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CNUR 103 > Units 1 & 2: Medical asepsis, Hygiene, Documentation > Flashcards

Units 1 & 2: Medical asepsis, Hygiene, Documentation Flashcards

Body's defenses, Chain of infection, Routes of transmission, PPE, Hygiene components, What and when to document

1
Q

Body’s defenses (2 types and examples)

A

Body’s Specific and Nonspecific Defenses
• Skin and Normal Flora
• Mouth and mucous Membranes
• Inflammation: Acute and Chronic

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2
Q

Chain of infection

A
  1. An infectious agent or pathogen
  2. A reservoir or source for pathogen growth
  3. A portal of exit from the reservoir
  4. Mode of transmission
  5. A portal of entry to the host
  6. A susceptible host
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3
Q

Modes of transmission

A
  • Contact
  • Droplet
  • Airborne
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4
Q

Vector-borne transmission example

A
  • Transmission is through a carrier

* Sources: mosquitoes, mice, skunks

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5
Q

Vehicle-borne Transmission

A
  • Transmission through a contaminated source

* Sources: food, water, medication, IV fluids, or equipment

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6
Q

• Portal(s) of entry

A 
•	Same as portal of exit, but within a susceptible host
•	Common Portals: 
- Mucous Membranes
- Mouth, nose, vagina, rectum
- Breaks in the Skin
- Wounds
- Blood and Body fluid
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7
Q

Infectious agent

A

• Microorganisms: bacteria, virus, fungi, or protozoa
• Can be removed through vigorous scrubbing and antibacterial agents and antiseptics
• Transient flora
• Factors that influence the transmission include:
- Type of organism
- # of organisms present
- Source of transmission and destination
- Size and virulence (better ability to reproduce in different environments) of microorganism
- Colonization = ability to grow

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8
Q

Reservoir

A
  • An environment that supports the microorganism’s life to remain as is or multiply
  • Can be in living and nonliving places
  • Someone could be colonized but not infected
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9
Q

Portal of exit

A

Same as portal of entry

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10
Q

Droplet precaution

A 
•	Larger droplets, >5 microns in size
•	Only travel short distance <1metre
•	Environmental surfaces or objects become contaminated
- Ex) doorknobs, bedside tables
•	Regular mask
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11
Q

Airborne

A

• Microorganisms are <5microns
• Remain suspended in air
• Widely disperse by air current
• Source of exposure is usually inhalation
• Used for
- Tb, open shingles , open chicken pocks
• Full gown, and mask

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12
Q

Contact

A

• Can be either direct or indirect

- Gloves and gowns

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13
Q

5 Moments of Hand Hygiene

A 
•	Before touching a patient
•	Before clean or sterile procedures
•	After body fluid exposure/risk 
•	After touching a patient 
and their environment.
•	Before touching the glove box
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14
Q

Whole person systems

A
  • Indigenous medicine
  • Traditional chinese medicine
  • Ayurveda
  • Homeopathic medicine
  • Naturopathic medicine
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15
Q

Mind-Body systems

A
  • Psychotherapy
  • Biofeedback
  • Art therapy
  • Music therapy
  • Imagery
  • Meditation
  • Yoga
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16
Q

Touch Therapies

A
  • Massage

- Acupressure

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17
Q

Energy therapy

A
  • Prayer
  • Reiki
  • Therapeutic touch and healing touch
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18
Q

Prayer

A
  • Source of strength, tranquility, and restoration

- Performed by client, family member etc.

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19
Q

Reiki

A
  • Japanese healing method used by hcp
  • Caring presence and reflective abilities
  • Chanel energy from his or her body to the chakra system in the client’s body
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20
Q

Therapeutic touch and healing touch

A
  • TT used to decrease anxiety by increasing the relaxation response, accelerating wound healing and decreasing pain
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21
Q

Acupressure

A
  • Traditional Chinese medicine that uses touch (firm pressure with the fingers) to the body pressure points
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22
Q

Massage

A
  • Therapeutic manipulation of the soft tissues of the body by various hand movements
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23
Q

Yoga

A
  • Healing modality for the body, mind, and soul

- Strengthen body awareness

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24
Q

Meditation

A
  • Technique to slow down the mind and to remove psychological stress that comes from rushing and unbidden thoughts and unwanted conclusions
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25
Q

Imagery

A
  • Artwork strategically placed in hospitals and health centers to foster positive client experiences
26
Q

Music therapy

A
  • Effective for all clients in all stages of life
27
Q

Art therapy

A
  • For people who have difficulty expressing feelings and emotions
  • Self-expression through writing, sculpting, music
28
Q

Biofeedback

A
  • Client-guided treatment that alerts the client to biologic cues (pulse rate, respirations, temperature, muscle tension)
29
Q

Psychotherapy

A
  • Many techniques to promote healing
  • Hypnosis
  • Relaxation therapy
30
Q

Naturopathic medicine

A
  • Healing is integral to living organisms and that heao8hgninvolves a restoration to equilibrium that can be done by self-healing and or/ with the help of others
31
Q

Homeopathic medicine

A
  • Treats the whole person by matching remedies to the individual
32
Q

Ayurveda

A
  • A Sanskrit word defined as the science of life and longevity
  • The focus of Ayurveda medicine is on having a heathy body and mind to cope with everyday stresses
33
Q

Traditional Chinese medicine

A
  • Centers on beliefs about the body’s state of unbalance in terms of qi, yin and yang, five elements and meridians
  • Qigong is an ancient Chinese technique that has become popular in NA
  • It involves the training of the body, breath, voice and mind
34
Q

Indigenous medicine

A
  • Described as healing based on knowledge that involves a holistic approach through interaction with the entire universe, the interrelationships of all living things, and meaningfully lived encounters
  • The medicine wheel is described as an Indg worldview for healing and healthy living
  • Spiritual leaders are people with a special gift
35
Q

4 components of health

A
  • Health promotion
  • Health maintenance
  • Health education
  • Illness prevention, restorative care, and palliation
36
Q

What is documentation?

A
  • Any written or electronically generated information about a patient that escribes the care or services provided to them
    o Confidential
    o Permanent
    o Legal
37
Q

What do nurses document about?

A

o Plans of care
o Assessments
o Care and treatments (interventions)
o Patient outcomes

38
Q

What does the chart’s information include:

A

o Patients health status and needs
o Treatments delivered
o Response to therapies
o Results of diagnostic tests

39
Q

What are the four purposes of documentation?

A
  1. Effective communication
  2. Continuity of care
  3. Proof of safe, professional practice and accountability
  4. Meeting legal, professional, and organizational standards
40
Q

Documentation of assessments

A
  • Objective: Onset, location, description of patient condition (including severity, duration, frequency & precipitating/aggravating/relieving factors)
  • Subjective: - Description of episode/event in patient’s words in quotation marks. Clarity onset, location, description of condition
    o Pain
    o Unwitnessed fall
    o Understanding of patient teaching
  • Patient behaviours:
    Onset, behaviours exhibited, precipitating factors
    o Anxiety
    o Confusion
    o Hostility
41
Q

Documentation of Interventions and evaluation

A

Treatments:
- Time of treatment, description of treatment, equipment used, patient’s response (objective and subjective)
o Bath
o Enema
o Dressing change
Medication Administration
- Time of administration, dose, route, any preliminary assessment, patient response or effect of medication
o Patient states pain to left knee 5/q0/ 650mg acetaminophen given PO
Patient teaching
- Information presented, method of instruction, patient response (including questions and evidence of understanding)
o “discussed with patient the signs and symptoms of infection. Patient stated he understands and repeated some back”
Discharge planning
- Measurable patient goals or expected outcomes, progress towards goals, need for referrals

42
Q

Documentation Guidelines (18)

A
  1. It must be clear, concise, complete, factual, legible, and organized
  2. Not documented, not done
  3. Document only for yourself
  4. Document right after providing care
  5. Be specific; avoid using general statements
  6. Begin each entry with the date and time (use 24 hour clock, eg/ 1445)
  7. End each entry with your signature and designation —————-J. Treleaven, NS
  8. Use black or blue pen only (or red when documenting patient’s temperature)
  9. Only use abbreviations that are approved by your agency
  10. Use exact measurements (mm, cm, mL, etc)
  11. Never chart before you have provided care
  12. Keep charts intact
  13. Communicate where the chart is if you are going to be using it
  14. Ensure you document in the correct patient’s chart
  15. Correct errors by drawing a single line through the error, writing “void” or “error” above it with your initials
  16. Late entries: start with the date and time you are making the entry, then write “Late entry for [time you should have documented],” then continue your entry
  17. Never leave blank spaces
  18. If there is not enough room for your signature and designation, move to the next line
43
Q

Hygiene

A
  • Conditions or practices of cleanliness or care of the body that are conducive to health and wellness.
44
Q

Basic hygienic care that nurses perform:

A

o Bathing & skin care
o Perineal care – genital and anal
o Oral care
o Care of hair and nails

45
Q

Purposes of hygienic care:

A
  • Promote and preserve physical and mental health
  • Provide comfort, safety, and well-being
  • Essential for maintaining skin integrity by promoting circulation and hydration
  • Gives the nurse the opportunity to
    o Discuss health concerns
    o Physically assess
    o Provide patient education
  • Promotes self-care
46
Q

Self-care

A
  • a person’s ability to perform primary care functions in bathing, feeding, toileting, and dressing without the help of others .
47
Q

What are the different types of baths?

A
  • Cleansing

- Therapeutic

48
Q

What are the different types of cleansing baths?

A
  • Complete bed bath – for patients that are confined to bed
  • Partial bed bath – somewhat independent but cannot reach to certain areas, baths washing most important areas
  • Sponge bath at sink – basin or patient sits in chair at sink, help with some areas
  • Tub bath – thorough bath
  • Shower – stand or sit, can be tiring for older patients, patients who just had surgery or IV’s– avoid shower or bath,
  • Disposable bed bath – travel baths, baby wipes
49
Q

What are the different types of therapeutic baths?

A
  • Sitz bath – perineal area, cleanses, reduces pain and inflammation
  • Medicated bath
50
Q

What is the assessment involved in Hygiene?

A
  • Safety of room – any spills, tubes?
  • Patient’s fall risk status – should stay in chair?
  • Patient’s tolerance for bathing – are they in pain?
  • Cognitive functioning – physically able?
  • Visual status, sitting ability, ROM of extremities
  • Presence of external medical devices or equipment – do they have a catheter?
  • Bathing preferences – how often, what time of day, special products?
  • Ask re: skin problems
  • Conditions of skin – assess skin, dryness, flakiness?
  • Risks for skin impairment – old age, immobility, drainage, poor nutrition, hydration
51
Q

Perineal and “Peri” Care

A
  • Cleaning of the patient’s external genitalia and surrounding skin
  • Done during complete bed bath
  • May need to be done more frequently for patients with:
    o Fecal or urinary incontinence
    o Indwelling urinary catheter
    o Recent genital or rectal surgery
  • Always wear clean gloves
  • Act in a professional, sensitive manner and provide privacy
  • Wash from cleanest to less clean or dirty areas
52
Q

Oral Care

A
  • Involves brushing, flossing, rinsing, and denture care
  • Nurses responsibly
  • Frequency depends on the patient’s condition – OD, hs or after every meal
  • Benefits:
    o Prevent and control oral disease or infection
    o Promote comfort
    o Make swallowing easier= better food intake
    o Improve verbal communication
53
Q

Oral care assessment

A
  • Safety of room
  • Inspection of oral cavity (lips, teeth, buccal mucosa, gums, palate, and tongue) – integrity of oral cavity
  • Identify common oral problems (dental cavities, gingivitis, periodontitis (gaps b/w teeth), halitosis (bad breath), cheilosis (cracking lips), stomatitis, mucositis (inflammation of mucous membranes), thrush)
  • Identify the patient’s risks for oral hygiene problems – NPO, chemo, radiation, feeding tubes, NG tubes
  • Determine the patient’s regular oral care practices – how often brush, preferred toothpaste, last trip to dentist
  • Assess the patient’s ability to perform oral care – total independent? Need encouragement?
54
Q

Principles and Guidelines of tub baths

A
  1. Clean skin regularly and at time of soiling
  2. Maintain privacy and comfort at all times
  3. When washing, use strokes from distal to proximal and avoid force or friction
    a. Helps with venous blood flow
  4. Accommodate the patient’s preferences and culture
  5. Consider the patient’s normal hygiene routines
  6. Involve family members when possible
  7. Keep personal hygiene care items within the patient’s reach
  8. Use clean gloves when in contact with nonintact skin, mucous membranes, drainage, secretions, excretions, or blood
  9. Always perform hygiene measures moving from cleanest to less clean or dirty areas
  10. Test water temperature to prevent burn injuries
  11. Use principles of body mechanics and safe patient handling
  12. Bathing patients with dementia may present challenges; focus on preserving the patient’s dignity and emphasizing comfort, safety, autonomy, and self-esteem
  13. Assess and evaluate the patient before and after hygienic care and document it
55
Q

For unconscious patient: Oral care

A 
-	Increased risk for
o	Alterations of oral cavity 
o	Infection – plague formation, saliva production decreased 
o	Aspiration
-	Assess for gag reflex
-	Place patient in side-lying position
-	Use oropharyngeal suction 
-	Keep oral cavity moist
56
Q

Hair care

A
  • Includes shampooing, brushing, combing and shaving
  • Proper hair care is important to body image
  • Shaving: disposable or electric razor, mustache or beard care
  • Shampooing, tub bath/shower, shampoo board, or disposable shampoo cap
  • Cultural sensitivities
57
Q

Nail and foot care

A
  • Important for prevention of infection, odors, pain, and soft tissue injury
  • Increased risks for patients with:
    o Diabetes
    o Peripheral vascular disease
  • Best done during daily bath
  • Assess condition of extremities for:
    o Dryness, inflammation, cracking
    o Between toes and fingers and soles
    o Circulation: skin color, temperature, peripheral pulses, capillary refill
58
Q

Foot care for patients with diabetes or peripheral vascular disease – have reduced blood flow to feet

A
  1. Inspect feet daily
  2. Cleanse with warm water and gentle soap
  3. Do not soak feet
  4. Thoroughly dry feet, especially between toes
  5. Apply lotion only to the tops and bottom of feet, not between toes
  6. Trip toenails straight across, not too short, and file edges
59
Q

Documentation of Hygienic Care

A
  • What you did
  • Level of assistance provided
  • What you assessed (and if abnormal findings were found, what you did as a result)
  • Patient’s response (how they tolerated it)
  • Patient teaching you provided
  • Any other interventions you did
  • Safety practices
60
Q

Elimination of fecal matter

A
  • Terms: feces/stool, defecation, flatus (gas), flatulence (back up of gases)
  • Affected by lifestyle, intake, medications, functional status, chronic conditions
  • Normal assessment findings:
    o Brown and soft but formed (b/c of bilirubin)
    o Soft (type 4)
    o Passing flatus
  • Abnormal: diarrhea, constipation
  • Use of toilet, commode, or bedpan
  • Documentation: bowel care record
    o Would use, sm., medium, lg
    o Colour
    o Treatments
    o Soft, hard?
61
Q

Urinary elimination

A
  • Terms: micturition (to pee), voiding (pee = void)
  • Normal assessment findings:
    o Greater than 30ml/hr
    o Clear and amber-colored
    o Faint smell
  • Use of toilet, commode (toilet like seat), bedpan (restricted to bed), or urinal
  • Documentation in Clinical A Form and Nurses notes

CNUR 103 (11 decks)

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