NSE 111: Midterm Review Latest Update Graded A+

NSE 111: Midterm Review Latest Update Graded A+ patient centered care a standard of care that places the patient as the focus of the care DIPPS or DIPPERS dignity, independence, privacy, preference, and safety; dignity, independence, privacy, preference, empathy, respect, and safety nursing process a clinical decision making approach to care that assists nurses with identifying and treating health related concerns and helps the patient reach their health outcomes/goals assessment collection of data or cues that are important to the patient's care to understand the patient's needs diagnosis analysis of the assessment to determine key issues and create a diagnosis creation of outcomes/goals for the patient planning creation of a plan that identifies strategies to reach patient's health outcomes implementation carrying out the plan of care evaluation determining if the implementation of the plan was successful in reaching patient outcomes infections a disease state that results from the entry of a pathogen into the tissue of the host pathogen a microorganism that causes disease local limited to a specific part of the body systemic spreads throughout the entire body chain of infection infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host infectious agent pathogen that causes disease reservoir a site where pathogens can survive but may or may not multiple survival needs of pathogen food, water, pH level (5-8), minimal light, oxygen, and temperature between 35-37 degrees portal of exit the path by which the pathogen leaves the reservoir mode of transmission route of transmission by which the pathogen travel from the reservoir to host direct between infected individual and host (to skin) indirect between the host and contaminated object (intermediate object) airborne organism travel from respiratory system of infected source to host propelled through air farther than 1m (chicken pox, measles) droplet organism travels from respiratory system of infected source to host through air up to 2m (COVID-19) vehicle one contaminated source infects multiple hosts (water in Flint, MI) vectorborne microbes transmitted from insects to humans (West Nile virus) portal of entry the path by which the pathogen can enter the body (possibly through the same path used for exiting) susceptible host a person who gets an infection or disease defences against infection immune system, normal flora, inflammatory response, body system defence factors that affect patient susceptibility age, nutritional intake, stress, and medication Health care associated infection An infection that is acquired after admission that is not present or incubating at the time of admission aspesis keeping away disease-producing microorganisms medical asepsis reduce and prevent the spread of microorganisms surgical aspesis Use of precise practices to eliminate all micro-organisms including pathogens and spores from an object or area routine practices used in the care of all patients regardless of their diagnosis or possible infection status breaking the chain of infection: infectious agent cleaning, disinfecting, sterilizing, and educating others to reduce or eliminate microorganisms breaking the chain of infection: reservoir eliminating or controlling sources of body fluid that might harbour microorganisms (ex. changing dressings) breaking the chain of infection: portal exit avoiding talking, coughing, or sneezing over open wounds or sterile fields, covering the mouth and nose when coughing or sneezing wearing a mask handling of blood and fluids correct disposal of soiled items breaking the chain of infection: modes of transmission be knowledgeable of modes of transmission appropriate hand hygiene don't share equipment hold soiled linen away from the body breaking the chain of infection: portal of entry maintain patient's skin integrity implement strategies for susceptible skin hygiene correct disposal of soiled linens breaking the chain of infection: susceptible host maintaining patient's skin integrity adequate fluid and diet maintaining immunization regular hygiene soap and water physical removal of microbes using friction if hands are visibly soiled, exposed to C. diff or alcohol-based hand rub is not available alcohol-based hand rub better than soap and water; excellent steps of hand washing 1. Turn on water 2. Wet hands 3. Apply soap 4. Later soap for 20+ seconds 5. Palms, interlaced fingers, knuckles 6. Each thumb and crease 7. Wrist 8. Rinse hands separately pointing down towards sink basin 9. Get paper towel and dry hands (leave water on) 10. Get another paper towel and turn off water steps to alcohol-based hand rub 1. apply 1-2 pumps 2. rub for 20+ seconds or until dry 3. palms, interlaced fingers, knuckles, etc. 4. thumb and pinky personal protective equipment a barrier between a person and pathogens; includes gloves, gowns, masks, and goggles gown prevents contamination of uniform and clothing gloves handwear worn to prevent transmission of pathogens by direct or indirect contact but DOES NOT REPLACE HAND HYGIENE mask and goggles protects eyes, nose, and mouth from splashes of body fluids donning PPE 1. hand hygiene 2. gown 3. mask 4. goggle 5. gloves doffing PPE 1. gloves 2. gown 3. hand hygiene 4. goggles 5. mask 6. hand hygiene Tier 2 of isolation precautions contact: private or cohort room, hand hygiene, and gown with gloves for direct care droplets: private or cohort rooms, hand hygiene, mask, and goggles airborne: N95 mask, hand hygiene, private room with door kept closed and negative air flow systems involved in movement Skeletal Muscular Nervous body alignment relationship of one body part to another along a horizontal or vertical line body balance when the centre of gravity is balanced over a stable base of support; enhanced by posture gait manner of walking gravity A force that exerts a downward force on the body friction occurs in a direction to oppose movement body mechanics movement of the body in an efficient way w/ good posture and using the strongest muscles mobility the ability to move easily and freely immobility inability to move easily and freely functional decline the loss of the ability to perform self care or activities of daily living Systemic effects of immobility Metabolic Respiratory Cardiovascular Urinary Elimination Musculoskeletal Psychosocial Integumentary metabolic changes altered endocrine metabolism calcium Resorption decreased GI motility cardiovascular changes orthostatic hypotension -thrombus formation --damage to the vessel wall --alterations of blood flow --alterations in blood constituents urinary elimination changes Altered urinary elimination Urinary stasis Increased risk of calculi formation respiratory changes Atelectasis Hypostatic pneumonia musculoskeletal changes Temporary or permanent impairment of permanent disability Restricted mobility & impaired joint mobility psychosocial changes Quality of life and well being Boredom Feelings of isolation Depression Anger Grief - coping with the loss Distributive sleep patterns Fear integumentary changes Pressure ulcer Localized injury to skin Usually over bony prominence Results from pressure or pressure with shear & friction restorative care Care that helps a patient maximize functional mobility, independence, and reduce functional deficits includes activities of daily living (ADLs) and instrumental activities of daily living (IADLs) range of motion (ROM) the movement of a joint to the extent possible without causing pain in 1 of 4 planes; steps of ROM start slowly with smooth and easy movements move joint until slight resistance is felt assess for fatigue or pain during ROM leave joint in correct alignment when finished flexion decreases the angle of a joint extension increases the angle of a joint abduction movement of the bone away from the midline of the body adduction movement of the bone toward the midline of the body