Nu 136 Exam 1 Guaranteed distinction

Primary illness - answersDevelops without being caused by another health problem Secondary illness - answersResults from or is caused by a primary illness Stages of Illness - answersTransition, Acceptance, Convalescence Transition Stage - answersMay deny feeling ill, but recognize symptoms of illness are present Acceptance Stage - answersAcknowledge illness and take measures to become well Convalescence Stage - answersRecovering after the illness and regaining health Adaptation - answersThe adjustment or changes in behavior, physiology, and structure ie: Exercise and good nutrition when you develop diabetes Maladaptation - answersLack of adjustment ie: "I know I have diabetes now so I'll just take an insulin pump instead of trying to exercise and eat right" Health Behavior - answersAny action taken that promotes good health, prevents disease, or detects disease in early, asymptomatic stages ie: watching nutrition, exercise, obtaining immunizations, having regular check ups Illness Behavior - answersWays in which people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the health care system. ie: seeing the doctor and taking prescribed meds after sickness has occured Holistic Approach - answersConsiders biologic, psychological, sociologic, spiritual needs Five areas of need (Maslow) - answers-Physiologic -Safety and Security -Love and Belonging -Self-esteem -Self-actualization Examples of stress-related diseases/disorders - answersHeadaches, gastritis, asthma, lumbar pain, ulcerative colitis, IBS, allergies, HTN, cancer, sexual dysfunction, Crohns, General Adaptation Syndrome (GAS) - answersSelye's concept of the body's adaptive response to stress in three phases—alarm, resistance, exhaustion. Alarm Stage - answers-The first stage of the general adaptation syndrome, in which the person experiences a burst of energy that aids in dealing with the stressful situation. -Hormonal release mobilizes body's defense mechanisms -Temp increase, malaise, appetite loss Resistance Stage - answers-The second stage of the general adaptation syndrome, when there are intense physiological efforts to either resist or adapt to the stressor. -If prolonged, responce becomes maladaptive and a pathologic condition can occur -> "stress related disorder" Exhaustion Stage - answers-The third stage of the GAS, characterized by weakened resistance and possible deterioration. -Critical Illness or death Miller-Keane dictionary defines health as: - answersA relative state in which one is able to function well physically, mentally, socially, and spiritually in order to express the full range of one's unique potentialities within the environment in which one is living Acute illness - answersDevelops suddenly and resolves in a short time ie: Flu, Appendicitis Chronic Illness - answers-Develops slowly -Can be controlled but not cured -Long lasting ie: Diabete, HTN Terminal Illness - answersIllness for which there is no cure and ends in death ie: Cancers 4 basic physiologic needs - answersFood Water Air Rest Idiopathic Illness - answersAn illness without known etiology Risk of low self esteem nursing interventions - answers-Active Listening -Provide with appropriate and adequate info on disease and plan Repression - answersUnconscious blocking of a wish or desire from conscious awareness Projection - answersAttributing an unconscious impulse, attitude, or behavior to someone else ie: blaming, scapegoating Denial - answersEscaping unpleasant, anxiety causing thoughts and realities by refusing to acknowledge their existence Reaction-Formation - answersAn intense feeling regarding an object, person, or feeling is out of awareness and is unknowingly acting out consciously in an opposite manner Regression - answersReturn to an earlier level of adaption ei: potty training Rationalization - answersUnconsciously falsifying an experience by giving a contrived, socially acceptable and logical explanation to justify an unpleasant experience or questionable behavior identification - answersModeling behavior for someone else Diplacement - answersDischarging intense feelings for one person onto another object or person who is less threatening thereby satisfying an impulse with a substitute object Sublimination - answersRechanneling an impulse into a more socially desired object ie: satisfying sexual curiosity by conducting sophisticated research on the subject Primary Illness Prevention - answersto avoid or delay illness ie: exercise, immunizations, sunscreen, vaccines, seatbelts, Secondary Illness Prevention - answersEarly detection and treatment; ie: mammogram, colonoscopy, Pap smears Tertiary Illness Prevention - answersRehabilitation ie: PT, counseling, support groups Homeostasis - answersThe tendency of the body to adjust constantly to changing conditions Bacteria - answers-single-celled organisms that lack a nucleus -Classified by: oxygen needs, gram staining, shape -Reproduce every few minutes for up to several weeks 4 most common drug resistant organisms - answers-Methicillin-resistant Staphylococcus aureus (MRSA) -Vancomycin-resistant Enterococcus (VRE) -Extended-spectrum beta-lactamase-producing (ESBL) pneumonia (Klebiella pneumonia or E. Coli) -Clostridium difficile (C. diff) Normal Flora - answersNon-pathogenic organisms that are prevalent on and in the body Gram-negative bacteria - answersConsidered more dangerous due to production of an endotoxin can cause hemorrhagic shock, severe diarrhea, and can alter resistance to other bacterial infections C&S test - answers-A test that identifies bacterial resistance or susceptibility -Results available 48-72 hours after culture Prions - answers-Infectious protein particles that do not trigger an immune response -Cause degenerative neurologic disease (Mad cow) Viruses - answers-Tiny particles, smaller than bacteria. Composed of DNA or RNA with protein coat -Must invade living cells in order to reproduce; when they invade, the cells are damaged or destroyed in the process releasing new particles to infect other cells -Depends on host tissue Protozoa - answers-One-celled, belong to animal kingdom -Malaria and dysentary Rickettsias - answers-Resemble bacteria, often enter the body through lice, fleas, and mites that act as vectors -Rocky Mountain Spotted fever Fungi - answers-Tiny primitive organisms of the plant kingdom that contain no chlorophyll -Feed off living animals and decaying organic matter -Reproduce by use of spores -Cause candidiasis and tinea pedis (athlete's foot) Helminths - answers-Parasitic worms -Pin, round, & tape -Ova & Parasite test: collect stool and send to lab ASAP before worms start dying Process of Infection (In Order) - answers--Causative agent --Reservoir --Portal of exit --Mode of transfer --Portal of entry --Susceptible host Causative Agent - answersInfectious microorganism Reservoir - answersPlaces where microorganisms are found; ie: wounds, waste, animals, insects Portal of exit - answersRoute by which pathogen leaves current host; ie: GI tract, Resp tract, Skin/Mucous Membranes Mode of Transfer - answersThe way a microorganism is transported to a host; -Direct person -Indirect contact through contaminated inanimate obj -Vectors (fleas,etc.) -Droplet -From one body part to another Portal of Entry - answersWay for the causative agent to enter a new reservoir or host; - eyes, mouth, nose, skin, mucosa Susceptible Host - answersA person likely to get an infection or disease; -age -immunocompromised -broken skin Virulence is affected by the causative agent's ability to: - answers-Adhere to mucosal surfaces or skin -Penetrate mucous membranes -Multiply once in the body -Secrete harmful enzymes or toxins -Resist phagocytosis Most affective way to destroy viruses and all other kinds of microorganisms: - answersExpose them to high temp for specified amount of time; Steam: at least 250 degrees for 20-30 minutes Dry: at least 320 for 90 min - 3 hours Mode of transfer can be interrupted by: - answers-Effective hand hygiene -Proper disinfecting and sterilization of medical equipment -Use of both sterile and medical aseptic techniques during procedures and tests -Use of standard precautions to prevent contamination Factors placing older individual at risk for infection: - answers-Poor Nutrition -Immobility -Poor hygiene -Chronic Illness -Physiologic changes Body Defenses (3) - answersFirst line: Skin Second line: Fever, leukocytosis, phagocytosis, inflammation, and interferon action Third line: Immune Response Passive aquired immunity - answersGiving antitoxin or antiserum containing antibodies developed by another person; ie: Tetanus shot - protects a person from a current invasion but does not provide lasting immunity Naturally acquired passive immunity - answersAntibodies are passed from mother to fetus via the placenta and breast milk; typically only lasts until infant's own immune response matures enough to function properly Artificially acquired immunity - answersImmunity that results from a vaccination that contain dead or inactive viruses or their toxins; Hep B, Flu, Measles Artificially acquired passive immunity - answersInjection of antibodies derived from infected people or animals to fight off the infection; Hep A Medical Asepsis - answersReducing number of organisms or reducing the risk of transmission of organisms; Clean technique Surgical Asepsis - answersPreparing and handling instruments and materials in a way that prevents the patient's exposure to living microorganisms; Sterile Technique Items included in PPE - answers-Gloves -Gowns -Masks -Protective Eyewear -Shoe Coverings -Hair coverings Infectious Process Stages (4) - answers-Incubation -Prodromal -Illness -Convalescence Incubation Period - answers-Begins when organism first enters the body until the ssx appear Prodromal Period - answers-From onset of vague ssx to onset of specific disease -highly infectious Illness period - answers-Localized and systemic symptoms appear -Severity and Duration depend on virulence of pathogen and person's susceptibility Convalescent Period - answersSsx begins to subside and continues until the person returns to normal Health Care Associated Infection - answersAn infection that was not present on admission to a health care institution and develops during the course of treatment for other conditions (nosocomial); -Greatest risks: Surgical incisions, lines or tubes, implanted prosthetic devices, immunocompromised When do you implement Standard Precautions - answersUsed for every patient contact; includes the use of hand hygiene and PPE When do you implement Transmission-Based Precautions? - answersFor patients with known or suspected specific diseases What is the order of donning PPE - answersGown -> mask/respirator -> goggles/face shield -> gloves Specimen prep and transport - answersVerify order -> label container with pt name & medical record number -> don gloves and explain to pt what's needed -> collect specimen without contaminating outside -> apply lid and clean/disinfect if visibly contaminated before transport to lab When transporting an isolation patient: - answersGive pt a standard mask to wear outside of the room & notify the unit receiving the pt ahead of time that they are on a particular type of transmission—based precautions How do you help to prevent sensory deprivation in isolation patients: - answersActive listening, encourage grooming and activity efforts, engage in meaningful conversations about interests or hobbies, and make visitors feel welcome Three main modes of occupational exposure to blood borne pathogens - answersPuncture wounds, Skin contact, Mucous membranes Correcting breaks in asepsis - answersA scrub is begun again. Sterile gloves discarded and new ones donned. Discard or put aside for resterilization any contaminated supplies and open new packs aseptically to replace them. Factors affecting hygiene - answersCulture, religion, environment, developmental level, health and energy, personal preferences Risk factors for Pressure Injuries - answersImmobility Incontinence Diaphoresis Inadequate nutrition Lowered mental awareness Excessive diaphoresis Extreme age Edema Stage 1 Pressure injury - answers-Intact skin with localized area of non-blanchable erythema -Warmth, edema, induration Stage 2 Pressure Injury - answers-Partial thickness skin loss with exposed dermis -Abrasion, blister, shallow crater Stage 3 Pressure Injury - answers-Full thickness loss, looks like deep crater extend to fascia, subcutaneous tissue damaged -Necrotic fat visible undermining -Tunneling may be present -Damage to surrounding tissue Stage 4 Pressure Injury - answers-Full-thickness skin and extensive tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. -Slough and/or eschar may be visible. Unstageable Pressure Injury - answersFull-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Deep Tissue Pressure Injury - answersLocalized discolored intact skin that is maroon or purple or a blood filled blister resulting from damage to underlying soft tissue from pressure or shearing Initial care of a pressure injury involves: - answersDebridement Wound Cleansing Application of Dressings Four Purposes of Bathing - answersCleanse the skin Promote comfort Stimulate circulation Remove waste products Cleansing Bath - answers-Done in bed, tub, or shower -Most Common Whirlpool Bath - answersA therapeutic bath of heated or cooled water in which all or part of the body is exposed to forceful, massaging currents in the water. -Wound care, cleansing, debridement, joint therapy, stimulate circulation Sitz Bath - answersApplication of heat and cleansing to the perineal area -Medication may be added -Dermititis, OB, rectal surgery, hemorrhoids Sponge Bath - answersMay be used to bring down fevers - Doc order required Mouth care for unconscious patient - answersEvery 4 hours; If mouth breathing, provide moist swab every 2 hours Safety or Comfort Issues During a Back Rub - answers-Move the pt closer to you -Raise bed, lower side rail -Warm hands and lotions -3-5 min - Do not massage if contraindicated for clots Denture Care - answers-In the morning and at bed time. -Dentures should be removed for at least 6 hours daily to relieve pressure. -If not in mouth, dentures are kept in a labeled denture container filled with water or normal saline. -Don't place on meal tray If crusting on the eye is present, you should.. - answersSoak with washcloth for 2-3 min -Use a different part of the towel for each eye Skin Function - answersProtection, secretion, excretion, temperature regulation, and sensation Shaving is contraindicated in patients: - answers-On anticoagulant therapy -On chemotherapy -On aspirin -Who are Immunocompromised Factors affecting patient environment - answersTemperature Ventilation and humidity Lighting Odor Noise Neatness Privacy Normally humidity - answers30-50% -Lower humidity can dry skin and respiratory passages -Higher humidity can provide environment for microbial growth Ways to reduce noise in hospital setting: - answers-Avoiding long conversations in the hallways -Encouraging staff to speak in lowered voices -Avoiding jokes and laughter at the nurses' station -Answering alarms on IV pumps and equipment promptly Providing Privacy - answersKnock gently and announce yourself before entering, close curtains Common factors for falls - answers-Impaired physical mobility -Altered mental status -Sensory and/or motor deficits Preventing burns in sensory impaired - answers-barrier between pt's skin and thermal application -check temp of oral liquids -avoid lying on heating pads or ice packs -inspect all outlets and appliances RACE - answersrescue, alarm, contain, extinguish Acute Radiation Syndrome (ARS) Symptoms - answers-Initial: Nausea, vomiting, diarrhea -Later: loss of appetite, fatigue, skin damage, hair loss, seizures, coma, death Triage patients are assessed by - answersAccording to the priority of care: -immediate (require life saving interventions) -delayed (in need of major or prolonged care) -minimal (minor injuries) -expectant (severe, life threatening that probably wont survive with medical care) Principles for protective devices - answers-Must help the pt or be needed for continuation of medical therapy -Obtain written order and notify PCP as soon as device is unnecessary -Use least amount of immobilization possible -Apply it snuggly but not so tightly to interfere with circulation (2 fingers) -Remove and change pt position q2h, perform ROM Musculoskeletal Changes with Aging - answers-Decreased bone mass -Loss of bone density -Loss of muscle cells and replaced by fat -Muscle elasticity is decreased -Joint motion decrease Good body posture is essential to: - answersPrevent injuries Guidelines for Moving/Lifting - answers-Get help when possible -Ask pt to assist -Bend at the knee -Use greatest number of muscles possible -Smooth coordinated movements -WIDE BASE OF SUPPORT -Work close to the body -Pull rather than push -No twisting -Use arms as levers Hazards of improper alignment - answers*Interference with circulation, which may lead to pressure ulcers *Muscle cramps and possible contractures *Muscle atophy *Fluid collection in lungs