Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
154 Cards in this Set
- Front
- 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 |
|
Colonization:
|
-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
-reservoir -portal of exit -mode of transmission -portal of entry -host |
|
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
|
|
Convalescence:
|
-acute symptoms are gone and the recovery phase begins
|
|
Means of infection transmission?
|
-Contact
-Droplets -Airborne -Common Vehicle -vector |
|
Contact:
|
-direct or indirect
|
|
Droplets:
|
-sneezing or suctioning
|
|
Airborne:
|
-dust
-droplets remain suspended in the air |
|
Common Vehicle
|
-equipment
-food -water |
|
Vector:
|
-mosquito
-rat |
|
Iatrogenic:
|
-result from procedure
-example: catheter or IV |
|
Endogenous:
|
-normal flora become altered & overgrowth occurs
-example: yeast infection from taking meds |
|
Exogenous:
|
-organism present outside of clients normal flora
|
|
Risk factors that make a pt more susceptible to infection:
|
-malnutrition
-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 |
|
Asepsis:
|
-is the absence of pathogenic (disease producing) microorganisms
|
|
Aseptic technique:
|
-procedures that assist in reducing the risk for infection or infection transmission
|
|
Sterility:
|
-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?
|
-HIV
-AIDS -Hep C |
|
Cohort:
|
-Someone with the same infection
|
|
Reduce reservoirs of infection by:
|
-bathing
-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
|
|
Smoking:
|
-increased risk of CV, pulmonary disease
|
|
Excessive stress:
|
-increased risk of accident, illness
|
|
Sexual practices:
|
-risk of HIV
-Hepatitis -STD’s -undesired pregnancy |
|
MSDS:
|
-material safety data sheet
|
|
Musculoskeletal changes:
|
-impair mobility
|
|
Nervous system changes:
|
-slows reflexes
-reaction time |
|
Sensory changes:
|
-decreased vision
-touch |
|
Genitourinary changes:
|
-nocturia
-incontinence |
|
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 -lighting -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 -osteoporosis -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 -sitter -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?
|
-blood
|
|
Personal Protective Equipment:
|
-exam gloves
-mask -goggles -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?
|
-patient
|
|
Cues:
|
-information obtained through use of senses
|
|
Inference:
|
-are judgments or interpretations of cues
|
|
How often is an assessment done?
|
-initial assessment
-every shift -hourly, weekly, monthly -ongoing -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
-summarize -offer client opportunity to ask questions |
|
Subjective:
|
-what pt/family tells you
-pt health hx |
|
Objective:
|
-findings with physical assessment
-diagnostic test results |
|
What are the 4 assessment types?
|
-complete
-episodic -follow up -urgent car/ER |
|
Complete:
|
-admitted to the hospital
|
|
Episodic:
|
-doctors office
|
|
Follow up:
|
-after surgery
|
|
Urgent care/ER:
|
-ABC
-pain |
|
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:
|
-age
-address -occupation -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 -intensity -quality -what makes them worse -what makes them better |
|
Family history:
|
-blood relative health issues
-recent losses -religious influences -relationships |
|
Spiritual health:
|
-religion
-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
-spouse -children -friends -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) -allergies -injuries/accidents -disabilities -blood transfusions -childhood illnesses -immunizations |
|
Activates of Daily Living:
|
-Physical self care
|
|
Instrumental Activates of Daily living
|
-things in which enable a person to function independently at home
|
|
ABCT:
|
-appearance
-behavior -cognition -thought processes |
|
Inspection:
|
-looking at the client
-any data collect through smell is also considered to be a part of inspection |
|
Palpation:
|
-use of hands to determine texture, size, shape consistency and location of certain body parts
-identify areas identified by pt as tender or painful |
|
Auscultation:
|
-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
|
|
PERRLA:
|
-pupils equal
-round -reactive to light -accommodation |
|
JVD:
|
-jugular vein distension
|
|
Clubbing:
|
-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:
|
-restlessness
-anxiety -acute disease -mental status change -progresses to lethargy -drowsiness |
|
Eupnea:
|
-abnormal quiet respiration
|
|
Bradypnea:
|
-abnormally slow respiration
|
|
Tachypnea-
|
-rapid, shallow respirations
|
|
Hyperventilation:
|
-rapid, deep respirations
-caused by exertion, fear, anxiety, compensation for acidosis |
|
Apnea:
|
-complete or intermittent cessation of breathing
|
|
Cyanosis:
|
-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
|
|
Vesicular:
|
-rustling like wind in trees
-sound of air in bronchioles & alveoli -primarily during inspiration |
|
Bronchial:
|
-harsh, hollow sound
-normally heard over trachea & larynx -abnormal if heard over lungs fields, associated with consolidation (pneumonia) |
|
Bronchovesicular:
|
-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 |
|
Crackles:
|
-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) |
|
Wheezes:
|
-due to narrow airways
-high pitched musical sound similar to squeak -occurs in small airways |
|
Gurgles/Rhonchi:
|
-low pitched, coarse, loud
-heard primarily during expirations -coughing may clear |
|
Atelectasis:
|
-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
|
|
Bronchitis:
|
-proliferation of mucous glands causing excessive mucous secretion & inflammation
-Harsh cough |
|
Emphysema:
|
-destruction of pulmonary connective tissue & permanent enlargement of air sacs, trapped air
|
|
Asthma:
|
-reactive airway
|
|
Pleural effusion:
|
-collection of excess fluid in Intrapleural space (water, puss, blood)
|
|
CHF:
|
-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
|
|
S1:
|
-lub
-first heart sound -beginning of systole -produced by closure in mitral & tricuspid valve -heard best in mitral or apex are -coincides with carotid artery |
|
S2:
|
-dub
-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 |
|
S3:
|
-ventricular gallop
-apex or lower LSB -early sign of heart failure |
|
S4:
|
-atrial gallop
-heard at apex -may occur normally after exercise -may indicate CAD, cardiomyopathy, aortic stenosis, systemic hypertension |
|
Murmur:
|
-blowing, swooshing sound that occurs with turbulent blood flow in heart or great vessels
|
|
Heave:
|
-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 -ascites |
|
Order of assessing the abdominal:
|
-I ate pecan pie
-inspection -auscultation -percussion -palpation |
|
What area of the stomach do you start?
|
-RLQ
|
|
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
-peritonitis -paralytic ileus -late bowel obstruction -med side effect |
|
Visceral Pain:
|
-dull pain
-poorly localized |
|
Parietal Pain:
|
-sharp
-localized -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?
|
-assessment
-diagnosis ADPIE -planning -implementation -evaluation |
|
Anaphylaxis
|
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.
|
|
Adduction:
|
is movement toward the body.
|
|
Abduction:
|
is movement away from the body.
|
|
Resonance:
|
is the low, hollow sound of normal lungs.
|
|
Hyperresonance:
|
can be heard over emphysematous lungs as a booming sound.
|
|
Tympany:
|
is the high-pitched, drumlike sound heard over a gastric air bubble.
|
|
Dullness:
|
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.
|
|
Lordosis:
|
(swayback) is increased lumbar curvature.
|
|
Scoliosis:
|
is lateral spinal curvature.
|
|
Hypotonic muscle
|
has little tone and feels flabby, usually because of atrophy of muscle mass.
|