6409258
Descrição
FlashCards por Gwen Paparone, atualizado more than 1 year ago
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Criado por Gwen Paparone
aproximadamente 8 anos atrás
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| Questão | Responda |
| Safety | Freedom from psychological and physical harm. |
| Patient Nurse Relationship | Trust, sensitivity, assisting in physical, emotional , and spiritual needs. |
| Patient Nurse Relationship STEPS | Introduce yourself Identify client by name Ensure privacy when providing care Actively listen Maintain eye contact Maintain professional boundaries Respect cultural differences |
| A safe environment | Includes meeting basic needs Reducing physical hazards Reducing/eliminating the transmission of pathogens Controlling pollution |
| Reasons for safety concerns in Older adults? | Higher risk for falls Deteriorating vision, hearing, mobility, reflexes, circulation polypharmacy |
| poly pharmacy | Patients are on a multitude of regular Rx medications. |
| RACE (fire safety) | Rescue, Alarm, Contain, Extinguish |
| The nurse’s first action after discovering an electrical fire in a patient’s room is to… | 3. Remove all patient’s in immediate danger |
| A client is being discharged with oxygen therapy via a cannula. Which of the following instructions should the nurse give to the client and family? | 3. Use cotton clothing to avoid static electricity |
| Electrical Safety | Maintain all electrical equipment Check electrical cords and outlets for exposed, frayed or damaged wires Avoid overloading circuits Disconnect a plug before cleaning If client receives an electrical shock, turn off electricity before touching them |
| Radiation Safety | Strict guidelines Be familiar and follow agency guidelines Limit time near source of radiation and use shielding devices |
| Infectious Waste | Handle all infectious waste as a hazard Dispose of waste in designated areas, using proper containers Dispose of all sharps immediately after use in closed, puncture-resistant disposable containers that are leak-proof and labeled or color coded NEVER RECAP |
| Contributing factors that increase risk of falls | Age 65 or older Reduced vision Use of walking aids Physical hazards also increase risk Inadequate lighting Barriers along normal walking areas Lack of safety devices in the home |
| The nurse is completing admission histories for the newly admitted clients on the unit. The nurse is alert that the client with the greatest risk of injury… | 3. Has a history of falls |
| Restraints | Protective devices used to limit the physical activity of a client or to immobilize a client or extremity |
| Do you need an order from a HCP to administer a restraint? | Yes |
| What is the amount of slack needed for physical restraints? | 1-2 Fingers between the restraint and the patient. |
| How often do you asses the skin integrity when a restraint is in place? | Every 30 minutes |
| How often do you have to remove the device? | Every 2 hours |
| Do you leave all 4 side rails up in a patient's bed to ensure the patients risk for falls is minimal? | No. Having all 4 side rails in place is considered a physical restraint. |
| What are some ways to occupy a patient or prevent them from leaving the bed? | Give them wash clothes to fold. Put the tray table up in front of them |
| Types of restraints | Side rails Bed (Sleeping bag) Jacket Belt Extremity |
| The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation by the nurse indicates unsafe application of the safety device by the UAP? | 2. Safely securing the safety device to the side rails |
| HIPAA | The Health Insurance Portability and Accountability Act (HIPAA) describes how personal health information (PHI) may be used and how the client can obtain access to the information |
| PHI | individually identifiable information that relates to the client’s past, present or future health treatment; and payment for health services |
| infection | Invasion of host by pathogen/ microorganism resulting in a disease |
| Colonization | growth of microorganisms without tissue invasion or damage. |
| Communicable Disease | Disease transmitted from one person to another |
| Symptomatic | pathogens multiply and cause clinical signs and symptoms |
| Asymptomatic | free from clinical signs and symptoms. Can you think of a communicable disease that can be asymptomatic? |
| Chain of Infection | An infectious agent or pathogen A reservoir for pathogen growth A port of exit from the reservoir A mode of transmission A port of entry to a host A susceptible host |
| Infectious agent | microorganism-including bacteria, viruses, fungi, and protozoa |
| Reservoir | Where the microorganism survives, multiplies, and awaits transfer to a host. (humans, food, water, inanimate surfaces) |
| Port of Exit | How the microorganism transmits out of the reservoir-include blood, skin, mucous membranes, respiratory tract, GU tract, GI tract and transplacental |
| Port of Entry | Organisms enter the body through the same routes they use for exiting |
| Susceptible host | depends on the individuals degree of resistance to pathogens |
| Pathogens | Bacteria Viruses Fungus Protozoa/parasite |
| localized | limited damage to host tissues Effective host defense- leukocytes, containment, bacterial killing |
| Systemic | Entire body is involved - can be a single organ- or throughout- can be fatal organ injury- |
| Incubation Period | Interval Between entrance of pathogen and symptoms |
| Prodromal Stage | Interval from initial non-specific symptoms to specific symptoms |
| Illness stage | Symptoms specific to type of infection |
| Convalescence | Acute symptoms resolve- start to feel better |
| Skin defense mechanisms | Mouth (saliva), eyes (blinking tearing), Respiratory Tract (Cilia, mucous lining), Urinary tract (urine flow, pH), GI tract (acidity), Vagina (pH, Flora) |
| Immune Response | Involves specific reactions in the body to antigens or foreign material |
| Requirements of healthy immune response | Requires intact skin, mucous membranes and blood cell production. Lymphatic system and spleen. Differentiate between self and foreign tissue |
| Natural KiIller cells | Release Cytotoxic granulocyte |
| Helathcare associated infection (HAI) | Infection Obtained in relation to healthcare administration |
| Latrogenic | Healthcare system caused infection (Ex. Dirty Catheter) |
| Nosocomical | Infection spread from person to person |
| Exogenous | microorganisms found outside the individual |
| Endogenous | When the patient's flora becomes altered, E.g. after receiving antibiotics. |
| Neutropenic | Immuno-Suppressed- low white blood cell count- especially in older patients |
| Older adults Immune response | less lymphocytes poor nutrition weight loss low albumin stress/ depression /confusion decreased pain/inflammatory response incontinence |
| Nurses roles in infection | Defense mechanisms Patient susceptibility Nutritional status Stress Specific disease Medications Physical symptoms/appearance Lab data |
| How often do you wash your hands? | Before and after seeing a patient Or when there is bodily fluid contact |
| Asepsis | The absence of pathogenic microorganisms |
| Aseptic technique | measures to help reduce the risk of infection. 2 types – medical and surgical |
| Medical asepsis | clean technique. HAND WASHING |
| Surgical asepsis | sterile technique |
| How can a sterile object become unsterile? | Sterile objects become unsterile when touched by unsterile objects Sterile items that are out of vision or below the waist level of the nurse are considered unsterile Sterile objects can become unsterile by prolonged exposure to airborne microorganisms |
| The nurse observes a family member changing the dressing and recognizes that further education is needed after observing which of the following behaviors? | 1. Placing the sterile field on the over bed table with family members between the table and the wound |
| A nurse has been assigned to care for four clients that are stable. Using the principle of medical sepsis, which client should be assessed first? | 3. A client who is severely neutropenic |
| PPE | Personal protective equipment |
| Gown | if soiling of clothing is likely from blood or bodily fluid |
| Masks/eye protection | if client activities may generate splashes of blood or other bodily fluids |
| Droplet | private room or cohort client, wear surgical mask, use proper hand hygiene, and some dedicated –care equipment |
| Airborne | private room, door must remain closed, respirator mask, mask on patient if they leave room |
| Contact | private room or cohort client, wear gown and gloves |
| The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which item when performing this care? | 2. Particulate respirator, gown and gloves |
| Contact precautions are initiated for a client with an nosocomial infection caused by methicillin-resistant staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? | 4. Gloves, gown, goggles and face shield |
| Post Mortem Care | After death, the body should be prepared in order to give a clean, peaceful impression for family members |
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