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144 Cards in this Set
- Front
- Back
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healthcare-associated infection
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infection not present on admission to healthcare agency, acquired during the course of treatment for other conditions
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medical asepsis
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clean technique; involves procedures and practices that reduce the number and transfer of pathogens
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nosocomial infection
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hospital-acquired infection
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personal protective equipment (PPE):
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specialized clothing or equipment worn by a healthcare worker for protection against infectious materials.
Gloves, gowns, HEPA masks, N95 masks, face shields, goggles |
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Standard Precautions
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precautions used in the care of all hospitalized individuals regardless of their diagnosis or possible infection status; these precautions apply to blood, all body fluids, secretions and excretions (except sweat), nonintact skin, and mucous membranes
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surgical asepsis
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sterile technique; involves practices used to render and keep objects and areas free from microorganisms
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Transmission-Based Precautions
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precautions used in addition to Standard Precautions for patients in hospitals who are suspected of being infected with pathogens that can be transmitted by airborne, droplet, or contact routes; these precautions encompass all the diseases or conditions previously listed in the disease-specific or category-specific classifications
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Standard Precautions
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used for all patient receiving care in hospitals w/out regard to their diagnosis or infectious state.
Hand washing and gloves mask, goggles, face shield, and gown is splash or spraying fluids |
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Airborne Precautions
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used for patients who have infections that spread through the air. TB, Varicella, and rubeola
use of respiratory protection |
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What actions should you take for patient with varicella, TB, or rubeola to prevent spread of infection?
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Put into Airborne Isolation
1. Patient should have private room 2. Negative air pressure 3. keep door shut, patient in 4. respiratory protection for those entering |
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Droplet Protection
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Used for patients with an infection that is spread by large particle droplets such as rubella, mumps, diptheria, and adenovirus (kids)
Mask (if w/i 3 ft) |
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What actions should you take for patients with diptheria, rubella, mumps, or adenovirus to prevent spread of infection?
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Put into Droplet Isolation
1. private room (door can be open) 2. if they leave, need surgical mask 3. keep visitors 3ft from patient 4. staff wear mast if working within 3 ft of patient |
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Contact Precautions
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used for patients who are infected/ colonized by microorganisms that spread by direct or indirect contact like MRSA, VRE, or VISA
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What actions should you take for patients with MRSA, VRE, or VISA colonization to prevent spread of infection?
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Put into Contact Isolation
1. Private room if possible 2. Wear gloves when enter room, remove before leaving, wash hands 3. Wear gown if contact or if patient has diarrhea, and ileostomy, colostomy, or wound drainage not contained by a dressing 4. Limit patient movement through the room. 5. Avoid sharing patient-care equipment |
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When should you wash your hands?
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1. Before and after each patient
2. After removing gloves 3. if they are visibly dirty 4. When in contact with blood/body fluids 5. Before eating and after using the restroom 6. If exposed to microorganisms like anthrax, C. diff. |
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Why do we wash our hands the way we do?
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Nursing diagnosis: Risk of Infection
Washing hands prevents spread of microorganisms. To and From the patients. |
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When should I use an alcohol based Hand Rub?
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1. If hands not visibly soiled with blood or body fluids.
2. before and after patient contact, or surfaces in their environment they are fast acting, reduce the number of microorganisms on skin, and cause less irritation |
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How do you effectively use PPE?
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1. put on before contact with patient (B4 entering room)
2. Choose appropriate PPE for situation 3. When wearing gloves go clean to dirty. 4. Touch few surfaces 5. Avoid touching other PPE 6. Keep gloves away from face 7. remove and replace torn or heavily soiled gloves 8. Glasses are not substitutes for goggles. |
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Why do we wear a normal mask?
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to protect the nurse or patient from droplet nuclei and large particle aerosols. Must fit securely to provide protection.(Lynn Skills 147)
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Where should a respirator be removed?
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Outside the patient room after the door is closed. (Lynn Skills 146)
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What part of PPE is considered clean? why?
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The inside, outside back, ties on head and back
They are not likely to have been in contact with the infectious organism. (Lynn Skills 146) |
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So you need to document the use of standard precautions or specific PPE used?
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No, but you should record the implementation of specific transmission based Precautions. (Lynn Skills 148)
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What should you do if you realize you need PPE at the beginning of task and did not apply it?
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Stop task and obtain the appropriate protective wear (Lynn Skills 148)
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What do you do if you are accidentally exposed to blood and body fluids?
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Stop task and immediately follow agency protocol for exposure, including reporting the exposure. (Lynn Skills 148)
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alopecia
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baldness
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tartar
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hard deposit on the teeth near the gum line formed by plaque buildup and dead bacteria
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caries
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cavities of the teeth
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cerumen
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ear wax; consists of a heavy oil and brown pigmentation
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dermis
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underlying portion of the skin
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epidermis
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superficial portion of the skin
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gingivitis
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inflammation of the gingivae (gums)
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halitosis
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offensive breath
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integument:
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skin
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necrosis
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death of cells
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pediculosis
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infestation with lice
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plaque
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transparent, adhesive coating on teeth consisting of mucin, carbohydrate, and bacteria
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podiatrist
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one who treats foot disorders; synonym for chiropodist
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pyorrhea
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extensive inflammation of the gums and alveolar tissues; synonym for periodontitis
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sebaceous gland
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gland found in the skin that secretes an oily substance called sebum
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Why would you wait to put antiembolitic stockings on if a patient has been sitting or walking? How long do you wait?
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Dependent position of legs encourages blood to pool in the veins, reducing the effectiveness of the stockings if they are applied to congested blood vessels. (Lynn Skills 357)
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Even with antiembolitic stockings, patient can get DVT. What are the signs?
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A unilateral swelling, redness, tenderness, positive Homans' sig(pain on dorsiflexion), and warmth. (Lynn Skill 361)
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What are some special considerations for antiembolitic stockings?
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1. remove 20 - 30 min once every shift
2. Wash and air dry as necessary per and per manufacturer. (Lynn Skill 360) 3. check for color, temp, sensation, swelling, and movement every shift 4. Check for rolling (Lynn Skills 360) |
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What do you do if a patient becomes chilled during bath?
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Increase the room temp if you can or add another bath blanket.
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What do you do if a patient becomes unstable during the bath?
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Critically ill often need to be bathed in stages. If BP falls stop and give rest (Lynn Skills 333)
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When looking into the mouth of the patient you see white patches. What would you first think this is?
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Thrush (Lynn Skills 336)
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While cleaning the teeth, you notice a large amount of bleeding from the gum line. What actions do you take?
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Stop brushing. rinse mouth with water and spit into emesis basin. Check most recent platelet level before brushing again. (Lynn Skills 339)
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What should I do for a patient with braces when brushing teeth?
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Brush extra thoroughly because braces collect food. (Lynn Skills 339)
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How do we meet the oral hygiene needs of patients with cognitive impairments?
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1. Choose a time of day they are most calm
2. Enlist aid of family member 3. Break tasks into small parts 4. provide distraction (music etc) 5. Get them to participate (guide if needed or nurse start and they finish) 6. If they strongly refuse, don't do it. (Lynn skill 339) |
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When should you start brushing a child's teeth?
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As soon as the teeth erupt. Start by wiping with damp cloth, then as they get more, as small toothbrush can be introduced. Water used NOT toothpaste. (Lynn Skills 339)
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Why do you not use toothpaste when assisting small children in brushing teeth?
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Excessive amounts of ingested fluoride can lead to a discoloration of the teeth. (Lynn Skills 339)
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What do you do if a dependent patient starts to bite on toothbrush?
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Dont jerk it away. Wait for the patient to relax mouth before removing. (Lynn Skills 342)
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What should you do if the patients mouth is extremely dry with crusts that remain after oral care provided?
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Increase frequency of hygiene. Apply mouth moisturizer to oral mucosa. (Lynn Skills 342)
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How often are dentures cleaned?
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Daily to prevent infection and irritation, help self esteem (Lynn Skills 343)
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What should you do if food or other materials don't come off denture with brushing.
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Place denture in cup with cool water and soak. Then, brush them again if needed with commercial denture cleaner added in cup to soak, then brush clean. (Lynn Skills 345)
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What should you do if you can not remove a contact lens?
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Use a tool to remove the lens. Hard lenses - suction cup tool. Soft contacts rubber grippers.
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What can happen if you leave shampoo in a patient's hair?
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Can cause pruritus (itching) (Lynn Skills 351)
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What should you do if if you find glass in a patient's hair when assisting with hygiene?
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Carefully comb through hair before washing to remove as much glass as possible. When massaging scalp, be alert to signs of pain from patient as glass may be cutting.
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What type of patient should have shaving done with an electric razor?
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patients with low platelets or taking antuthromoblytic. (Lynn Skills 354)
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Which direction should you shave in on a patient?
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legs-opposite direction of hair growth
face- same direction of hair growth (Lynn Skills 355) |
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Why do you not shake the sheets when making the bed?
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Shaking them out causes miscroorganisms to be carried on air currents. (Lynn Skills 369)
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event report
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documentation that describes any injury or potential for injury sustained by a patient in a healthcare agency
Lynn pg. 93 |
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R-E-S-T-R-A-I-N-T
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Respond to the current condition
Evaluate potential injury(self/others) Speak to family members Try alternatives Reassess Alert Doc and Family if restraints needed Individualize use of restraints Note important info in chart Time-Limit use of restraints Lynn pg 96 |
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What are some things you can check to find other causes for patient agitation and reduce use of restraints?
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Respiratory status, vital signs, blood glucose levels, fluid and electrolyte issues, and medications.
Lynn pg 94 |
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What are some steps that can be taken to reduce patient agitation and reduce use of restraints?
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1. reduce noise, stimulation, and lights.
2. Distract & redirect using calm voice 3. Use simple, clear instructions and directions. 4. ask family to stay with patient 5. Treat pain appropriately 6. Use night light 7. Check for hazards, address needs for nutrition, toileting, and fluids, give frequent orientation and explanations. Lynn pg 94 |
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how often does the doctor assess the use of restraints?
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every 24 hours-Lynn 95
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How often does a nurse assess a patient in restraints?
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adults-every 4 hours
children 9-17 - every 2 hours younger than 9 - every hour Lynn pg 95 |
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What are primary causes of falls?
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1. change in balance of gait
2. Muscle weakness 3. Dizziness, syncope, and vertigo 4. Cardiovascular changes 5. change/impairment in vision 6. Environmental hazards 7. Acute illness 8. Neuorlogic Disease, dementia 9. Polypharmacy 10. Language disorder, impaired communication Lynn pg 97 |
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When should restraints be used?
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Physical restraints should be considered as a last resort after other care alternatives have been unsuccessful...and the patient is at increased risk for harming himself or others.
Lynn pg 94 & 103 |
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How do you know when wrist or ankle restraints are not too tight or too big?
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Ensure you can insert 2 fingers between the restraint and patient's wrist or ankle so as not to interfere with circulation. (Lynn pg 105)
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Where do you tie the securing end of wrist restraint and why?
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Tie to bed frame, NOT side rail. This ensures that it will not tightened when pulled and can be removed quickly in emergency. On the side rail, it can injure the patient when rail lowered. Tying out of patient reach adds security. (Lynn, pg 105)
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What position should you avoid placing a patient when in restraints?
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supine position
If they vomit they can aspirate. (Lynn, pg 106) |
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How can you tell a vest restraint is not too tight?
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You should be able to insert your fist between the restraint and patient. Ensure breathing is not constricted by assessing respirations before and after application of vest. (Lynn pg 109)
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Should vest be worn over clothes or under?
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Vest should be worn over patients gown with V opening in the front so the patient does not choke. Be sure there are no wrinkles in the back that would lead to skin impairment. (Lynn pg 108)
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What do you do if a patient slides down and neck is caught in restraint?
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Immediately release restraint. Find alternative method for restraint. (Lynn, pg 110)
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Generally, on which patients are elbow restraints used?
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infants and children (Lynn, pg 110)
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What is the best position for an elbow restraint?
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1. Should not extend below the wrist or place pressure on the axilla which can lead to skin impairment.
2. Be sure 2 fingers can fit between restraint and patient so as not to impair circulation. |
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What action should you take if a patient cries when elbow is moved when using elbow restraint?
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remove restraint more frequently with active or passive ROM. If elbow is not moved, it will become stiff and painful.
(Lynn pg 113) |
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When assessing a patient in restraints, what should the nurse include?
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1. restraint placement
2. neurovascular assessment of the affected extremity 3. skin integrity 4. signs of sensory deprivation such as increased sleeping, daydreaming, anxiety, panic, & hallucinations. (Lynn pg 118) |
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What action should a nurse take if a patient is pulling on leather restraints and causing injury to extremities?
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Notify physician. Patient may need sedation, Talk with patient to see f there is anything that can be done to help him or her relax. (Lynn pg 119)
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What action should a nurse take if she is afraid for own safety when releasing restraints for inspection and range of motion?
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Call for assistance. For their own safety, nurses should have assistance when releasing combative or agitated patient from leather restraints. Security can assist. (Lynn pg 119)
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partial or peripheral parenteral nutrition (PPN)
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nutritional therapy used for patients who have an inadequate oral intake and require supplementation of nutrients through a peripheral vein. (Lynn pg. 594)
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vitamins
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organic substances needed by the body in small amounts to help regulate body processes; are susceptible to oxidation and destruction. (Lynn pg. 594)
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triglycerides
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predominant form of fat in food and the major storage form of fat in the body; composed of one glyceride molecule and three fatty acids. (Lynn pg. 594)
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trans fat
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product that results when liquid oils are partially hydrogenated; these oils then become more stable and solid; trans fats raise serum cholesterol levels (Lynn pg. 594)
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total parenteral nutrition (TPN)
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nutritional therapy that bypasses the gastrointestinal tract; used in patients who cannot take food orally; meets the patient's nutritional needs by way of nutrient-filled solutions administered through a central vein. (Lynn pg. 594)
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residual
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as applied to tube feeding, the amount of gastric contents in the stomach after the administration of a tube feeding. (Lynn pg. 594)
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recommended dietary allowance (RDA)
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recommendations for average daily amounts of essential nutrients that healthy people should consume over time. (Lynn pg. 594)
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protein
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vital component of every living cell; composed of carbon, hydrogen, oxygen, and nitrogen (Lynn pg. 594)
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percutaneous endoscopic jejunostomy tube (PEJ)
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a surgically or laparoscopically placed jejunostomy tube (Lynn pg. 594)
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percutaneous endoscopic gastrostomy tube (PEG)
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a surgically or laparoscopically placed gastrostomy tube (Lynn pg. 594)
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obesity
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weight greater than 20% above ideal body weight. (Lynn pg 594)
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nutrition
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study of the nutrients and how they are handled by the body, as well as the impact of human behavior and environment on the process of nourishment. (Lynn pg 594)
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nutrient
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specific biochemical substance used by the body for growth, development, activity, reproduction, lactation, health maintenance, and recovery from illness or injury. (Lynn pg 594)
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ketosis
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catabolism of fatty acids that occurs when an individual's carbohydrate intake is not adequate; without adequate glucose, the catabolism is incomplete and ketones are formed, resulting in increased ketones. (Lynn pg 594)
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lipid
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group name for fatty substances, including fats, oils, waxes, and related compounds. (Lynn pg 594)
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minerals
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inorganic elements found in nature. (Lynn pg 594)
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NPO (nothing by mouth)
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nothing can be consumed by mouth, including medications, unless ordered otherwise. (Lynn pg 594)
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nasogastric (NG) tube
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a tube inserted through the nose and into the stomach. (Lynn pg 594)
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nasointestinal (NI) tube
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a tube inserted through the nose and into the upper portion of the small intestine. (Lynn pg 594)
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enteral nutrition
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alternate form of feeding that involves passing a tube into the gastrointestinal tract to allow instillation of the appropriate formula (Lynn pg 593)
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cholesterol
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fatlike substance, found only in animal tissues, that is important for cell membrane structure, a precursor of steroid hormones, and a constituent of bile (Lynn, pg 593)
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carbohydrate
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organic compounds (commonly known as sugars and starches) that are composed of carbon, hydrogen, and oxygen; the most abundant and least expensive source of calories in the diet worldwide (Lynn, pg 593)
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calorie
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measure of heat, or energy; kilocalorie, commonly referred to as a calorie, is defined as the amount of heat required to raise 1 kg of water by 1°C (Lynn, pg 593)
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body mass index (BMI)
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ratio of height to weight that more accurately reflects total body fat stores in the general population (weight in kg/height2 in meters) (Lynn, pg 593)
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anorexia
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lack or loss of appetite for food (Lynn, pg 593)
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basal metabolism
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amount of energy required to carry out involuntary activities of the body at rest (Lynn, pg 593)
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What should a nurse check before assisting the patient with feedings?
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1. orders for diet
2. food allergies 3. religious/cultural preferences 4. scheduled labs or diagnostic studies 5. at beginning assess swallowing (Lynn, pg 599) |
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After assisting a patient with feeding, what should nurse do?
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Remove the tray from the room. Document the amount and types of food consumed so that they can be sure the patient is able to meet nutritional requirements. (Lynn, pg 601)
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What should the nurse do if a patient does not want to eat anything on the tray (when doing a feeding)?
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Explore the reason why. Psychological factors? Mutuall develop a plan, consult dietitian. (Lynn, pg 602)
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What should the nurse do if a patient states that she feels nauseated or cannot eat when doing a feeding?
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remove the tray from the room. Ask if they want to eat a small amount like crackers or ginger ale if diet permits. (Lynn, pg 602)
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Why would a nurse insert a nasogastric tube?
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1. to allow the intestinal tract to rest and promote healing after bowel surgery
2. monitor bleeding in GI tract 3. remove undesireable substances (lavage) like poison. 4. help treat intestinal obstructions (Lynn, pg 602) |
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What abnormalities would the nurse look for when assessing a patient before inserting a nasogastric tube?
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1. patency of nares to be sure air passes
2. facial trauma, polyps, blockages, or surgeries. 3. abdomen distention or firmness 4. ascultate the bowel for bowel sounds. if firmness, 5. measure girth to get baseline. (Lynn, pg 603) |
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What position should a patient be in when a nasogastric tube is inserted?
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High Fowler
(Lynn, pg 604) |
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How do you known how long a nasogastric tube should be?
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Measure the distance to insert tube by placing tip of tube at patient's nostril and extending to tip of ear lobe and then tip of xiphoid process. (Lynn, pg 605)
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Why should you use a water soluble lubricant when inserting a nasogastric tube?
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this lubricant wont cause pneumonia if inadvertently inserted into the lungs. (Lynn, pg 605)
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When inserting a nasogastric tube, a patient begins to have tears in their eyes. What action should the nurse take?
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Offer comfort and reassurance but no other action is needed as this is a natural response as the tube passes into the nasopharynx. (Lynn, pg 605)
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Why is a sterile field created?
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to provide a surgically aseptic workspace. This should be considered a restricted area (Lynn pg. 130)
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Which side of the sterile drape should be facing down?
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waterproof side
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What does water do to a sterile drape?
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contaminates it. Water is a conduit for bacteria to enter the sterile field. (pg 131)
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Why would a nurse select a work space that is waist level or higher?
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This allows work area to be in sight. Bacteria tends to settle, so there is less contamination above the waist. (pg. 131)
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How much of a sterile drape is considered contaminated?
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outer 1 inch (2.5cm) of drape is considered contaminated. Any items touching this area are also considered contaminated. (pg. 131)
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Does a nurse need to document that a sterile field was prepared?
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No, but should document that sterile technique was used when sterile technique was used for any procedure.(pg 132)
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what should be done if a part of the sterile field is contaminated?
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discard all portions of the sterile field and start over. (pg. 132)
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what should be done if a nurse realizes she is missing a supply?
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Call for help. Do not leave the sterile field unattended. If you are not able to visualize the field at all times, it is considered contaminated. (pg 132)
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What should the nurse do if a patient touches your hands or the sterile field?
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If just the hands, don new gloves, you should bring 2 pair into the room before beginning. If the field, discard and start again. (pg. 132)
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When you have a prepackaged sterile item with a sterile field, which corner do you open first?
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The one farthest away from me first, then the sides, then the corner closest to me. this helps maintain the sterility of the inside wrapper. (pg. 134)
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Is it okay to reach over a sterile field?
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No this could contaminate. (pg 135)
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What are the first 2 things you should do before opening or making a sterile field?
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1. Identify the patient and explain the procedure.
2. Perform hand hygiene (pgs. 131, 133, 136) |
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Which direction should you open an Agency Wrapped and Sterilized item?
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away from you (pg 136)
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Should a nurse open the package of a sterile item and pull it out with sterile gloves?
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No, hold it 6 inches above the surface of the sterile field and drop onto the field being careful to avoid touching the surface or other items or the 1inch boarder. This prevents contamination. (pg 137)
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How should the cap of a sterile solution be placed on the table and why?
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place cap on table with edged up so that the sterility of the cap is maintained. (pg. 137)
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What should be done if a bottle of sterile solution is already opened?
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"lip" the bottle by pouring a small amount into waste container. this cleans the lip of the bottle. (pg. 137)
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When pouring a sterile solution, on which side should the label be?
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label should be facing the palm of your hand and prepare to pour from a height of 4 to 6 inches. This helps label stay dry and legible. (pg 137)
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Why should sterile solution be poured from 4-6 inches?
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this limits splashing (pg 137)
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What should be done after a sterile solution has been recapped?
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label the container with date and time of opening. (pg 138)
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Which direction should sterile gloves be placed when putting them on the hands?
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cuff end closest to the body. This allows for ease of glove application (pg 140)
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which hand applies the first sterile glove?
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with thumb and forefinger of the non-dominant hand, grasp the folded cuff of the glove for dominant hand. (pg 140)
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What is the first step to putting on the second sterile glove?
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Hold thumb of gloved hand outward. Place the fingers of the gloved hand inside the cuff of the remaining glove. Lift it from the wrapper, taking care not to touch anything with the gloves or hands. (pg 141)
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Which sterile glove is removed first?
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Use dominant hand to grasp the opposite glove near the cuff end on the outside area. (pg 42)
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When removing sterile gloves, how does the nurse contain the contamination?
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Pulls off one glove, then holds it in the still gloved hand and pulls off the second glove inverting it with the first glove still inside. (pg 142)
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What is the last thing you do after wearing sterile gloves?
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hand hygiene (pg. 143)
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What should the nurse do if a whole tear is noticed in one of the gloves?
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discard the gloves, wash hands, then don new gloves. (pg 143)
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What should the nurse do if a whole tear is noticed in one of the gloves during procedure?
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Stop the procedure. remove gloves, wash hands, and put on new gloves. (pg 143)
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What should the nurse do if a patient has a latex allergy?
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wear latex free gloves. (pg 143)
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