonly residing in the intestinal tract)

41
Q

Reservoirs of C. diff.

A

people and contaminated surface/objects

42
Q

When dealing with C. Diff what must healthcare workers do?

A

Use specific cleaner for objects and surfaces, and you MUST wash your hands since alcohol based hand cleaners will not kill spores

43
Q

Symptoms of a C. Diff infection?

A

watery diarrhea, abdominal cramping, fever, weight loss

44
Q

C. Diff mode of transmission?

A

Fecal or Oral route

45
Q

What is the relationship between C. Diff and Antibiotics?

A
  • when ABO are discontinued, a fifth of cases resolve, but the remaining 4/5 require more antibiotic therapy
  • since ABO kill helpful flora, C diff can grow out of control
    -Moral: Be careful prescribing antibiotics
46
Q

Ways to Prevent C. Diff infection/spread?

A

-Private room for infected patients
-Excellent hand washing
-PPE: gloves, gowns
-cautious ABo prescription
-contact precautions on door
-have cleaning equipment with BLEACH in it

47
Q

Sterilization

A

Destroys all microorganisms and spores

48
Q

Disinfection

A

Destroys all pathogenic organisms except spores

49
Q

Factors determining whether to use Sterilization or Disinfection?

A
  • Organisms nature (infectious or not)
  • Load (amount)
    -equipment type
    -intended equipment use
    -available means of sterilization and disinfection
    -time period
50
Q

Types of Sterilization

A
  1. Physical
    a. Steam - autoclaving
    b. Boiling - doesnt destroy spores/viruses
    c. Dry Heat - not used in healthcare
    d. Radiation - risky to personnel
  2. Chemical
    a. ethylene Oxide gas - toxic to humans (be careful)
    b. Chemical - treated wipes can take care of spores,
    but normal alcohol wipes do not - also can irritate
    skin and lungs
51
Q

Surgical Asepsis

A

elimination of all microoganisms (including pathogens and spores) from object or area

52
Q

Examples of when Surgical Asepsis is used?

A
  • insertion of urinary catheter
    -insertion of IV catheter
    -suctioning the airways
    -reapplying sterile dressings
    -Invasive procedures
    -handling sterile objects
    -opening sterile package and prepping sterile field
    -pouring sterile solutions
    -adding sterile supplies to a sterile field
    -sterile glove donning
53
Q

11 Principles of Surgical Technique (Sterile Field)

A
  1. Surface clean and dry first
  2. do not cough or sneeze over the field
  3. always face the field
  4. below the waist = unsterile
  5. do not reach across the field
  6. keep unsterile objects away, only sterile can touch sterile
  7. 0.5-1 inch border around sterile field is unsterile and OK to touch
    8.check expiration date
  8. protect from excess air currents
  9. handle liquids carefully - if surface is wet the sterile field is contaminated due to capillary action
  10. sterile instruments can have one end sterile and the other end contaminated
54
Q

Latex Allergies

A
  • need to know patient and coworker allergies to latex (always ask)
    -keep latex away from bare skin (webroll used before BP cuff)
    -try to use latex free supplies
    -wear vinyl or synthetic gloves
55
Q

Things containing Latex?

A

-BP cuffs
-Stethoscopes
-Electrode pads
-Tourniquets
-IV tubing
-urinary catheter
-surgical masks
-baby bottle nipples
-pacifiers
-syringes

56
Q

What is body mechanics?

A

-efficient use of the body as a machine and as a means of locomotion

-the the study of proper body movement to prevent and correct posture problems, reduce stress and enhance physical capabilities

57
Q

Body Alignment

A

-arrangement and positioning of the body

-alignment of body parts allows optimal BALANCE and OPERATION and promote physiologic functioning

-avoid undue strain on joints, muscles, tendons, ligaments while balance is maintained

58
Q

Line of Gravity

A

vertical line transecting the body through the center of gravity (can change based on posture)

59
Q

Center of Gravity

A

the center of the pelvis, about midway between the umbilicus and symphysis pubis (AKA: the center of mass)

60
Q

Base of Support

A
  • “Triangle”
  • foundation that provides the object/person’s stability, and the wider it is and the lower the center of gravity - the greater the stability and balance

-spreading feet father apart can widen the “triangle” base

  • think of how a fundamentals course is a base of support for knowledge
61
Q

Movements to Avoid?

A
  1. Twisting the thoracolumber spine
  2. acute flexion of the back when the hips and knees are straight (bending at the waist)
  3. Back movements without device support
62
Q

complications due to poor body mechanics?

A

muscle fatigue
joint strain
lower back injury
repetitive motion injury

63
Q

Most common injury for nurses?

A

back injury

64
Q

How to get proper body mechanics?

A
  1. Erect posture
  2. using the longest and strongest muscles to do activities
  3. when lifting tighten the abs and hold the object/patient as close as possible to the center of gravity
65
Q

Factors for Proper Lifting Technique

A

1.keep feet at least a food apart and keep load close to the body

  1. ask for assistance
  2. use assistive devices
  3. tight abdominal muscles
  4. Use the weight of the body as a force for pulling/pushing, by rocking on feet
  5. slide, roll, push, or pull rather than lift
66
Q

Immobility (in patients) is associated with …

A
  1. Cardiac Changes (decrease in plasma volume and hemoglobin increase then decrease)
  2. Respiratory Changes (decreased rate/ability)
  3. Gastrointestinal Changes (decreased motility, increased constipation)

4.Bone/Joint/Integument/Emotional Changes (calcium loss, thin skin, bed sores, pressure injury, depression)

67
Q

Nursing is concerned with what needs of the individual?

A

Physical and Psychological needs

68
Q

Safety is…

A

the freedom from psychological as well as physical injury

69
Q

Safety and security is comprised of ?

A
  • physical and emotional aspects (free of fear, anxiety, fear of unknown, and maslows needs met)

-hand hygiene and sterile technique

  • proper use of equipment and administration of medications

-use of proper skill and techniques when working with an ambulating clients

70
Q

Factors affecting patient safety?

A
  • health literacy / literacy
  • mobility/lifestyle

-sensory perception

-communication abilities

-health and psychosocial state

71
Q

A nurse should always ask themselves…

A

is this situation safe

72
Q

How to assess the environment for safety?

A

-check door sign (always)

-doorway survey for falls, fires, fluid leaks, hazards, poisoning, choking, joint commission safety goals being fulfilled

73
Q

What to do in a fire?

A

PULL and RACE

Pull, Aim, Squeeze, Sweep extinguisher

Rescue, alarm, confine, evacuate when an alarm is heard

74
Q

Safety Tips involving Electrical Equipment

A
  • do not run wires under carpet

-do not pull plug using the cord, grab by base

  • do not use appliances near water sources

-always remove plugs from outlets before cleaning/maintenance of appliances

  • if someone is shocked, turn off electricity before touching them
75
Q

Fall Risk Factors

A
  • 79+
    -history of falls documented
    -impaired vision or balance
    -altered posture/gait/mobility
    -medication regime
  • postural hypo tension
    -slow reaction time
    -confusion/disorientation
    -unfamiliar environment
76
Q

Measures to prevent falls?

A

orient them to their surroundings

explain call bell

lock all beds, wheelchairs, stretchers

keep bed low with side rails up

keep personal items in reach

eliminate room clutter

adequate lighting

reduce bathroom hazards

maintain clients toileting schedule so they do not try to do it themselves

provide good footwear/traction socks

77
Q

How to prevent falls during hourly rounding?

A
  • Assess pain, need to use the potty, need for repositioning, need for a pump to be taken care of, possessions within reach

-instruct client to seek assistance

-alert other personnel to risk of falling

-restraints (non-preferable)

78
Q

Entrapment

A

death from asphyxiation due to restraints/4 rails

79
Q

Joint commission limitations on restraint use?

A
  • only use if they are a risk to self or others

-use least restrictive form first

  • assessment be done within an hour by medical provider

-remove every 2 hours

-reassessment schedule be made according to age - in order to assess skin integrity

80
Q

What position should the bed be kept?

A

in a low position with wheels locked and a max of 2 side rails up (sicne 4 rails can cause entrapment as a restraint)

81
Q

Have the instructor present during …

A

transfers until they give the OK

82
Q

Remember to use a ___ ___ to transfer/lift a client

A

gait belt

83
Q

Keys to Safety/Security Success

A

F.A.T.

Focused
Aware
Thorough

84
Q

Never Events

A

medical errors that should never occur

85
Q

Acronyms on the DO NOT USE list

A

-U,UI,Q.D.,Q.O.D., trailing zero, lack of leading zero, MS, MSO4

  • Use unit, international unit, daily, every other day, X or 0.X, morphine or magnesium sulfate

*Exception: Trailing zeroes are okay for lab results

86
Q

Order of Donning

A

Hand Hygiene
1. Gown (waist then neck tie)
2.Mask (top then bottom ties)
3. Eye protection
4.Mask/Respirator

87
Q

Order of Doffing

A
  1. Gloves
    Hand Hygiene
    2.Eye protection
  2. gown (waist then neck tie and roll inward)
  3. mask (lower then top tie)
    hand hygiene

N321: Nursing Assessment of Clients (18 decks)

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