30 Questions
What is the goal of Surgical Asepsis?
To keep an area or object free from all microorganisms
What is the primary focus of Medical Asepsis?
Reducing the growth of microorganisms
What is the term for the state of being free from disease-causing microorganisms?
Asepsis
What is the purpose of using Personal Protective Equipment (PPE)?
To protect the healthcare practitioner and client from infection
What is the term for practices that destroy all microorganisms and spores?
Aseptic Technique
What is the rule followed in Medical Asepsis?
Clean to Clean Rule
What is the primary purpose of repositioning a client who cannot move independently?
To prevent pressure ulcers and maintain skin integrity
What should be assessed during the nursing process to determine specific restrictions regarding client positioning?
The client's physician's order
What is a expected outcome of repositioning a client?
The client will maintain skin integrity without skin burns, pressure areas or ulcers
How often should a client who cannot move independently be repositioned?
Every 2 hours
What should be avoided when positioning a client?
Placing one body part, particularly one with bony prominences, directly on top of another body part
What is a potential diagnosis for a client who is immobile?
All of the above
What should the nurse do before repositioning the client?
Explain the procedure to the client and encourage questions
What is the main purpose of using pillows or foam wedges in repositioning a client?
To maintain body alignment
What is the name of the position where the head and trunk are raised 45° to 60° relative to the bed?
Fowler's Position
What should the nurse instruct the Nurse Attendant to do while delegating a task?
Provide information regarding the patient's individual needs for body alignment
What is the purpose of using gloves when repositioning a client?
To prevent infection transmission
What is the main purpose of repositioning a client?
To provide comfort and prevent complications
What is the effect of heat on blood viscosity?
Decreases blood viscosity
What is a contraindication for heat application?
The first 24 hours after injury
What is the maximum vasoconstriction temperature for cold application?
15°C (60°F)
What is the effect of prolonged exposure to cold?
Reflex vasodilation
What is a nursing consideration for heat application?
Check the doctor's order for specific instruction
What is the opposite of heat application in terms of physiological effects?
Cold application
What is the primary goal of attending to the client's elimination needs?
To promote safety and hygiene
What is the first step in the nursing process when assisting with bedpan and urinal?
Check for doctor's order for any specific instruction
What is a potential diagnosis for a client who has difficulty voiding and defecating?
All of the above
What is the nurse's role in promoting the client's privacy and comfort?
To ensure the client's privacy and comfort as allowable
What is the expected outcome of the nursing process when assisting with bedpan and urinal?
The client will be able to void and defecate when necessary
What is a potential outcome of altered elimination patterns?
All of the above
Study Notes
Positioning and Repositioning
- Ensure the mattress is firm and level to support natural body curvature
- Place support devices in specified areas according to the client's position
- Avoid placing one body part, particularly one with bony prominences, directly on top of another body part
- Plan a systematic 24-hour schedule of position change
- Clients who cannot move independently must be repositioned every 2 hours
Assessment
- Assess the client's ability to move independently
- Assess the client's flexibility
- Assess the client's age, medical diagnosis, cognitive status, skin integrity, nutritional status, continence, and altered sensation
- Assess the overall condition of the musculoskeletal system
- Assess the client's physician's order for specific restrictions regarding client positioning
Diagnosis
- Impaired Physical Mobility
- Risk for Impaired Skin Integrity
- Activity Intolerance
- Acute Pain
Planning
- The client will maintain skin integrity without skin burns, pressure areas or ulcers
- The client will maintain adequate circulation
- The client will be comfortable as evidenced by verbal and nonverbal cues
Implementation
- Introduce self to client
- Check client's identification band
- Explain procedure before beginning
- Wash hands
- Gather equipment
Delegation
- Inform the Nurse Attendant of positioning restrictions
- Designate specific times throughout the shift at which nurse attendant must reposition the patient
- Provide information regarding the patient's individual needs for body alignment
Turning of Patient to Various Positions
- Fowler's Position: head and trunk raised 45° to 60° relative to the bed, with knees flexed or not
- Semi-Fowlers position: head and trunk raised 15 to 45 degrees
- High Fowler's position: head and trunk raised 60 to 90 degrees
Aseptic Precautions
- Asepsis: the state of being free from disease-causing microorganisms
- Surgical Asepsis: practices that keep an area or object free from all microorganisms
- Medical Asepsis: absence of disease-causing microorganisms, concerned with eliminating or reducing the number and growth of microorganisms
Heat Application
- Vasodilation: decreases blood viscosity, reduces inflammation, reduces muscle tension, and has a sedative effect
- Indications: muscle spasm, inflammation, pain, contracture, joint stiffness, traumatic injury
- Contraindications: first 24 hours after injury, active hemorrhage, localized malignant tumor, skin disorder, decreased sensation, impaired mental status, open wound
Cold Application
- Generally, the physiologic effect of cold is the opposite of heat application
- Cold lowers the temperature of the skin and the underlying tissue and causes vasoconstriction
- Classification: dry form (cold pack, ice bag/ice collar)
Assisting with Bedpan/Urinal and Specimen Collection, Voiding, and Defecating
- Attend to the client's needs with proper techniques to support and promote adequate rest, safety, hygiene, cleanliness, and integrity
- Assess equipment, client, privacy, and unexpected interruptions
Diagnosis
- Constipation
- Bowel Incontinence
- Stress urinary Incontinence
- Urge Urinary Incontinence
- Urinary Retention
- Toileting self-care deficit
- Situational low self-esteem
- Powerlessness
- Altered Comport
Test your knowledge on infection control measures, including personal protective equipment, sharps safety, and aseptic techniques. Learn about the importance of maintaining a sterile environment and preventing the spread of disease-causing microorganisms.
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