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Basic Nursing Skills > Unit 4: Ch. 10,22,28 > Flashcards

Unit 4: Ch. 10,22,28 Flashcards

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1
Q

Define surgical asepsis

A

totally free of microorganisms, including spores

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2
Q

Medical asepsis

A
  • antimicrobial agent used
  • containing
  • handwashing
  • PPE/ isolation
  • clean technique **
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3
Q

Surgical asepsis

A
  • sterilization (physical and chemical)

- surgical hand antisepsis

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4
Q

Sterile techniques

A

practices that avoid contaminating microbe-free items

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5
Q

Autoclave

A

pressure steam sterilizer

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6
Q

Principles of surgical asepsis

A
  • sterile with sterile
  • partially unwrapped packaging is considered unsterile
  • if you question if its sterile, consider it unsterile
  • longer the time = less sterile
  • expiration dates
  • once an item is open its only a matter of time before it is contaminated
  • if item gets wet its contaminated
  • coughing,sneezing, or excessive talking over a sterile field contaminates it
  • dont reach over a sterile field
  • below waist level is considered contaminated
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7
Q

Sterile field

A

work area free of microorganisms

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8
Q

Lipping

A

before use of a sterile solution, pour and discard small amount of liquid from the mouth of the container to wash away airbourne contaminators

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9
Q

Mask

A

wear a mask if there is a risk for coughing or sneezing within a radius of 3 feet

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10
Q

Particulate filter respirator

A

wear if there is a potential for acquiring diseases caused by droplet or airborne transmission

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11
Q

Colonization

A

condition where microorganisms are present but there are no signs or symptoms

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12
Q

Course of infectious diseases

A
  • incubation period
  • prodromal stage
  • acute stage
  • convalescent stage
  • resolution
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13
Q

Incubation period

A

infectious agents reproduces, but there are no signs or symptoms

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14
Q

Prodromal stage

A

initial symptoms appear

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15
Q

Acute stage

A

symptoms become severe and specific to the tissue or organ that is affected

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16
Q

Convalescent stage

A

symptoms subside

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17
Q

Resolution

A

pathogen is destroyed, health is restored

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18
Q

When do we wear PPE?

A

Anytime you are exposed to bodily fluids

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19
Q

Diseases that require isolation

A
  • pulmonary TB
  • measles (rubella)
  • chicken pox (variscella)
  • severe acute respiratory syndrome (SARS)
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20
Q

Transmission based precaution

A
  • isolation precautions
  • airborne
  • droplet
  • contact
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21
Q

Airborne

A
  • private room
  • negative air pressure
  • 6 to 12 air changes per hour
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22
Q

Airborne protection

A
  • follow standard precautions
  • door closed
  • wear PPE
  • N95 mask
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23
Q

Airborne diseases

A
  • pulmonary TB
  • Measles
  • chicken pox
  • SARS
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24
Q

Droplet

A

private room
within 3ft
ciughing sneezing etc

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25
Q

Droplet protection

A
  • follow standard precautions
  • leave door open or closed
  • wear a mask
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26
Q

Droplet diseases

A
  • influenza
  • rubella
  • strep pneumonia
  • meningitis
  • whooping cough
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27
Q

Contact

A

-private room or in a room with similarly infected patients

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28
Q

Contact protection

A
  • standard precautions
  • don gloves before entering
  • handwashing
  • avoid transporting the client
  • have equipment exclusively for that specific pt
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29
Q

Reverse isolation

A
  • use with patients who are immunocompromised
  • standard precautions AND gown, gloves, mask
  • limit visitor contact
  • no sick visitors
  • no fresh plants or flowers
  • no raw or uncooked foods
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30
Q

Providing sensory stimulation

A
  • move bed
  • position pt so that they can look out the window
  • encourage telephone calls
  • converse with pt
  • encourage activity
  • offer wide choice of foods
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31
Q

Early signs of infection in older adults

A

change in behavior or mental status

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32
Q

Visitors in isolation rooms

A
  • plan frequent social contact
  • encourage visitors to come as often as policy allows
  • visitors must follow infection control precautions
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33
Q

Types of drainage

A
  • serous
  • sanguineous
  • serosanguineous
  • purulent
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34
Q

Serous drainage

A
  • mostly clear or slightly yellow

- a bit thicker than water

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35
Q

Serosanguineous drainage

A
  • thin and watery

- pink in color

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36
Q

Sanguineous drainage

A
  • fresh bloody exudate

- bright red, thick

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37
Q

Purulent drainage

A
  • thick with yellow,green, brown color

- foul odor

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38
Q

What type of drainage is a sign of infection?

A

Purulent

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39
Q

Gauze dressing

A
  • made of woven cloth fibers

- ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage

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40
Q

Transparent dressing

A
  • clear acrylic film wound coverings
  • allow nurses to assess wound without removing dressing
  • commonly used to cover peripheral and central intravenous insertion sites
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41
Q

Hydrocolloid, hydrogel, and alginate dressings

A

-self adhesive, opaque, air and water occlusive

keep wound moist

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42
Q

First intention healing

A
  • primary intention
  • wound edges are directly next to each other
  • small amount of scar tissue
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43
Q

Second intention healing

A
  • wound edges are widely separated
  • more time consuming and and complex reparative process
  • conspicuous scar
  • wound care must be performed cautiously
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44
Q

Third intention healing

A
  • wound edges are intentionally left widely separated and later brought together with some kind closure material
  • broad, deep scar
  • extensive drainage and tissue debris
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45
Q

TED hose

A
  • compression stockings
  • must have physician order
  • remove every 8 hours
  • apply after elevating legs for 15 minutes
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46
Q

Drains

A

tubes that provide a means for removing blood and drainage from a wound

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47
Q

Open drains

A
  • flat flexible tubes that empty into a dressing
  • use gravity or capillary action
  • can be shortened by nurse
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48
Q

Closed drains

A
  • tubes that terminate in a receptacle
  • Jackson pratt (PV), hemovac
  • use nonmechanical vacuum or negative pressure
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49
Q

Vacuum assisted closure (VAC)

A
  • wound packed with foam filler and sealed with an occlusive dressing
  • attached to a suction tube and pump
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50
Q

Factors that negatively impact healing

A
  • compromised circulation
  • infection
  • purulent, bloody, or serous fluid accumulation
  • KEY TO WOUND HEALING IS ADEQUATE BLOOD FLOW*
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51
Q

Pressure ulcer

A
  • decubitus ulcer

- wound caused by prolonged capillary compression that impairs circulation to the skin and underlying tissue

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52
Q

Pressure ulcer stage 1

A
  • intact but reddened skin

- skin that remains red when pressure is relieved

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53
Q

Pressure ulcer stage 2

A

pressure ulcer is red and accompanied by blistering or a skin tear

54
Q

Pressure ulcer stage 3

A
  • pressure ulcer has a shallow skin crater that extends to subcutaneous tissue
  • may be accompanied by serous drainage or purulent drainage
55
Q

Signs & symptoms of wound infection

A
  • discharge
  • redness
  • odor
  • hot to the touch
56
Q

Actions for suspected wound dehiscence or evisceration

A
  • position the client to the least strain to the open area

- place sterile dressings moistened with normal saline

57
Q

SALTT method

A
  • size
  • appearance
  • location
  • treatment
  • tolerance
58
Q

hyperendemic infections

A

infections that are highly infectious in all age groups

59
Q

Open wound

A

one in which the surface of or the skin or mucous membrane

60
Q

Closed wound

A

there is no opening in the skin or mucous membrane

61
Q

Incision

A

clean separation of skin and tissue with smooth, even edges

62
Q

Laceration

A

separation of skin and tissue in which the edges are torn and irregular

63
Q

Abrasion

A

surface layers of skin are scraped away

64
Q

Avulsion

A

stripping away of large areas of skin and underlying tissue, leaving cartilage and bone exposed

65
Q

Ulceration

A

shallow crater in which the skin or the mucous membrane is missing

66
Q

Puncture

A

opening of skin, underlying tissue or mucuos membrane caused by a narrow sharp pointed object

67
Q

Contusion

A

injury to soft tissue underlying the skin from the force of contract with a hard object, sometimes called a bruise

68
Q

Proliferation

A

period during which new cells fill and seal a wound

69
Q

Integrity of skin and damaged tissue is restored by

A
  • resolution
  • regeneration
  • scar formation
70
Q

Slough

A

dead tissue on the wound

71
Q

dehiscence

A

separation of wound edges

72
Q

evisceration

A

wound separation with the protrusion of organs

73
Q

montgomery straps

A

strips of tape with eyelets

74
Q

debridement

A

removal of dead tissue

75
Q

undermining

A

erosion of tissue from underneath intact skin

76
Q

Normal white blood cell count

A

5000-10,000

77
Q

Gauze

A

highly absorbent dressing

78
Q

Temp for eye/ear irrigation

A

body temp

79
Q

sharp debridement

A

removal of necrotic tissue with sterile scissors

80
Q

enzymatic debridement

A

use of topically applied chemically substances that break down and liquify wound debris

81
Q

autolytic debridement

A

painless, natural physiologic process that allows body enzymes to soften, liquify, and release devitalized tissue

82
Q

10 microorganisms

A
  • nonpathogens
  • pathogens
  • bacteria
  • viruses
  • fungi
  • rickettsiae
  • protozoans
  • mycoplasmas
  • helmiths
  • prions
83
Q

Virulence

A

how strong a bacteria or virus is

84
Q

Means of transmission

A
  • indirect contact
  • direct contact
  • vehicle
  • vector
  • airborne
  • droplet
85
Q

Antiseptics

A

inhibit the growth but do not kill microorganisms

Ex: alcohol

86
Q

Disinfectants

A

destroy active microorganisms but not spores

Ex: bleach

87
Q

Antimicrobial agents

A

chemicals that destroy or suppress the growth of infectious microorganisms
Ex: antiseptics, disinfectants, anti-infective drugs

88
Q

Antibacterial

A

alter metabolic process of bacteria not viruses

89
Q

Antiviral

A

control viral replication

90
Q

Resident microorganisms

A

nonpathogens constantly present on the skin

91
Q

transient microorganisms

A

pathogens picked up during brief contact with contaminated reservoirs

92
Q

5 moments for hand hygiene

A
  • before touching a patient
  • before clean/aseptic procedure
  • after body fluid exposure risk
  • after touching a patient
  • after touching patient surroundings
93
Q

Surgical hand asepsis

A
  • no jewelry/ watches
  • antibacterial soap
  • 2 to 6 minutes
  • hands held above elbows
  • orange sticks to clean fingernails
  • friction with brush/sponge
  • dry with sterile towels
  • sterile gloves immediately after
94
Q

Concurrent disinfection

A

keeping pt environment clean on a daily basis

95
Q

Standard precautions

A

measures for reducing the risk of microorganism transmission

96
Q

Standard precautions include:

A
  • hand hygiene

- PPE

97
Q

N95

A
  • individually fitted

- can filter particles 1 micron with an efficiency of 95%

98
Q

Powered air purifying respirator

A

-an alternative if a caregiver has not been fitted for an N95 or has facial hair

99
Q

communicable disease

A

transmitted from one source to another by infectious bacteria or viral organisms

100
Q

contagious disease

A

communicable disease that can spread rapidly among others, close proximity

101
Q

community acquired infections

A

those that are not present or incubating prior to health care providers

102
Q

wound

A

damaged skin or soft tissue

103
Q

trauma

A

general term referring to injury

104
Q

Wound repair process

A
  • inflammation
  • proliferation
  • remodeling
105
Q

inflammation

A
  • lasts 2 to 5 days
  • limit local damage
  • remove injured cells and debris
  • prepare wound for healing
106
Q

Proliferation

A
  • period during which new cells fill and seal a wound
  • occurs 2 days to 3 weeks after inflammation phase
  • characterized by the appearance of granulation tissue
107
Q

remodeling

A
  • period in which the wound undergoes changes and maturation
  • may last 6 months to 2 years
108
Q

granulation tissue

A

combo of new blood cells, fibroblasts, and epithelial cells

109
Q

necrotic tissue

A

dry, brown, or black devitalized tissue

110
Q

capillary action

A

movement of a liquid at the point of contact with a solid

111
Q

sutures

A

knotted ties that hold incision together

112
Q

staples

A

wide metal clips

113
Q

Bandage

A

strip or roll of cloth wrapped around a body part

114
Q

Binder

A

type of cloth generally applied to a particular body part like the abdomen or breast

115
Q

Roller bandage principles

A
  • elevate and support limb
  • wrap from distal to proximal direction
  • avoid gaps
  • exert equal tension
  • no wrinkles
  • secure with metal clips
  • check color and sensation of toes and fingers
  • remove for hygiene and replace at least twice a day
116
Q

mechanical debridement

A

physical removal of debris from nonhealing wounds

117
Q

hydrotherapy

A

therapeutic use of water

118
Q

irrigation

A

technique for flushing debris

119
Q

wound irrigation

A
  • before applying new dressing
  • best when granulation tissue has formed
  • surface tissue should be gently removed without disturbing healthy cells
120
Q

eye irrigation

A
  • flushes toxic chemical from eyes

- displaces mucus or other drainage

121
Q

ear irrigation

A
  • removes debris from the ear
  • contraindicated if eardrum is perforated
  • direct solution towards the roof of the auditory canal
  • afterwards loosley place a cotton ball
122
Q

vaginal irrigation

A
  • aka douche
  • cleansing vaginal canal
  • sometimes necessary to treat infection
123
Q

primary goal for wound management

A

reapproximate the tissue to restore its integrity

124
Q

Compresses

A

moist,warm, or cool cloths

125
Q

aquathermia pad

A

an electrical heating or cooling device

126
Q

soak

A

body part is submerged in fluid to provide warmth or to apply a medicated solution

127
Q

pack

A

commercial device for applying moist heat

128
Q

Therapeutic bath

A

those performed for other than hygiene purposes

129
Q

Most common therapeutic bath

A

Sitz bath: soak of the perineal area

130
Q

Decubitis ulcer

A

pressure ulcer

131
Q

locations for pressure ulcers

A
  • sacrum
  • hips
  • heels
  • elbows
  • shoulder blades
  • back of head

Basic Nursing Skills (6 decks)

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