Term
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Definition
responsible for providing clear directions when a task is initially
delegated and for periodic reassessment and evaluation of the outcome of the task
-know of state nurse practice act
-so they can complete higher level tasks
may be RNs LPNs or APs
NEVER DELEGATE NURSING PROCESS |
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Term
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Definition
Monitoring client findings (as input to the
RN’s ongoing assessment of the client)
• Reinforcing client teaching from a standard
care plan
• Performing tracheostomy care
• Suctioning
• Checking nasogastric tube patency
• Administrating enteral feedings
• Inserting a urinary catheter
• Administrating medication (excluding
intravenous medications in several states) |
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Term
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Definition
• Activities of daily living (ADLs)
• Bathing
• Grooming
• Dressing
• Toileting
• Ambulating
• Feeding (without swallowing precautions)
• Positioning
• Bed making
• Specimen collection
• Intake and output (I&O)
• Vital signs (for stable clients) |
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Term
| Five rights to delegation |
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Definition
What tasks should be delegated (right task)
■■ Under what circumstances (right circumstance)
■■ To whom (right person)
■■ What information should be communicated (right direction/communication)
■■ How to supervise/evaluate (right supervision/evaluation) |
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Term
| Maslow’s hierarchy of basic needs |
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Definition
1. Psychological Needs (Body temp, elimination, fluids, nutrition, oxygen, sex, shelter)
2. Safety and Security Needs (Physical and psychological safety)
3. Love and Belonging Needs
4. Self Esteem
5. Self Actualization |
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Term
| Critical thinking evolves through which distinct levels and has what components |
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Definition
Reflection, language and intuition
Knowledge, experience and competence |
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Term
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Definition
ABC - Airway, Breathing, Circulation
Acute versus Chronic
Emergent versus Routine |
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Term
| Refusal to comply with interventions that could increase pain (coughing, deep breathing), support that the client is in pain |
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Definition
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Term
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Definition
| the absence of illness-producing micro-organisms; maintained through use of aseptic technique with hand hygiene as the primary behavior in the technique |
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Term
| Medical versus Surgical Asepsis |
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Definition
Medical - reduce, "clean technique"
Used for: administering oral meds, managing nasogastric tubes, providing personal hygiene, other common tasks
Surgical: "sterile technique"
Used for: parenteral medication administration, insertion of urinary catheters, surgical procedures, sterile dressing changes, etc
always check latex allergy first |
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Term
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Definition
single most important practice to reduce transmission of infection agents
-antimicrobial or plain soap/water as well as alcohol based products (gels, foams, rinses)
Soap, water, friction |
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Term
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Definition
single most important practice to reduce transmission of infection agents
-antimicrobial or plain soap/water as well as alcohol based products (gels, foams, rinses)
Soap, water, friction
Before and after every client contact, after removing gloves, after contact with body fluids, restroom, contact with anything in clients room, after touching contaminated items, soap.water when visibly soiled |
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Term
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Definition
15 seconds to remove transient flora
Up to 2 min when hands are more soiled |
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Term
| Maintaining a sterile field |
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Definition
only sterile items in the field
prolonged exposure can make items nonsterile
1-inch edges are non sterile
Touch only sterile materials
Below waist or above chest means contamination
Do not turn back or reach across field
hold items to be added at least 6 inches above field
Keep dry |
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Term
| Sterile technique procedure |
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Definition
-Hand hygiene
-Open plastic covering top flap away from body with thumb and index finger
-Side flaps using hand on that side
-Last flap gets turned down toward body
-Pour sterile solutions: remove cap and place face up on surface, hold bottle with label in the palm so solution doesnt run down it, dont touch bottle to site |
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Term
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Definition
with the cuff side pointing toward body, use left hand to pick up the right glove by folded bottom edge and pull right gloves onto hand
then place fingers of right hand inside cuff of left glove, lifting it
then adjust |
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Term
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Definition
Remove cap and place face up on DF
Hold w label in palm to avoid drainage onto it
Start with small amounts into available receptacle
Dont let bottle touch site |
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Term
| compromised health or defenses against infection |
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Definition
immunocompromised
those who have had surgery
those with indwelling devices
a break in the skin
poor oxygenation
impaired circulation
chronic or acute disease |
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Term
| Health-Care Associated Infections (HAIs) |
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Definition
acquired while receiving care in a health care setting from exogenous (outside client) or endogenous source (inside when flora is altered)
most common in ICU
most common site is urinary tract
most common agents: E. coli, enterococci and Staph aureus
Iatrogenic infection-HAI from procedure |
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Term
| systemic/generalized infection s/s |
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Definition
Fever
increased pulse and RR
Malaise
Anorexia, nausea or vomiting
Enlarged lymph nodes (waste) |
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Term
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Definition
first stage of inflammatory response
Redness from bringing blood there
Warmth on palpation
Edema
Pain/tenderness
loss of use of affected part |
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Term
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Definition
1. Local infection
2. Fluid with dead tissue cells and WBCs accumulate and exudate appears then leaves through lymph system
-serous (clear), sanguineous (w RBCs), or purulent (w leukocytes and bacteria)
3. damaged tissue is replaced by scar tissue |
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Term
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Definition
WBC left shift or over 10,000/uL
elevated ESR rate
culture |
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Term
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Definition
infection agent (bacteria, virus, fungi, protozoa)
Reservoir to grow (wound drainage, food, O2 tubing)
Exit portal (skin, R or GI tract)
Transmission means (droplet, contact)
Entry portal to susceptible host (skin, tract)
Host that must be susceptible to agent |
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Term
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Definition
Adequate fluid intake prevents the stasis of urine by flushing the urinary tract and decreasing the growth of micro-organisms
Keeps skin from breaking down which prevents micro-organisms from entering |
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Term
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Definition
Tier 1 of standard precautions applies to all body fluids except sweat, nonintact skin and mucous membranes
Tier II - droplet, contact and airborne precautions |
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Term
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Definition
droplet infections smaller than 5mcg
measles, varicella, pulmonary or laryngeal TB
Requires a private room, masks/respiratory protection (N95 or HEPA for known/suspected TB), negative pressure airflow exchange at least 6 per hour |
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Term
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Definition
Droplets larger than 5mcg
stretococcal pharyngitis or pneumonia, scarlet fever, rubella, pertussis, munps, mycoplasma penumonia, meningococcal pneumonia/sepsis, pneumonic plague
Requite: private room or client with same disease, masks |
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Term
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Definition
protect visitors and caregivers against client/environmental contact infections
Resp syncytial virus, shigella, enteric diseases from micro-organisms, wound infections, herpes simplex, scabies, multidrug-resistant organisms
Require: private room or same infection, gloves and gowns worm, disposal of infectious dressing material into single, nonporous bag without touching the ourside of the bag |
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Term
| Cleaning contaminated equipment |
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Definition
gloves
rinse in cold water first
wash in hot water with soap
use a brush/abrasive to clean corners to hard to reach areas
rinse well in warm/hot water
dry
clean equipment used and sink
remove gloves and clean hands |
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Term
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Definition
quick release knot to bed frame
never PRN
doctor must face to face examine patient
renew every 24 hours
emergency - then get provider
descriptive prescription |
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Term
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Definition
R - Rescue
A - Alarm
C - Contain
Close doors/windows, turn off o2,
bag-valve for life support
E - Extinquish
Class A - paper, wood, rags,
trash fires
Class B - flammable liquids/gas
Class C - electrical fires
Pull pin, aim, squeeze lever, sweep |
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Term
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Definition
backward facing car seat until 1 yr and 20 lb
booster seat for under 4'9" or 40lb |
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Term
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Definition
binds with hemoglobin and ultimately reduces the O2 supplied to tissues in the body
cannot be seen smelled or tasted
s.s: nausea, vomiting, headache, weakness, unconsciousness...death |
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Term
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Definition
Most caused by E. coli, listeria, monocytogenes and salmonella
few day recovery if healthy (very young/old, pregnant, immunocompromised)
Risk: unsanitary food practice, low microbial diet |
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Term
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Definition
dissemination of harmful toxins, bacteria, viruses and pathogens for purpose of causing illness/death
agents: anthrax, variola, clostridium botulism, yersinia pestis |
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