Lab Midterm Review PDF

Lab midterm review Week 1: Guidelines: 1. Wash hands before any client control 2. Identify the client correctly 3. Maintain the privacy of the client 4. Provide an explanation of the nursing measure to the client and/or family in a manner that could be understood 5. Assess the client's understanding...

Lab midterm review Week 1: Guidelines: 1. Wash hands before any client control 2. Identify the client correctly 3. Maintain the privacy of the client 4. Provide an explanation of the nursing measure to the client and/or family in a manner that could be understood 5. Assess the client's understanding 6. Promote the comfort of the client using verbal and non-verbal assessments 7. Promote the health and safety of the client 8. Prevent the spread of infection or cross-contamination 9. Consider the priority of clients' needs 10. Record and report significant observations accurately to the appropriate situation 11. Follow the procedure of the employing agency where applicable 12. Integrate theoretical concepts as they relate to nursing interventions Aspesis: absence of disease-producing microorganisms Nosocomial: associated with or originating in a hospital setting Antiseptic: an agent that inhibits or kills microorganisms on skin or tissues Pathogen: a microorganism that produces disease in most circumstances Bacteriostatic agent: an agent that prevents the growth and reproduction of bacteria Contaminated: possessing pathogenic organisms sterilization: complete elimination of all microorganisms including spores Carrier: a person who carries pathogens but is not ill Medical asepsis: practices that limit the transmission of microorganisms, also called clean technique disinfection: a process that eliminates many microorganisms from inanimate environmental surfaces Chain of infection: Infectious agent: - diagnosis/treatment - (bacteria, fungi, virus) Susceptible host: - treatment of underlying diseases - Immunization Portal of the enemy: - First aid - Personal hygiene - Handwashing Means of transmission: - Handwashing - Isolation - Disinfection - (direct contact, Inhalation, airborne) Exit: - Handwashing Control of aerosols and splatter Source: - education/ policy - Disinfection - Environmental sanitation An infectious agent: an organism that produces disease (ex, viruses, fungi) A reservoir: habitat where agent normally lives/grows/multiples (ex, humans) A portal of exit: a path by which a pathogen leaves its host (ex, cough/sneeze) A mode of transmission: the passing of a pathogen (ex, contact/ droplets) A portal of entry: how a pathogen enters a host (ex, inhalation/ absorption) Two infection control measures to reduce reservoirs of infection: 1. Hand hygiene: washing hands can reduce the spread of infection 2. sterilization/ disinfection: cleaning surfaces that could be infected can stop the spread of infection Four stages of infection: 1. Incubation 2. Prodromal -> general symptoms 3. Illness -> certain symptoms 4. Decline Pathogen: bacterium, virus that can cause disease Normal flora: microorganisms that do not cause disease Sterile: free from bacteria or other living microorganisms (fully clean) Contaminated: made impure by exposure to a polluting substance HAI: health-care associated infection develops as of result of medical care The potential for microorganisms to cause disease depends on which of the following four factors? 1. 4 sufficient number of organisms 2. Virulence or the ability to produce disease 3. The ability to enter and survive in the host 4. The susceptibility of the host What does cross-contamination mean? How do you prevent it? - Pathogens (disease) are on it - Handwash, clean, proper PPE When would you wear clean examination gloves? - Before and after patients, after touching blood/ bodily fluids, stool, contaminated items, open wounds Give an example of when a gown would be appropriate. - Splashing of bodily fluids - To protect uncared skin - Protect yourself Give an example of when eye protection would be appropriate. - Anything splashing - Mouth care What is your responsibility if you have an open or draining lesion? - Tell the supervisor - to cover the area - Go to occupational health Week 2: Beds should be made with two goals in mind 1. Clean 2. Comfortable The reason for completely finishing one side of the unoccupied bed and then moving to the other side is 1. Not reaching/ leaning over the bed 2. Save time/ energy The important safety features of beds include: 1. Locks on wheels 2. Alarms The most important safety step when making an occupied bed is to remember to: - Turing the patient to the side prevents falls, and injuries, and provides safety and comfort Open bed: when sheets are folded back to provide easy access for the patient to get in Closed bed: when the sheets are brought all the way up, preparing for a new patient How do nurses maintain proper body mechanics in bed-making? 1. Adjusting the height of the bed 2. Moving back and forth from the sides (do not reach/ lean over) 3. Put the side rail down Principles of basic body mechanics: 1. Keep weight balanced above the base of the support (women's center abdomen) (men's center 2 inches below the belly button) 2. Enlarge base of support as necessary to increase the body’s stability 3. Lower center of gravity toward the base of support as necessary to increase the body’s stability 4. Enlarge base of support in the direction in which force is to be applied 5. Tighten abdominal and gluteal muscles in preparation for all activities 6. Face in the direction of the task and turn the body in one plane 7. Bend hips and knees rather than back when lifting 8. Move objects on a level surface when possible 9. Slide rather than lift objects on smooth surfaces when possible 10. Hold objects close to the body and stand close to objects to be moved 11. Use body weight to assist in lifting or moving when possible 12. Carry out tasks using smooth motions and reasonable speed Describe the different bed positions and give an example of when you would use each: 1. High- Fowler: while the patient eats 2. Fowlers: prevent aspiration during tube feeding 3. Semi-fowlers: promotes lung expansion, dialysis 4. Trendelenburgs: postural drainage, head of the bed down feet up 5. Reverse trendelenburgs: promotes gastric emptying emptying, head up feat down 6. Flat: hypotensive patients Orthostatic hypotension: bones are flat and stand up, low blood pressure. (make them sit down with their feet on the ground until leveled) How to prepare a client for ambulation: - Make sure does not feel dizzy or light-headed and is able to tolerate the upright position - No clutter around - Put shoes and glasses on - Help them push up to sit, don't pull up Two reasons for bathing a client: 1. Proper hygiene 2. Reducing the risk of skin breakdown 3. Skin assessment/ skincare 4. Comfort Complete bed baths: total depend and require total hygiene care, may require full help from a nurse Partial bed baths: bathing body parts that require. Nurse and client help. (would be uncomfortable/ odor) 1. Eyes are cleaned from inner to outer canthus - Flip the cloth (never use the same side to wipe) 2. When washing a client's arms and legs, the nurse washed distal to proximal. This stimulates venous blood flow Explain foot and nail care guidelines and the related assessments: - Inspect feet daily - Wash feet with lukewarm water - Patients with diabetes mellitus need a full foot exam once a year - Do not cut corns/ calluses - If needed apply foot powder Rub a lotion if needed Trim the toenails What would you assess when caring for the feet? - Any wounds - Any dryness - Looking at the surface, between toes - Temperature - Color Explain the purpose of oral hygiene: - Helps to maintain the healthy state of the mouth, gums, lips, teeth, and tongue Comparing sides (right to left) = symmetry Week 3: Dermatitis: condition of skin becomes red, swollen and sore Ischemia: a condition in which blood flow is constricted or reduced in part of the body Turgor: how fast skins return to the body Blanching: skin remains white for longer than normal after pressing down Cyanosis: blue color in the skin, lips, and nail beds caused by shortage of oxygen in the blood Pallor: skin and mucous membranes turn lighter than usual Petechiae: purple or red spots on the skin Hematoma: Localized swelling and bruising formed Erythema: reddening of the skin, red inflammation Edema: swelling caused by a collection of fluid in the spaces that surround the body tissues/ organs Melanoma: skin cancer develops from melanocytes Eczema: chronic disease by dry, itchy skin. Dermatitis Jaundice: yellow discoloration of body tissue. Appears on top of mouth (palet) first Lesions: cell abnormality, could be benign or malignant. Would, injury, pathology change Induration: thickening and hardening of soft tissues Necrosis: death of body tissue Basal cell carcinoma: most common cancer, arises on skin damaged skin, malignant Risk situations associated with pressure ulcer development: 1. Bedrest (does not move) 2. Older individuals (less fat, longer healing time) 3. Impaired sensory perception (stroke etc) 4. Lack of nutrition Factors that contribute to pressure ulcer formation: Shearing force: pushing down on the body and resistance between the patient and the surface Moisture: reduces the resistance to other physical factors, more damage can be done, softens the skin Anemia: decreases of red blood cells, slow healing Impaired circulation: not enough blood flow Poor nutrition: delayed/ impaired healing, damage quicker Age: skin is more gentle, tears easily most comment sites where pressure ulcers develop: 1. sacrum/ coccyx 2. trochanter/ iliac crest 3. Bottom of heal/ foot 4. Back of head 5. Between knees (medial, lateral side of knees, bone on bone) 6. The medial, and lateral sides of the ankles 7. Elbows Maceration: prune-like skin, wound too wet, skin too wet, easier to cut, easier to get ulcer