infections - with Answers:bacteria, viruses fungi reservoir - with Answers:natural habitat of the organism portal of exit - with Answers:point of escape for the organism from the reservoir means of transmission - with Answers:direct contact, indirec

  infections - with Answers:bacteria, viruses fungi reservoir - with Answers:natural habitat of the organism portal of exit - with Answers:point of escape for the organism from the reservoir means of transmission - with Answers:direct contact, indirect contact, airborne route portal of entry - with Answers:point at which organisms enter a new host susceptible host - with Answers:must overcome resistance mounted by host's defenses the infection cycle - with Answers:Infectious agent, reservoir, portal of exit, means of transmission, portal of entry and susceptible host. handwashing-number 1 way to prevent infection in 20 seconds most common found infection in health care - with Answers:bacteria factors affecting organisms potential to produce disease - with Answers:number of organsims virulence competence of persons immune length and intimacy of contact which infection or disease may be spread by touching a contaminated inanimate article a. rabies ia enza d.e coli - with Answers:influenza common portals of entry - with Answers:Respiratory Gastrointestinal Genitourinary tracts Breaks in skin Blood and tissue Stages of infection - with Answers:incubation-organisms grow and multiply prodromal-person is most infectious, non specific signs of disease full stage of illness-prescense of specific signs and symptoms convalescent-recovery factors affecting host susceptibility - with Answers:1) intact skin & mucous membranes 2) normal pH levels 3) body's WBCs 4) Age, sex, race, hereditary factors 5) immunization, natural or acquired 6) fatigue, climate, nutritional & general health status. 7) Stress 8) Use of invasive or indwelling medical devices. outcome identification and planning infection control - with Answers:hand hygiene identify signs of infection adequate nutritional intake proper disposal of soiled articles appropriate cleansing and disinfecting techniques awareness of the necessity of proper immunizations stress-reducing techniques cardinal signs of acute infection - with Answers:redness, heat, swelling, pain, loss of function 5 moments for handwashing - with Answers:1. before touching a patient e a clean or aseptic procedure body fluid of exposure risk touching a patient touching patient surroundings transient - with Answers:attached losely on skin, removed with relative ease resident - with Answers:found inf creases in skin, requires friction with brush to remove majority of hospital required infections comes from - with Answers:catheter associated urinary tract infection surgical site central line associated blood stream infection ventilator associated pneumonia Factors Determining Use of Sterilization and Disinfection Methods - with Answers:nature of organisms present number type of equipment intended use of it available means time PPE (personal protective equipment) - with Answers:gloves, gowns, masks, protective eye gear standard precautions - with Answers:A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious. new additions are respiratory and hygiene cough etiquette transmission based precautions - with Answers:used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes recognizes the disease may have multiple means of transmission standard precautions should be used when caring for a noninfectious post patient who is vomiting blood - with Answers:true medical aspesis - with Answers:-"clean technique" -used predominantly, things we can do to minimize number/spread of pathogens -hand hygiene -keep nails short, no artificial nails -wear PPE as indicated -change linens -clean floors, room surfaces -biohazard bags/containers -clean from least soiled to more soiled surgical asepsis - with Answers:sterile technique -operating room, labor and delivery areas certain diagnostic testing areas patient bedside-catheter insertion, sterile dressing changes, prepping and injecting meds patient teaching for medical asepsis at home - with Answers:Wash hands before preparing or eating food. Prepare foods at high enough temperatures. Use care with cutting boards and utensils. Keep food refrigerated. Wash raw fruits and vegetables. Use pasteurized milk and fruit juices. Wash hands after using bathroom. Use individual care items. goals techniques of medical asepsis health happy and lifestyle patterns promote good health state signs and symptoms of an infection identify unsafe situations temperature - with Answers:oral, temporal, tympanic, axillary, rectal(MOST ACCURATE) effecting agents-excersie, stress, metabolic rate, environment, fever, meds, activity infants temp is usually higher (99 F) elderly is lower 37.0 C or 98.6 F thermometer must be set in correct setting for that age group sweat disrupts temporal laying on side-heat production-disrupts ear higher in the evening pulse - with Answers:radial or apical effecting agents-fever, meds, activity active athletes could fall below 60-100 (80 is average)-30 sec x2 or 15 sec x4 respirations - with Answers:watching chest or abdomen rise or fall while taking pulse 12-20 breaths/min blood pressure - with Answers:taken at heart level on the skin systolic-changes due to environment diastolic-worried if their is a change bp cuff too small-higher bp cuff too big-lower infants-apical pulse taken, 120 or 140, bp on calve 120/80-must indicate where it was taken pain - with Answers:asses in every vital sign when to asses vital signs - with Answers:On admission to any health care facility or institution Based on facility or institutional policy and procedures **Any time there is a change in the patient's condition*** Any time there is a loss of consciousness Before and after any surgical or invasive diagnostic procedure Before and after activity that may increase risk, such as ambulation after surgery Before administering medications that affect cardiovascular and respiratory function types of fever - with Answers:intermittent-temp returns to normal once every 24 hours remittent-temp doesn't return to normal and fluctuates a few degrees up and down sustained-temp remains normal, minimal variation relapsing or recurrent-temp returns to normal for one or more days with one or more episodes of fever, each as long as several days heat loss sources - with Answers:skin evaporation of sweat warming and humidifying inspired air eliminating urine and feces rectal temp-core-highest forehead-lowest transfer of body heat to external environment - with Answers:Radiation-energy is radiated through the air by means of electromagnetic radiation Convection-the transfer of heat from a surface by means of a fluid such as air. Evaporation-The latent heat of a fluid can be used to transfer heat by absorbing the energy required to evaporate that fluid. The heat absorbed is released by allowing the fluid to condense outside the enclosure. Conduction-This is the transfer of heat through a solid. factors affecting body temperature - with Answers:-circadian rhythms -age and gender -physical activity -state of health -environmental temperature Pulse physiology - with Answers:Regulated by the autonomic nervous system through cardiac sinoatrial node (SA node) Parasympathetic stimulation—decreases heart rate Sympathetic stimulation—increases heart rate ventalation - with Answers:The movement of air in and out of the body via inhalation and exhalation diffusion - with Answers:exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood perfusion - with Answers:exchange of oxygen and carbon dioxide between the circulating blood and tissue cells primary hypertension - with Answers:denotes high blood pressure from an unidentified cause; also called essential hypertension secondary hypertension - with Answers:high blood pressure caused by the effects of another disease increases in co2 - with Answers:the most powerful respiratory stimulant respiratory rates - with Answers:Eupnea: normal, unlabored respiration; one respiration to four heartbeats Tachypnea: increased respiratory rate; may occur in response to an increased metabolic rate Bradypnea: decreased respiratory rate; occurs in some pathologic conditions Apnea: periods when no breathing occurs Dyspnea: difficult or labored breathing Orthopnea: changes in breathing when sitting or standing factors affecting personal hygiene - with Answers:1. Culture 2. Socioeconomic class 3. Spiritual practices 4. Developmental level 5. Health state 6. Personal preferences factors to consider when examining skin - with Answers:Cleanliness Color Temperature Turgor Moisture Sensation Vascularity Evidence of lesions assessment of oral cavity - with Answers:Lips Buccal mucosa Color and surface of gums Teeth Tongue Hard and soft palates Oropharynx self care deficits diagnoses - with Answers:feeding bathing and hygienbe dressing and grooming toileting *don't assume routine, ask* give opportunity to let patient do what they can early morning care (AM care) - with Answers:Routine care given before breakfast; AM care toileting refresh wash face and hands mouth care back massage special skin measures hair care dressing position for comfort refresh's linenes tidying up bedside-tray!!! feel special Afternoon care (p.m. care) - with Answers:Ensure that the patient is comfortable after lunch and offer assistance with toileting, handwashing, and oral care. Straighten the bed or help someone to reposition for comfort. Hour of sleep care (H.S. care) - with Answers:Before the patient goes to bed, offer to toilet them again, wash face and hands, and oral care. This is also a good time for a back massage as patients find it soothing and may help them to fall asleep. Some patients may also find a bath to be soothing and sleep promoting at this time. At this time it is also important to change soiled linens, position the patient comfortably, and ensure the call be is within reach. As needed care (p.r.n. care) - with Answers:Offer individual hygiene measures as needed. Change clothing and bed linens of diaphoretic patients. Provide oral care every 2 hours if indicated. never massage - with Answers:pain or clot bed bath - with Answers:face, one side, other side, perineal PRIVACY! not cold oral cavities assemsment - with Answers:dental carries periodontal disease dentures-must be taken out soft toothbrush is the best care for eyes - with Answers:inner to outer ear and nose care - with Answers:with wash cloth-ear do not use cotton swab hearing aid teaching clean nose by having patient blow remove crusted secretions hair care - with Answers:one history of hair or scalp problems using a protective pad and plastic tray when shampooing hair nail and foot care - with Answers:Assess nails for color and shape, intactness and cleanness, and tenderness. Check for history of nail or foot problems. Soak nails and feet and assist with cleaning and trimming nails (if not contraindicated). Massage the feet to promote relaxation and comfort. Provide diabetic foot care if indicated. Perineal and Vaginal Care - with Answers:Assess for perineal or vaginal problems and related treatments. Perform a physical assessment of male and female genitalia. Perform perineal care in matter-of-fact and dignified manner according to procedure. Cleanse vaginal area with plain soap and water. Ensuring Bedside Safety - with Answers:The bed is in its lowest position. The bed position is safe for the patient. The bed controls are functioning (bed is electrically safe). Call light is functioning and always within reach Side rails are raised if indicated. The wheels or casters are locked. patient outcome for hygiene - with Answers:participation in care change and knowledge the info from the health assessment is used to formulate nursing diagnoses that require nursing care - with Answers:true types of health assessment - with Answers:comprehensive- conducted upon admission ongoing partial-conducted at regular intervals (follow uos, beginning of shifts, monitor changes) focused-conducted to asses a specific problem emergency-conducted to asses life threatening or unstable conditions preparing the patient for a physical assessment - with Answers:Consider the physiologic and psychological needs of the patient. Explain the process to the patient. Explain that physical assessments will not be painful (decrease patient fear and anxiety). Explain each procedure in detail as it is conducted. Ask the patient to change into a gown and empty bladder. Answer patient questions directly and honestly. Preparing the Environment for Physical Assessment - with Answers:Agree on a time for the assessment - The time should not interfere with meals, daily routines, or visiting hours Make sure patient is as free of pain as possible Prepare the examination table Provide a gown and drape for the patient Gather the supplies and instruments needed Provide a curtain or screen if the area is open to others equipment used during a physical - with Answers:thermometer scale flashlight stethescope metric tape measure/ruler-wound or skin season, infant height eye chart Positions Used During a Physical Assessment: - with Answers:Standing: assessment of posture, balance, and gait Sitting: allows visualization of upper body Supine: allows relaxation of abdominal muscles Dorsal recumbent: used for patients having difficulty maintaining supine position Sim's: assessment of rectum or vagina Prone: assessment of hip joint and posterior thorax Lithotomy: assessment of female genitalia and rectum Knee-chest: assessment of anus and rectum what position do you use to asses the rectum - with Answers:sims components of a preventative health assessment - with Answers:health history, risk for depression, functional ability, level of safety, physical examination, patient education and counseling considerations when performing health assessment - with Answers:Lifespan considerations Cultural considerations and sensitivity Patient preparation Environmental preparations (privacy and respect for all patients is key) Factors to Assess During a Health History - with Answers:Biographical data Reason for seeking health care-chief complaint History of present illness-API Past health history Family history Functional health Psychosocial and lifestyle factors Review of systems techniques used during a physical assessment - with Answers:-Inspection: assessing size, color, shape, position, and symmetry -Palpation: assessing temperature, turgor, texture, moisture, vibrations, and shape -Percussion: assessing location, shape, size, and density of tissues -Auscultation: assessing the four characteristics of sound, that is, pitch, loudness, quality, and duration characteristics of masses determined by palpation - with Answers:Shape Size Consistency Surface Mobility Tenderness Pulsatile (plantar-fingertips/pads-sensory texture) (dorsal-temp) abdominal quadrants and underlying organs - with Answers: characteristics of sound hear when using auscultation - with Answers:pitch-ranging from high to low loudness-ranging from soft to loud quality-gurgling or swishing duration-short medium long general survery - with Answers:general appaerance vital signs heigh weight waist circumference BMI physical assessment - with Answers:Integument Head and neck Thorax and lungs Cardiovascular and peripheral vascular systems Breasts and axillae Abdomen Female and male genitalia Anus, rectum, prostate Musculoskeletal system Neurologic system risk factors for altered health assessed in health history - with Answers:history of: trauma pain surgery smoking alc intake frequency or type of exercise dietary intake of calcium assessing level of awareness - with Answers:time, place,person documenting this is important for patient care and treatment purpose of documentation - with Answers:Identify actual and potential health problems Make nursing diagnoses Plan appropriate care Evaluate patient's responses to treatment (educate patient-especially for testing and procedures) Nurse's Role in Diagnostic Procedures - with Answers:Assist before, during, and after diagnostic tests. Be responsible for other activities associated with diagnostic tests. Witness the patient's consent. Schedule the test. Prepare the patient physically and emotionally for the test. Provide care and teaching after the test. Dispose of used equipment. Transport specimens. focus of safety assessments - with Answers:/The person The environment Specific risk factors among older adults - with Answers:falls are the leading cause of injury or fatality physical examination - with Answers:Assess mobility status Assess ability to communicate Assess level of awareness or orientation Assess sensory perception Identify potential safety hazards Recognize manifestations of domestic violence or neglect Factors that contribute to falls - with Answers:Lower body weakness Poor vision Gait and/or balance issues Problems with feet and/or shores Use of psychoactive medications Postural dizziness Hazards in the home (and community) Risk factor Assessment - with Answers:Falls (65 and older) Fires (smoking in bed, faulty wires, space heaters) Poisoning (overdose, medications) Suffocation & Choking (cosleeping, asphyxiation) Firearm injuries indications of a concussion - with Answers:Physical: headache, vomiting, problems with balance, fatigue, dazed or stunned appearance Cognitive: mentally foggy, difficulty concentrating and remembering, confusion, forgets recent activities Emotional: irritability, nervousness, very emotional behavior Sleep: drowsiness, difficulty falling asleep, sleeping more or less than usual Safety Improvement Strategies - with Answers:Preventing Falls Targeted Solutions Tool® (TST®) Falls Toolkit Falls Prevention Training Program Root Cause Analysis (RCA) hospital safety devices - with Answers:chair alarm bed alarm galt alarm transfer and mobility devices-maxi slides/air Sara maxi-sky(overhead railing system) Hendrich II Fall Risk Model - with Answers:Fall Scene Investigations (FSI) Hourly patient rounding Root cause analysis (RCA) Morse Fall Scale - with Answers:Six-item fall risk assessment tool, widely used nationally and internationally since the late 1980s in acute care and long-term care settings calibrated for each healthcare setting or unit so that fall prevention tragedies are targeted to those more at risk different on your facility RACE acronym for fire - with Answers:R—Rescue anyone in immediate danger. A—Activate the fire code and notify appropriate person. C—Confine the fire by closing doors and windows. E—Evacuate patients and other people to safe area. Procedure-Related Accidents/Possible Errors - with Answers:Administering medications or intravenous solutions Transferring a patient Changing a dressing Applying external heat to a patient's extremity safety event reports - with Answers:Must be completed after any accident or incident in a health care facility that compromises safety Describes the circumstances of the accident or incident Details the patient's response to the examination and treatment of the patient after the incident Completed by the nurse immediately after the incident Is not part of the medical record and should not be mentioned in documentation Physiologic hazards associated with restraints - with Answers:Increased possibility of serious injury due to fall Skin breakdown Contractures Incontinence Depression Delirium Anxiety Aspiration and respiratory difficulties Death a side rail - with Answers:is not considered a restraint PASS acronym for fire extinguishers - with Answers:Pull the pin Aim at the base of fire when spraying Squeeze the handle Sweep back and forth at the base of the fire Maintaining Emergency Preparedness - with Answers:Addressing biological threats Addressing chemical threats Addressing radiation threats Addressing cyber terror Preparing for mass trauma terrorism Identifying disaster resources Addressing psychological aspects of disasters Chemicals Used for Mass Destruction - with Answers:Biotoxins Blister agents/vesicants Blood agents Choking/lung/pulmonary agents Blood agents Incapacitating agents Long-acting anticoagulants Metals Nerve agents Organic solvents Riot control agents/tear gas Toxic alcohols Vomiting agents joint commission 2019 national patient safety goals - with Answers: Drug Nomenclature: Chemical Name - with Answers:precise description of the drugs chemical composition; identifies atomic/molecular structure Drug Nomenclature: Generic Name - with Answers:assigned by the manufacturer that 1st develops the drug, often derived from chemical name drug nomenclature: official name - with Answers:name by which the drug is identified in official publications; USP and NF (often use generic names) Drug Nomenclature: trade name - with Answers:brand name copyrighted by the company that sells the drug Drug Preparations - with Answers:•* Oral* - Capsule, pill, tablet, extended release, elixir, suspension, syrup •* Topical* - Liniment, lotion, ointment, suppository, transdermal patch •* Injectable*-insulbin, sub q, epipen drug classifications - with Answers:pharmaceutical class and therapeutic class Pharmacokinetics - with Answers:absorption, distribution, metabolism, excretion factors affecting absorption of medication - with Answers:Route of administration Lipid solubility pH Blood flow Local conditions at site of administration Drug dosage pharmacodynamics - with Answers:process by which drugs alter cell physiology and affect the body adverse drug affects - with Answers:allergic effects drug intolernace toxic effect idiosyncratic effect drug interaction factors affecting drug action - with Answers:Developmental considerations Weight Gender Genetic and cultural factors Psychological factors Pathology Environment Timing of administration Drug Dose and Serum Drug Levels - with Answers:-Therapeutic range: concentration of drug in the blood serum that produces the desired effect without causing toxicity -Trough level: the point when the drug is at its lowest concentration, indicating the rate of elimination -Half-life: amount of time it takes for 50% of blood concentration of a drug to be eliminated from the body metric system conversions - with Answers:• To convert larger unit to smaller unit, move decimal point to right • To convert smaller unit to larger unit, move decimal point to left - 1 kilogram = 1,000 grams - 1 gram = 1,000 milligrams - 1 milligram = 1,000 micrograms Types of Medication Orders - with Answers:-Standing order (routine order): carried out until cancelled by another order -PRN order: as needed -Single or one-time order -Stat order: carried out immediately parts of the medication order - with Answers:Patient's name Date and time order is written Name of drug to be administered Dosage of drug Route by which drug is to be administered Frequency of administration of the drug Signature of person writing the order Three Checks of Medication Administration - with Answers:READ LABEL -When the nurse reaches for the container or unit dose package -After retrieval from the drawer and compared with the CMAR, or compared with the CMAR immediately before pouring from a multidose container -Before giving the unit dose medication to the patient or when replacing the multi-dose container in the drawer or shelf medication errors - with Answers:REPORT ALL -Check patient's condition immediately; observe for adverse effects. -Notify nurse manager and primary care provider. -Write description of error and remedial steps taken on medical record. -Complete form used for reporting errors, as dictated by the facility policy. Type of Medication Errors - with Answers:Inappropriate prescribing of the drug Extra, omitted, or wrong doses Administration of drug to wrong patient Administration of drug by wrong route or rate Failure to give medication within prescribed time Incorrect preparation of a drug Improper technique when administering drug Giving a drug that has deteriorated Rights of Medication Administration - with Answers:Right medication Right patient Right dosage Right route Right time Right reason Right assessment data Right documentation Right response Right to education Right to refuse administration of oral medication - with Answers:oral, enteral, sublingual, buccal-dont give water administration of parenteral medications - with Answers:Subcutaneous injection—subcutaneous tissue Intramuscular injection—muscle tissue Intradermal injection—corium (under epidermis) Intravenous injection—vein Intraarterial injection—artery Intracardial injection—heart tissue Intraperitoneal injection—peritoneal cavity Intraspinal injection—spinal canal Intraosseous injection—bone Criteria for Choosing Equipment for Injections - with Answers:Route of administration Viscosity of the solution Quantity to be administered Body size Type of medication site for intramuscular injections - with Answers:, vastus lateralis-children, thigh deltoid muscle ventrogluteal-side of hip dorso gluteal site-no longer recommended parts of needle and syringe - with Answers: intradermal injection - with Answers:administered into the dermis, just below the epidermis longest absorption rate used for-sensitivity tests and local anesthesia reaction by body is easily visible 5-15 degrees inner surface of arm, upper back and under scapula subcutaneous injection - with Answers:injection into the subcutaneous tissue that lies between the epidermis and the dermis sites: outer aspect of arm abdomen anterior aspect of thigh upper back upper ventral or dorsogluteal intravenous injections of meds - with Answers:DRUG DIRECTLY TO BLOOD immediate effect in emergency situations most often Topical Administration of Medications - with Answers:Skin applications Eye instillations and irrigations Ear instillations and irrigations Nasal instillations Vaginal applications Rectal instillations medical record documentation - with Answers:Name of the medication Dosage Route and time of administration Name of person administering medication Site used for an injection Intentional or inadvertently omitted drugs Refused drugs Medication errors