Fundamentals of Nursing Quiz 1

Institute of Medicine:
A nonprofit organization specifically created for science-based advice on matters of biomedical science, medicine and health.

provides a vital service by working outside the framework of government to ensure scientifically informed analysis and independent guidance. The IOM's mission is to serve as adviser to the nation to improve health.

To Err is Human: Building A Safer Health System (1999)
Crossing the Quality Chasm: A New Health System for the 21st Century (2001)
Health Professions Education: A Bridge to Quality (2003)
Keeping Patients Safe: Transforming the Work Environment of Nurses (2004)
Preventing Medication Errors: Quality Chasm Series (2006)

44,000 to 98,000 people die in hospitals every year as a result of medical errors that could have been prevented. Even using the lower estimate, preventable medical errors exceed attributable deaths to such feared threats as MVAs, breast cancer and AIDS.
Average = 71,000 = 195 people/day, 1,365 people/week, almost 6,000 people/month

faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.

described what kind of health system we need to create.

STEEEP

Safe
Timely
Effective
Efficient
Equitable
Patient-Centered

Safe: avoiding injuries to patients from the care that is intended to help them.
Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.
Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.
Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.
Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
Patient-centered: providing care that is respectful of and responsive to in dividual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions

Agency for Healthcare Research and Quality (AHRQ):
AHRQ serves as the lead agency on medical errors within the Quality Interagency Coordination Task Force (known as the QuIC), which developed the Federal response to the IOM report
National Guideline Clearinghouse

Research shows that it take 17 years before evidence based practices are incorporated into widespread clinical use (AHRQ, 2004).

An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 16,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards

Tracks sentinel events nationally
National Patient Safety Goals are determined by the tracking of sentinel events nationally.

A sentinel event is an unexpected ocurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or funtion. The phrase “or the risk therof” includes may process variation for which a recurrence would carry a significant chance of serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.

the National Quality Forum

Setting national priorities and goals for performance improvement;
Endorsing national consensus standards for measuring and publicly reporting on performance; and
Promoting the attainment of national goals through education and outreach programs.

Institute for Healthcare Improvement

the 5 million lives campaign
and the
"No Needless List"

no needless death
no needless pain or suffering
no needless helplessness in those served or serving
no unwanted waiting
no waste
no one left out

Quality and Safety Education for Nurses (QSEN)

preparing future nurses with the knowledge, skills and attitudes (KSA)

Patient Centered Care
Teamwork & Collaboration
EBP
Quality Improvement
Informatics
Safety

going after "Medical Harm"

Unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death.
Such injury is considered harm whether or not it is considered preventable, whether or not it resulted from a medical error, and whether or not it occurred within a hospital.

Deploy Rapid Response Teams…at the first sign of patient decline
Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack
Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation
Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps
Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time
Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps
Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention
Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) Infection…by reliably implementing scientifically proven infection control practices
Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin
Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by the Surgical Care Improvement Project (SCIP)
Deliver Reliable, Evidence-Based Care for Congestive Heart Failure…to reduce readmissions
Get Boards on Board….Defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care

Complex Adaptive Systems
CAS approach understands that systems often include the following characteristics: unpredictability, ambiguity, time pressure, stress laden situations, high stakes and decision making by teams with frequently changing members.
Causality is not unidirectional but often bidirectional, involving the interaction of two or more entities. From these complex interactions emerge unpredictable behvavior patterns leading to small changes that may or may not lead to wide-spread changes.

requires recognition and appreciation for the bidirectionality and unpredictability of system relationships, including human, technical and process.

hazards exist on a spectrum from the blunt end to the sharp end of an "arrow" which points towards losses". These "holes" start out with organizational factors and line management factors at the blunt end. At the sharp end are holes caused by active failures Holes in each successive layer eventually line up to allow actual losses.

a science focused on human performance in varying situations and environments, often in interaction with technology.

discontinuities in the layers of defense in work environments

the failure to appreciate the complexity of work.

Dynamism
Large number of parts and connectedness between parts
High uncertainty
Risk

Time pressure
High stakes
Inadequate information (missing, ambiguous or erroneous)
Ill defined goals
Poorly defined procedures
Dynamic conditions
People working in teams
Stressful conditions

Missing equipment
Interrptions
Waiting for access to needed systems and resources
Lack of time to complete interventions that were judged necessary to reach desired outcomes
Inconsistencies in how information was communicated

because of its reliance on individual performance as the main key to improvement. Other industries have reduced errors by understanding that the way to be safer is to design systems so that it is difficult to make a make a mistake and easy to recover from mistakes that do occur.

Infectious Agent
Reservoir (Source)
Portal of exit for the pathogen
Mode of transmission
Portal of entry into the host
Susceptible host

. Infectious agents
Bacteria, Viruses, Fungi, Parasites, Drug-resistant Microbial strains

2. Reservoir (source)
Humans, Animals
Soil, air, food, water

Portal of exit
Sputum, emesis, stool, urine, wound drainage, secretions from genitals

Mode of transmission
Contact & droplet, vehicle, airborne, vectorborne

. Portal of entry
Body orifices, breaks in skin or mucus membranes, invasive procedures/equipment

6. Compromised (susceptible) host
Weakened body defense mechanisms
Increased infection risk

Pathogenicity
Organism’s ability to cause harm/disease

Virulence
Vigor to grow and multiply

Invasiveness
Ability to enter tissues

Specificity
Attraction to a host, including humans

Secretions containing antibodies
Secretions with acidic pH that inhibit bacterial growth
Hair-like cilia that line respiratory tract
Skin
Nodes
Peristalsis
Urination
Immune system

Over-prescription of antibiotics
Use of inappropriate antibiotics for the infecting organisms
Incomplete use of antibiotic prescriptions as symptoms subside
Harboring and spreading of resistant organisms by carriers who remain symptom free
Increased use of antibiotics in farming, thus contaminating milk and meat

About one-third of people in the world have S. aureus bacteria on their bodies at any given time primarily in the nose and on the skin.
Of the people with S. aureus present, about 1 percent has MRSA, according to the Centers for Disease Control and Prevention (CDC)

Persons who have been previously treated with antibiotics
Persons who are hospitalized, particularly when they receive antibiotic treatment for long periods of time
Persons with weakened immune systems, such as patients in intensive-care units, cancer, or transplant wards
Persons who have undergone surgical procedures, such as abdominal or chest surgery
Persons with medical devices that stay in for some time, such as urinary catheters or central intravenous catheters

MRSA Colonization is the term used to describe those who
have drug resistant staph aureus bacteria on or in their
bodies but have not yet become ill through the infection of a wound or other area of tissue.

Once colonized with MRSA, a person can remain a carrier of
the bacteria from a few days or weeks, up to several years.
During this time period, people colonized with MRSA are not
only at an increased risk for infecting others, but also
themselves.

Arterioles at injury dilate = increased blood flow = redness and warmth
Inflammatory mediators delivered to the site = increased permeability of vessels  edema
Edema = pressure on nerves  pain
WBCs ingest/destroy organisms and cellular debris  increased WBC count

Serous: clear, like plasma
Sanguineous : contains RBCs (pinkish color)
Purulent: contains WBCs and bacteria (white pus, greenish)

Serious medical condition caused by the body's response to an infection.
Leads to widespread inflammation and blood clotting.
Blood clotting during sepsis causes reduced blood flow to limbs and vital organs, and can lead to organ failure or gangrene (damage to tissues).
worst case scenario

Decreased urine output
Fast heart rate
Fever
Hypothermia
Shaking
Chills
Warm skin or a skin rash
Confusion or delirium
Hyperventilation (rapid breathing)

Systemic (fever, malaise, weakness)
Local:
Heat, redness, pain/tenderness, swelling
Drainage (bloody, serous, purulent)
Abscess (localized collection of pus)
Cellulitis (involves cellular and connective tissue)

precautions taken for all patients because All body fluids of all patients should be considered hazardous, regardless if a diagnosis is known

Applies to clients with documented or suspected infections with highly transmissible or epidemiologically important pathogens by contact, droplet or airborne modes of transmission

Criteria: Droplet nuclei <5μm (small droplet)

Can stay suspended and widely dispersed by air currents

For patients with: Measles, Varicella Zoster Virus, TB

Accommodations: Private, negative air flow room

Precautions: respirator or N95 mask (for provider when in room, for patient when he/she out of room); dedicated equipment

Criteria: diseases spread by direct patient or environmental contact

For patients with MRSA, VRE, other drug resistant organisms, RSV, various enteric pathogens (C. difficile diarrhea), shingles (disseminated varicella)

Respiratory syncytial virus (RSV)

Accommodations: private room or cohort

Precautions: glove and gown; dedicated equipment

Criteria: droplets >5μm

For patients with diphtheria, rubella, pertussis, mumps, meningococcal pneumonia

Accommodations: private room or cohort patients (must be at least 3 feet between patients)

Precautions: simple mask (for provider when in room, for patient when he/she out of room); dedicated equipment

Neuropenic patients (neutrophils < 500/mm3)
Burns, chemotherapy, radiation therapy, immunosuppressive medications

Private room / Door closed

Meticulous hand hygiene by patient, HCWs, visitors

Restrict visitors with infectious diseases

No fresh fruit, vegetables (controversial), flowers, plants, uncooked meat/fish

Limited social interactions can cause psychological problems, especially with children

The absence of pathogenic, or disease producing, microorganisms

Medical asepsis (aka clean technique)
Includes procedures used to reduce and prevent the spread of pathogens
e.g., using gloves, cleaning the environment

Surgical asepsis (aka sterile technique)
An object must be free of all microorganisms

Masks
Gowns
Caps and Shoe Coverings
Gloves – latex, vinyl
Private Rooms
Equipment and Refuse Handling

Soap-water should be used when:
Hands are visibly soiled
Before and after eating
After using the restroom
AND
if patient has C. difficile-alcohol is not effective against this pathogen

ALWAYS WEAR GLOVES DURING CLIENT CARE WHEN YOUR SKIN IS ABRADED

NEVER TOUCH WITH BARE HANDS ANTHING THAT IS WET COMING FROM A BODY SURFACE
Use clean, nonsterile when touching blood, body fluids, secretions, excretions, contaminated articles
Put on gloves just before touching mucous membranes or nonintact skin

Never assume an object is sterile
Check packaging / expiration date
Always face the sterile field
Sterile articles only touch sterile articles

Hands must be kept above waist and on top
Close doors, DO NOT reach across sterile fields, cough, sneeze or talk excessively over field
A person who is considered sterile who becomes contaminated must reestablish sterility

A sterile object or field becomes contaminated by prolonged exposure to air

When a sterile surface comes in contact with a wet, contaminated surface, the sterile field becomes contaminated by capillary action.

The edges of a sterile field or container are considered to be contaminated

PRERENAL CONDITIONS
Factors that decrease circulating blood flow through the kidneys with subsequent decreased perfusion to renal tissue
Decreased renal blood flow
Outside of the urinary system

INTRARENAL CONDITIONS:
Factors that cause injury directly to the glomeruli or renal tubules interfering with their normal filtering, reabsorptive, and secretory functions
Within the kidney filtration areas

Postrenal CONDITIONS:
Result from obstruction to the urinary collecting system anywhere from the calyces to the urethral meatus
Urinary is formed by the urinary system but cannot be eliminated by normal means

if urinary output is less than </= 30 mL for two consecutive hours is cause for concern-CALL MD!

Dysuria, N/V, fever, chills, fatigue
Older persons – confusion or vague abdominal discomfort
Cystitis: frequency, urgency
Hematuria: blood in urine
Bacteriuria may lead to urosepsis
Pyleonephritis: flank pain, tenderness; fever; chills

Acute urinary retention or bladder outlet obstruction
Accurate measurement of urine output in critically ill patients
Selected perioperative situations
Patient requires prolonged immobilization
To assist in healing of open sacral or perineal wounds in incontinent patients
End-of-life care

Collection of guidelines and interventions that, when consistently followed, have been shown to improve outcomes.

Insert catheters for appropriate indications only
Leave catheters in place only as long as needed
Ensure that only properly trained persons insert and maintain catheters
Insert catheters using sterile technique
Maintain a closed drainage system
Maintain unobstructed urine flow
Practice hand hygiene and standard precautions

Non-invasive Interventions
Bladder Ultrasound (BUS): A portable US device measures urine volume using a probe that is attached to a screen capable of visualizing bladder. Used to measure post void residual (PVR

Older than 65 years
Documented history of falls
Impaired vision or sense of balance
Altered gait or posture; impaired mobility
Medication regimen
Postural hypotension
Slowed reaction time; weakness and physical frailty
Confusion or disorientation; unfamiliar environment

Reorienting patient verbally on a consistent basis
Provide visual cues to reorient patient
Remind patient of use of call light
Family member at bedside
Use of distraction to keep patient safe without restraints

informed consent

If client is unable, the consent of a proxy must be obtained with full disclosure of risks/benefits
Restraint of patient without informed consent or sufficient justification is false imprisonment

every 2 hours
check circulation and exercise limbs.

A Physician's Order!
Apply restraints in an emergency but get physician order ASAP
Orders specify the duration and circumstances
No PRN orders

Patient must be offered nutrition, hydration, use of toilet on a regular basis
Need for restraints must be revisited every shift
New order for restraints is needed every 24 hours
Restraints must be removed, circulation must be assessed on a regular basis (see facility policy for time interval)

Respond to the present, not the past.
Evaluate the potential for injury.
Speak with family members or caregivers.
Try alternative measures first
Reassess the patient to determine whether alternatives are successful.
Alert the physician and family if restraints are indicated.
Individualize restraint use.
Note important information on the patient’s chart.
Time–limit the use of restraints.

Direct Injury
Nerve injury, ischemic injury, asphyxiation, sudden death, death
Indirect Injury
More likely to fall, increased LOS, decline in social behavior, cognition and mobility, increase in disorientation, development of pressure ulcers, bowel/bladder incontinence

Perform standardized fall risk assessment for all patients on admission and whenever patients’ clinical status changes.
Identify at every shift the patients most at risk of moderate to serious injury from a fall.