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3802 CSL Exam 1

QuestionAnswer
the absence of disease-producing microorganisms asepsis
a method to eliminate contamination, germs or infection aseptic technique
introduction of disease, germs, or infectious materials into or on normally sterile objects contamination
all practices that limit the number and growth of microorganisms and their transmission medical asepsis
practices which will maintain area free from microorganisms, as by a surgical scrub, or sterile technique surgical asepsis
1st tier CDC guidelines, blends features of univ precautions (blood & body fluids) & body substance isolation into single set of precautions for care of all clients in hospitals, regardless of diagnosis or presumed infection-reduce risk of transmission standard precautions
an infection acquired while in the hospital that was not present or incubating at the time of admission nosocomial infection
practices designed to prevent the transmission of communicable diseases isolation technique
to prevent spread of endogenous & exogenous flora to other clientsreduce potential for transferring organisms from hosp env to clientprotect hosp personnel from infectionprevent immunosuppressed clients from nosocomial infections objective of isolation
single most important means of preventing the spread of infectionfirst fundamental principle that should be applied to all clients HAND HYGIENE
-contact, droplet, and airborne-contaminated food, water, devices, and equipment-vector borne (mosquitoes, fleas, rats) routes of microorganism transmission
1 infectious agent2 reservoir3 portal of exit4 mode of transmission5 portal of entry6 susceptible host chain of infection
reduce risk of airborne transmission of infectious agents, such as measles, varicella, & tuberculosis airborne precautions
used to prevent the transmission of diseases, such as memingitis, pneumonia, scarlet fever, diptheria, rubella, & pertussis droplet precautions
used for clients known or suspected to have serious illnesses easily transmitted by direct contact, such as herpes simplex, staphylococcal infections, hepatitis A, respiratory syncytial virus (rsv), and wound or skin infections contact precautions
to be worn to provide a protective barrier, prevent gross contamination of the hands when touching body substances or blood, and reduce the risk of exposure to blood pathogens use of gloves
to prevent the spread of microorganisms to others or to the client proper placement of clients in the hospital
to prevent the spread of microorganisms to health care workers and other clients appropriate use of isolation equipment
-Stand in front of but away from sink-paper towel hanging down-turn on warm water-wet, soap hands rubbing vigorously for 10-15 sec-rinse under water, keep fingers pointed down-rewash-dry w/ towel, hands pointed up-turn off water with towel Proper hand hygiene
-hand hygiene-glove dominant hand then use gloved hand to glove other hand-remove by touching only outside of glove(turn inside out)-place in gloved hand, slip finger under cuff edge & remove-dispose-hand hygiene donning and removing clean gloves
-hand hygiene-gown: arms 1st, tie neck, waist-mask-face shield-gloves donning protective gear using standard precautions
-untie gown waist, below waist dirty-remove gloves-untie gown neck, back of neck clean-gown off: pull shoulders, turn inside out, dispose-remove eyewear then mask-hand hygiene, exit, hand hygiene-dispose dbl-bagged soiled stuff-hand hygiene removing protective gear when exiting a client's room using standard precautions
-hand hygiene-place package on clean, dry, firm surface-remove outside wrapper-lift edges up & away-glove dominant hand then use gloved hand to glove other hand-keep both gloved hands in front & above waist level donning sterile gloves
R-rescue & remove all clients in immediate dangerA-activate alarmC-confine the fire by closing doors & windows & turning off O2 & electrical equipmentE-extinguish the fire using an extinguisher priorities in case of fire
-water-under-pressure or soda-acid type-use on cloth, wood, paper, plastic, rubber or leather fires Class A fire extinguisher
-foam, dry chemical, carbon dioxide types-use on fires such as gasoline, alcohol, acetone, oil, grease, or paint thinner/remover Class B fire extinguisher
-dry chemical or carbon dioxide types-use on electrical wiring, electrical equipment or motors Class C fire extinguisher
-contains graphite-use on any type of fire-most common Class ABC combination fire extinguisher
movement of the body in a coordinated & efficient way so that proper balance, alignment, & conservation of energy is maintained body mechanics
mechanical device that enables one person to safely transfer a client from bed to chair and back to bed Hoyer lift
mattress remains unbent but the head of the bed is lowered and the foot is raised Trendelenburg's position
Head of bed is at a 45 deg angle; client's knees may or may not be flexed Fowler's position
Head of bed is at a 60 deg angle; often used to acheive maximum chest expansion High-Fowler's position
Head of bed is at a 30 deg angle; often used for client's with cardiac & respiratory problems Semi-Fowler's position
Head of bed is at a 15 deg angle; necessary degree elevation for ease of breathing, promotes skin integrity, client comfort Low-Fowler's position
-use proper stance-work at comfortable height-flex knees for lower level duties-accommodate for high surface levels-work close to body, prevent back strain-use longest & strongest muscles to move & turn clients-roll, push, & pull ilo lifting Maintaining proper body alignment
lateral position on side
prone position on stomach
supine position on back
position in which the patient lies on one side with the under arm behind the back and the upper thigh flexed, used to facilitate vaginal examination. Also called lateral recumbent position Sim's position
-low-frequency sounds that are regarded by the Amer Heart Assoc as the best index of blood pressure in an adult-sounds are produced as a result of changes in blood flow through a compressed artery Korotkoff's sounds
-pulse is smooth & rounded & is felt as a sharp upstroke & gradual downstroke-provides info about cardiac status & blood volume-correlates with cardiac contraction-60 to 100 bpm-assess for rate, rhythm & quality) Normal pulse
difference between systolic and diastolic pressure (about 30 to 40 points) Pulse pressure
occurs when the heart rate counted at the apex by auscultation is greater than the heart rate counted by palpitation of the radial pulse Pulse deficit
-cardinal signs that reflect the body's physiologic status and provide information critical to evaluating homeostatic balance-temperature, pulse, respiration, blood pressure, pain Vital signs
97-99.5 oral+1 rectal+0.5 ear canal-1 axillaryhighest in afternoon & eveningregulated by hypothalamus temperature
12-20 breaths per minute-assess for rate, rhythm, depth respirations
100-120 (S)--------60-80 (D) Blood pressure
brachial pulse bend of arm
radial pulse wrist
femoral pulse groin
apical pulse-index finger just left of sternum & palpate 2nd intercostal space-middle finger in 3rd intercostal space & continue downward until locate apical impulse at 5th intercostal space-move finger laterally along 5th IS to midclavicular line over the apex of heart
carotid pulse neck
popliteal pulse behind knee
dorsalis pedis top of foot
posterior tibial inside ankle
P-palliative, provokingQ-quality, quantity (dull/sharp)R-radiation, regionS-severityT-timing, acute/chronic, sudden/gradual, when does it hurt Pain assessment
blood in urine hematuria
-test used when blood glucose is over 200-dip Keto-diastix strip in urine-compare strip against color chart & note findings Test for urine ketone bodies
-swab clean finger before puncture-insert test strip into monitor-use penlet on side of finger-massage finger, place drop of blood on test strip-obtain reading on monitor-Normal range: 70 - 105 Blood glucose
-1st specimen obtained early in am before eating/drinking provides best sample-rinse mouth-deep cough-obtain 1-2 tsp of sample in container, close & seal lid-label specimen-evaluate client's status post sample-deliver to lab w/in 30 min Obtaining sputum specimen
SaO2 90-100% Normal Pulse Oximetry reading
1-2 L of O2 flow3-4 L of O2 flow5-6 L of O2 flow 24-28% by nasal canula30-35% by nasal canula38-44% by nasal canula
8-12 L of O2 flow 35-65% by simple face mask
6-10 L of O2 flow6-15 L of O2 flow 40-60% by mask with reservoir bag with partial rebreather60-100% by mask with reservoir bag, nonrebreather
24-50% venturi mask
5-8 L of O2 flow8-12 L of O2 flow 28-40% by oxygen hood40-85% by oxygen hood
8-12 L of O2 flow 28-100% by face tent
10-15 L of O2 flow Up to 50% by oxygen tent
bath requiring a physcian's order, used for specific conditions. order should include type of bath, water temperature, and solution to be used therapeutic bath
essential component of daily care because excessive perspiration interacts with bacteria to cause odor & dead skin cells can lead to infection if impaired skin integrity occurs routine bathing
-Identifying data & source of history-Chief complaint(s)-Present Illness-Past History-Family history-Personal & social history-Review of symptoms Comprehensive Adult Health History
1 location2 quality3 quantity or severity4 timing, including onset, duration, & frequency5 setting in which it occurs6 factors that aggravate or relieve symptoms7 associated manifestations 7 attributes of principal symptom
-inspection-palpation-percussion-auscultation 4 classic techniques of physical examination
Created by: garzakd
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