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1323 Final BP
| Question | Answer |
|---|---|
| Bacteria | single-cell microorganisms lacking a nucleus that reproduce anywhere from every few minutes up to several weeks. |
| Aerobic Bacteria | Need oxygen to grow and thrive |
| Anaerobic Bacteria | can grow only when oxygen is not present |
| Hand Hygiene | One of the most effect ways to prevent the spread of infection. |
| When to wash your hands | ¨Before and after care of the patient ¨When hands are visibly soiled ¨Before/After Eating ¨Before/After Toileting ¨Before/After Smoking |
| Inflammatory Response | immediate response of the body to any kind of injury to its cells and tissues. Can be induced by mechanical, chemical, or infectious disease-producing factor that injures cells of the body. |
| Inflammation | is a localized protective response brought on by injury or destruction of tissues. The blood vessels dilate, bringing more blood to the damaged area, causing redness, warmth and edema. |
| Purpose of Inflammatory response | Neutralize and destroy harmful agents, limit their spread to other tissues in the body, and prepare the damaged tissues for repair |
| Asepsis in the Home | Not as strict as in the hospital due to less pathogens. Dressings and disposables are secured in baggies before disposal. Contaminated Linens in baggies before washing in hot water. Run dishwasher on "sanitize". Frequent "damp" dusting. |
| Susceptability of the Elderly | Poor nutrition, poor mobility, poor hygiene, chronic illness, and pysiologic changes all contribute to higher risk of infection. |
| Physiologic Factors that Increase susceptibility to infection | Age, Malnutrition, Excessive stress or fatigue, Low WBC count, Altered defense mechanisms, Alcoholism, Chronic Illness, Indwelling tubes or equipment, Immunosuppressive treatment |
| Disease Producing Organisms | Bacteria, Prions, Viruses, Protozoa, Rickettsiae, Fungi, Helminths, Clamydiae, Mycoplasms |
| CDC Guidelines | When and how to wash your hands. (p 221) |
| Standard Precaution Guidelines | developed by the CDC to facilitate breaking the chain of infection. These precautions protect boththe nurse and patient and are to be used for every patient contact. (p 225) |
| Preventing Spread of MRSA | Wash hands frequently; use an alcohol based rub when not running water. Keep cuts and abrasions clean and covered with a bandage until healed. Avoid sharing personal items. Avoid contact with others bandages or wounds. |
| Once exposed to a microorganism the body will produce antibodies against that invader. In this way, | Naturally acquired immunity occurs. |
| Principles of Aseptic Technique (p 244) | Sterile on sterile remains sterile. Sterile on unsterile is contaminated. Must be kept dry - moisture=microorganisms. Open sterile pack away from body. Avoid Coughing, sneezing, or unnecessary talking near sterile field. 1" around sterile area=unsterile. |
| Isolation Precautions(p 241) | Floors are contaminated. Pts should be grouped according to epidemiology of transmission. Keep dust down. Protect pt from drafts. Removal of items from room must be in proper containers. Never rub eyes or nose in isolation. Never shake linen.... |
| Health Promotions | Perform proper hand hygiene before and after caring for the pt. before donning gloves and after their removal. |
| Cleanse hands and change gloves between procedures that involve | contact with mucous membranes, the perineal or perianal area, feces, wound drainage, or other contaminated matter. |
| Keep urinary cather drainage bags below | the level of the bladder at all times even when transferring a patient. Not all drainage bags have a fail-proof one-way valve. |
| Clean residual urine off the | catheter bag drainage tube after emptying the bag; do not let the tube touch the collection container. |
| Assist all patients on bed rest to | turn, deep breathe, and cough effectively every two hours. |
| Assess IV line sites for | signs of infection whenever you enter the pts room. |
| Use correct aseptic technique for cleansing | the skin before peforming an invasive procedure. |
| Cleanse from the urinary meatus toward | the rectum. Never cleanse from the rectum to the urinary meatus. |
| Clean incontinent patients | promptly. Carefully cleanse feces from surface of indwelling catheters as well as the skin and mucous membranes. |
| Always use aspetic technique | when suctioning the airway. |
| Correcting breaks in aspesis | Wash your hands again, put on new gloves. Sterile supplies are replaced. It is up to every nurse to point out breaks in sterile technique that occur when others seem unaware that they have contaminatd themselves or the sterile field. |
| Transmission-Based precautions requirements (237) | Use for the care of all pt.s |
| Psychological aspects of isolation | At risk for decreased self-esteem and sensory deprivation. Especially for young children and the elderly. Ongoing assessment for sensory deprivation is necessary. Visitors is helpful. Listen to the pts. feelings. Try to engage. Assist visitors. |
| PPE | Presonal Protective Equipment: Gown, mask, goggles or face shield, gloves. |
| N95 mask | Suspected pulmonary tuberculosis mask |
| health-care associated infections | Infections that are transmitted to a person while receiving health care serviecs. |
| Patients and families must be taught the importance of hand hygiene. Stress that hands must be cleansed before caring for the pt and after care is finished. Gloves are needed in | addition to hand hygiene for tasks such as tracheal suctioning and tracheostomy care; dressing changes and wound or drain care; tube feedings; and cleansing of personal areas. |
| Used dressings, tissues, wound-cleaning supplies and any other item contaminated with body fluids should be | discarded into a plastic bag and sealed before being placed in the household trash for pickup. |
| Kinesiology | study of the movement of body parts (body mechanics). |
| alignment | the body functions best when it is in correct anatomic position (arrangement in a straight line, bringing a line into order). |
| One of the most common injuries for healthcare workers is | lower back strain |
| Principles of Body Movement for Nurses | Obtain Help whenever Possible, Use your leg muscles, Provide stability for movement, Use smooth, coordinated movements, Keep loads close to the body, Keep loads near your center of gravity, Pull and pivot. |
| Therapeutic Exercises | Full Range of motion exercises should be performed either actively or passively several times a day. |
| ACTIVE ROM | used for the pt who independently performs activities of daily living but for some reason is immobilized or limited in activity or is unable to move one extremity due to injury or surgery. |
| Passive ROM | performed on the pt who cannot actively move. Pt. cannot contract muscles, so muscle strengthening cannot be accomplished. |
| Positioning Devices | Pillows, boots or splints, footboards, cushioned boots or hight-top sneakers, trapeze bar, sandbags, hand rolls, trochanter rolls, side rails, and bed boards. |
| Fowler's Position | elevating head of bed 60 - 90 degrees |
| Semi-Fowler's Position | elevating head of bed 30-60 degrees |
| Low Fowler's Position | Elevating head of bed 15-30 degrees |
| Dorsal Recumbent | pt is on their back with knees flexed and soles of feet flat on the bed. |
| Dorsal Lithotomy | used for examing pelvic organs. Pt on the back with feet in stirrups |
| Side-lying or lateral position | alleviates pressure from the bony prominces on the back |
| Sims' Position | Used for rectal exams, administering enemas, or inserting suppositories, is a variation of side-lying |
| Prone position | lying face down. Provides alternative for pts who are on prolonged bed rest. Spinal cord-injured patients use this position. |
| Knee-chest Position | variation of prone position. Face down with head turned to one side. Chest, elbows, and knees rest on the bed and the thighs are perpindicular to the bed. Lower legs rest flat on the bed. Rectal exams and as a method to restore the uterus to normal. |
| Logrolling | turning the patient as a single unit while maintaining straight body alignment at all times. |
| Functions of the skin | protection, sensation, temperature regulation, and excretion. |
| Epidermis | Outer, thicker, layer of the skin. Consists of stratified squamous epithelial tissue and does not contain blood vessels. It receives its nutrtition by diffusion from vessels underlying tissues. It is also calle dstratum corneum. |
| The bottom layer of the epidermis contains melanocytes that secrete | melanin, the main determinant of skin color |
| Dermis | inner thinner layer of skin. Is made of dense connective tissue that gives the skin strength and elasticity. |
| The Dermis contains | blood vessels, nerves, fibroblasts, the base of hair follicles, and glands; the nails are derived from the epidermis. Fibroblasts produce new cells to heal skin after injury |
| Hair and nails are made of | keratin and have no never endings or blood supply |
| Sebaceous glands secrete an oily substance called | sebum |
| Sweat glands secrete sweat, and ceruminous glands secrete a waxy substance called | cerumen. |
| Skin assessment for pressure ulcers | Perform a skin assessment for pressure ulcer risk upon arrival. A commonly used tool is the Braden Scale for predicting pressure sore risk. After initial assessment, reassess every 24hours. This may be done while you bathe the pt. |
| Suspected Deep Tissue injury | Localized discolored intact skin that is maroon or purple or a blood-filled blister resulting from damage to underlying soft tissue, from pressure or shear. The area may be painful, firm, mushy, boggy, warmer, or cooler when compared to adjacent tissue. |
| Stage 1 | An area of red, deep pink or mottled skin that does not blanch with the fingertip pressure. In people with darker skin, discoloration of the skin, warmth, edema, or induration (area feels hard) may be signs. |
| Stage 2 | Partial-thickness skin loss involving epidermis and or dermis it may look like an abrasion, blister, or shallow crater. The area surrounding the damaged skin may feel warmer. |
| Stage 3 | Full-thickness skin loss that looks like a deep crater and may extend to the fascia. Subcutaneous tissue is dammaged or necrotic. Bacterial infection of the ulcer is common and causes drainage fromthe ulcer. There may be damage to surrounding tissue. |
| Stage 4 | Full-thickness skin loss with extensive tissue necrosis or damage to muscle, bone, or supporting structures; sinus tracts may be present. |
| Unstageable | Loss of full thickness of tissue. The base of the ulcer is coverd by eschar in the wound bed, or the base of the ulcer contains slough. |
| Four purposes for bathing | cleanse the skin, promote comfort, stimulate circulation to all areas of the body and remove waste products secreted through the skin |
| Water should be warm but should not | burn the patient. |
| Therapeutic Bath | bath with healing or medicinal qualities. performed to achieve a dsired effect and include several types. |
| Whirpool bath | therapeutic bath used to cleanse, stimulate peripheral circulation, and provide comfort. |
| Starch or oatmeal bath | used for pts with dermatitis |
| Sitz Baths | used to apply moist heat and clean the perineal or anal area. Promotes healing and relieves pain and discomfort. Usually used after birth and vaginal or rectal surgery. |
| Cool Sponge Baths | Used to cool a fever |
| Perineal Care | Proper draping helps promote comfort with the procedure. Explain the procedure to reassure the pt and gain cooperation. Maintain matter-of-fact attitude. Professional and dignified attitude can help reduce embarrassment. |
| Mouth Care for conscious pt. | Raise the head of the bed 45-90 degrees. Wear gloves. Place a towel under the chin. Moisten the brush. Brush from the gum line to the edge of the teeth. Have the pt. spit. |
| Mouth Care for Unconscious pt. | (p 304) A pt who is unconscious should be provided full mouth care at least once every 8 hours. If mouth-breathing every 4 hours. Dry secretions must be removed bc they cause halitosis. Moist swabbing is done every 2 hours. |
| Hair care | brushing, combing, shampooing, shaving and mustache and beard care. Morale and body image are improved when the pt is comfortable with his appearance. |
| Factors Affecting the Environment | Temperature, Ventilation, Humidity, Lighting, Odor Control, Noise Control, Interior Design, Neatness, and Privacy. |
| Neatness | Straighten the pt unit after making the bed. Old dishes and unused equipment should be removed promptly. |
| Ventilation | the process or act of supplying a building or room continuously with fresh air |
| Humidity | is the amount of moisture in the air. A range of 30-50% is normally comfortable. |
| Use good body alignment, a wide base of support and a proper working height | when making the bed. Face the direction of movement and bend at the knees, not the back. |
| Complete the linen change on one side before moving | to the other side to save time and conserve energy. |
| Avoid contaminating clean linen. Once linens enter a unit, they are exposed to that patient's | microorganisms and must not be returned to the clean supply or used elsewhere. |
| Unfold linens onto the | bed. Do not flip or fan linens, to avoid stirring up air currents. Microorganisms travel on air currents and could be carried out of the unit. |
| Remove linens one piece at a time to avoid wrapping | dentures, eyeglasses, religious objects, or other patient belongings in soiled linens. |
| Do not place used or soiled linen from one pt on the | bed, table or chairs belonging to another pt's unit. |
| Falls | are the most frequent cause of injury for the elderly pt in an acute care facility |
| The three most common factors that predispose a person to falls are | impaired phyiscal mobility, altered mental status, and sesonry and or motor deficits. |
| Every pt must be assessed and periodically reassessed for risk for | falling, particularly correlating the pts meds with increased risk for falls. |
| The use of protective devices must help the pt or | be needed for the continuation of medical therapy. |
| Use the least amount of | immobilization needed for the situation. |
| For all devices that limit movement or immobilize the pt, there must be a | written order. As soon as the device is no longer needed, the physician must be notified. |
| Apply the device snugly but not so tightly as to | interfere with blood circulation or nerve function. |
| The device must be removed and the pts position changed at least every | 2 hours. Active or passive exercises are performed for immobilized joints and muscles. |
| Characteristics of a Pulse | weak and regular, strong and regular, full and bounding, feeble, irregular, thready, absent. |
| When to measure vital signs | on admission. when assessing during home health. In a hospital on routine schedule according to physicians order. Before and after surgical procedure Before and after admin of meds that affect cardio, respira, and temp-control. |
| Factors that influence pulse | Age, body build and size, blood pressure, drugs, emotions, blood loss, exercise, increased body temperature, pain. |
| Risk Factors of HTN | Prolonged HTN can cause permanent damage to the brain, kidneys, heart, retina of eyes, and it is the cause of may CVA's (strokes) |
| Body Temperature Regulation | Hypothalamus controls body temperature. |
| If body heat rises above normal | the hypothalamus sends a message for vasodilation and sweating. |
| If body heat rises below normal | the hypothalamus sends a message for vasoconstriction of the blood vessels to conserve heat and induce shivering to increase heat production. |
| Measuring the apical pulse | Place the stethoscope over the left chest wall, fifth intercostal space. Listen to the heart sounds for one full minute. Routinely obtained prior to administering digitalis. |
| Hyperthermia | A condition in which the pts temperature is above the normal range. Not considered significant until the temp reaches 101.3. |
| Pulse Rate | Produced by cardiac contractions. Palpable bounding of the blood flow in a peripheral artery.Measured over one full minute. Normal: 60-100 BPM |
| Temperature | Norms: 97-99 |
| Respiratory Patterns | As respirations are being counted, observe for variations in the pattern of breathing. |
| Eupnea | Normal, relaxed breathing |
| Dyspnea | Difficult and labored breathing |
| Apnea | Absence of breathing |
| Tachypnea | Increased or rapid breathing |
| Bradypnea | slow and shallow breathing |
| Hyperventilation | an increased in the rate and depth of breaths and carbon dioxide expelled |
| Kussmauls Respirations | increased rate and depth with panting and long grunting exhalation |
| Cheyne-stokes respirations | a pattern of dyspnea followed by apnea |
| Measuring oxygen saturation | Use a pulse oximeter - measures oxy saturation by determining the percentage of hemoglobin that is bound with oxygen |
| External respiration | Ventilation, Dispersion, Diffusion, Perfusion |
| orthostatic hypotension | drop in blood pressure occuring with change from supine to standing or from sitting to standing position |
| S/S Hypoxemia | Restlessness, irritability, confusion, difficulty in breathing, rapid breathing, abnormal lung sounds, cyanosis, retractions, dysrhythmias, acid-base balance disturbance, decreased oxygen saturation |
| Using a pulse oximeter | Used to monitor any pt at risk for hypoxia, measures changes in serum oxygen continuously, sensor attached to fingers, toes, ears, or skin, helps track changes in oxygen therapy. |
| CPR | must be started whenever someone is found in respiratory or cardiac arrest, meaning without breathing or without a heartbeat. It is vitally important to call for help while beginning to assess the victim. |
| The Effective Cough | Most effective in the sitting position, Two deep breaths and then inhale deeply again, breathe rapidly and forcibly exhaled as quickly as possible with the mouth open. This moves secretions up the bronchial tree. |
| Upper airways | carry air to and from the lungs |
| Postural Drainage | Different positions drain different segments of the lungs. Specific segments drained into the bronchi to facilitate coughs. Each position assumed 5-15 mins 2-4x's a day as tolerated |
| Nasal Cannula | Way to deliver oxygen. A plastic tube with short, curved prongs that extend into the nostril about 1/4-1/2 inch. Held in place by looping it over the ears and cinching under the chin; can be easily adjusted for comfort. |
| Humidification takes place | in the upper airways |
| Oxygen Administration | Used to supplement oxygen in inspired air (21% oxygen). Can be delivered by nasal cannula, mask, tent, croupette, or catheter. Requires humidification, flow rate prescribed by physician. Common flow rate: 4-6 L/min. COPD pts get 2-3 L/min |
| Bronchi channel air | to and from the lungs |
| Cilia lining mucous membranes help | trap and remove foreign particles in the respiratory tract. |
| Alveoli contain | macrophages that phagocytize inhaled bacteria |
| Mucus and ceilia propel | foreign substances to airway openings to be expelled |
| Central nervous system controls | rate and depth of respiration |
| Chemoreceptors | in the aorta and carotid bodies send signals to the brainstem |
| Chemoreceptors measure serum pH, | Serum carbon dioxide and serum oxygen to trigger changes in rate and depth of respiration |
| Oxygen diffuses across the | alvolar membranes into the blood. |
| Carbon Dioxide diffuses across the | alveolar membranes out of the blood into the lungs for exhalation. |
| Foods allowed on liquid diet - Clear Liquids | Grape, apple, cranberry juice. Strained fruit juices. Vegetable broth. Carbonated water. Clear fruit-flavored drinks. Tea, coffee. Gelatin and ices. Clear candies. Popsicles. Clear Broth. |
| Substance Abuse | Abuse of drugs and alcohol. Interferes with food intake by decreasing appetite and decreasing financial resources for food. May lead to impared absorption of nutrients. Thiamine deficiency is seen in alcohol abuse. |
| Dietary intake for cardio diseases | Focus on reduction of fat and sodium intake to decrease atherosclerosis |
| Foods allowed on Liquid Diet - Full Liquids | milk and milk beverages, yogurt, eggnog, pudding, custard and ice cream, pureed meat, vegetables in cream soups, vegetable juices, sweetened plain gelatin, cooked refined cereals, strained or blended gruel, cream |
| pts with a history of substance abuse should have | dietary counseling |
| Infants void | 5-40 times a day |
| Preschool Children void | every 2 hours |
| adults void | 5-10 times per day |
| males void | 300-500 mL |
| Females void | 250 mL |
| Average output should be | approximately 30 mL / Hour |
| Assessing Urinary Status | Usual Patter, Incidences of incontinence/frequency, Burning, Sense of urgency, Times of day, Total daily fluid intake |
| When a pt comes into the hospital usually you will see a UA ordered as general admission criteria. Anytime you have an order to obtain a urine specimen the one of the main things you need to do: | Instruct the pt correctly, collect and store correctly, document. |
| Voided Specimen | The urine is voided directly into a cup and sent to the lab for analysis. |
| Clean Catch Urine Specimen | You may hear this referred to as a mid-stream specimen. Make sure the pt cleans correctly for this specimen. They will start voiding and catch the urine mid stream. Will need at least 30mLs |
| Normal Stool Colors | Adult: Brown Infant: Yellow |
Created by:
christinego
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