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154 Cards in this Set

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  • Back
What is the purpose of OSHA?
-designed to protect the employee from exposure
What is the purpose of the CDC?
-protect the patients and employees from infection transmission
What is an infection?
-entry and multiplication of infectious agent or pathogen in host tissue
-causes cell injury
-pathogen is present, but does not cause cell injury
Symptomatic Infection:
-pathogens multiply and cause clinical s/sx
What is the chain of infection?
-infections agent
-portal of exit
-mode of transmission
-portal of entry
Incubation Period:
-the time entrance of the pathogen and the appearance of the first symptoms
Prodromal Stage:
-from general to specific symptoms
Illness Stage:
-symptoms of the specific disease
-acute symptoms are gone and the recovery phase begins
Means of infection transmission?
-Common Vehicle
-direct or indirect
-sneezing or suctioning
-droplets remain suspended in the air
Common Vehicle
-result from procedure
-example: catheter or IV
-normal flora become altered & overgrowth occurs
-example: yeast infection from taking meds
-organism present outside of clients normal flora
Risk factors that make a pt more susceptible to infection:
-immuno suppression drugs
-chronic disease
-deficient knowledge regarding infection control
-invasive procedure
-impaired primary/secondary defense mechanisms
Measurable criteria pt does not have an infection?
-vital signs stay with normal range
-pt remains afrebile (w/out fever)
-wound decreasing in size
-lungs clear, sputum white or clear
-urine clear, no pain or burning w/voiding
-is the absence of pathogenic (disease producing) microorganisms
Aseptic technique:
-procedures that assist in reducing the risk for infection or infection transmission
-maintain sterility of anything that’s going to enter client’s body (except thru GI tract)
Which blood borne pathogens can be found in blood or body fluid?
-Hep C
-Someone with the same infection
Reduce reservoirs of infection by:
-change of dressings
-moisture resistant bags
-needles or sharps features and containers
-keep table surfaces dry and clean
Excessive smoking:
-increased risk of liver disease, MVA
-increased risk of CV, pulmonary disease
Excessive stress:
-increased risk of accident, illness
Sexual practices:
-risk of HIV
-undesired pregnancy
-material safety data sheet
Musculoskeletal changes:
-impair mobility
Nervous system changes:
-slows reflexes
-reaction time
Sensory changes:
-decreased vision
Genitourinary changes:
Environmental Risks:
-equipment or furniture inhibits ambulation
-call light, personal supplies out of reach
-equipment malfunction
-chemicals spills
Home Hazards:
-throw rugs
-electrical equipment
-obstructed pathways
-need for safety equipment in bathroom
-smoke detectors
What factors increase the risk of patient falls?
-hx of falls
-meds se
-need to use the restroom
-slow call light response
-disoriented or confused
-use assistive device
-age >65 forget how to walk
-chronic diseases leading to weakness and dizziness
-unsteady gait, hemi paresis
-uncooperative pt gets up without asking for help
How can you reduce the risk of patient falls?
-bed alarms
-toilet schedule every 2 hours
-beside commode and urinal within reach
-call light, beside table within reach
-non-skid reach
-educate on use of call light, special call light
-vail bed or posey
How often should you assess a pt in restraints?
-every 15 mins
Status epilepticus:
-Seizures lasting >15 min. or repeated seizures in a 30 min. period
What do you do when you have a status epilepticus?
-insert airway when jaw is relaxed
-have O2, suction, and IV equipment available
-administer meds as directed by MD
How can you reduce the risk of aspiration if a pt vomits?
-turn them on their side
Risk management:
-root cause analysis to determine underlying causes
Sentinel Events:
-are occurrences that cause or have the potential to cause serious harm or death in a patient
When can restraints be used?
-ONLY as a last resort to immobilize pt or an extremity
How long can restraints be used for?
-remove every 2 hours to assess
-reassess every 24 hours
How are Hepatitis A, B, C, and HIV transmitted?
Personal Protective Equipment:
-exam gloves
-face shields
-shoe covering
-leg coverings
Health hx survey should be done before the physical exam. Why?
-helps you focus on what you should be looking at during the physical.
Who should you get health hx info from?
-information obtained through use of senses
-are judgments or interpretations of cues
How often is an assessment done?
-initial assessment
-every shift
-hourly, weekly, monthly
-before and after a procedure or meds
-if pt has a health complaint
How do you prepare a client for an assessment?
-explain purpose
-establish a report
Orientation/introductory phase:
-explain purpose of interview
-ask non-threatening biographical information
-establishing nurse-client relationship
Working Phase:
-data regarding chief complaint and health hx collected for care plan development
Termination phase:
-give clue that interview is coming to an end
-offer client opportunity to ask questions
-what pt/family tells you
-pt health hx
-findings with physical assessment
-diagnostic test results
What are the 4 assessment types?
-follow up
-urgent car/ER
-admitted to the hospital
-doctors office
Follow up:
-after surgery
Urgent care/ER:
Complete Nursing Health History:
-biographical info
-present illness or health concerns
-family history
-psychosocial history
-nutritional status
-client expectations
-past health history
-environmental history
-spiritual health
-functional status
-medication profile
Biographical data:
-marital status
-health care insurance
Client expectations:
-find out what clients expect to happen to them while seeking treatments for their health
Present illness or health concerns:
-determine when the problem began
-how severe
-what makes them worse
-what makes them better
Family history:
-blood relative health issues
-recent losses
-religious influences
Spiritual health:
-religious habits
Health history:
-provides you with info regarding the clients past hx.
Environmental hx:
-home environment
-workplace environment
-exposure to pollutants
Psychosocial hx:
-support system
-family members
-coping mechanisms
Review of systems:
-a method for collecting data on body system
Past Health history:
-medical hx
-surgical hx
-medication (herbal and OTC)
-blood transfusions
-childhood illnesses
Activates of Daily Living:
-Physical self care
Instrumental Activates of Daily living
-things in which enable a person to function independently at home
-thought processes
-looking at the client
-any data collect through smell is also considered to be a part of inspection
-use of hands to determine texture, size, shape consistency and location of certain body parts
-identify areas identified by pt as tender or painful
-listen to the sounds of the body during a physical exam
Different types of palpation:
-pads of fingers (pulse)
-dorsum of hand (temp)
-bony part of palm at base of fingers (vibrations)
Light Palpation:
-1cm in depth
-gentle pressure to detect tenderness or pain
Deep Palpation:
-4cm in depth
-harder pressure is used to assess underlying organs
Diaphragm of stethoscope:
-to hear high pitch sounds
Bell of Stethoscope:
-to hear soft and low pitched sounds
-pupils equal
-reactive to light
-jugular vein distension
-in the fingers
-sx of chronic pulmonary disease
Normal chest:
-elliptical shape, ribs slope down
-1:2 ratio
Barrel chest:
-width & depth equal, ribs horizontal,
-normal with aging and infants
-1:1 ratio
Symptoms of Hypoxia:
-acute disease
-mental status change
-progresses to lethargy
-abnormal quiet respiration
-abnormally slow respiration
-rapid, shallow respirations
-rapid, deep respirations
-caused by exertion, fear, anxiety, compensation for acidosis
-complete or intermittent cessation of breathing
-bluish discoloration of nail beds, oral mucosa, conjunctiva
Angle of Louis:
-boney ridge forming articulation of manubrium and body of sternum, Continues with 2nd rib.
3 lobes:
-right lung
2 lobes:
-left lung
-rustling like wind in trees
-sound of air in bronchioles & alveoli
-primarily during inspiration
-harsh, hollow sound
-normally heard over trachea & larynx
-abnormal if heard over lungs fields, associated with consolidation (pneumonia)
-upper sternum & between upper scapulae
-normal over large bronchi
-equal on inspiration & expiration
-moderate pitch, mix of bronchial & vesicular sounds
-abnormal over lungs fields, associated with consolidation
-formerly rales
-alveoli popping open
-like hair rubbing together
-fine, pitched crackling and popping noise
-not cleared by coughing
-early inspiratory crackles in COPD
-late inspiratory in restrictive disease (CHF, pneumonia)
-due to narrow airways
-high pitched musical sound similar to squeak
-occurs in small airways
-low pitched, coarse, loud
-heard primarily during expirations
-coughing may clear
-collapsed shrunken section of alveoli due to airway obstruction by think exudates, foreign body, tumor
Lobar Pneumonia:
-infection in lung, alveoli fill with bacteria, debris, and fluid
-proliferation of mucous glands causing excessive mucous secretion & inflammation
-Harsh cough
-destruction of pulmonary connective tissue & permanent enlargement of air sacs, trapped air
-reactive airway
Pleural effusion:
-collection of excess fluid in Intrapleural space (water, puss, blood)
-Crackles at bases, sx fluid overload
Aortic Area: (a pig eats ten melons)
-2nd ICS, RTB
Pulmonic Area: (a pig eats ten melons)
-2nd ICS, LSB
Erb’s point or second pulmonary: (a pig eats ten melons)
-3rd ICS, LSB
Tricuspid: (a pig eats ten melons)
-5th ICS, LSB
Mitral/ Apical Area: (a pig eats ten melons)
-5th ICS, left midclavicular line or slightly medial
-first heart sound
-beginning of systole
-produced by closure in mitral & tricuspid valve
-heard best in mitral or apex are
-coincides with carotid artery
-second heart sound
-end of systole
-produced by closure of aortic and pulmonic valves
-heard best at base of heart (2nd ICS bilaterally)
-may be split-normal
-ventricular gallop
-apex or lower LSB
-early sign of heart failure
-atrial gallop
-heard at apex
-may occur normally after exercise
-may indicate CAD, cardiomyopathy, aortic stenosis, systemic hypertension
-blowing, swooshing sound that occurs with turbulent blood flow in heart or great vessels
-also known as lift
-sustained forceful thrusting of ventricle during systole
S/SX CHF, fluid overload:
-dyspnea on exertion, orthopnea, fatigue
-crackles in lungs
-dependent pitting edema
-increased BP, bounding pulse initially
-Jugular vein distension
-skin pale, gray, or cyanotic/ cool & moist
-dilated pupils – sympathetic nervous system
-N & V
Order of assessing the abdominal:
-I ate pecan pie
What area of the stomach do you start?
What do normal bowel sounds sound like?
-high-pitched irregular gurgling 5-30x/min
-present in all 4 quadrants
Abnormal bowel sounds:
-hyperactive-loud, high-pitched, rushing, tinkling sound
Hypoactive sounds:
-after abdominal surgery
-paralytic ileus
-late bowel obstruction
-med side effect
Visceral Pain:
-dull pain
-poorly localized
Parietal Pain:
-increased with movement
-inflammation of peritoneum
Somatic Pain:
-bone and muscle tendons
Referred Pain:
-disorder in another site
Blumberg’s Sign:
-rebound tenderness
-use if pt c/o pain or tenderness
-deep palpation in area away from the tender spot
-let go quickly - + if pain occurs on release of pressure
-contralateral tenderness
Murphy’s Sign:
-palpate liver border
-have pt take deep breath
-feels sharp pain
-stop inspiration
What are the 6 steps of the nursing process?
-diagnosis ADPIE
is a serious, potentially life-threatening allergic response that is marked by swelling, hives, lowered blood pressure, and dilated blood vessels. In severe cases, a person will go into shock. If anaphylactic shock isn't treated immediately, it can be fatal.
Which pts are at a higher risk for anaphylaxis?
People with a history of allergic reactions may be at greater risk for developing a severe reaction in the future.
is movement toward the body.
is movement away from the body.
is the low, hollow sound of normal lungs.
can be heard over emphysematous lungs as a booming sound.
is the high-pitched, drumlike sound heard over a gastric air bubble.
is the soft, thudlike sound that is heard over dense organ tissue.
A common abnormality encountered during inspection of the skin is pallor. Pallor is easily seen in the face, mucosa of the mouth, and nail beds. How would pallor appear in a brown-skinned client?
18. A common abnormality encountered during inspection of the skin is pallor. Pallor is easily seen in the face, mucosa of the mouth, and nail beds. How would pallor appear in a brown-skinned client?
A) As shiny skin
B) As bluish skin
C) As yellowish skin
D) As ashen gray skin

Feedback: CORRECT
Pallor would appear as yellowish brown in brown-skinned people. Pallor would manifest as bluish skin in light-skinned people. Pallor would appear as ashen gray skin in black-skinned people. Shiny skin indicates edema.
Using an otoscope, the nurse can inspect the tympanic membrane. A normal tympanic membrane appears
A normal tympanic membrane is translucent, shiny, and pearly gray. Dark yellow and sticky describes normal moist cerumen (earwax) in front of the tympanic membrane. A white color indicates pus behind the membrane. A pink or red bulging membrane is an indication of inflammation.
Kyphosis is:
(hunchback) is an exaggeration of the posterior curvature of the thoracic spine and is common in older adults.
(swayback) is increased lumbar curvature.
is lateral spinal curvature.
Hypotonic muscle
has little tone and feels flabby, usually because of atrophy of muscle mass.