week 3 ati --ch 5 & hw Flashcards
vehicle transmission
transmission from contaminated items to multiple persons
*E.coli on produce
Inflammatory Response Stages
- Bacteria invade an open wound
- Histamine, Kinins, & prostaglandins arrive @ site
- Plasma from blood enters the site
4.Phagocytosis occurs - Pus develops
Stages of Infection
- Incubation Stage–no symptoms
- Prodromal Stage –nonspecific symptoms
3.Acute Illness –specific symptoms - Period of Decline
- Period of Convalescence–feels better
wash hands for how long
15-30 seconds
Preparing a Sterile Field
*flat surface 12-18in away from walls
*items placed in middle (1in border)
*peel flaps away from body–farthest package first
*peel sides 1 at a time
contact precautions
gown & gloves
client in private room
droplet precautions
surgical mask
private room
airborne precautions
respirator mask
private room w door closed
client must wear mask
AIIR room
4 major HAI’s
- central line-associated bloodstream infection
- Catheter associated UTI
- surgical site infection
- ventilator assisted pneumonia’s
Infection Control bundles
guideline for practice to help prevent HAI’s
PPE application order
- gown
- mask
3.goggles - gloves
PPE Removal Order
- gloves
- goggles/shield
- gown
- mask
Obtaining a Throat Culture
*avoid if epiglottis is inflamed
*resuscitation equipment nearby
*wait 1 hr if client ate
1. check for indications of infection
2. gather info
3. client sit upright
4. have client hyperextend neck w/ tongue out saying ‘ah’
5.apply pressure to anterior 3rd of tongue w tongue blade while visualizing oropharynx w penlight
6. remove tongue blade
7. Use sterile swab & insert to posterior oropharynx only
8. gently swab oropharynx, tonsils & red areas/exudate
9 assess pain
when a client is taking anticoagulants a nurse must continually monitor..
weight
renal
hepatic
dosage frequency
amount prescribed
drug interaction
suicidal ideation is assessed in all clients begininng
at age 12
R.A.C.E.
R-rescue
A-alarm
C-contain
E-extinguish
Class A Fire Extinguisher
water-based–paper, plastic, wood, cloth, & rubber
Class B fire extinguisher
CO2—oils, gas, grease, & paint
class c fire extinguisher
dry chemicals–electrical fires
class D fire extinguisher
metals – magnesium, potassium, sodium, & titanium
Class K fire extinguisher
kitchen–oils & fats
Alpha
least risky radiation exposure—no penetration
Beta
middle risk radiation–special clothes required
Gamma
highest radiation risk–penetrates skin & lead protection
elopement
client leaves or wanders away from a health care facility
a nurse is preparing info for a change-of-shift report. Which of the following should the nurse include in the report?
- Input & output for the shift
- Blood pressure from the previous day
- Bone scan scheduled for today
- Medication routine from the medication administration record
Bone scan scheduled for today
A nurse manager is discussing HiPPA…what should she include?
- A single electronic records password is provided for nurses on the same unit
- Family members should provide a code prior to receiving client health info
3.Communication of client info can occur at the nurses station
- a client can request a copy of their medical record
- a nurse can photocopy a clients medical record for transfer to another facility
- Family members should provide a code prior to receiving client health info
3.Communication of client info can occur at the nurses station - a client can request a copy of their medical record
- a nurse can photocopy a clients medical record for transfer to another facility
Which of the following legal guidelines should be followed when documenting in a client’s record? (select all that apply)
- cover errors with correction fluid & write in the correct information
- Put the date & time on all entries
- Document objective data, leaving out opinions
- Use as many abbreviations as possible
- Wait until the end of the shift to document
- Put the date & time on all entries
- Document objective data, leaving out opinions
A nurse is discussing occurrences that require incident reports. Which of the following should the nurse include in the teaching? (Select all that apply)
1. Medication error
2. Needlesticks
3.Conflict w/ provider & nursing staff
4. Omission of prescription
5. Missed specimen collection of a prescribed lab test
- Medication error
- Needlesticks
- Omission of prescription
A nurse is receiving a provider’s prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (select all that apply).
- Repeat the details of the prescription back to the provider
- Have another nurse listen to the telephone prescription
- Obtain the provider’s signature on the prescription within 24hrs
- Decline the verbal prescription because it is not an emergency
- Tell the charge nurse that the provider has prescribed morphine by telephone
- Repeat the details of the prescription back to the provider
- Have another nurse listen to the telephone prescription
- Obtain the provider’s signature on the prescription within 24hrs
Subjective Data
vs
Objective Data
Sub — what the client says direct quotes
Obj—what the nurse sees, feels, hears, & smells
Begin all data entries with
date & time
flow charts
show TRENDS in levels
** vital signs, blood glucose levels, & pain levels
Types of Problem Oriented Medical Records (3)
- S.O.A.P. = Subjective data, Objective data, Assessment, Planning
- P.I.E. = Problem, Intervention, & Evaluation
- D.A.R. = Data, Action, & Response
clinical pathways
standardized method of health care delivery for a specific group of clients through the use of practices based on EBP
privacy rule
vs
security rule
privacy — protects personal privacy (client ID & PHI)
security–protects use 7 disclosure of ELECTRONIC pih
how are breaches in privacy reported?
- MAIL
*emergency—phone call
*within 60 days
adverse drug event
vs
medication error
ADE – injury caused my medical intervention linked to medicine
ME – preventable error capable of harm to client
source oriented medical record
documentation divided into sections (ex: history, physical, notes)
**created separately by members of care team
***limited sharing of info
