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Skills Exam 1 Review
Asepsis, Wound Care, Blood Pressure
170
Nursing
Not Applicable
01/25/2013

Additional Nursing Flashcards

 


 

Cards

Term
PPE removal sequence
Definition

gloves

hand hygeine

mask

gown

hand hygeine and save paper towel for door, dispose in pt room

Term
Virulence
Definition
ability to grow and mutiply
Term
Invasiveness (of a pathogen)
Definition
ability to enter tissue
Term
Pathogenicity (of organism)
Definition
ability to cause disease
Term
Chain of infection
Definition

An

INFECTIOUS AGENT, which resides in a

RESERVOIR, leaves said resovoir via a 

PORTAL OF EXIT via a particular

MODE OF TRANSMISSION and, through a

PORTAL OF ENTRY, infects a

SUCCEPTIBLE HOST

 

All links must occure for infection

Term
What do masks block?
Definition
Droplets and airborne transmission
Term
Where is isolation equip normally located?
Definition
Just outside pt room
Term
When to don masks
Definition
before enering room
Term
Another term for transmission based precautions
Definition
Isolation precautions
Term
Three types of transmission based precautions
Definition

Airborne -- pathogens suspended on evaporated droplets

Droplet -- within 3 feet eg sneezing, coughing, suctioning

Contact -- direct skin to skin, or indirect skin to item to skin

Term
Medical Asepsis
Definition

Less stringent than surgical aspesis

Use of disinfectants, antiseptics,etc

Assume microorganisms are everywhere, except sterilized

standard precautions apply

keep clean

clean to dirty when cleaning

can use nonantimicrobial soap (unlike surgical asepsis), antimicrobial soaps, or hand gels

Term
Which namd hygeine method has the fasted and greatest reduction of microbial counts?
Definition
Hand antispesis (alchohol gels)
Term
Bacterial resistance and alchohol
Definition
non-existant
Term
Hand Antisepsis procedure
Definition

Hand gels

rub at least 15 sec UNTIL DRY, must be dry to work

quarter to golf ball size as directed

Term
Surgical Asepsis
Definition

Removal of microorganisms and protection of such sterile state

Physical removal - boiling, radiation, steam, dry heat, 

Chemical like ethylene gas

Many ways sterility is contaminated, like if questionable, past expiration, outer 1 inch marging, MOISTURE, left unattended, crossing over field, below waist, turning back on field

Term
What additional hand hygeine act is needed when wearing gloves?
Definition
Sanitize hands before and after gloving
Term
Cough Etiquette
Definition

CDC 2007

= Respiratory Hygeine 

Applys to ALL

Cover mouth with tissue and dispose, wear mask, turn head, stay 3 feet from others, disinfect hands

Term
Moisture and PPEs
Definition
 must change mask when wet
Term
Regular hand washing, direction of hands
Definition
down when washing, up when drying
Term
When you must wear protective eyewear
Definition

suctioning

irrigating wound (face shield)

inserting hemo lines

any potential for splashes

Term
What type of lotion can break down gloves?
Definition
Petroleum based
Term
When is surgical asepsis initiated?
Definition

Labor and delivery

burn units

puncturing patients

sterile dressings

Term
PPEs for surgical asepsis
Definition

Hair covers

mask

eyewear

shoe covers

sterile gown

sterile gloves

Term
Distance non-sterile personnel must stay from sterile field
Definition
at least 1 feet
Term
Closed-gloving technique
Definition

hands are covered with gown, preferred technique for surgical aspesis

vs open gloving (we learn this, for sterile procedures requiring only sterile gloves)

Term
Height to drop sterile items onto sterile field
Definition
6-8 inches (ATI)
Term
Moisture and sterile fields
Definition
Bad, can't add moistened cotton balls, must be in basin
Term
Airborne precautions
Definition

Negative air pressure, must keep room air separate

N95 respirator

TB

Measles (rubeola)

Chickenpox

SARS

Private room or similar infected pt

Term
Droplet precautions
Definition

Mask always within 3 feet of client

Flu

Rubella

strepto pneumonia

meningococcal meningitis

whooping cough

priavte room preferred, can be with other pt but must be at least 3 feet away

Term
Contact precautions
Definition

gloves, gown (usually)

intestinal infections

wound infections that are resistant

gas gangrene

acute diarrhea

viral conjunctivitis

drainiong abcesses

Private room or with similar infected pt

Term
rickettsiae
Definition

resemble bacteria, but must remain in host to survive

eg lyme disease in ticks

vector borne

Term
mycoplasms
Definition
no cell walls, similar to bacteria, primariy infect linings of resp, gi and genitourinary tracts
Term
helminths
Definition
worms
Term
prion
Definition

protein without nucleic acid, normal brain prions exist to protect brain, but when mutated, can be infectious

possible cause of alzheimers, parkinsons, etc....

Term
spore
Definition
temporarily inactive form of microbe that can survive without moisture
Term
fomite
Definition
a non-living reservoir for a pathogen
Term
Antimicrobial agents
Definition

destroy or supress growth

include antiseptics, disinfectants and anti-infective drugs

Term
antispeptics
Definition

bacteriostatic agents

inhibit growth, DO NOT KILL, pathogens

eg ALCOHOL

 

So how do alcohol gels clean hands if bacteria are not killed? Hmmmm.....

Term
Disinfectants
Definition

germicides

kills active pathogens, but NOT SPORES

eg bleach, phenol, formaldehyde

Rarely applied to skin

Term
General idea of how antivirals work
Definition

Do not destory them, they affect replication

Therefore, person still infected and contagious

Term
def of HAND ANTISEPSIS
Definition

without soap and water

gels, foams

Term
When must WASH hands (vs antisepsis)
Definition

visibly soiled

before eating

after using restroom

possible spore exposure

Term
Jewelry and handwashing
Definition

For regular hand washing, can have wedding band

For surgical scrub, NO JEWELRY

Term
concurrent vs terminal disinfections
Definition
during hospital stay, vs after dc - much more thorough
Term
Does sterilization kill spores?
Definition
yes indeed
Term
Rules for boiling for disinfection
Definition
at least 15 minutes at 212 F (100C)
Term
Most dependable mothod of sterilization
Definition
steam under pressure, i.e. autoclave
Term
how often are sterile solutions replaced?
Definition
Every day if opened
Term
Infection vs colonization
Definition

colonization no signs or sx

both contagious

Term
Stages of infection
Definition

incubation - no s/s

prodromal - minor s/s, vague (fatigue, headache, etc)

acute

convalescense

resolution

Term
basal temp of elderly
Definition
tends to be lower, so during infection it may actually be at "normal"
Term
3 newer additions to standard precautions
Definition

cough etiquette

safe injection practices

infection control for lumbar punctures

Term
Where is biodegradable material disposed?
Definition
Toilet
Term
5 signs of infection
Definition

pain

decreased function

redness

warmth

swelling

Term
First thing to assess when performing wound care
Definition
PAIN!
Term
Open vs closed wound
Definition
Closed include bruising, compartment syndrome, etc
Term
laceration
Definition
torn and irregular edges
Term
avulsion
Definition
stripping away of large areas of skin and tissue, cartilage and bone are exposed
Term
ulceration
Definition
shallow crater with missing skin or mucous membranes
Term
Types of debridement, how many?
Definition

Are 4

Sharp - painful and bloody

Enzymatic - Santyl, requires dressing

Autolytic - must be infection free and small

Mechanical - wet-to-dry dressing, hydroptherapy, irrigation, etc.

Term
6 reasons to dress a wound
Definition

Absorb drainage

Keep clean

Control bleeding

Prpotect from further injury

Hold in meds

Maintain moist environment

Term
Another important thing to check before applying a dressing
Definition
Allergies to tape, adhesives, etc
Term
What to assess/doc when removing a dressing
Definition
Drainage, integrity, type
Term
Purpose of wound packing
Definition
mechanical debridement (lecture)
Term
2 general types of wound drains
Definition

Open - gravity, passive

Closed - neg pressure - HEMOVAC and JACKSON-PRATT (JP)

Term
Steri-strips
Definition
Butterfly adhesive strips to hold incision together
Term
K-pad
Definition
aquathermia pad with hollow channels through which hot or cold water runs through with a thermostat
Term
Key to wound healing
Definition
oxygenation
Term
Hydrogel
Definition
water gel to keep wound moist
Term
Purpose of wet-to-damp dressings
Definition
Wound protection and moisture, NOT for debridement!
Term
One caveat of surgical sterility
Definition
Can never be fully sterile bc can't sterilize patient
Term
For sterile technique, what must be assessed of each product?
Definition
Expirationn date, integrity, moisture
Term
What happens when you get comfortable?
Definition
"You get fat wads in your eyeballs."
Term
Phases of wound repair, how many and what?
Definition
Are 3
  • Inflammation 2-5 days - limits local damage, removes injured cells/debris, preparation for healing
  • Proliferation 2-21 days - granulation tissue, grows from outside inward
  • Remodeling 6 mo - 2 years - wound contracture and scar formation
Term
Syn. of First Intention Healing
Definition
Primary Intention Healing
Term
2nd intention wounds
Definition

Pressure sores for example

Fills in with granulation tissue

Term
3rd intention wound healing
Definition

Mostly from surgery when too much swelling to close

Allow to remain open for a while, then later close up

These are usually "great big wounds"

Term
What to assess re: wounds
Definition
  • 1st is always PAIN
  • type dressing removed
  • S/S infection
  • location
  • drainage - type (serous, serosanguinous, sanguinous, purulent) and amount (scant, moderate, saturated)
  • size
  • tunneling/undermining
  • type of tissue present (granulation, eschar/necrotic, slough)
  • surrounding tissue- bruising, edema, boggy from maceration, signs of decreased blood flow like pallor, mottled, coolness
  • edges approximated? 
  • odor (malodorous or without odor)
  • dressing appied
  • how left patient
  • consider also diet, oxygenation, health status, drugs (esp. immunosuppressants), stress, age, etc

 

Term
3 means of assessment
Definition

inspection

auscultation

palpation

Term
DEHISCENCE
Definition
  • would comes open after being closed
  • if happens, bed to 45 to decrease pressure, moisten sterile gauze with saline, cover, and call dr/surgeon
  • commonly caused from increased pressure, obesity, poor wound healing/circulation/diabetes

 

Term
EVISCERATION
Definition
  • wound opens and organs fall out
  • commonly caused from increased pressure, obesity, poor wound healing/circulation/diabetes
Term
2 main things that are done to wounds
Definition

dress

debride

Term
sharp debridement, why, when, how?
Definition
Preferred when infected, is sterile procedure
Term
Enzymatic debridement and infected wound
Definition
Nope, only for uninfected wounds
Term
What to assess re: wound drains (open or closed)
Definition

amount and color/type

asess insertion site for signs of infection

assess the mechanism to make sure is working

Term
proper application of heat/cold
Definition

cold first to decrease inflammation for first 24-48 hours

then hot to increase circulation for healing

Term
How are rolling bandages wrapped?
Definition

From distal to proximal

And don't cut off circulation

Term
CMS
Definition

or CMST

 

This is what to assess when pt has cast or binder

 

Circulation - color, cap refill

Movement

Sensation

(Temperature - also assesses circulation)

 

Do this bilaterally to compare

Term
3 terms to describe drainage amounts
Definition

scant

moderate

saturated

Term
Strength of scar tissue
Definition
80% of previous skin
Term
What common OTC drug can affect wound healing?
Definition
Aspirin, decreases clotting
Term
Chronic wounds
Definition
usually heal through 2nd intention (edges not approximated) and can be repeatedly infected
Term
BRADEN SCALE
Definition

tool to assess risk for pressure sore

the lower the number the worse

Term
Stages of pressure sores
Definition

4

NPUAP adds two more stages: pre-stage (suspected deep tissue injury) and unstageable

Term
When should negative pressure wound drains be used cautiously?
Definition
Patients on bood thinners, etc
Term
What is ultrasound therapy
Definition
Can increase blood flow to injured tissue through vibrations
Term
Examples of antiseptics
Definition

iodine, H2O2, sliver

inhibit or kill

Term
When assessing a wound, first thing is to always
Definition
check for PAIN
Term
How much does protein requirement increase during wound healing?
Definition
50 to 100%
Term
when are dehiscence and evisceration most likely and what are some of the contributing factors?
Definition

within 7-10 days after surgery

obesity, distension from gas, pressure from coughing, vomiting, weakened integrity from previous surgeries in same area

Term
Reasons to use a binder dressing
Definition

hold dressings in place

support areas around wound to reduce pain

limit movement to promote healing

Term
which method of debridement helps to wound to heal the fastest when it is infected
Definition
sharp, for infected wounds
Term
Can enzymatic debridement be used on an infected wound?
Definition

no

same with autolytic

Term
When should cold/heat applications be used cautiously?  What is max time for application
Definition

Under 2, elderly, diabetic, comatose, neuro impaired

Apply no more than 20-30 min a time, and let recover at east 30 min

 

Term
Regarding pressure, about when do cells die?
Definition
If pressure is reduced to less than 32 mmHg for 1 to 2 hours
Term

When removing a dressing that is taped, what direction should the tape be removed?

When reapplying, how should it be oriented?

Definition

Remove by pulling old tape toward the wound

Reapply by putting tape perpendicular to wound

Term
How much saline should be instilled when irrigating a wound?
Definition
Until runs clear
Term
3 things that BP reflects
Definition

1 - stretch of arteries

2 - volume of blood

3 - resistance heart must overcome (eg viscosity of blood)

Term
Normal blood volumes, male and female, adult
Definition

male is 5-6 L

female is 4.5-5.5

Term
5 variable that affect BP
Definition
  1. blood voume
  2. heart contractility
  3. cardiac output
  4. blood viscosity
  5. peripheral resistance
Term
Conditions that affect heart contractility
Definition
meds like digitalis, sympathetic inervention, valve issues, etc
Term
Things that can affect peripheral resistance in CV system
Definition

blood viscosity

narrowing vessels from arterio/athero-sclerosis

Term
Some pathologies that can affect BP
Definition

arrythmias

MIs (tissue destruction)

HF - L, R and complete

Term
Most common type of heart failure
Definition

Left sided - occurs first usualy

Backs up in lungs

 

Other types are R and complete (L and R)

Term
Circadian rhythm of BP
Definition
lowest after minight, starts to rise at 4am, peaks late am or early afternoon
Term
Gender and blood pressure
Definition
Women tend to have lower, though this has been changing....
Term
Other non-pathologies that affect BP
Definition

position like legs crosses

full bladder

cold temp

certain drugs like nicotine, caffeine, etc

Term
AUSCULTORY GAP
Definition
silence bt beats when taking bP
Term
When is a change in BP clinically significant?
Definition

systolic 20 mmHg

diastolic 10 mmHg

Term
PULSE PRESSURE
Definition
  • Difference bt systolic and diastolic
  • Normal range is 30-50
  • During exercise can be up to 100, will return in about 10 min
  • Needed to perfuse tissues
  • Can be low with heart failure, shock, aortic stenosis; most commonly is from error of measurement - If genuinely low, is accompanied by high pulse rate
  • High values from HTN, hyperthyroidism, etc - if along with bradycardia, must report immed.
Term
Stethescope bell and diaphragm, which used for what sounds?
Definition

Bell for low pitched

Diaphragm for higher pitch

Term
How to increase Korotkof sounds
Definition

Hold arm up during inflation, lower after

Open/close fist after inflation

Term
Purpose of taking ESBP
Definition
to make sure that starting point is not during an auscultory gap, and so don't have to pump up super high
Term
Use of Doppler stethescope for BP measurement
Definition

Mark pace found with perm marker

doc D

Term
BP - normal, pre-HTN, HTN1 and HTN2
Definition

normal under 120/80

pre-HTN 120-139 OR 80-89

HTN1 140-159 OR 90-99

HTN2 160+ OR 100+

Term
Conditions associated with HTN
Definition

HF

anxiety

obesity

stroke

kidney disease

Term
With a high pulse pressure, when should it be reported immediately?
Definition

If there is also bradycardia

BC is associated with up intracranial pressure

Term
When does death usually occur regarding extreme body temps?
Definition

34C or 93.2F

OR

43C or 109F

Term
S/S hypothermia
Definition

pale/cool skin

listessness

decreased pulse and RR

decreased mental state

diminished pain 

Term
Normal pulse rates, NIH and AHA
Definition

NIH says 60-100

AHA says 60-80

 

Term
S/S bradycardia
Definition

from diminished oxygenation:

  • syncope or near syncope
  • dizziness - this is usuay the first
  • weakness
  • fatigue
  • SOB
  • chest pain
  • disturbed seep
  • confusion/memory impaiment
  • easiy tire
Term
S/S tachycardia
Definition

also from diminished oxygenation bc heart can't fill adequately:

  • dizziness
  • SOB
  • lightheadedness
  • palpitations
  • chest pain
  • syncope
  • some no s/s at all
Term
Febrile VSs
Definition
increased BP and pulse bc body trying to remove heat
Term
Factors that affect pulse rate
Definition
  • larger the organism's size, slower
  • women > men
  • younger > old
  • hormones
  • pathology
  • meds - e.g. digitalis slows rate
Term
2 pulse points on feet
Definition

posterior tibial - back of ankle

dorsalis pedis - top of foot

Term
How to take apical-radial pulse
Definition

2 persons needed to take both simultaneously

should be equal, if not = PULSE DEFICIT

Term
PULSE DEFICIT
Definition
When the pulses bt heart and radial are different
Term
RESPORATION vs VENTILATION
Definition
 
  • book says respiration is gas exchange, either internally and tissues or externally at alveoli
  • book says ventilation is act of breathing
  • lecture notes say the opposite.....
Term
ORTHOPNEA
Definition
respiratory changes when changes in position, e.g. c COPD is easier to breath when bent over
Term
primary reasons for low BP
Definition
first is dehydration, second are meds
Term
What must be checked before administering meds?
Definition
VSs, esp when a narcotic (RR affected)
Term
Pulse and RR assessment terms
Definition

Pulse

rhythm - irreg, reg, regularly irreg

rate

volume - thready/weak, normal=strong, bounding

 

Pulse

rate

rhythm - reg, irreg, labored, etc

volume - deep, shallow, etc

Term
Normal temp
Definition

is NOT 98.6!  There is a normal range, that is

 

96.4 to 99.1

 

rectal is 1 point higher than oral

ax/tymp are 1 point lower than oral

Term
C to F conversion
Definition
F = 1.8C +32
Term
Taking a rectal temp
Definition

use red sheath

gloves

lube

1-1.5 inches toward umbilicus

remove ASAP if resistance

Term
Temperature sites and accuracy
Definition

axilla not so much 

tympanic, quite

Term
Tympanic temp procedure
Definition

pull pinna back, up and out

correct angle to seal canal

Term
Sounds of the apical pulse and what reflects
Definition

S1 = clsoe of tricuspis and mitral valves after ventricles have filled

S2 = closing of pulmonic and aortic valves after systolic contraction

 

PMI is point of maximal impulse, in L 5th IC space at mid-clav line

 

Take for 1 min if irregular

 

Is used when there is heart problems

 

pulse deficit when doesn't match peripheral pulses (radial)

Term
Another term for depth of respiration
Definition
TIDAL VOLUME
Term
What if the 5th korotkof sound is not present
Definition

5th sound is silence

if no silence, record distolic when sound fades

Term
Some other conditions that can affect how to check VSs
Definition

obesity - larger cuff

nasal congestion - causes mouth breathing, can't do oral temp

mastectomy - affects lymph drainage, BP on same side can hurt and cause lymphedema

Term
Best position (in bed) for respiration
Definition
head 40-60 degress
Term
Semi-lunar valves =
Definition
aortic and pulm valves
Term
Shell vs core temps
Definition

shell is at skin surface

core is internal, more significant bc must be within narrow range

Term
What regulates temp?
Definition
hypothalamus
Term
How does food affect temp?
Definition
Food metabolism creates heat, protein creates most heat
Term
Which group has greatest fluctuations in body temp?
Definition
newborns and infants bc greatest surface area rt to internal, also a higher metabolic rate
Term
How does climate affect metabolic rate?
Definition
Colder climates, higher met rate and increased borwn adipocytes
Term
How does age affect febrile repspose to illness?
Definition
older adults may lack febrile response, so must assess other things like cog fnx, restlessness, anxiety
Term
THERMISTOR CATHETER
Definition
vary accurate way to measure core them, inserted into bladder, heart, esophagus
Term
Which peripheral method of temperature measurement is most reflective of core temp?
Definition

Tympannic, close to brain

 

Temporal is also very accurate

Term
When is oral temp contraindicated?
Definition
uncooperative, very young (under 3 or 4), unconscious, shivering, seizure prone, mouth breathers, oral surgery, talkers during temp must wait 30 min after chewing gum, smoking, or eating hot/cold food
Term
Phases of a fever
Definition
  1. prodromal - mild headache, lethargy, low appetite, muscle aches
  2. onset phase - pale, shivering, feels cold
  3. stationary phase - slushed skin and feels hot
  4. resolution phase - sweating
Term
Numerical values for pulse volumes and corresponding meanings
Definition

0 - absent

1+ - thready

2+ - weak

3+ - normal

4+ - bounding

Term
At what point in time is an apneic event life threatening 
Definition
4-6 minutes, hypoxia and can trigger serious cardiac arrythmias
Term
STERTOROUS BREATHING
Definition
noisy ventilation
Term
STRIDOR
Definition
harsh, high-pitched sound upon inspiration when there is a laryngeal obstruction
Term
AFTERLOAD
Definition

= peripheral reistance

force against which heart must pump

Term
After cleaning a thermometer with alcohol, how much time should the nurse wait before using?
Definition
30  minutes
Term
Wound healing intentions
Definition

1 - clean slice

2 - natural healing, granulation tissue and epithelializaton

3 - intentially left open

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