Semester One - Safety And Protection Flashcards
What does the ADPIE nursing process consist of?
- ASSESSMENT: noticing reflecting in action.
- DIAGNOSIS: interpreting reflecting in action.
- PLANNING: reflecting in action.
- IMPLEMENTATION: responding reflection in action.
- EVALUATION: reflecting on action.
How can a nurse gather clinical information? And from where?
- observations - what you see, hear, smell, touch.
- interview/Assessment
- physical examination
This is from the client or secondary sources such as family members, significant others, medical records, diagnostic assessments and procedures.
What is hypersensitivity?
Innapropriate excessive immune response.
What is autoimmunity?
An innpropriate immune response to self.
What is alloimmunity?
An immune response to foreign antigens from the same species. For example, can occur after allograph (transplant of body tissue) or allotransfusion (plasma, immunoglobulin, plasma products)
In manual handling, what does LITE stand for and what does it mean?
LOAD: patient charactaristics that can effect handling risk. Age, gender, diagnosis, dependency, neurological status, size, weight, ability to co-operate, fall risk.
INDIVIDUAL: capabilities of the carer. Language, education, physical limitations, stress, fatigue.
TASK: the nature of the task. What, how and when.
ENVIRONMENT: the working environment. Facilities, staff levels, culture, resources.
What is the gauge of the needle?
The diameter of the needle.
The bigger the gauge number, the bigger the needle. True or false?
False. The smaller the gauge number, the bigger the needle. Eg. 23 gauge needle is smaller than a 16 gauge needle.
What unit are needles measured in?
Inches.
Where is a subcutaneous injection administered?
Injected beneath the epidermis into fat and connective tissue underlying the dermis.
Why would the intramuscular injection route be used?
This route is used when medication is needed quickly. Muscles have rich blood flow meaning rapid absorption of medication.
What are the four sites for IM injections?
- Ventrogluteal site (hip/side/bum) THIS IS THE SAFEST SITE
- Dorsogluteal site (buttocks)
- Deltoid site (upper arm)
- Vastus Lateralis (thigh) this is where babies usually get IM injections.
How much adrenaline would you give to an adult for anaphylaxis? How often can you give this dose?
0.5ml . Can repeat this at 5 to 15 minute intervals to a max dose of three doses.
What does lymph fluid contain?
Lymphocytes, macrophages, antigens and a collection of excess fluid from the body.
Where are antigens killed when collected by the lymph fluid?
The lymph nodes.
Where does lymph fluid go once it leave the lymph node?
It leaves the node then travels to the superior vena cava where it empties in to the circulatory system.
Anaphylaxis is an immediate hypersensitive immune response true or false?
True.
During anaphylaxis, IgE bind to mast cells and basophils. The mast cells then explode which leads to a release in histamine and heparin. Following this, leukotrienes and prostaglandins are relseased causing what?
- vasodilation
- increased capillary permeability
- hives
- respiratory distress
- fluid shift
- vascular collapse, systemic shock and death
What are some symptoms of lymphoedema?
Whenever normal lymph drainage is disturbed, swelling may occur.
- Swelling, weakness, aching and pain in affected arm
- Feeling of fullness or tightness in limb
During anaphylaxis, what effects should the administration of adrenaline have?
- Prevents (or relieves) – laryngeal oedema, circulatory collapse, release of histamine and other mediators.
- Provides bronchodilation (SYMPATHETIC)
Which two cells are activated during an autoimmune disease?
B or T cells become activated against self-antigens –this is the basis of autoimmune disease.
Which cells are activated during alloimmunity?
- Immune responses are mediated by T lymphocytes
- CD4 (T helper cells) are the main cells in the rejection of transplanted tissue or transfusion.
What are the most common ways for HIV to be aquired?
- unprotected sex (including anal and oral sex),
- contaminated blood transfusions
- hypodermic needles
- mother to child during pregnancy, delivery, or breastfeeding