Test 1 Flashcards
Goal of asepsis
- Protect yourself
2. Protect your patient
Bacteria
Most common infectious agent
Virus
Cannot use “antibiotics” for treatment
Fungi
Can be normal flora; problem for immunosuppressed pt’s (mold)
Parasite types
- Endoparasites: in your body
2. Ectoparasites: outside of you
Common Portals of Exit
- Respiratory
- Gastrointestinal
- Genitourinary tracts
- Breaks in skin
- Blood and tissue
Modes of Transmission
- Contact route (direct or indirect)
- Vehicle route (food, water, blood, equipment)
- Airborne route
- Droplets (close contact or touching infected objects)
- Vectors (mosquito, tick, flea)
Stages of Infection
- Incubation period
- Prodromal stage
- Full stage of illness
- Convalescent period
Incubation period
Organisms growing and multiplying (no symptoms)
Prodromal stage
Person is most infectious, vague and nonspecific signs of disease; most contagious
Full stage of illness
Presence of specific signs and symptoms of disease
Convalescent period
Recovery from the infection
Normal Body Defenses
- Nasal passages
- Skin/mucous membrane
Skull/Spinal column - GU Tract
- GI Tract
Types of normal flora
- Transient
2. Resident
Transient
Bacteria that can be washed off, not permanent
Resident
Stays in//on your body, cannot be removed easily
Body’s Defense Against Infection
- Body’s normal floral
- Inflammatory response
- Immune response
Inflammatory response
Localized response to injury or infection
Immune response
Antibody response to specific antigen
Natural immunization
After getting the virus you would be immune the next time
Acquired immunization
Getting the vaccine
Cardinal Signs of Acute Infection
- Redness
- Heat
- Swelling
- Pain
Lab data indicating infection
- WBC (normal is 5,000-10,000/mm3
2. Positive culture (presence of pathogen in urine, blood, sputum)
Nosocomial infection
Infections associated with the delivery of health care (pt’s or health care workers)
Common nosocomial infections
- Urinary tract infections
- Surgical site infections
- Bloodstream infections
- Pneumonia
Standard precautions
- Wash hands
2. Wear gloves for any contact with body fluids
When do you use a mask
During spinal procedures, protects against meningitis specifically
PPE (personal protective equipment)
- Gloves
- Gowns
- Masks
- Protective eyewear
PPE for airborne
N-95 respirator and negative pressure room
Common airborne diseases
- Tuberculosis
- Measles
- Chickenpox
PPE for droplet
Mask, no N-95 respirator, no negative pressure room, private room
Common droplet diseases
- Influenza
- Whooping cough
- Mumps
- Meningitis
PPE for contact
Gown and gloves
Drug resistant organisms
- MRSA
- VRE
- C. diff.
Protective Isolation AKA
Neutropenic precautions
Protective Isolation precautions
- Positive pressure room
- No carpet
- No flowers
- Pt’s wear N-95 respirator when transporting
Aseptic Technique
Includes all activities to prevent or break the chain of infection
Categories of aseptic technique
- Medical asepsis (clean technique)
2. Surgical asepsis (sterile technique)
Medical asepsis
Things are assumed clean unless proven dirty
Surgical asepsis
Things are assumed dirty until proven clean
Rules for surgical asepsis
- Don’t touch anything not sterile
- Don’t reach over sterile field
- Hands above waist
- Do not turn back on sterile field
- Peel open packages away from you and drop items
- Pour liquids carefully
Communication
Interchange of information or thoughts
Levels of communication
- Intrapersonal: Self-talk
- Interpersonal: Two or more people
- Group: Small group
Forms of communication
- Verbal: Spoken, written
2. Nonverbal: Body language
Things that influence/effect communication
- Developmental level
- Gender
- Values
- Environment
Types of proxemity
- Intimate zone (0-18 inch)
- Personal zone (18in-4ft)
- Social zone (4-12 ft)
- Public zone (12-25 ft)
Helping relationship
- Not spontaneous
- Unequal sharing of info
- Nurse is helper, pt is being helped
- Used to establish rapport and helping-trust relationships
Social relationship
- Spontaneous
- Equal sharing of info
- Both people’s roles are equal
- Used to establish rapport and trust
Phases of the helping relationship
- Orientation phase
- Working phase
- Termination phase
Orientation phase
- Introductions
- Clarify roles (I am you SN…)
- Establish agreement about the relationship
- Orient pt to the health care system
Working phase
- Work together to meet pt’s needs
- Provide assistance to meet goals
- Provide teaching and counseling
Termination phase
- Examine goals
- Make suggestions for the future
- Encourage pt’s to express emotions about the termination
- Help pt establish a helping relationship with another nurse
- Assist pt in transferring
Therapeutic interviewing questions
- Open-ended questions
- Closed questions
- Validating questions
- Clarifying questions or comments
- Reflective questions or comments
- Sequencing questions or comments
- Directing questions or comments
Types of nursing notes
- Narrative
2. Flowsheet
Narrative
Uses sentences to describe the pt’s progress and what just happened
Flowsheet
Uses checklists and is usually electronic, only charts significant findings or exceptions to the norm (charting by exception)
HIPPA stands for
Health Insurance Portability and Accountability Act
Drug/medication
Any substance that modifies the body functions when ingested
Examples of drug/medications that you wouldn’t think of
- Over the counter meds
- Herbal supplements
- Marijuana
- Caffeine
- OXYGEN
- Alcohol
Chemical name
Identifies drug’s atomic and molecular structure
Generic name
Assigned by the manufacturer that first develops the drug
Official name
Name by which the drug is identified in official publications. (usually generic name)
Trade name
Brand name copyrighted by the company that sells the drug
Pharmacodynamics
Process by which drugs alter cell physiology and affect the body
Types of parenteral medication injections
- Subcutaneous injection
- Intramuscular injection
- Intradermal injection
- Intravenous injection
Types of medication orders
- Standing order: Carried out until cancelled by another order
- PRN: As needed
- Single or one-time
- Stat: Carried out immediately
Parts of the Medication Order
- Patient’s name
- Date and time order is written
- Name of drug
- Dosage of drug
- Route of drug
- Frequency of administration
- Signature of person writing the order
MAR
Medical administration record; list of medication of a pt
Where do you open a unit dose
At the bedside
- So you don’t mix up
- If pt refuses
5 rights of medication administration
Right:
- Medication
- Patient
- Dosage
- Route
- Time
3 checks of medication administration
- When nurse reaches for medication
- After retrieval from drawer and compared with MAR/CMAR
- Before giving medication
1 kilogram= ?g
1,000 g
1 gram= ?mg
1,000 mg
1 mg= ?mc
1,000 mc
60 mgs= ?gr
1 grain
1 teaspoon(tsp)= ?mL
5 mL
1 Tablespoon(Tbsp)= ?mL
15 mL
1 ounce= ?mL
30 mL
What is the first identifier when ID’ing a pt
Validate the pt’s name
What is the second identifier when ID’ing a pt
Validate the pt’s ID number, medical record number, or birth date
Adverse drug effects
- Allergic effects (anaphylactic reaction)
- Drug tolerance
- Toxic effect
- Idiosyncratic effect: Wild reaction
- Drug interactions (antagonistic and synergistic effects)
Antagonistic effect
Two meds fight each other off
Synergistic effect
The two meds work even better together
Who can prescribe a narcotic
Some states say only physicians, others allow APN’s (Advanced practice nurse) and PA’s
What extra security measures are taken for narcotics
- Must be locked
- Record must be kept
- Routine counts done
- When another nurse comes, they also count and verify any meds that are discarded (if pt refuses)
What are the nursing responsibilities concerning meds
- Give medication appropriately as ordered
- Know the indication
- Know the drug action
Common high alert medications
- Insulin
2. Anticoagulants
What organs should you assess because of their function before giving meds
- Liver (metabolize meds)
2. Kidneys (eliminate meds)
Liver function tests
- Albumin
- ALT
- AST
- Bilirubin
- Total protein
Renal function tests
- BUN
- Creatinine
- Creatinine clearance
- Albumin
What to do when you give the wrong med
- Check pt
- Notify manager and PCP
- Write description of error
- Complete form used for reporting errors
When is medication reconciliation required
- Shift report
- Admission
- Transfer to another hospital
- Discharge
- Surgery (usually)
Classification of pain based on duration
- Acute
2. Chronic
Sources of pain
- Nocieptive
2. Neuropathic
Types of nocieptive pain
- Cutaneous (skin)
- Somatic
- Visceral
Nocieptive pain
Normal way of interpreting pain; using the pain process
Neuropathic pain
Nerve problem; no actual stimulus
Origins of pain
- Physical
- Psychogenic (unidentified)
- Referred (perceived in an area distant from point of origin)
Pain process
- Transduction
- Transmission
- Perception of pain
- Modulation
Transduction
Activation of pain receptors
Transmission
Conduction along pathways
Perception of pain
Awareness of the characteristics of pain
Modulation
Inhibition or modification of pain
Gate control theory of pain
Small nerves carry pain stimuli to brain, large diameter nerve fibers inhibit pain stimuli; gating mechanism determines the impulses that reach the brain (you can distract from the pain)
Common responses to pain
- Physiologic (sympathetic/parasympathetic)
- Behavioral
- Affective (facial expression)
FLACC pain scale
F: Faces L: Legs A: Activity C: Cry C: Consolability - Used for infants, 0-2 points for each item
When are PO meds evaluated
Within 45-60 minutes of administration
When are IV meds evaluated
Within 15-30 minutes of administration
Analgesic drugs
- Nonopiod analgesics
2. Opiod or narcotic analgesics
Analgesics ladder (what type of pain relief to use first)
- Nonopiod and/or adjuvant
- Opioid and/or nonopiod/adjuvant
- Opiod for severe pain and/or nonopiod/adjuvant
Narcotic side effects
- RESPIRATORY DEPRESSION (can kill)
- Sedation
- Confusion
- Hypotension
- Constipation
Nursing Process
A systematic method that directs the nurse (and patient) in planning and providing care
Steps of the nursing process
- Assessing
- Diagnosing
- Outcome identification and planning
- Implementing
- Evaluating
Characteristics of the Nursing Process
- Systematic
- Dynamic
- Interpersonal
- Outcome oriented
- Universally applicable
Types of data you gather during assessment
- History (subjective)
2. Physical (objective)
Types of nursing assessments
- Initial (comprehensive) assessment
- Focused assessment
- Emergency assessment
- Time lapsed assessment (follow up)
Goal of asssessment
To identify pt needs by
- Take all the data collected
- Cluster it into related categories
Medical diagnosis
A clinical judgment identifying the illness/ disease
Nursing diagnosis
A clinical judgment on a client’s response to actual or potential health problems or life processes
NANDA stands for
North American Nursing Diagnosis Association
What is NANDA
- An approved standardized list of health problems treated by nurses
- Organization meets and revises the list every 2 years
Types of Nursing Diagnoses
- Actual nursing diagnosis
- Risk nursing diagnosis
- Possible nursing diagnosis
- Wellness nursing diagnosis
- Syndrome nursing diagnosis
How do you write a nursing diagnosis
They come in 2 or 3 parts (we use 2)
- First pick best choice from NANDA list (1st part)
- Then add the phrase “related to” RT
- Add the etiology (cause/contributing factor) of the problem (2nd part) (*dont include medical diagnosis!)
- EX. Impaired gas exchange RT mucus in alveoli
Maslow’s hierarchy of human needs (lowest to highest)
- Physiological
- Safety
- Love/belonging
- Esteem
- Self-actualization
Steps in Planning (nursing process)
- Identify overall goal
- Id. how you will measure the goal (outcomes)
- Id. interventions to reach goal
How to document goals (example)
The pt will have improved mobility AS EVIDENCED BY the ability to raise his arm above his head by discharge
- Don’t use vague immeasurable sentences, has to be measured in some way
- Also state a time for this goal to be accomplished by
Nursing Interventions
Any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes
Types of
Nursing Interventions
- Independent (nurse-initiated): Without physician orders
- Dependant (Prescriber-initiated): Initiated by physician
- Collaborative
How to write nursing interventions
- Be specific (who what where…)
- Start with action verb (“administer”)
- Detailed instructions
- Include a time
(Ex. Assess respirations for rate, ease, and depth every shift)