Podcast
Questions and Answers
Which condition is associated with respiratory complications?
Which condition is associated with respiratory complications?
What is a common intervention for managing constipation?
What is a common intervention for managing constipation?
Which psychosocial complication may arise from loss of mobility?
Which psychosocial complication may arise from loss of mobility?
What is the recommended intervention to help prevent urinary retention?
What is the recommended intervention to help prevent urinary retention?
Signup and view all the answers
Which intervention is specific for managing atelectasis?
Which intervention is specific for managing atelectasis?
Signup and view all the answers
What describes the motion of pronation?
What describes the motion of pronation?
Signup and view all the answers
Which condition is characterized by loss of lean muscle mass?
Which condition is characterized by loss of lean muscle mass?
Signup and view all the answers
What intervention should be taken to monitor emotional status?
What intervention should be taken to monitor emotional status?
Signup and view all the answers
What type of isolation requires a private room with a negative pressure system?
What type of isolation requires a private room with a negative pressure system?
Signup and view all the answers
Which type of PPE is recommended for caregivers treating a patient with a Herpes Simplex infection?
Which type of PPE is recommended for caregivers treating a patient with a Herpes Simplex infection?
Signup and view all the answers
When should hand hygiene be performed?
When should hand hygiene be performed?
Signup and view all the answers
Which PPE is necessary for a provider exposed to potential splash contamination?
Which PPE is necessary for a provider exposed to potential splash contamination?
Signup and view all the answers
What is the primary reason for using soap and water for hand hygiene in cases of clostridium difficile?
What is the primary reason for using soap and water for hand hygiene in cases of clostridium difficile?
Signup and view all the answers
Which type of infection is associated with ventilator use?
Which type of infection is associated with ventilator use?
Signup and view all the answers
What is a critical consideration for protective isolation?
What is a critical consideration for protective isolation?
Signup and view all the answers
Which of the following is NOT a type of healthcare-associated infection?
Which of the following is NOT a type of healthcare-associated infection?
Signup and view all the answers
What is apnea characterized by?
What is apnea characterized by?
Signup and view all the answers
Which condition is associated with Cheyne-Stokes breathing?
Which condition is associated with Cheyne-Stokes breathing?
Signup and view all the answers
How would you document a pulse that is weak or diminished?
How would you document a pulse that is weak or diminished?
Signup and view all the answers
What is the normal range for oxygen saturation?
What is the normal range for oxygen saturation?
Signup and view all the answers
Which temperature measurement site is considered the most accurate?
Which temperature measurement site is considered the most accurate?
Signup and view all the answers
What distinguishes active range of motion (ROM) from passive ROM?
What distinguishes active range of motion (ROM) from passive ROM?
Signup and view all the answers
What is the primary benefit of the prone position?
What is the primary benefit of the prone position?
Signup and view all the answers
How should crutches be properly fitted according to the guidelines?
How should crutches be properly fitted according to the guidelines?
Signup and view all the answers
What is a recommended intervention for low oxygen saturation?
What is a recommended intervention for low oxygen saturation?
Signup and view all the answers
Which site for temperature measurement is considered non-intrusive?
Which site for temperature measurement is considered non-intrusive?
Signup and view all the answers
What is the first step when applying antiembolism stockings?
What is the first step when applying antiembolism stockings?
Signup and view all the answers
In case a client can bear no weight, what assistive device is recommended?
In case a client can bear no weight, what assistive device is recommended?
Signup and view all the answers
What complication can arise from immobility in the cardiovascular system?
What complication can arise from immobility in the cardiovascular system?
Signup and view all the answers
What should be done to help prevent pressure injuries in immobile patients?
What should be done to help prevent pressure injuries in immobile patients?
Signup and view all the answers
What is a common sign of systemic infection?
What is a common sign of systemic infection?
Signup and view all the answers
Which exudate type indicates a purulent infection?
Which exudate type indicates a purulent infection?
Signup and view all the answers
What is an effective action to break the chain of infection?
What is an effective action to break the chain of infection?
Signup and view all the answers
Which intervention is a part of falls risk assessment?
Which intervention is a part of falls risk assessment?
Signup and view all the answers
Why are restraints used in healthcare settings?
Why are restraints used in healthcare settings?
Signup and view all the answers
What is the purpose of ISBARR in client communication?
What is the purpose of ISBARR in client communication?
Signup and view all the answers
Which is a key nursing intervention during a seizure?
Which is a key nursing intervention during a seizure?
Signup and view all the answers
What is the normal range for blood pressure?
What is the normal range for blood pressure?
Signup and view all the answers
What defines Stage 1 hypertension?
What defines Stage 1 hypertension?
Signup and view all the answers
What is a nursing intervention for hypotension?
What is a nursing intervention for hypotension?
Signup and view all the answers
Where is the apical pulse taken?
Where is the apical pulse taken?
Signup and view all the answers
What should be noted when measuring blood pressure?
What should be noted when measuring blood pressure?
Signup and view all the answers
Which method is effective for counting respirations?
Which method is effective for counting respirations?
Signup and view all the answers
Which of the following is a cause of eupnea?
Which of the following is a cause of eupnea?
Signup and view all the answers
Flashcards
Isolation Precautions
Isolation Precautions
Guidelines to prevent disease transmission for patients with infections.
Contact Isolation
Contact Isolation
Used for infections like RSV and Scabies requiring gowns and gloves.
Droplet Isolation
Droplet Isolation
For diseases like Strep Throat; involves wearing a surgical mask.
Airborne Isolation
Airborne Isolation
Signup and view all the flashcards
Protective Isolation
Protective Isolation
Signup and view all the flashcards
When to Wear Gloves
When to Wear Gloves
Signup and view all the flashcards
Hand Hygiene Importance
Hand Hygiene Importance
Signup and view all the flashcards
Health Care Associated Infections
Health Care Associated Infections
Signup and view all the flashcards
Respiratory Complications
Respiratory Complications
Signup and view all the flashcards
Gastrointestinal Complications
Gastrointestinal Complications
Signup and view all the flashcards
Genitourinary Complications
Genitourinary Complications
Signup and view all the flashcards
Psychosocial Complications
Psychosocial Complications
Signup and view all the flashcards
Musculoskeletal Complications
Musculoskeletal Complications
Signup and view all the flashcards
Flexion
Flexion
Signup and view all the flashcards
Extension
Extension
Signup and view all the flashcards
Abduction and Adduction
Abduction and Adduction
Signup and view all the flashcards
Signs of Infection
Signs of Infection
Signup and view all the flashcards
Local Inflammation Signs
Local Inflammation Signs
Signup and view all the flashcards
Exudate Stages
Exudate Stages
Signup and view all the flashcards
Chain of Infection Break
Chain of Infection Break
Signup and view all the flashcards
Falls Risk Interventions
Falls Risk Interventions
Signup and view all the flashcards
Use of Restraints
Use of Restraints
Signup and view all the flashcards
Nursing Actions in Fires
Nursing Actions in Fires
Signup and view all the flashcards
Client Identification
Client Identification
Signup and view all the flashcards
Seizure Precautions
Seizure Precautions
Signup and view all the flashcards
Home Oxygen Safety
Home Oxygen Safety
Signup and view all the flashcards
Proper Body Mechanics
Proper Body Mechanics
Signup and view all the flashcards
Blood Pressure Normal Range
Blood Pressure Normal Range
Signup and view all the flashcards
Hypertension Stages
Hypertension Stages
Signup and view all the flashcards
Orthostatic Hypotension Diagnosis
Orthostatic Hypotension Diagnosis
Signup and view all the flashcards
Apnea
Apnea
Signup and view all the flashcards
Cheyne-Stokes
Cheyne-Stokes
Signup and view all the flashcards
Kussmaul’s breathing
Kussmaul’s breathing
Signup and view all the flashcards
Peripheral pulses locations
Peripheral pulses locations
Signup and view all the flashcards
Pulse quality scale
Pulse quality scale
Signup and view all the flashcards
Normal oxygen saturation
Normal oxygen saturation
Signup and view all the flashcards
Low oxygen interventions
Low oxygen interventions
Signup and view all the flashcards
Temperature measurement sites
Temperature measurement sites
Signup and view all the flashcards
Active vs Passive ROM
Active vs Passive ROM
Signup and view all the flashcards
Supine position
Supine position
Signup and view all the flashcards
Proper crutch fit
Proper crutch fit
Signup and view all the flashcards
Ambulation assistance
Ambulation assistance
Signup and view all the flashcards
Effects of immobility
Effects of immobility
Signup and view all the flashcards
Interventions for immobility
Interventions for immobility
Signup and view all the flashcards
Temperature site accuracy
Temperature site accuracy
Signup and view all the flashcards
Study Notes
Infection Control and Isolation
-
Room Assignments: Clients with infections require specific rooms, based on the type of infection.
-
Isolation Precautions (Types): Different types of isolation are used to prevent the transmission of infections.
-
Contact Precautions: Used for infections spread by direct contact (e.g., wound infections, RSV, scabies). Caregivers and visitors wear gowns and gloves. Patients are placed in private rooms or cohorted with others with the same infection, maintaining 3 feet between clients. PPE must be removed before leaving the room.
-
Droplet Precautions: Used for infections spread through large droplets produced by coughing or sneezing (e.g., rubella, pertussis, mumps). Providers and visitors wear surgical masks. Private rooms or cohorting are used, with at least 3 feet between clients. Clients wear masks when moving outside their rooms. Cough etiquette and hand hygiene are crucial. Use individual equipment whenever possible.
-
Airborne Precautions: Used for infections spread by small airborne particles (e.g., measles, varicella, tuberculosis, COVID-19). Patients need private rooms with negative pressure and closed doors. Providers and visitors wear N95 or higher masks (fit testing is required). Wear full PPE if splashing is expected.
-
Protective Isolation: Used for immunocompromised clients, especially during the first 100 days after hematopoietic stem cell transplant or as needed. No plants; this is maintained using positive airflow, and masks should be worn if they move outside the room.
-
Personal Protective Equipment (PPE)
-
Gloves: Worn when contact with blood, bodily fluids, secretions, excretions, non-intact skin, mucous membranes, or contaminated items is anticipated.
-
Eye Protection: Protective eyewear should be worn if there's a risk of splash contamination when dealing with body fluids or during wound irrigation.
Hand Hygiene
-
Frequency: Hand hygiene is performed before and after client interaction.
-
Importance: Essential to prevent the spread of germs.
-
Specific Situations: Different techniques may be necessary for different pathogens. For Clostridium difficile, soap and water are essential to eliminate spores.
Healthcare-Associated Infections (HAIs)
-
Types: Include catheter-associated urinary tract infections (CAUTIs), surgical site infections (SSIs), ventilator-associated pneumonia (VAPs), and central line-associated bloodstream infections (CLABSIs).
-
Concerns: HAIs are costly. They pose serious risk of morbidity and mortality, and generate a negative perception of the healthcare system.
Signs of Infection and Inflammation
-
Generalized Infection Signs: Fever, chills, increased pulse and respiratory rate, malaise, fatigue, anorexia, nausea/vomiting, abdominal cramping/diarrhea, and enlarged lymph nodes.
-
Inflammation Signs (Local): Redness, warmth, edema, pain/tenderness, and loss of function in the affected area.
-
Inflammation Signs (Exudate): Clear (serous), bloody (sanguineous), or pus-filled (purulent) discharge.
-
Inflammation Signs (Late Stages): Tissue repair with formation of scar tissue.
Breaking the Chain of Infection
- Methods: Proper handwashing, disinfection/sterilization, and isolation of infected patients are vital.
Safety
Fall Risk Assessment and Interventions
-
Assessment: Multidisciplinary approach with strong administrative support to review past falls, investigate causes, and develop policies.
-
Interventions: Non-skid footwear, low bed positions, locked bed wheels/wheelchair brakes, adequate lighting, call lights within reach, client education, signage.
Restraints
-
Rationale: Restraints are used with extreme caution and when necessary to minimize risk of injury.
-
Application: Applied correctly, with minimal tightness to prevent circulation problems.
-
Nursing Care: Regular assessment, repositioning, care to prevent skin breakdown, frequent monitoring of vital signs.
-
Complications: Potential for complications including pressure injuries, circulation impairments and emotional distress.
Fire Safety
- Actions: Remove persons from danger, activate alarm, close doors/windows, address small fires.
Client Safety Goals
-
Identification: Use of two client identifiers.
-
Communication: Clear communication; use ISBARR method and communicate critical results.
-
Medication Safety: Label medications correctly; be aware of high-alert medications like anticoagulants; perform medication reconciliation.
Seizure Precautions
- Interventions: Call rapid response team (RRT), place in side-lying position (avoid aspiration), protect head, remove harmful objects, loosen tight clothing around the neck, continuous monitoring, document seizure characteristics, and monitor ABCs (airway, breathing, circulation).
Home Oxygen Use Education
- Precautions: No smoking around oxygen; keep open flames and electrical appliances away; never use while cooking; turn off if a fire; install/test smoke detectors.
Body Mechanics
- Positioning: Stay close to the object; contract abdominal/back muscles, keep head/shoulders aligned, slightly bend your knees, and pivot/step instead of twisting.
Vital Signs
Blood Pressure
-
Technique: Use a cuff appropriate size to client arm; place cuff 1 inch above elbow crease, with arrow aligned with brachial artery; client can be seated or lying, arm supported at heart level, palm up, or thigh if needed; inflate 30 mmHg above expected systolic, release slowly 2 mmHg /sec; record first and fifth Korotkoff sounds. Use a two-step process when possible.
-
Normal Range: 120/80 mmHg
-
Hypertension Stages: Stage 1 (130-139/80-89), Stage 2 (>140/>90), Crisis (>180/>120).
-
Risk Factors: Excessive sodium, obesity, alcohol consumption, stress, family history.
-
Interventions: Exercise, stress reduction, low-sodium diet, and weight loss (if needed).
-
Hypotension Intervention: Change positions slowly, increase fluids, avoid temperature extremes, elevation (unless contraindicated).
-
Orthostatic Hypotension: Measure blood pressure changing position (lying to sitting, sitting to standing). Diagnosed by drop of at least 20 mmHg systolic, or 10 mmHg diastolic.
Apical Pulse
-
When Taken: When illness, weakness or rapid radial pulse are suspected.
-
Duration: 1 minute
-
Where: At apex of the heart (5th intercostal space, left mid-clavicular line).
Respirations
-
Counting: One breath in and one breath out equals one respiration count.
-
Patterns: Eupnea (normal), apnea (cessation), Cheyne-Stokes (cyclical shallow/deep with apnea), Kussmaul (deep, rapid, regular).
-
Causes of Patterns: Eupnea occurs when relaxed; Apnea in opioid overdose & heart failure; Cheyne-Stokes in stroke, brain tumor, and heart failure; Kussmaul in DKA and renal disease.
Peripheral Pulses
-
Locations: Temporal, carotid, brachial, femoral, popliteal, dorsalis pedis, posterior tibial.
-
Documentation: 0 absent, +1 weak, +2 normal, +3 strong, +4 bounding.
Oxygen Saturation
-
Obtaining: Place sensor on intact digit, earlobe, or bridge of nose; document stable readings.
-
Normal: 95-100%.
-
Low Interventions: Auscultate lungs, increase oxygen flow, monitor for respiratory arrest, possible intubation.
Temperature
-
Sites: Oral, temporal, rectal, axillary, tympanic.
-
Benefits/Limitations: Assess benefits and drawbacks of temperature from chosen sites.
Mobility
Range of Motion (ROM)
- Active vs. Passive: Active ROM performed by the client; Passive ROM supported by staff
Bed Positions
- Positions Used For: Supine, prone, semi-Fowler's, Fowler's, Trendelenburg, semi-prone positions with their intended use.
Mobility Aids
-
Crutches Fit: Crutches should be placed 1-2 inches below the axilla, at a 15-30 degree angle, with body weight supported by hands, not axilla.
-
Stockings (Anti-embolism): Applied in the morning before leg distention, or 15-30 minutes after elevation.
-
Ambulation Assistance: Support the back and hold the gait belt.
-
Moving Clients in Bed: Place sling from shoulders to mid-thigh, raise the side rail, move to the other side of the bed, then lower the side rail and roll the client.
-
Transferring: Methods based on patient's weight bearing: lift, sit-to-stand, gait belt/ambulation, or no assistance.
-
Immobility Complications: A summary of complications by system, categorized by complication with interventions.
Movement Pairs
- Types: Flexion/extension, abduction/adduction, pronation/supination, circumduction, rotation, inversion/eversion, dorsiflexion/plantar flexion.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
This quiz explores the critical aspects of infection control and isolation practices in healthcare settings. It covers the specific types of isolation precautions, including contact and droplet precautions, and the necessary procedures for room assignments and protective equipment. Perfect for healthcare professionals and students in infection prevention.