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176 Cards in this Set

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nosocomail infections
hospital acquired infection
rationale for donning and removing gloves
* to prevent the spread of microorganisms from worker or environment to client
* prevent he spread of microorganisms from client to worker
* to prevent the spread of microorganisms between clients
rationale for handwashing
* decrease # of bacteria on the hands
* prevent the spread of microorganisms from worker or environment to client
* prevent the spread of microorganisms between clients
Principles for handwashing
1-wash hands thoughly at the beginning of the shift before providing client care
2- wash hands for 30 sec before and after proving client care
3-wash hands before and after preparing medication
4- wash hands after handling soiled linen, equipment or supplies
5-wash hands between contact with different clients
6-wash hands after removing gloves
7-wash hands after you sneezed or coughed
8-wash hands before and after eating
9-wash hands before leaving the nursing unit
what is the estimated amount of nosocomial infections that could be elimanted by hand washing
50%
When do you use latex gloves?
for proceedures requiring fine motorskills & lenghty proceedures
when do you use vinyl gloves?
*personal hygiene with clients
*empty bedpans
*handling specimens
*dealing with body fluids
when are standard precautions used
used for all clients in hospital
*apply to blood, body fliud, excretions and secretions(except sweat)
*contact with nonintact skin
*contact with mucous membrans
what are the 3 routes of transmission in tier 2 precautions?
Airboure
Droplet
contact
what are isolation techniques?
-proper handwashing
-proper cleaning of reusable equipment
-donning &removing isolation attire
-proper disposal & labelling of soiled linen & equipment
what are some factors that makes a client more susceptible to infection?
-altered nutritional status
-stress
-fatigue
-disease
-drugs
-metabolic functions
-age
what is an anatomic barrier?
-skin mucous membranes
(unable to protest if the integrity is broken down)
what kind of immunity protects the body?
antitoxins & vaccines
-natural immunity = inherited
-aquired immunity = vaccination, exposure to disease/infection
how does inflammatory process protect the body?
-activates various systems in body (plasma, clotting)
-blood flows to inflammed area is increased
- drainage of inflammed debris to external enviroment
what are the predispostions to infection?
-broken integrity of skin/membranes (surg.wounds)
-change in immunity
-implants-heart values, grafts
-extensive use of I.V. therapy
What are the 3 major oragnisms responsible for nosocomial infection?
-clostridium difficile
-MRSA (methicillin resistant staphylococcus aureus)
-VRE (vancomycin resistant enterococcus)
what kind of restriants are there?
-chemical (drugs)
- physical (requirer a doctors order)
when putting on a isolation gown what are the steps?
1-wash hands
2-pull gown on to both arms
3-wrap gown around self and tie at waist
4-tie gown at neck
5-don mask & eye protectio
6-don gloves tucking in sleeves
What is the proceedure for removing isolation clothing?
1-untie gown at waist
2- remove gloves turning inside out
3-untie gown at neck
4-turn gown inside out as you pull it off
5- dispose of gown
6- rermove mask and eye ware
7- wash hands
what are the rationales to restraints?
-identify clients who need to be protected from injury
-employ preventive measures before restraints are implemented
-identify most appropriate type of restraint for client
-apply restraints appropriately to prevent circlutory & range-of-motion complications
what are the signs of a latex allergy?
facial swelling, rhinitis, eye symptoms,generalized urticaria, and respiratory distress
what other allergies may a person with a latex sensitive have?
avocados, bananas, kiwifruit, or chestnuts
What is the rationale of bathing?
-decreased possiblity of infection by removing excessive debris, secretions and persperation from skin
-prevent body oder
-promote circulation
-maintain muscle to through active or passive movement during bath
-assess clients overall status, skin condition, level of mobility and comfort
What tempeture should the water be in a bed bath or regular bath?
105 degrees F
in what order do you do a bed bath?
-face
-upper extemities from wrist to shoulders
-soak hands provide nail care
-chest and abdomen
-legs ankle to hip
-soak feet and provide nail care
-change water
-back and buttocks
-peri-care
what is tapotement?
alternating fleshy part of hands on clients back as you move up and down the back
what is petrissage?
pinching of the skin, subcutaneous tissue, & muscle as you move up and down the client's back
What are the rationales of bed making?
-provide a clean, comfortable sleeping and restinf environment
-eliminate irrants to skin by providing wrinkle free sheets
-avoid clint discomfort when making a occupied bed
-properly dispose of bed linens to prevent cross contamination
what are the rationales of skin care?
-prevent skin breakdown for clients at risk or on bed rest
-promote feelings of self-esteem by decreasing or preventing skin problems
-prevent infections by maintaining intact skin
-maintain skin cleanliness and prevent body odor
what are the body positionin rationales?
-prevent contactors
-promote optimal jiont movement
-prevent injury due to improper movement
-prevent pressure ulcer formation
What is semi fowler postion and when is it used?
on back with head of bed raised to a 45 degree angle, pillows under patients arms
-frequently post-op
-allows lungs to expand and thus prevent pneumonia
what is lateral postion in bed?
laying on side with pillow at chest hieght to support arm and a pillow between legs, sometimes a pillow at back
What is prone position in bed?
laying on stomach. pillows under stomach and shins. no pillow under head.
what does it mean to dangle a client and why so we do this?
sit client at edge of bed after they have been laying down.
-a client may experience orthostatic hypotension if they have been on bed rest for a period of time/
what is orthostatic hydrotension?
blood pressure that falls upon standing
What is the rationale of range of motion?
-improve or maintian jiont function
-improve or maintain muscle tone & strenght
-prevent contractures
-prepare clients for ambulation
what is abduction?
movement of a bone away from midline of body
what is adduction?
movement of bone towards the midline of the body
What is eversion?
turning outwards
What is extension?
movement that increases the angle of 2 bones
What is flexion?
movement that decreases the angle between 2 bones
what is hyperextension?
can't extend beyond
What is inversion?
turning inward
What is pronation?
rotation of forearm so palm faces backward
What is rotation?
movement of bone around it's own axis
What is supination?
rotation of forarm so palm faces forward
What are the rationale of ambulation?
increase strength and promote exercise tolerance
-prevent complications of immoblity
-promote healing by increasing circulation to muscles
-to restore independance & a feeling of self worth
What are the steps to teach a client to use a walker?
instuct client to hold hand grips
-move walker 6-8in. ahead
- move weaker side 1st
-balance self & move unaffected side
- move walker ahead
What are the istructions for a client witha cane?
-size-allows a 20-30 degree flexion at elbow
-hold cane on stong side
-move cane and weak side @ same time
-walk with patient on their affected side
What is another method for using a cane?
-Move cane forward 12"
-move weak side forward to cane
-move strong leg ahead of cane and weak side
what are 3 different types of crutches?
Axillary (under arm)
Lofstrand Forearm crutches
shelf crutches (used if unable to use wrists to wt. bear)
what is the 4 point gate?
-move right crutch
-move left foot
-move left crutch
-move right foot
What is the 3 point gate?
-2 crutches support weaker extremity
-balance weight on crutches
-move both crutches & affected leg forward
-move unaffected leg forward
What is the 2 point gate?
advance right foot & left crutch simultaneously
-advance left foot & right crutch simultaneously
what is swing gate?
-move both crutches forward
-swing to gait: lift and swing body to crutches
-swing through gait: lift and swing body past crutches
-bring crutches infront of body and repeat gait
What are the cardinal signs?
Vital signs; they reflect the body's physiologic status
what are the rationales of temperture
-determine if core temperature is within normal range
-provide a base line data for further evaluation
-determine alterations in disease
What regulates temperature?
the hypothalumas
What is hypothemia?
when body temp is below 34.4
-may be causes by; accidental exposure, frostbite or G.I. bleeding
-take recal temp.
What is hyperthermia?
body temp. higher than 100.4
-causes; infection, dehydration, exercise, enviromental factors
what is circadian thermal rhythm?
temp. changes throughout the day
-highest between 1700 &1900
-lowest between 0200 & 0600
when should you not use a tympanic thermometer?
In infected ears
draining ears
how far do you insert a rectal thermometer?
1 - 1 1/2 inches
what is the rationale of pulse taking?
-determine if pulse rate is normal and rhythm
-evaluate quality of corresponding arterial pressure
-monitor & evaluate amplitude& contour of pulse wave & artery elasticity
- monitor & evaluate changes in clients status
-reflect function of vital organs
when checking a pulse what are you looking for?
-rate
-rhythm
-amplitude
-also check for symmetry(left&right)
What is the pulse defict?
Apical pulse - Radial = pulse defict
what are all the pulse points?
-carotid
-apical
-brachial
-ulnar
-radial
-femoral
-popliteal
-posterior tibial
-dorsalis pedis
what is dysrhythmia?
abnormality of heart rate or rhythm
what is arrhythmia?
deviation from normal cardiac rate rhythm or time intervals
What are factors that increase or decrease heart rate?
-drugs
-decreased o2
-blood loss
-exercise
-body temp
what is stroke volume?
amt. of blood ejected from heart with 1 contraction
what is cardiac output?
heart rate /minute X stroke volume
what is hyperkinetic pulse?
bounding pulse
-may occur with increased stroke volume
what is hypokinetic pulse?
weak pulse
-may be associated with decreased stroke volume
what is pulsus alternans?
a regular pulse that alternates between strong and weak beats.
-maybe related to left ventricular failure
what is bigeminal pulse?
every 2nd beat has a decreased amplitude
-maybe due to premature contractions
what is hypoxia?
defiency of O2 reaching the tissues in the body
What does 0-3+ mean in recording a pulse?
0=absent
1+=weak
2+=normal
2+=bounding
what are the rationales of respiration?
-note respiration rate, rhythm, and depth
-establish baseline information upon admission of client to unit
-note labored, difficult, or noisy respirations or cyanosis
-identify alterations in resporatory pattern resulting from disease conditions
what is bradypnea?
a slower rate than normal of respirations
less than 10 breaths per minute
what is tachypnea?
a faster rate of breathing than normal
more than 24 breaths/minute
what is hyperpnea?
increased depth of respirations
what is the ratio of pulse to respirations
5-1
what is biot?
respirations are an irregular pattern
slow & deep or
rapid & shallow, followed by apnea
what is kussmaul?
respirations are deep & gasping (hyperventalation)
what part of the brain controls breathing?
medulla
What is cheyne-stokes?
cycles where respirations increase in rate and depth, then decrease, followed by apnea
what are the normal brathing rates for adults, children, infant?
adult- 12-18/min
child 20-25/min
infant up to 40/min
what is a spirometre used for?
to measure tidal volume
What are the rationales for blood pressure?
-note any change from prior assessment
-to determine size of cuff needed for accurate reading to be taken
-note beginning & disappearance of korotkoff sounds during a blood pressure reading
-note presence of factors that can alter blood pressure reading
what is systolic pressure?
the highest arterail blood pressure of a cardiac cycle occuring immediantly after systole of the left ventricle of the heart
what is diastolic pressure?
the lowest arterial blood pressure of the cardiac cycle occuring during diastole of the heart
what is measured by the systolic?
provides database about the condition of heart and great arteries
what is measured by the diastolic?
indicates arteriolar and peripheral vascular resistance
what is respiratory acidosis?
excessive retention of carbon dioxide due to a respiratory abnormality (obstructed lung disease)
what is respiratory alkalosis?
excessive elimanation of carbon dioxide due to a respiratory abnormality (hyperventilation)
what is atelectasis?
colasped lung
what do crackles sound like?
fizzing & popping heard at he end of inspiration
What do wheezes sound like?
musical sounds heard on inhalation or exhalation
what are the clinical manifestations of inadequate ventilation?
-crackles
-dyspnea
-restlessness and lose of muscle coordination
-use of accessory muscles to breathing
-change in cognition or level of response
-tachycardia
-tachypnea
-increased blood pressure
-cyanosis
what are the interventions to support respirtory function?
-adequate hydration(keeps secretions thin & easy to mobilize)
-positioning(semi fowlers)
-turning(prevents pooling)
-deep breathing
-coughing
-range of motion
-early ambulation
how & when do you collect a sputum sample?
-in A.M., before brushing teeth
-rinse mouth
-sit client up
-deep breath
-cough and spit sputum into a sterile container
what is a pulse oximetry?
measures % of O2 saturation
what is hypovolemia?
diminished circulating blood volume
what is arteriosclerosis?
arterial disease characterized by inelasticity and thickening of vessel walls
what is endocarditis?
inflammation of the endocardium which is the epithelial lining of the heart surface and cavities
what is pericarditis?
inflammation of the pericardium which is the double walled sac surrounding the heart
what is a pneumothorax?
accumilation of air within the pleural sac creating a positive pressure in the interplearal space resulting in collapse of lung tissue
What is COPD?
chronic obstructive pulmonary disease
what is rhinitis?
inflammation of the nasal mucous membranes
what is orthopnea?
difficulty breathing except in a upright position
what is anasarca?
generlized edema
what is azotemia?
nitrogenous wastes present in the blood
what is cachectic?
being in a state of malnutrition and wasting
what is calculus?
concentration of mineral salts in the body leading to the formation of stones
what is cystitis?
inflammation of the bladder
what is dialysate?
solution used in dialysis
What is dialysis?
mechanical means of removing nitrogenous waste from the blood by imitataing the function of the kidneys nephons
What is dysuria?
difficult or painful urination
What is erthropoiesis?
production of RBC and thier release from the bone marrow
What is fulguration?
procedure to destroy tissue with long high frequency electrical sparks
What is ileal conduit?
implantation of the urethers into a piece of ileuni which is attached to the abd. wall as a stoma so urine can be removed from the body
What is litholapaxy?
proceedure involving crushing of a bladder stone and immediante washing out of the fragments theough a catheter
What is micturation?
process of expelling urine from the bladder. same as voiding and urination
What is nephrotoxic?
quality of a substance that cause the kidney tissue damage
what is noctural enuresis?
incontinence of urine that occurs during sleep (bed wetting)
What is overflow incontinence?
leaking of urine when the bladder becomes very full and distended
What is pylonephritis?
bacterial infection of the renal pelvis tubles and interstitial tissue of one or both kidneys
what is pyuria?
pus in urine
what is renal colic?
severe pain produced by the passage of a calculus from the kidney thru the ureter
What is residual urine?
urine remaining int the bladder after the individual has urinated
What is retroperitioneal?
behind the peridoneun outside the peritoneal cavity
what is stress incontinence?
leaking of urine when the indivual does anything that strains the abd.
what is urge incontinence?
inability to surpress the sudden urge ot need to urinate
what is urinary incontinence?
involutary loss of urine from the bladder
what is urinary retention?
inablity to void when there is an urge to void
What is urolithiasis?
calculus or stone formed in the urinary tract
what is urine made of?
95% water
5% made of
-nitrogenous waste
-electrolytes
-bile pigment
-hormones
-metobolized drugs and toxins
what are the rationales for catherization?
determine need for intermittent catherization
-promote urinary elimination
-determine emptying abliity of bladder after voiding
-prevent or releive bladder distention
-completly assess abd. & pelvic pain
-obtain sterile urine specimen
-prevent urinary tract infections through catheter care
what is a straight catheter used for?
-used to drian the bladder or get a urine sample. not to be left in.
what is a indwelling or retention catheter?
intended to remain in place for an extended period of time
What is a suprapubic catheter?
inserted above the symphysis pubis into bladder.
what is the procedure for straight catheterization of a female?
-prep & drape
-open sterile package
-place sterile pad under buttocks
-don sterile gloves
-open sterile anticeptic prepare cotton balls
-open lubrication prepare catheter tip
-place drape over perineum exposing meatus
-clease meatus
-insert catheter 2-3" or until urine flows
remove catheter when flow stops
what is the procedure for a straight catheter for a male?
prep and drape
-cleanse penis
-open sterile package
-don sterile gloves
-place sterile pad under client
-place steile drape over penis
-prepare cotton balls
-prepare catheter tip with lub
-cleanse penis
-lift penis to 90 degree angle
-insert catheter to about 8" until urine flow starts
-obtains speciman
-remove catheter
-
what extra step do you take with an indwelling catheter?
Inflate balloon
-tape tubing to leg
-attach catheter bag
when removing a indwelling or retention catheter what is important to remember to do?
-Deflate the balloon
-pull gently on the catheter to make sure balloon is deflated
what are the complications associated with a indwelling cathater?
-UTI
-cathater leaks
-pain
-bladder spasm
-urethral sphinter damage
-epididymitis(males)
-prostatitis (males)
-scrotal abscess(males)
-prostatic abscess(males)
-urinary calculi
what are the rationals of catheter & bladder irrigation and instillation?
-remove blood clots following prostatic surgery
-instill medication into bladder
-ensure patency of drainage system
-releive bladder spasm
what do you do to collect a urine sample from a closed system?
-clamp cathater for 15mins
-clean aspiration port with alcohol swab
-insert needle at 30- 45 degree
-remove urine
-remove needle, wipe port again
what are the rationales for rectal tubes
promote removal of flactulence following abd. surgery or for clients who have swollowed excessive amounts of air
-stimulate expulsion of flatus in lower digestive tract
-prevent abd. distention that can result in diaphragmatic muscle contractions & cause dyspnea
-manage continual diarrhea
what are the rationales or enema administration?
-relieve constipation
-reduce amt. of flatus
-releive bowel impaction
-cleanse bowel before and or after surgery or diagnostic exam
-obtain fecal specimen
what are the four types of enemas
-cleansing
-retention
-distention reduction
-medicated
What type of enema is the harris flush enema (return flow)?
distention reduction
why would you give a retention enema?
-to lubracte rectum & colon and to softed stool
-to provide nourishment in temporary or emergency situations
wo far do you insert a rectal tube and a enema tube?
rectal tube 4-6"
enema tube 3-4"
How long should fleet enema anda retetion enema be held?
fleet enema- 5-7 min.
retention enema 1-3 hours
what is the normal specific gravity range?
1.003 - 1.030
how many beats does the pulse raise for every degree of tempeture?
8 beats per minute for every 1 degree F
where is an ileostomy located?
what are the characteristics of the stool?
-the right side of the abd.
-the stool is dark green liquid to mush, not usually odorus, pouch needs emptyong 6 or more time a day
Where is a sigmoid colostomy located?
what are the characteristics of the stool?
the left side of the adb.
-stool is semi formed or formed, usually needs emptying 1 or 2 times a day
where is a transverse colostomy located?
what are the characteristics of the stool?
left or right side on the upper abd.
-mushy to semi formed stool and gas, needs to be emptyed several times a day
what are the route of admistation for non parental drugs?
-oral (mouth)slowest absortion
-topical (skin ear, eyes)
-mucosa (mouth subliqual, lung, nose, rectum, vagina
What are the routes of administation of parental drugs?
injections via
-intradermal
-subcutaneous (S.C.)
-intramuscular (I.M.)
-intravenous (I.V.)
what are the 7 rights
-medication
-dose
-route
-time
-cleint
-reason
-documentation
what kind of medication should you never crush?
-enteric coated
-long acting tablets
-contents of capsules with beads or pellets
-sublinguel meds
-don't give oral meds sublingeally
when giving ear drops to children and adults what do you do?
children-pull ear down and back
adults-pull ear up and back
what are some topical medications?
lotions, creams, transdermal patches, eye drops, ear drops,
what are some mucosa medications?
sublingeaul pills
inhalers
nebulizor
suppositories
what are some safe actions to alter pills?
-chewable meds can be crushed
-powder from capsules can be mixed with food or liquid
-liquid capsules can be drained and mix with food or liquid
-beads from opened capsules can be sprinkled on food but should not be chewed
how many times should you check a drug label against the MAR?
3 times
-when taking the med. from the storage place
-before preparing med.
-before returning it to storage place
what are the rationales of respiratory preventive measures?
-improve pulmonary function
-prevent hypoventilation & atelectasis
-prevent pulmonary infection
-promote clients awareness of breathing
-to loosen secretions & promote airway clearence
how do you use an insentive spirometry?
instuct client to exhale completely, then place mouth tightly around mouth piece
-inhale slowly to raise & maintain flow rate indicator at beat flow rate range, and continue inhaling to try to raise piston to prescribed volume level
-encourge to use hourly
what is a peak flow meter?
a device used to evaluate lung function by measuring max expiratory flow rates.
what is vital capacity?
max. amount of air that can be exhaled after normal inhalation
what is forced vital capacity?
vital capacity with forced inhalation and exhalation
what are the 2 types of masks with reservoir bags and the difference betwen them?
Partial rebreathing mask
-no inspiratory valve, so that the begining portion of exhaled air returns to the bag and mixes with the inhaled air, ports are present so most exhaled air escapes
Nonrebreathing mask
-valve closes during exhalation so that exhaled air does not enter the resevior and is not reabsorbed. Valves on mask side perts allow ehalation, but close on inhalation of room air