NURC 1104 Exam II

Airborne Isolation Precautions

- spread through air from one person to another Ex: - tuberculosis, measles, chicken pox

Aspiration Precautions

1. Aggressive oral care before and after meals. 2. Sit up at 90 degree angle in bed or chair for meals, or follow specific positioning guidelines per the Speech-Language Pathologist. Stay up 30 minutes after meal. Then 45 degree angle at all times. 3. Set-up suction in the patient's room 4. Monitor lung sounds and temps, especially after meals. 5. Monitor intake and offer supplements or between meal snacks as needed.

Cause of false BP readings

1. Venous congestion can "muffle" sounds while taking BP. Result = Recorded systolic pressure may be artifically high and the diastolic artificially low. 2. Unrecognized "ascultatory gap". Result = abnormally low diastolic pressure readings 3. Legs crossed.

How far away from sterile field should you stand?

12 inches

Average Respiratory Rate

12-20 breaths per minute

Healthy BMI

18.5-24.9

Multi use pour saline bottles solutions are considered sterile for...

24 hours

Normal Urine Output per Hour

30 mL per hour

Average Temperature Range

36-38 Celsius (96.8-100.4 Fahrenheit)

Average Pulse Rate

60-100 bpm

Average SpO2

95-100%, below 90 is a clinical emergency

Urine Specimen

A sample taken of a person's urine used for testing

Intentional wound

A wound created for therapy

Chronic Wound

A wound that does not heal easily

Clean Wound

A wound that is not infected, usually intentional

Unintentional wounds

Accidental

What do you do if the patient complains of pain?

Assess patency of urinary system Make sure no traction on catheter Notify health care provider (may be having bladder spasms or symptoms of CAUTI)

Average Blood Pressure

BELOW 120/80 mmhg (systolic/diastolic)

CAUTI

Catheter associated urinary tract infection

Signs and symptoms of a CAUTI

Chills Fatigue Fever Flank pain Vomiting Confusion or mental status changes (in the elderly)

COPA

Color, odor, particles, amount

Infected Wound

Contains bacteria, signs of infection

Purpose of sterile technique

Create a sterile field or sterile area and maintain sterility throughout procedure and Provide protection to patients that need a special barrier against microorganisms

What could be a cause of orange urine?

Dehydration, liver/bile issues, food dye

Pulse Deficit

Difference between the apical and radial pulse rates

Drain is considered _______, clean last

Dirtiest

What could be a cause of purple urine?

Dye, laxatives, chemo drugs

Protective Environment

For clients who have are immunocompromised such as patients who've had an allogenic hematopoietic stem cell transplant

Stage 4 Pressure Injury

Full thickness skin and tissue loss

Stage 3 Pressure Injury

Full thickness skin loss

Contact Precautions PPE

Gown and Gloves

Short Term Reasons for Foley Insertion (6)

Inability to void Surgical repair of bladder, urethra, surrounding areas During surgery Prevention of blood clots Output In critically ill pts Bladder irrigations

Primary Intention Healing

Incision edges of a clean surgical incision remain closed, tissue loss is minimal and skin quickly regenerates

Ways to Prevent CAUTI's

Insert catheters only for appropriate indications Leave catheters in place only as long as needed Only those properly trained insert and maintain catheters Use aseptic technique and sterile equipment Maintain unobstructed urine flow

What could be a cause of foamy urine?

Kidney issues or excess protein

What do you do if the catheter enters the vagina?

Leave in place, change gloves, re-clean and insert new catheter

What could be a cause of brown urine?

Liver disease or severe dehydration

Contact Precautions

Measures taken to prevent the spread of diseases transmitted by the physical transfer of pathogens to a susceptible host's body surface

Droplet precautions

Methods of infection control that must be used for patients known or suspected to be infected with pathogens transmitted by large particle droplets expelled during coughing, sneezing, talking, or laughing.

Airborne Precautions PPE

N95 mask and gloves

Stage 1 Pressure Injury

Non-blanchable erythema of intact skin

Sterile items can touch _____

Other sterile items

When is a sterile object or field considered contaminated?

Out of range of vision or held below waist Left out too long Unattended Comes in contact with wet surface Touches something unsterile

Stage 2 Pressure Injury

Partial thickness skin loss with exposed dermis

Restraints

Protective devices that limit or restrict movement

Eating more ________ can help wounds heal better

Protein

Alternatives for Indwelling Catheter

Purewick Condom catheter Primo fit Liberty

What if there is contamination during procedure?

Replace contaminated items. May need to get new equipment and start over

Infection

Results when a pathogen invades and begins growing within a host

Define SBAR

S: Situation B: Background A: Assessment R: Recommendation

Braden Scale

Sensory perception, moisture, activity, mobility, nutrition, friction and shear

Long Term Reasons for Foley Insertion

Severe retention Pressure ulcers, wound or skin irritation caused by moisture Terminal illness when bed changes are painful or compromise pts condition

Droplet Precautions PPE

Surgical mask

Partial Thickness Wound

The dermis and epidermis of the skin are broken

Full Thickness Wound

The dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved

Open wound

The skin or mucous membrane is broken

Closed wound

Tissues are injured but the skin is not broken

Clean from _____ to _____ of incision

Top to bottom

T-PLEEDS

Type of healing Palpation Length/Location Erythema Edema Drains Sutures/ Staples

When would you use a bladder scanner?

Use a bladder scanner to assess bladder volume whenever inadequate bladder emptying is suspected such as after the removal of indwelling urinary catheters, in the evaluation of new-onset incontinence, and after urologic surgery.

Secondary Intention Healing

Wound edges not approximated; pressure ulcers; healing occurs by granulation tissue formation, wound contraction and epithelialization

Tertiary Intention Healing

Wound is left open for 3-5 days to allow edema or infection to resolve, then stapled or sutured shut

Contaminated Wound

a wound with a high risk of infection, usually unintentional

Isolation Precautions

airborne, droplet, contact, and protective environment

CAT

center, away, towards (when cleaning wound)

COCA

color, odor, consistency, amount

What could be a cause of blue urine?

food dye, medication, bacterial infection

What could be a cause of green urine?

liver issues

What is the most common use for a bladder scanner?

measure postvoid residual (PVR) (i.e., the volume of urine in the bladder after a normal voiding).