3802 CSL Exam 1
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| the absence of disease-producing microorganisms | asepsis
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| a method to eliminate contamination, germs or infection | aseptic technique
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| introduction of disease, germs, or infectious materials into or on normally sterile objects | contamination
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| all practices that limit the number and growth of microorganisms and their transmission | medical asepsis
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| practices which will maintain area free from microorganisms, as by a surgical scrub, or sterile technique | surgical asepsis
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| 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
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| an infection acquired while in the hospital that was not present or incubating at the time of admission | nosocomial infection
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| practices designed to prevent the transmission of communicable diseases | isolation technique
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| 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
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| single most important means of preventing the spread of infectionfirst fundamental principle that should be applied to all clients | HAND HYGIENE
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| -contact, droplet, and airborne-contaminated food, water, devices, and equipment-vector borne (mosquitoes, fleas, rats) | routes of microorganism transmission
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| 1 infectious agent2 reservoir3 portal of exit4 mode of transmission5 portal of entry6 susceptible host | chain of infection
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| reduce risk of airborne transmission of infectious agents, such as measles, varicella, & tuberculosis | airborne precautions
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| used to prevent the transmission of diseases, such as memingitis, pneumonia, scarlet fever, diptheria, rubella, & pertussis | droplet precautions
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| 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
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| 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
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| to prevent the spread of microorganisms to others or to the client | proper placement of clients in the hospital
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| to prevent the spread of microorganisms to health care workers and other clients | appropriate use of isolation equipment
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| -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
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| -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
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| -hand hygiene-gown: arms 1st, tie neck, waist-mask-face shield-gloves | donning protective gear using standard precautions
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| -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
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| -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
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| 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
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| -water-under-pressure or soda-acid type-use on cloth, wood, paper, plastic, rubber or leather fires | Class A fire extinguisher
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| -foam, dry chemical, carbon dioxide types-use on fires such as gasoline, alcohol, acetone, oil, grease, or paint thinner/remover | Class B fire extinguisher
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| -dry chemical or carbon dioxide types-use on electrical wiring, electrical equipment or motors | Class C fire extinguisher
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| -contains graphite-use on any type of fire-most common | Class ABC combination fire extinguisher
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| movement of the body in a coordinated & efficient way so that proper balance, alignment, & conservation of energy is maintained | body mechanics
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| mechanical device that enables one person to safely transfer a client from bed to chair and back to bed | Hoyer lift
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| mattress remains unbent but the head of the bed is lowered and the foot is raised | Trendelenburg's position
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| Head of bed is at a 45 deg angle; client's knees may or may not be flexed | Fowler's position
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| Head of bed is at a 60 deg angle; often used to acheive maximum chest expansion | High-Fowler's position
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| Head of bed is at a 30 deg angle; often used for client's with cardiac & respiratory problems | Semi-Fowler's position
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| 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
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| -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
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| lateral position | on side
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| prone position | on stomach
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| supine position | on back
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| 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
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| -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
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| -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
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| difference between systolic and diastolic pressure (about 30 to 40 points) | Pulse pressure
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| 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
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| -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
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| 97-99.5 oral+1 rectal+0.5 ear canal-1 axillaryhighest in afternoon & eveningregulated by hypothalamus | temperature
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| 12-20 breaths per minute-assess for rate, rhythm, depth | respirations
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| 100-120 (S)--------60-80 (D) | Blood pressure
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| brachial pulse | bend of arm
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| radial pulse | wrist
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| femoral pulse | groin
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| 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
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| carotid pulse | neck
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| popliteal pulse | behind knee
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| dorsalis pedis | top of foot
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| posterior tibial | inside ankle
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| P-palliative, provokingQ-quality, quantity (dull/sharp)R-radiation, regionS-severityT-timing, acute/chronic, sudden/gradual, when does it hurt | Pain assessment
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| blood in urine | hematuria
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| -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
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| -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
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| -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
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| SaO2 90-100% | Normal Pulse Oximetry reading
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| 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
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| 8-12 L of O2 flow | 35-65% by simple face mask
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| 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
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| 24-50% | venturi mask
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| 5-8 L of O2 flow8-12 L of O2 flow | 28-40% by oxygen hood40-85% by oxygen hood
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| 8-12 L of O2 flow | 28-100% by face tent
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| 10-15 L of O2 flow | Up to 50% by oxygen tent
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| 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
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| 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
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| -Identifying data & source of history-Chief complaint(s)-Present Illness-Past History-Family history-Personal & social history-Review of symptoms | Comprehensive Adult Health History
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| 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
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| -inspection-palpation-percussion-auscultation | 4 classic techniques of physical examination
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