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116 Cards in this Set
- Front
- Back
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Define colonization
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when a microorganism is present or invades a host, grows, or multiplies but not causing disease or infection
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Define fomite
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inanimate objects or material on which disease producing agents may be conveyed
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Define natural active immunity
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immunity resulting from the development within the body of substances that render a person immune (ex have the disease measles)
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Define natural passive immunity
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immunity acquired in utero from antibodies that pass to the fetus through the placenta or acquired by the newborn ingesting mother's milk
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Define acquired immunity
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vaccinations
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Define health care associated infections/nosocomial infections
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infections acquired during hospitalization or a stay in a health care facility
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Define virulence
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the ability of a microorganism to produce disease;the strength of a microorganism
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Define resident flora
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normally present in stable #s, located on superficial skin layers, some located in deep epidermal layers
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Define transient flora
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organisms loosely attached to skin, easily removed w/ thorough hand washing, mostly found under fingernails
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Define reservoirs
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places where microorganisms can survive, multiply, & await transfer for a susceptible host
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Mode of transmission
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is the most fragile link in the chain of infection. Common modes of transmission are direct, indirect, droplet, airborne, vehicle, & vector
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Development of an infection depends on
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1. # of organisms
2. virulence of organisms 3. portals of entry/exit 4. susceptibility of host 5. favorable environment (warm, dark, moist) |
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What is the most effective way to break the chain of infection?
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hand hygiene
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Name some factors that influence susceptibility to disease
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1. age
2. nutrition 3. stress 4. state of health 5. medical therapies 6. heredity 7. cultural practices 8. inadequate/compromised defenses 9. immunity 10. personal habits 11. environmental factors |
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What are some measures to strengthen the barriers against infection?
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normal flora
body system defenses inflammation immunity |
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What are the 3 major organisms seen in hospitals?
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e. coli
staph aureus pseudomonas |
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What are the 3 most frequent nosocomial infections?
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UTIs
wound respiratory |
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What are the stages of infection?
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1. incubation period (preclinical)
2. prodromal stage (clinical) 3. full stage (clinical) 4. convalescence (resolution) |
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Describe the incubation period
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preclinical, exposure to a causative agent, no symptoms present
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Describe the prodromal stage
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clinical, interval from onset of nonspecific symptoms to more specific symptoms
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Describe the full stage
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clinical, PT manifests signs & symptoms specific to the type of infection
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Describe convalescence
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Resolution, acute symptoms of infection disappear
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What are localized signs & symptoms?
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redness, warmth, odor, drainage, edema (swelling)
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What are systemic signs & symptoms?
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fever greater than 38 degrees C, 101 degrees F
hypothermia less than 36 degrees C chills hyperventilation hypotension changes in mental status |
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What does a urine culture test for?
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positive nitrites, increase leukocytes
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What are the 5 major types of precautions?
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1. standard
2. contact 3. respiratory 4. enteric 5. neutropenic |
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Equipment used for isolation
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gloves
gown mask mask w/ eye shield isolation cart red bags clear bags w/ biohazard label |
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What do PTs requiring airborne precautions need?
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a room w/ double doors w/ negative pressure ventilation
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What is the order for putting on PPE?
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1. gown
2. mask or respirator 3. goggles or face shield 4. gloves |
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What is the order for removing PPE?
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1. gloves
2. goggles or face shield 3. gown 4. mask |
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What initiates the communication process?
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stimulus/referent
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What is the process of communication?
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referent (stimulus) --> sender --> message (verbal or nonverbal) --> channel (auditory, visual, tactile) --> receiver --> feedback (ensures message was properly received
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What are some distances for communication?
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intimate distance
personal distance social & public distance |
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What are the 2 modes of communication?
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verbal & nonverbal; nonverbal is more powerful b/c harder to hide true feelings
*nurses need a congruence b/w verbal & nonverbal |
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What are some factors affecting verbal communication?
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vocabulary
pacing tone clarity/brevity timing & relevance |
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What factors affect nonverbal communication?
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appearance/smell
posture/gait facial expression gestures eye contact touch |
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What is the body's 1st line of defense against infection & injury to underlying tissues?
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healthy, unbroken skin
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What makes up the integumentary system?
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hair, skin, & nails
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What are the 2 main layers of the skin?
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1. epidermis-outer, thinner layer, contains pores of sweat glands & shaft of hair
2. dermis-inner, thicker skin, underneath is subcutaneous & adipose tissues |
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Describe the glands of the skin
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1. sebaceous glands: secrete oil, found where there is hair
2. sweat glands in the axillary, palms, soles of feet, forehead 3. ceruminous glands: secrete wax (cerumen), found in ear canal |
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What are the skin's functions?
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1. protection
2. secretion from glands 3. excretion of water & nitrogenous wastes 4. heat regulation 5. sensation |
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Describe the nutrition of the skin
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skin is nourished by the blood
if food/fluid intake is interfered w/, can see effects on the skin (dehydration, etc) edema: fluid accumulation poor nutrition causes slow healing in the skin albumin (protein in the body) responsible for tissue growth & repair |
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Describe normal skin
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-exhibits no variation in pigment & color
-shows no evidence of cyanosis, jaundice, or pallor -healthy skin falls back quickly (turgor) -texture is smooth, soft, & flexible -variety of pigmented areas -warm to the touch |
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Cyanosis
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a bluish color on lips, around mouth, in nail beds. seen in PTs w/ pulmonary and/or heart disease
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Jaundice
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yellow tinge to the skin, easily seen in sclera. often due to liver disease, drugs
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Pallor
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whitish-grayish tinge to skin, seen in PTs w/ anemia, internal hemmorage, & shock
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How do you assess turgor?
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pick up & pinch skin
-dehydrated skin stayes pinched for a short time |
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Purposes of bath
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1. cleanses
2. promotes comfort 3. opportunity for exercise 4. lowers body temp 5. stimulates circulation 6. observation 7. communicate w/ PT 8. teach hygiene 9. assess PT needs 10. caring |
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Types of bed baths
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1. partial bath (PT can wash some areas)
2. complete bath (nurse washes entire body) |
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Principles of back care (position, strokes, when performed)
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Performed after bath, before bed, when you turn a PT
-Position is prone or side lying (prone is preferred) -Use long, smooth, circular motions to increase circulation -Start at sacrum |
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Define sordes
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accumulation of foul matter (food, microorganisms, and epithelial elements) on the teeth
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Procedure for brushing teeth
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performed after each meal, or at least twice a day
brush at 45 degree angle at margin of gingiva & vibrate back & forth horizontally & vertically |
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Denture care
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Remove using gauze or a tissue
Always have labeled denture cup Cushion basin w/ water, washcloth, or paper towels Remove uppers 1st, then lowers Use lukewarm water-NOT HOT Store in tepid water *keeping dentures out for long periods of time may change gum line **never wrap dentures in tissues or napkins! |
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How to perform oral care for an unconscious PT
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Turn PT on side, or turn head to side to avoid aspiration
Use toothetes & hydrogen peroxide |
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What PTs get perineal care?
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PTs unable to do it themselves for any reason
PTs who can't reach All PTs w/ catheter Maybe PT who is obese or elderly |
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Describe pediculosis & treatment
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Head lice-comes from sharing combs, etc. Lice lay eggs called nits (like warm, moist areas), nits look like dander. use special shampoo to treat, & comb out nits
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Describe bed bath procedure
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First--offer bed pan or urinal!
--fold washcloth into mitt 1. Explain what you are doing/are going to do 2. use bath blanket for warmth 3. strip top linen & put folded blanket on chair 4. use soap 5. expose only what is being washed 6. change water to keep it warm and free of soap, always change after feet & genitals 7. start on arm/leg farthest away 8. use long, firm, smooth strokes distal to proximal to increase venous return & promote blood circulation |
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Bed bath body area steps
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1. eyes (inner to outer)
2. face, neck, ears 3. arms, axilla 4. hands 5. chest 6. abdomen 7. legs, feet |
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Describe Hibiclens
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used for ICU Pts & surgical PTs
Should be used for max of 3 to 5 days Need to rinse |
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Describe Coloplast
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Used for general, non surgical bathing or if there is an allergy to Chlorhexidine
"No Rinse" should be applied to wet washcloth |
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Gingiva
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gums
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os, stomato
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mouth
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bucca
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cheek
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embolus
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moving clot
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thrombo
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blood clot
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lympho
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lymph
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arteria
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artery
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vena, phlebo
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vein
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hem, hema, hemato
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blood
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angio, vaso
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vessel
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cardio
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heart
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I & O
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intake & output
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ad lib
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as desired
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BM
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bowel movement
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BP
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blood pressure
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BRP
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bathroom privileges
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stat
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immediately
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TPR
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temperature, pulse, respiration
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NPO
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nothing by mouth
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S
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without
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C
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with
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prn
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when necessary
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skeleto
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skeleton
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ano, procto
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anus
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recto
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rectum
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colo
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colon
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appendeco
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appendix
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caeco
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cecum
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ileo
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ileum
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jejuno
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jejunum
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duodeno
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duodenum
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entero
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intestines
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cholecyst
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gallbladder
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hepato
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liver
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gastro
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stomach
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esophago
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esophagus
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pharyngo
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pharynx
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glossa
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tongue
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Therapeutic nurse-client relationships need:
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caring
trust genuine, honest, & sincere engagement |
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Social Relationship
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occurs spontaneously
similar sharing of info mutual needs are considered |
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Helping Relationship
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occurs specifically
unequal sharing of info purposeful, client's needs are the goal |
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Goal of the Helping Relationship
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determined cooperatively
defined by the client's needs |
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Name the phases of the helping relationship
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1. orientation phase
2. working phase 3. termination phase |
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Describe SBAR
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hands off communication
provides accuracy provides communication w/: other hospital departments nurse to nurse report nurse to md discussion |
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What does SBAR stand for?
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situation
background assessment recommendations |
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What does CBS stand for?
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c=call bell in place
b=bed in lowest position s=siderails in place |
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What does the nursing history for safety include?
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assess for history of falls or accidents
note assistive devices be alert to history of drug or alcohol abuse obtain knowledge of family support systems |
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What is the leading cause of injury fatalities in adults older than 65?
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falls
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How is stress related to safety?
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stress causes pts to be more prone to accidents due to distraction
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What is a sentinel event?
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a terrible event that causes changes to be made
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What should a nurse do before attempting to use restraints?
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attempt alternatives first* restraints are a last resort
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How often should you assess a violent PT on restraints?
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every 15 mins
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How often should you assess a nonviolent PT on restraints?
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every half hour
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What are some primary causes of falls?
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change in balance or gait disturbance
muscle weakness dizziness, syncope, vertigo cardiovascular changes vision changes physical environment acute illness neurological disease language disorders impairing communication polypharmacy |
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What are the interventions for a PT who falls?
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immediately assess condition
provide care & interventions for status/injuries |
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What are some restraint alternatives?
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determine whether a behavior pattern exists
assess for pain & treat rule out physical causes for agitation involve family members reduce stimulation, noise, light check environment for hazards use therapeutic touch |
