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26 Cards in this Set
- Front
- Back
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What are the stages of pressure ulcers?
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Stage I - Erythema of intact skin
Stage II- Partial-thickness skin loss involves epidermis, dermis; abrasion, blister, shallow crater Stage III - damage/necrosis of skin; deep crater Stage IV - full-thickness skin loss w/extensive destruction, tissue necrosis, damage to muscle/bone, etc. |
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What is the nurses patient hygiene schedule?
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AM - offer bedpan/urinal; wash hands/face; assist w/oral care
After Bfast - offer bedpan; shower; oral care;foot/hand nail care; change gowns/linens PRN; straighten room Afternoon - wash hands/face; oral care; bedpan/urinal; straighten bed linen HS care - Change soiled linens; oral hygiene; bedpan/urinal |
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What is Maslow's hierarchy?
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1.Physiologic needs
2.Safety/security 3.Love/belonging 4.Esteem 5.Self actualization |
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The Definition of Nursing
Greek "nutrix" - to nourish |
*Assist individuals sick/well in the performance of those activities contributing to health, recovery, or to peaceful laughing.
*Healthcare team member-basic therapeutic, rehab, preventative care. *Provide health services under supervision. *Diagnose patient not disease. |
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What is the DOHs role in nursing?
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Require accredidation.
Makes sure the program is approved; it meets the minimum standards set by the DOH. |
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What is ANA, NANDA, and NLN?
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American Nursing Association
North American Nursing Diagnosis Association National League of Nursing |
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What are the basic before care nursing skills?
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1.Check medical record
2.Introduce self-name/title 3.ID pt 2 ways- ID bracelet/ask pt to state name 4.Explain procedure/why 5.Assess need for teaching 6.Assess pt 7.Wash hands/don gloves 8.Organize equipment needed 9.Privacy-close door/curtains; raise bed; use drape to cover |
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What are the basic during and after nursing skills?
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1. Promote pt involvement
2. Assess pt tolerance/discomfort level 3.Position pt to comfort w/call light. 4.Raise rails, lower bed 5.Remove any PPE 6.Wash hands 7.Document pt response, teaching, unusual outcomes 8.Report to RN if needed. |
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What is medical asepsis?
What is surgical asepsis? |
Medical - inhibits organism growth & spread of pathogen. AKA clean technique.
Surgical - Destroys all organisms and their spores. AKA sterile technique |
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What is the chain of infection?
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Infectious Agent
to Reservoir to Exit route to Method of transmission to Entrance to Host to Infectious Agent |
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Reservoir/Infection for
Staphylococcus aureus |
Reservoir - skin, hair, anterior nares
Infection - wound, pnemonia, food poisoning |
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Reservoir/Infection for
Staphylococcus epidermidis |
Reservoir - skin (part of normal flora)
Infection - IV line infection, endocarditis, bacteremia |
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Infection control to reduce reservoirs of infections
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*bathing secretions
*change dressings *proper disposal of soiled articles/contaminated needles *keep room clean/dry *date opened bottles; throw away after 3 days *drainage bottles/bags emptied Qshift and PRN |
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The bodies line of defense
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*#1 skin - multi layered; secretes sebum that kills some bacteria
*mouth - mucosa; saliva *respiratory tract - mucus lined cilia; upper airway *UT - urine flushes urethra *GI tract - acidity of gastric secretions *vagina - normal flora maintains low pH |
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Stages of infectious process
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*Incubation
*Prodromal - most contagious; organism rapidly multiplying *Illness - manifests Sx specific to pathogen *Convalescence - acute Sx disappear |
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What is a nosocomial infection?
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Greek "nosocomium"
Infection aquired at least 72 hrs after admission to a hospital. |
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Fomite
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Non-living microorganism vehicle
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Vector
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Living microorganism vehicle
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Virulent
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Highly pathogenic and rapidly progressive
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Exogenous vs. Endogenous
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Comes from the outside vs coming from the inside
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Airborne precautions and diseases
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Needed - gown, gloves, N95 respirator, private room, negative airflow
Diseases - measles, varicella, TB |
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Droplet precautions and diseases
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Needed - gloves, gown, mask, private room
Diseases - pertussis, meningitis, scarlet fever |
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Contact precautions and diseases
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Needed - gloves, gown, private room
Diseases - Hep A, E. coli 0157 and Chlostridium dificile |
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Immunocompromised patients
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Masks for visitors/nurse, private room
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Antiseptic vs. Disinfectant
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Antiseptic inhibits growth and is safe for use on skin.
Disinfectant destroys organisms but not spores and cannot be used on skin. |
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Sterile Technique - What does it involve?
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1. Sterile can only touch sterile
2. Sterile must never be below the waist or out of direct vision. 3. Avoid prolonged air exposure or currents. 4. If field gets wet then it's contaminated. 5. Outer 1 inch of field is contaminated 6. open sterile packages away from you |
