N3632 Exam 1

Verbal communication

includes vocabulary, credibility, denotation/connotation, clarity/brevity, timing/relevance, pacing, intonation

list the stages of an infection

incubation prodromal full stage of illness convalescent

nosocromial infection

infection acquired while in the hospital -exogenous (from other people) -endogenous (from self)

explain the infection cycle

infectious agent (bacteria, virus, fungi) > reservoir (people, animals, soil, food, water, milk, etc) > portal of exits > means of transmission (contact, airborne, droplet) > portal of entry (urinary, resp, GI, skin) > susceptible host

pediculosis

infestation with lice

gingivitis

inflammation of the gingivae or gums

stomatitis

inflammation of the oral mucosa

glossitis

inflammation of the tongue

Three Phases of Wound Healing

inflammatory phase, proliferavtive phase, maturation phase

nuclear terrorism

intentional dispersal of radioactive materials into the environment for the purpose of causing injury and death

plaque

invisible, destructive, bacterial film that builds up on teeth and eventually leads to the destruction of tooth enamel

Aggressive behavior

involves asserting one's rights in a negative manner that violates the rights of others -can be verbal or physical -communication is marked by tension and anger inhibiting the formation of good relationships and collaboration -characteristics include using an angry tone of voice, making accusations, and demonstrating belligerence and intolerance -focus is usually *winning at all costs*

never event

it should never happen e.g falls

KID SAFE

kids' developmental needs, infection, prophylaxis for deep vein thrombosis, sedation, skin integrity, analgesia, family, and enteral needs

Serous exudate

looks watery and has few cells

periodontits

marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone

implement recommended techniques for medical and surgical asepsis

medical- hand hygiene, keep soiled items/equipment from touching clothing, nothing goes on the floor, avoid raising dusst, clean from least to most soiled area, etc surgical- only sterile can touch sterile, hold sterile objects above waist level, avoid talking coughing sneezing or reaching over a sterile field/object, never walk away or turn back on sterile field, outer 1 inch of a sterile field considered contaminated (can touch this part),

Five modes of value transmission

modeling, moralizing, laissez-faire, rewarding and punishing, responsible choice

Bacteria

most significant infection-causing agents in the healthcare system. Bacteria can be categorized by shape *(cocci/bacilli/spirochetes)*, by their reaction to gram stain, or according to their need for oxygen -Gram postitive-> stain violet -Gram neg-> do not stain

identify multidrug resistant organisms that are prevalent in hospitalized patients and community settings

multidrug resistant staphylococcus aureus, vancomycin-resistant staphylococcus aureus, vancomycin-resistant enterococci, C. diff,

DAME

preventing falls in the home consideration of: D - Drug and alcohol use A - Age-related physiologic status M - Medical problems E - Environment

Confidentiality

protection of privacy without diminishing access to quality care

Parasites

rely on host for nourishment Example: malaria infection of mosquito.

Whistle blowing

reporting an illegal action of one's employer to protect the patient

RACE

rescue (evacuate pts in IMMEDIATE danger), alarm, contain, extinguish

Iatrogenic Infection

results from a treatment or diagnostic procedure

Autonomy

right to self-determination respect rights of patients to make health care decisions -plan care in partnership with patients -honors the right of patients and families to make decisions about health care -Provides information so that patients can make informed choices

Ethics

right vs wrong on the basis of body of knowledge not basis of opinions begins in childhood and develops gradually

Brevity

shortness -short is usually the most effective -long and complex can be difficult to understand

Mass trauma (safety concerns)

such as explosives

Advocays

support of pts health, wellness, safety, and personal rights including privacy

bioterrorism

the deliberate spread of pathogenic organisms into a community to cause widespread illness, fear, and panic

Privacy

the right of people not to reveal information about themselves

Utilitarian

the rightness or wrongness of an action depends on the consequences of the action

Intonation

the tone of voice can communicate a variety of feelings -nurses communicate feelings such as acceptance, judgement, and dislike through their tone of voice

Cyber terror (safety concerns)

the use of high-tech means to disable or delete critical electronic infrastructure data or information

cyber terror

the use of high-tech means to disable or delete critical electronic infrastructure data or information serious threat to national security hard to find terrorist in cyber space (can attack hospitals)

Ethical Dilemma

two or more clear moral principles apply but support mutually inconsistent courses of action

cheilosis

ulceration of the lips

Social Justice

upholding moral, legal, and humanistic principles -Supports fairness and nondiscrimination in the deliver of care -Promotes universal access to health care -Encourages legislation and policy consistent with the advancement of nursing acer and health care

cerumen

wax in the external ear canals, consisting of a heavy oil and brown pigment

Working Phase

work together to meet patients needs, provide assistance needed to achieve each goal, provide teaching/counseling *what are your goals for the day?* What is important to the patient? what is on the pt's plan of care. *Is the pt aware of the goals on the plan of care?*

FACTORS AFFECTING SAFETY

developmental level lifestyle mobility sensory perception knowledge level communication ability physical health state psychosocial state

Denotative

dictionary definition participants must share meaning

Justice

fairness in care delivery and use of resources

Ethical principles

for individuals, groups of individuals, and societies are standards of what is right and wrong with regard to important social values and norms

alopecia

hair loss or baldness

tartar

hard deposit on the teeth near the gum line formed by plaque buildup and dead bacteria

blast lung injury

has recently been recognized as a direct consequence of the blast wave from a high explosive detonation

Auditory Communication

communication that involves the use of sound in conveying a message

Alturism

concern for the welfare and well-being of others -demonstrates understanding of cultures, beliefs, and perspectives of others -Advocates for patients, particularly the most vunderable -Takes risks on behalf of patients and colleagues -Mentors other professionals

Vehicles of Transmission

contaminated blood, food, water, or inanimate objects (*fomites*)

list nursing diagnoses for a patient who has or is at risk for an infection

"Risk for Infection related to presence of chronic disease; altered immune response; effects of medication; altered skin integrity; malnutrition; presence of invasive or indwelling medical device; lack of proper immunization"

Laissez Faire

"free" to do whatever with little guidance through childhood

desiccation

(dehydration),

ischemia

(deficiency of blood in a particular area),

Referent

(functional components of communication) -incentive or motivation for communications between two people

maceration

(overhydration),

Chemical Agents (safety concerns)

**Nerve agents are the most severe and incapacitating** - Will be liquid at room temp but in vapor form nerve agents will penetrate the cornea, dermis, and resp tract

Ethical Agency

*AKA Ethical Capacity* Ethical practice requires a skill set that must be conscientiously learned and nurtured. the ability to behave in an ethical way; to do the ethically right thing because it is the right thing to do

Lab data indicating infection

*BOX 23-1* Elevated white blood cell count—normal is 5,000 to 10,000/mm3 -Increase in specific types of white blood cells -Elevated erythrocyte sedimentation rate (RBC settle more rapidly when inflammation is present) -Presence of pathogen in urine, blood, sputum, or draining cultures Normal WBC levels: -Neutrophils (60-70%) in in acute infection that produce pus/ inc risk for acute bacterial infection if dec., may inc in response to stress -Lymphocytes (20-40%) inc in chronic bacterial/viral infection -Monocytes (2-8%) inc. in allergic rxn and parasitic infection -Basophils (0.5-1%) unaffected by infections

Preventing falls in Health Care Facilities

*Box 26-5* -Falls (never event/ preventable) -Signage (call dont fall on water pitcher) -Hourly rounding (potty, position, pain, personal item (water, tissues, urinal, etc and also equipment cords) -pt near nurses station -bed alarms -keep beds in low position -call bell -wheels locked (bed and wheelchair) -leave a night light on -remove clutter -nonskid footwear

Biological Agents

*Table 26-2* ie botulism, small pox, ebola

Paternalism

*acting like a parent*

Escherichia coli (E. coli)

*bacteria* A common bacterium / opportunistic found in the gut If it migrates to the urinary tract-> UTI -found in water (drinking or swimming) -unwashed veggies and ground beef -Reservoir: feces, undercooked meet (beef), unpasteurized apple juice, tomatoes, peppers, spinach -Means of Transmission: contact (ingestions) -Disease transmitted: e. coli infection

Clostridium difficile (C. diff)

*bacteria* opportunistic colonization Infection-> symptoms emerge -soap and water is most effective in removing spores

Patient who have special needs

*box 20-6* -visual impairment, hearing impairment, physical barriers, cognitive impairment, unconscious, does not speak English

Pt teaching for medical asepsis at home

*clean technique* -reduce the # and transfer of pathogens -Hand hygiene and wearing gloves Teaching: -wash hands before food prep -prep foods @ high temp -use care with cutting boards/utensils -keep food refrigerated -was raw fruits/vegetables -use pasteurized milk and fruit juices -wash hands after using bathroom -use individual care items

Characteristics of the Care-Based Approach to Bioethics

*nurse-patient relationship is central+ -Caring relationship -Dignity and respect for patients as people -Patient preferences -Responsiveness to others

Purpose of the Code of Ethics for Nurses

*primary goals, values, and obligations of the profession* -Ethical obligations and duties of every nurse -Nonnegotiable ethical standard -An expression of nursing's own understanding of its commitment to society

Surgical Asepsis

*sterile technique* -render and keep objects and areas free from microorganisms -OR/ L&D -certain diagnostic testing areas -pt bedside (procedures that involve insertion of urinary catheter, sterile dressing changes, IV insertion, or preparing and injection medications) -sterile to sterile// unsterile to unsterile -open with the first edge away from the worker -wet field is contaminated -forceps soaked in disinfectant is not considered sterile -outer 1 inc is contaminated -solutions are considered sterile for 24 hrs after they are opned

Identify multidrug-resistant organisms that are prevalent in hospitalized patients and in community settings

- MRSA -VRE -CRE (carbapenem)

Sanguineous exudate

- consists of large amounts of red blood cells, indicates severe damage to capillaries

Factors Affecting an organisms potential to produce diseases

-# of organisms -virulence -competence of person's immune system -length and intimacy of contact between person and microorganisms

Soap Handwashing

-20 + second scrub with plain soap or disinfectant and warm water -soiled hands need longer

Giardia

-A microorganism that infects the digestive system -found in water (swimming or drinking)

Safety Plan for Victims of Domestic Abuse

-A place to stay & an escape route -A person you can call in a crisis -A signal to a neighbor to call for help -Keys for the house and car -Secure copies of important papers -A packed bag -Additional addresses and phone numbers

Procedure-Related Accidents/Possible Errors

-Administering medications or intravenous solutions -Transferring a patient "ticket to ride" -Applying external heat to a patient's extremity (can cause harm... follow safety regulations) -Using medical equipment "smart pumps"

Vectors

-An organism that transmits disease by conveying pathogens from one host to another -ie mosquitos, ticks, and lice (nonhuman carriers)

Nursing History (safety, security & emergency preparedness)

-Assess for history of falls or accidents. -Note assistive devices. -Be alert to history of drug or alcohol abuse. -Obtain knowledge of family support systems.

Nursing process for maintaining safety

-Assessing (pt, env. specific risk factors) -Diagnosis (risk for falls r/t hx of falls; effects of meds; unsteady gait) -Planning (pt will not fall .... (SMART goals) -Implementation (modify env; rounding) -Evaluating (actual outcome... did pt fall?)

Body's defense against infection

-Body's normal flora -Inflammatory response (*redness, heat, swelling, pain, loss of fn* signs of infection) -Immune response (antigen antibody)

Organisms Potential to Produce Disease

-Number of organisms (the more the better) -Virulence (ability to produce disease -Competence of person's immune system -Length/intimacy of contact between person and organism (colonization=long contact)

Indications of a concussion

-Physical: headache, vomiting, problems with balance, fatigue, dazed or stunned appearance -Cognitive: mentally foggy, difficulty concentrating and remembering, confusion, forgets recent activities -Emotional: irritability, nervousness, very emotional behavior -Sleep: drowsiness, difficulty falling asleep, sleeping more or less than usual -HX: fall, head trauma -Nursing: teaching for home care especially in children

Safety Considerations for Older Adults

-Prevent accidents. -Orient person to surroundings (avoid falls). -Maintain vehicle in working order, schedule eye exams, and keep noise at a minimum. -Promote safe environment at home (avoid fires). -Use medication trays / pre-filled medication tray (avoid poisoning). * pts > 65 Falls are leading cause of injury fatality*

Examples of Ethical Situations/ Problems

-Privacy & confidentiality -Valid consent or refusal -unprofessional, incompetent, unethical, or illegal physician practice or nurse practice -short staffing and whistle blowing -beginning of life issues and end of life issues

Advocacy in Nursing Practice

-Representaiton of pts "speak up" for pt -Promoting self determination facilitating a pts individual right to make a decision

Antigen

-foreign material

Communication

-professional (a hallmark of the professional nurse) -essential in fostering nurse-pt interactions -SAFETY issue for the healthcare environment -used by nurses to display caring, est. therapeutic relationship, obtain/ deliver info, and assist with changing behavior

Special considerations in communication (Assessment/ Data Collection) CULTURAL

-provide an interpreter -address the client directly when the interpreter is present -provide educational materials and instructions in the client's language

Special considerations in communication (Assessment/ Data Collection) OLDER ADULT CLIENTS

-recognize that many older adult clients require amplification of sound -make sure assistive devices such as glasses and hearing aids are available for those who need them -minimize distractions, and face clients when speaking -speak in short and simple sentences -allow plenty of time for clients to respond -ask for input form caregivers or family to determine the extent of any communication deficits and how to best communicate

Alcohol-based hand rub (ABHR)

-refers to a 60-95% ethanol or isopropyl (types of alcohol) -1-3 mL for 15 seconds+ -containing preparation designed for application to the hands to reduce microorganisms Used: -before direct contact with pt -after direct contact with pt -after contact with body fluids, mucus mem, non-intact skin, and wound dressings, *if hands are not visibly soiled* -after removing gloves -Before inserting a urinary catheter, IV, or invasive devices that do not require surgical placment -Before donning sterile gloves before an invasive procedure -If moving from a contaminated body site to a clean body site during pt care -after contact with objects in pts environment

Developing listening skills

-sit when communicating with a patient (eye level) -be alert and relaxed and take your time -keep the conversation as natural as possible -maintain eye contact if appropriate -use appropriate facial expressions and body gestures -think before responding to the patient -do not pretend to listen -listen for themes in the patient's comments -use silence, therapeutic touch and humor appropriately

Fires

-smoking in bed, faulty wires, candles -most fatal fires occur while people are sleeping -1/3 of home fire deaths occur in a home without a smoke detector

Airborne Precautions

-tb, varicella (chicken pox), rubeola (measles), severe acute resp syndrome (SARS) -private rm, neg air pressure, door closed -surg mask on pt w/ transport -PPE + resp protection (N95) -negative pressure

Remove PPE

-untie waist strings on gown -remove gloves -remove goggles or face shield -remove gown only touching the inside (roll with contaminated part facing in) -remove face mask/ resporator by grasping the elastic straps

Special considerations in communication (Assessment/ Data Collection) CHILDREN

-use simple straightforward language -be aware of nonverbal messages because children are especially sensitive to nonverbal communicaiton -enhance communication by being at the child's eye level -incorporate play in interactions

A pressure ulcer may form in

1-2 hr

Five Moments for Hand Hygiene

1. Before touching a patient 2. Before a clean or aseptic procedure 3. After a body fluid exposure risk 4. After touching a patient 5. After touching patient surroundings -wash at least 1 inch above the contaminated area -water runs towards fingers -pat hands dry starting with fingers

Structure of skin

1. Epidermis 2. Dermis 3. Subcutaneous

Identify risks to patient/client safety related to the healthcare setting. Plan interventions that maximize patient/client safety, including National Patient Safety Goals.

1. Identify pt correctly (two pt identifiers, transfusion) 2. Improve staff communication (test results to right person) 3. Use medicines safely (5 rights) 4. Use alarms safely 5. Prevent infection 6. Identify patient safety risks (most likely to commit suicide) 7. Prevent mistakes in surgery

Explore resources for developing and evaluating an emergency management plan.

1. National disaster medical system (NDMS)- managing and coordinating the fed med response to major emergences and federally declared disasters 2. FEMA- works to build and support national emergency management system 3. CDC- acts as the lead federal agency for disease prevention and control activities; provides backup support to state and local health departments 4. Joint Commission- accredits facilities according to established safety and quality standards; revises the EM standards for health care facilities 5.Red Cross- acts as the lead non-gov agency that provides safety info and disaster response 6. Homeland- protects the nation against further terrorist attacks and coordinates the response for future emergencies.

Function of the Skin (5)

1. Skin is the largest organ in the body 2. Protect underlying tissue from injury 3. Regulate body temperature 4. Secrete oily substance (sebum) that softens and lubricates the hair and skin 5. Produces and absorbs vitamin D

Four categories responsible for majority of Hospital-Acquired Infections (HAIs)

1. UTI (CAUTIs)- e. coli 2. Surgical site infections (wound infection) 3. Bloodsteam infections (venous access, central lines) 4. Pneumonia (vent associated pneumonia VAP)

Describe 7 steps in the valuing process

1. choose freely 2. choose from alternative 3. choose after considering consequences 4. Prizing (reward) with pride & happiness 5. Prizing (reward) with public affirmation 6. Acting with incorporation of choice into behavior 7. Acting with consistent and regularity

Factors that Cause Wounds (5)

1.Surgery/procedures 2. Trauma 3. Pressure 4. Friction 5. Shear Other causes

Viruses

cause infections including common cold and do not respond to antibiotics -influenza spread through touching *inanimate objects* Examples: flu, Hep B & C, AIDS Treatment: some antivirals given in the *prodromal state* can shorten the full stage of the illness

caries

cavities of the teeth

toddler/preschooler

child proof supervision ingestion of poisons running in street play with matches forward facing carseat alert to manifestations -abuse

accidental fall

clutter or a spill cause a person to trip

CRE

40-50% mortality rate

fires

85 % occur in the home Smoking The risk for home ______ can be determined by assessing the knowledge of family members and the presence of functioning smoke detectors. More than one-third of home fire deaths occur in a home without a smoke detector ask about how they heat their house Nurses must be aware of fire policies

Nail length

<1/4 of an inch long

Types of Fire Extinguishers: A, B, and C

A (wood, cloth, upholstery, paper, rubbish, plastic) B (flammable liguids ie gas, grease, tar, oil based paint) C (electrical equipment)

Develop nursing diagnoses that identify hygiene problems amenable to nursing intervention.

A careful assessment of the adequacy of a patient's hygiene practices and the assessment of the skin, mucous membranes, and other body areas may lead to the development of one or more nursing diagnoses related to alterations in hygiene. Each nursing diagnosis statement identifies a patient problem and suggests expected patient outcomes. The etiology of the problem directs nursing interventions. Problems concerning deficient hygiene are categorized as self-care deficits. Self-Care Deficit diagnoses address specific activities necessary to meet daily needs: feeding, bathing, dressing, and toileting.

(Fall scene investigation) FSI

A collaborative effort to examine the scene where the fall occurred and explore possible causes using a documentation tool that addresses safety hazards, future prevention strategies, and lessons learned

less

A person who is familiar with one's surroundings is ________ likely to experience an accidental injury. nurse should orient person to new surrounding like the hospital

hourly patient rounding

A proactive approach that involves hourly visits to patients during day and evening hours and 2-hour visits during the night to address patient concerns that may result in a fall (need for pain medication, position change, or a visit to the bathroom). These regularly scheduled visits reassure patients that their needs will be met in a timely manner. Some hospitals use managers or specially assigned nursing staff to conduct the rounding

Activated charcoal

A substance that absorbs many poisons and prevents them from being absorbed by the body

school aged child

Accidents -home school neighborhood Booster seats --4ft 9in 12yo younger -- back seat Bicycle accident (wear helmets) Sports-TBI, concussion Child abduction-amber alert system Nurse education to children and parents

Wound Classification

According to cause (how they're aquired) According to depth or tissue layers involved (Stage) Can be described according to likelihood of contamination

high risk for fall

Age older than 65 years Documented history of falls Impaired vision or sense of balance Altered gait or posture A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics Postural hypotension Slowed reaction time Confusion or disorientation Impaired mobility Weakness and physical frailty Unfamiliar environment

sensory perception

Any impairment in sight, hearing, smell, taste, or touch can reduce a person's sensitivity to the environment (people who are blind are at risk for falling, deaf people may not hear alarms, pt who cant smell wont detect gas leak)

mobility

Any limitation in _________ is potentially unsafe. An older patient with an unsteady gait is more prone to falling. Furthermore, if the patient is in an unfamiliar setting, such as a health care facility, the problem may be aggravated. Canes, walkers, wheel chairs

Pressure Ulcers

Any skin alteration caused by unrelieved pressure that results in damage to the underlying tissue Due to local ischemia Initially surface is pale, then reddened due to reactive hyperemia caused by vasodilatation Contributing forces: friction and shear

physical health state

Anything that affects the patient's health state potentially can affect the safety of the environment. When a person is chronically ill or in a weakened state, the focus of health care includes preventing accidents as well as promoting wellness and restoring the person to a healthy state

Implementing

Application of heat and cold Determine the client's ability to tolerate the therapy Explain the procedure to the client Assess the skin Ask client to report any discomfort Return to assess client 15 minutes after the application of heat, observe local skin Remove equipment at the designated time Examine the area

First-level preconventional stage

As children progress to toddlerhood, morals and values development begins as they identify behaviors that elicit reward or punishment. Kohlberg refers to this process as the first-level preconventional stage when children learn to distinguish right from wrong and understand the choice between obedience and punishment.

Physical examination (safety, security & emergency preparedness)

Assess (mobility status, ability to communicate, level of awareness/orientation, sensory perception) -ID potential safety hazards -Recognize manifestations of domestic violence/ neglect

physical exam safety

Assess the patient's mobility status, ability to communicate, level of awareness or orientation, and sensory perception in the physical examination. Early identification of any potential safety hazards is essential. Recognize any manifestations that suggest domestic violence or neglect

Non-maleficence

Avoid causing harm

Demonstrate techniques for assisting patients with hygiene measures, including those used when administering various types of baths and those used in cleaning each part of the body.

Bathing serves a variety of purposes, including: Cleansing the skin Acting as a skin conditioner Helping to relax a restless person Promoting circulation by stimulating the skin's peripheral nerve endings and underlying tissues Serving as a musculoskeletal exercise through activity involved with bathing, thereby improving joint mobility and muscle tonus Stimulating the rate and depth of respirations Promoting comfort through muscle relaxation and skin stimulation Providing sensory input Helping to improve self-image Providing an excellent opportunity to strengthen the nurse-patient relationship, to thoroughly assess the patient's integumentary system, to observe the patient's physiologic and emotional status closely, to teach the patient as indicated, and to demonstrate care and interest in the patient's general welfare

nursing history safety

Be alert to any history of falls or accidents, because a person with a history of falling is likely to fall again. Note any assistive devices that the patient uses (e.g., a cane or walker). Be alert to any history of drug or alcohol abuse Support from family?

emotional abuse

Behaviors that harm a child's self-worth or emotional well-being. Manifestations can include extremes in behavior, sleep problems, headaches or stomachaches, avoiding activities.

Beneficence

Benefit the patient, and balance benefits against risks and harms -action that promotes good for others, without any self-interst

transmission-based precautions

CDC precautions used in patients known or suspected to be infected with pathogens that can be transmitted by *airborne, droplet, or contact routes*; used in addition to standard precautions (previously PPE was only required w/ in 3 ft of pt) Routes: 1. airborne (TB, varicella, rubeola) 2. Droplet (rubella, mumps, diphtheria) may be routine to swab nose (MRSA) and butt (VRE) for infection at admission *contact precautions may be for carriers as well as those with active infections*

standard precautions

CDC precautions used in the care of all patients regardless of their diagnosis or possible infection status; this category combines universal and body substance precautions hand hygiene on all pts -wear gloves (body fluids)

Principle-based approach to bioethics

Combination of utilitarian and deontological theories and offers *specific action guides for practice* 4 Key principles: Autonomy, nonmaleficence, beneficence, justice (Fidelity)

Kinesthetic Communication

Communication through body motion.

Nursing Interventions to Prevent Falls in a Health Care Facility

Complete a risk assessment. Indicate risk for falling on patient's door and chart. Keep bed in low position. Keep wheels on bed and wheelchair locked. Leave call bell within patient's reach. Instruct patient regarding use of call bell. Answer call bells promptly. Leave a night light on. Eliminate all physical hazards in the room (clutter, wet areas on the floor). Provide nonskid footwear. Leave water, tissues, bedpan/urinal within patient's reach. Document and report any changes in patient's cognitive status to the physician and other nurses at the change of shift. Use alternative strategies when necessary instead of restraints. As a last resort, use the least restrictive restraint according to agency policy. If restraint is applied, assess patient at the required intervals.

Assessment of Wounds Untreated wounds

Control bleeding, prevent infection, control swelling and pain, assess for foreign bodies, assess for shock if bleeding severe

environment safety

Crime, Violence, acts of aggression, and terrorism are components of 21st-century life. Security measures such as locks, security systems, and exterior lighting can promote safety. nurses must be aware of risk

Feminist Ethics

Critiques existing patterns of oppression and domination in society especially affecting women and the poor

Identify factors affecting personal hygiene.

Culture, socioeconomic class, spiritual practices, developmental level, health state, and personal preferences

Factors that Impair Wound Healing (3)

Developmental Considerations - Healthy children and adults heal more quickly than older adults Nutrition - Wound healing places additional demands on the body Medications - Anti-inflammatory drugs, heparin, and anti-neoplastic agents interfere with healing

developmental level (consideration) safety

Each level is different Conception- adulthood (pregnant women on drugs) Several risks of injury at each age group Education to prevent these hazard are imperative nursing assessment plays a vital role in identifying risky environment

Identify four functions of institutional ethics committees

Education, Policy Making, Case Review, Consultation and Case Research -serving as a liaison between the family and the committee members -presenting explanations about technical terminology -advocating for the client's wishes

sexual abuse

Engaging a child in sexual acts including fondling, rape, and exposing a child to other sexual activities. Can be manifested by vaginal discharge, urinary tract infection, difficulty walking or sitting, sexually transmitted infections, and genital pain.

Orientation Phase

Establish tone and guidelines for the relationship. Identify each other by name. Clarify roles of both people. Establish an agreement about the relationship. Provide the patient with orientation to the health care system.

Ethical character

Ethical character is the development or cultivation of virtues such as humility, courage, and integrity to name just a few. The development or cultivation of these virtues allows the nurse to practice in a manner in which the nurse believes in.

Termination Phase

Examine goals of helping relationship for attainment. Make suggestions for future efforts, if necessary. Encourage patient to express emotions about the termination. If appropriate, help the patient establish a helping relationship with another nurse. Assist the patient transferring from one agency to another or from one unit in an agency to another.

Ethical theories

Examine principles, ideas, systems, and philosophies that affect judgments about what is right and wrong, good and bad (utilitarianism, deontology, consensus in bioethics, and ethics fo care)

Factors Affecting Skin Integrity (3)

Genetics/Heredity Age Underlying health of the individual Disease - PVD,DM Medications and treatments Nutritional status Heredity determines skin color, sensitivity to sunlight, allergies Age: old and young have more fragil skin and increased susceptibility to trauma Chronic illnesses and their treatments can affect skin integrity Heredity determines skin color, sensitivity to sun light, allergies

Types of Dressings

Hydrocolloids - Absorb exudate, provide moisture without causing maceration of surrounding skin, protect from contamination Hydrogels - Liquefy necrotic tissue or slough, rehydrate the wound bed and fill in dead space Polyurethane Foams - Absorb light to moderate amounts of exudate and debride wounds

Prevention of infection

Importance: major focus for nurses, leading issue in health care 1. Assessing (early detection and surveillance techniques) 2. Diagnosis (potential for infection or the presence of an infection) 3. Outcome ID and Planning (pt demonstrates preventing infection and infection control techniques) 4. Implementing (asepsis)

Types of Wounds

Incisional - open wound Contussion - closed wound Abrasion - open wound Puncture - open wound Laceration - open wound Penetrating - open wound Pressure Ulcers

Inflammatory Phase

Inflammatory Phase - Immediately after wound 3 - 6 days Hemostasis Phagocytosis

Nursing Management - Assessment of Skin Integrity nursing history

Information regarding skin diseases Previous bruising Skin lesions Unusual healing Medications Past medical history

(root cause analysis) RCA

Involves an investigation of the environment, collection of evidence regarding the contributing factors that caused the fall, and an actual drawing of the fall scene that details the patient's location, the position of the bed, and presence of any assistive devices. An interdisciplinary team then revisits the incident, looks for patterns and relationships, and reviews systems and processes with the goal of identifying patients at risk and system changes that are needed to ensure that the revised safety plan is effective

Planning

Maintain skin integrity Prevent pressure ulcers Promote wound healing

Maturation Phase

Maturation Phase - begins after about 21 days - may last 1 - 2 years Collagen organization Remodeling or contraction Scar stronger

Fungi

Molds and yeast can cause infection and are present in the air, soil, and water Examples: athlete's foot, ringworm, yeast infection Treatment: anti-fungal, many are resistant to treatment

MRSA

Multi-drug resistant staphylococcus aureus -different strains have emerged have to be treated with vanc. -community acquired MRSA causes skin and soft tissue infections -Treatment: wound drainage Most at risk: children, older adults, and people in close proximity

National Disaster Medical System

NDMS responsibility for the coordination of health care practitioners who supplement local disaster responses in large-scale disasters

Gas Gangrene

Necrosis in a wound infected by an anaerobic gas forming bacillus, the most common etiologic agent being Clostridium perfringens. -pathogen -found in soil

Implementing

Nursing Interventions for preventing pressure ulcers Provide adequate nutrition Fluids, protein, vitamins, zinc; dietary consult; weight and lab data Maintain skin hygiene Mild cleansers, avoid irritants, moisture/skin barriers, avoid hot water Avoid skin trauma Fowler's position Turn every 2 hours Exercise and ambulation Assistive devices Provide supportive surfaces Client/ Family teaching

falls

Occur at any age Most common reason for admission in older adult Fnquiring about, and inspecting for, factors that contribute to falls and an understanding of the types of or reasons for falls.

Plan, implement, and evaluate nursing care for common problems of the skin and mucous membranes.

Oral, Eyes, Ears, Noses, Vaginal, and other mucous membranes as well as the skin each require their own version of care. Performing or assisting with the performance of hygiene measures provides a means of at least daily contact with the patient to determine whether the patient is achieving outcomes related to hygiene and skin care. Indicators that can be used to determine outcome achievement include the following: Level of patient's participation in hygiene program Elimination of, reduction in, or compensation for factors interfering with the patient's independent execution of hygiene measures, for example, weakness, decreased motivation, and lack of knowledge Changes related to specific skin problems, for example, healing of skin lesions, elimination or reduction in causative factors, and independent patient management of the prescribed treatment program

Value System

Organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct

Phases of the helping relationship

Orientation phase Working phase Termination phase

symptoms of concussion

Physical: headache, vomiting, problems with balance, fatigue, dazed or stunned appearance Cognitive: mentally foggy, difficulty concentrating and remembering, confusion, forgets recent activities Emotional: irritability, nervousness, very emotional behavior Sleep: drowsiness, difficulty falling asleep, sleeping more or less than usual

Assessment of Wounds Pressure Ulcers

Pressure Ulcers Note location, size, stage, color of wound bed, condition of wound margins, integrity of surrounding skin, clinical signs of infection

Types of Wound Healing primary intention healing

Primary Intention Healing - Tissue surfaces have been closed and there is minimal or no tissue loss (closed surgical incision)

Anaerobic

Process that does not require oxygen

Describe three typical concerns of the nurse advocate

Promoting self-determination, Whistle-Blowing, Being politically active

Nuclear (safety concerns)

Radioactive material

Aerobic

Require oxygen

Human dignaty

Respect for the inherent worth and uniqueness of individuals and populations -Provides culturally competent and sensitive care -Protects patients privacy -Preserves the confidentiality of patients and healthcare providers -Designs care with sensitivity to individual patient needs

emergency, immediately

Restraints may be applied without a physician's order if the situation is an ______________ and the threat to safety is imminent. However, an order must be obtained _____________ afterward.

Nursing Diagnoses

Risk for impaired skin integrity Impaired skin integrity Impaired tissue integrity Additional Dx Risk for infection Pain

secondary intention healing

Secondary Intention Healing - Wound is extensive and involves considerable tissue loss and the edge can not or should not be closed (pressure ulcer); healing takes longer, scarring is greater, risk for infection is higher

Types of Wound Drainage

Serous exudate , Purulent exudate , Sanguineous exudate

Assessment of Skin Integrity Physical Assessment Inspection and palpation

Skin color distribution Skin turgor Presence of edema Characteristics of any skin lesions Note especially areas at risk for break down

outcome identification/ planning

Some expected outcomes for patients that promote safety and prevent injury are as follows. The patient will: Identify unsafe situations in his or her environment Identify potential hazards in his or her environment Demonstrate safety measures to prevent falls and other accidents Establish safety priorities with family members or significant others Demonstrate familiarity with his or her environment Identify resources for safety information Remain free of injury during hospitalization

fire arm injuries

Some people believe that keeping a gun in the home provides protection for family and property. However, when a gun is available it is more likely that the owner or a family member, rather than an intruder, will suffer a fatal injury Gun in home is a risk factor The intent is to inform families about the risks of firearm injury and discuss appropriate safety measures

social behavior

Some people by nature are more inclined to take risks and place themselves at jeopardy for injury. (not wearing helmets, stress leads to drug use)

Stages of Pressure Ulcer Formation stage 1

Stage I - Non-blanchable erythema of intact skin

Stages of Pressure Ulcer Formation stage 2

Stage II - Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial

Stages of Pressure Ulcer Formation stage 3

Stage III - Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia

Stages of Pressure Ulcer Formation stager 4

Stage IV - Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to the muscle, bone or supporting structures, such as tendons and joints

adults

Stress-coping, unsafe health habits (drugs) Domestic Violence- (IPV) rape, physical/sexual violence, stalking-- child abuse? Abuse Assessment Screen - specific protocol Safety plan (escape) place to stay escape route person to call important paperwork bank account and money packed bag of clothes

psychosocial health state

Stressful situations tend to narrow a person's attention span and make the individual more prone to accidents. (Depression may result in confusion and disorientation, accompanied by reduced awareness or concern about environmental hazards)

Nursing ethics

Subset of bioethics, formal study of ethical issues that arise in the practice of nursing The analysis by nurses to make ethical judgments

Implementing Nursing Interventions for maintaining skin integrity

Sufficient nutrition Sufficient fluids Asepsis to prevent wound infections Proper positioning

Tertiary Intention

Tertiary Intention (Delayed Primary Intension) Healing - Initially left open; infection, edema, exudate resolve, then wound is closed

identify patients at risk for developing an infection (factors that affect host susceptibility)

patients with compromised/nonintact skin and mucous membranes, abnormal pH levels, low WBC counts, age sex race and hereditary factors (neonates and elderly patients are more vulnerable), patients with non-up to date immunizations- these help fight infections, fatigue, nutritional and general health status, evidence of preexisting illnesses, previous or current treatments, certain medications- all play a part in host susceptibility increased stress may play a role in the body defense mechanisms- weakening them indwelling or invasive medical devices

poisoning

The focus of emergency treatment of------ is to stabilize vital body functions, prevent the absorption of the poison, and encourage excretion of the toxic substance.

Evaluation

The goals established during the planning phase are evaluated according to specific desired outcomes

restrictive, convenience

The least ____________ restraint should be the first option. Restraints must never be applied for the __________________ of the staff. The patient's family must be consulted and involved in the plan of care before applying restraints in a long-term care setting.

Describe agents commonly used on the skin and scalp, including any precautions necessary for their use.

The use of chlorhexidine gluconate for bathing has been shown to reduce colonization of skin with pathogens and is becoming part of personal hygiene policies in some facilities. Topical emollient agents—also known as moisturizers—can be applied to the skin as a lotion, cream, gel, or ointment. Skin barrier products include creams, ointments, and films; they are used to protect vulnerable skin and to protect skin at risk for damage caused by excessive exposure to water and irritants, such as urine and feces.

physical abuse

Unexplained or repeated injuries resulting from physical force. Manifestations include bruises, fractures (arms, legs, facial, ribs), burns, bite marks, head injuries and any other indications of force.

Assessment of Wounds Treated Wounds

Usually assessed during a dressing change Frequency of documentation varies Transparent dressings offer advantage of visualization

Contact precautions

VRE, C-Diff (wash with water and soap), MRSA, influenza, RSV, wound infections, skin infections, eye infections (conjunctivitis) -private room or cohort client -gloves and a gown when entering clients room

Implementing Wound Care (RYB)

Variety of products available- choice depends on location, size, exudate and condition of underlying wound bed In general: R - Red Protect/cover RED Y - Yellow Cleanse YELLOW B - Black Debride BLACK

Gastric lavage

Washing out of the stomach no longer prescribed routinely for treatment of ingestion of a toxic substance because it may propel the poison into the small intestine, where absorption will occur. The amount of toxin removed by gastric lavage is relatively small.

Describe the priorities of scheduled hygiene care.

When patients require nursing assistance with personal hygiene, provide this care at regular intervals. In most hospitals and long-term care settings, early morning care, morning care, afternoon care, hour of sleep care, and care as needed are provided. These are individualized according to the patient's personal and cultural preferences. Personal care assistance in the home and other community-based settings centers on patient preferences and routines.

the person, the environment, and specific risk factors.

When performing a safety assessment, the nurse focuses on three categories:

Accountability

Willingness to take credit and blame for ones actions.

PPE (personal protective equipment)

a barrier between a person and pathogens; includes gloves, gowns, masks, goggles, and face shields refer to CDC guidelines *pt wear mask in droplet precautions during transport*

Veracity

a commitment to tell the truth (preserves the integrity of the client-provider relationship/ the duty to be honest and avoid deceiving or misleading a client.)

anticipated psychological fall

a direct consequence of gait imbalances, effects of medication, or dementia

ipecac

a medicinal drug used to evoke vomiting (especially in cases of drug overdose or poisoning) not recommended

Tetanus

a sustained muscular contraction resulting from a rapid series of nerve impulses -Pathogen -Found in soil

Eschar

a thick layer of dead tissue and tissue fluid that develops over a deep burn area

Integrity

acting in accordance with an appropriate code of ethics and accepted standards of practice -Provides honest information to patients and the public -Documents care accurately and honestly -Seeks to remedy errors made by self or others -Demonstrates accountability for actions

poison control

agency that handles poison exposure and provides poison prevention teaching to the general population

when to wash hands with an alcohol based rub vs soap and water

alcohol based rubs when hands are not visibly soiled, soap and water when they are soiled, before eating, and after restroom

fistula

an abnormal passage from an internal organ tothe outside of the body or from one internal organ to another.Fistulas may be created purposefully;

disaster

an emergency event of greater magnitude that requires the response of people outside the involved community natural or manmade

sentinel event

an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

describe nursing interventions used to break the chain of infection

aseptic techniques!! : medical (clean) or surgical (sterile)

ICN Code of Ethics,

nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health, and to alleviate suffering. The need for nursing is universal.

Lifestyle safety

occupation social behavior

radiation burn

occur as a result of exposure to a radioactive source. The severity of injury depends on a variety of factors, including the duration of the exposure and the distance between the source and the person. A higher dose increases the likelihood of developing later effects such as bone marrow depression and cancer

intentional fall

occur when patients act out behaviorally with intent to fall

Ethical Distress

occurrence when the nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action Use 4 A's (Ask, afirm, assess, and act)

halitosis

offensive breath

identify situations in which hand hygiene is indicated

before touching a patient, before a clean or aseptic procedure, after body fluid exposure risk, after touching patient, after touching patient surroundings

Morals

behavior in accordance with customs or traditions, usually reflecting personal or religious beliefs. are personal values or communal standards of right and wrong

Values

belief about the worth of something, about what matters, that acts as a standard to guide one's behavior *Values are standards for decision making that endure for a significant time in one's life* Influenced by: environment, family, and culture Values associated with activity and exercise include sensory pleasure, competition, image, and play

unanticipated psychological fall

caused by unknown or unexpected medical issues such as a stroke or seizure

Rewards and Punishments

children are rewarded for demonstrating values held by parents and punished for demonstrating unacceptable values

Sterilization

destroys all microorganisms including spores

Disinfectant

destroys all pathogenic organisms except spores safe for skin or equipment that does not enter the body

ANA Standards- RN

-Use code of ethics to guide practice -deliver care in a maner that preserves and protects -promotes pt centered care -upholds health care consumer confidentiality -assists pt in self determination and informed decision making -therapeutic relationship with pt -be able to resolve ethical issues -take action reguarding illegal, unethical, or inappropriate -speaks up when appropriate -advocate for equitable pt care

Antimicrobial Handwashing

-Used in any setting where the risk for infection is high -these agents can kill bacteria or suppress their growth. *alcohol based hand rubs have been found to more effectively reduce bacterial and viral counts than antimicrobial soap*

Personal Values-Professional Values

-Values are formed during a lifetime form information from the environment, family, and culture Professional Values: Altruism Autonomy Human dignity Social Justice

Droplet Precautions

-adenovirus, diphtheria, epiglottitis, influenza, meningitis, mumps, pneumonia, parvovirus, pertussis, rubella, scarlet fever, sepsis, strep -private room or cohort client (have same cultures) -wear a surgical mask within 3 feet of client -place mask on pt when leaving room

Using the Nursing Process to Make Ethical Decisions *ADPIE*

-assess the situation (gather data) -diagnose (identify) the ethical problem -plan (id options, think ethical problem through, make a decision) -implement your decision -evaluate your decision

Shigella

-bacillary dysentery -found in water (drinking or swimming)

Antibody

-body produces antibody to defend itself.

Safety considerations for toddlers/preschooler

-childproof home environment -prevent poisoning -be alert to manifestations of child maltreatment or abuse -use car seats properly

Safety Event Reports

-completed after any accident/ incident in a health care facility that compromises safety -describe circumstances -detail pts response to exam and treatment of pt -completed by nurse immediately after incident *not part of med record and should not be mentioned in documentation*

Risk factors for Vancomycin Resistant Enterococci (VRE)

-compromised immune system -recent abd or chest surgery -presence of urinary or central IV catheter -prolonged antibiotic use especially in an ICU

Characteristics of the assertive nurse's self presentation

-confident; open body posture -use of clear, concise "i" statements -ability to share effectively one's thoughts, feelings, and emotions -asking for help when necessary -giving and accepting compliments -admitting mistakes and taking responsibility for them

Measures to Reduce Incidence of Nosocomial Infections

-constant surveillance by infection-control committees and nurse epidemiologist -written infection-prevention practices for all agency personnel -hand hygiene practices -infection control precaution techniques -keeping pt in best possible physical condition

Develop conversation skills

-control the tone of your voice, avoid words that might have different interpretation, take advantage of available opportunities.

outcome identification and planning/ infection control

-demonstrate effective hand hygiene and good personal hygiene practices -id signs of infection -maintain adequate nutritional intake -demonstrate proper disposal of soiled articles -use appropriate cleansing and disinfecting techniques -demonstrate the awareness of the necessity of proper immunizations -demonstrate stress-reduction techniques

Factors to promote effective communication

-demonstrate friendliness, show respect, express empathy, show genuine concern and caring behavior, display competence *pt focused and not task focused*

Maintaining emergency preparedness

-emergency response teams -disaster action plans -community resources -national disaster emergency medical system -on go education and mandatory training for health care workers

Restraints (Application)

-endure 2 fingers -quick release knot secured to *bed frame* -remove the restraints every 2 hours or according to agency policy/pt need -keep call bell within pts reach

restraint

device used to limit movement or immobilize a client physical/ chemical potentially dangerous- serious injuries Additional negative outcomes of restraint use include skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration and respiratory difficulties, and even death. use as last resort

Describe strategies for implementing CDC guidelines for standard and transmission-based precautions

-C.Diff (prescribe antibiotics cautiously, contact precautions, private rooms, effective hand hygiene (soap and water), non-disposable equipment cleaned with bleach, notify new facility of c.diff)

Identify alternatives to restraints and patient/client care issues related to use of restraints.

-Chemical to control behavior -Physical (devices used to limit pts movement... side rails/ geriatric chairs) -Not acceptable practice to use routinely -Know hospital policies -Side rails are a form of restraint (pt must be able to lower them) *Box 26-7* *Skill 26-1*

Electronic communication in health care

-Electronic health records (who has access and to what information) -social media guidelines for RNS (ANA & National Council for the state board of nursing) -emails, texts, fax (risk for violating pt privacy and confidentiality)

Risk factor assessment

-Falls (65 and older) -Fires (smoking in bed, faulty wires, space heaters) -Poisoning (overdose, medications) -Suffocation & Choking (cosleeping, asphyxiation) -Firearm injuries

Safety considerations for school aged children

-Help to avoid activities that are potentially dangerous. -Provide interventions for safety at home, school, and neighborhood. -Teach bicycle safety. -Teach about child abduction. -Wear seatbelts.

Four levels or types of communication

-INTRApersonal (self talk) -INTERpersonal (two + people exchange messages... factors that influence include educaiton and developmental difference between sender and receiver) -Small group (2+ people) -Organization (occurs in groups when there is a common goal) Other from ATI: -Public (communication within groups) -Transpersonal (communication that addresses spiritual needs)

Aseptic Technique

-Includes all activities to prevent or break the chain of infection -Two categories: 1. medical (clean technique) 2. surgical asepsis (sterile technique)

Safety considerations for adults

-Remind them of effects of stress on lifestyle and health. -Counsel about unsafe health habits (reliance on drugs and alcohol). -Counsel about domestic violence.

Salmonella

-Reservoir: Intestinal tracts of humans and other animals, including birds -Means of transmission: contact (ingestion) -Disease transmitted: diarrheal illness

Mycobacterium Tuberculosis

-Reservoir: Sputum (resp. tract) -Means of transmission: Airborne -Disease transmitted: Tuberculosis

Hep B Virus

-Reservoir: blood, feces, body fluids and excretions -Means of transmission: contact (indirect) -Disease transmitted: Hep B

HIV

-Reservoir: blood, semen, vaginal secretions, breast milk -Means of transmission: contact (direct) -Disease transmitted: HIV

Staphylococcus Aureus

-Reservoir: skin surface, mouth, nose, throat -Means of transmission: contact (direct) -Disease transmitted: wound infection, abscess, carbuncle, boil

Borrelia Burgdorferi

-Reservoir: ticks (sheep, cattle, deer, mice), contact (direct) -Means of transmission: vectors -Disease transmitted: *lyme disease*

Using hand-off communication: SBAR to Physician

-Situation -Background -Assessment- *the problem seems to be* -Recommendation or request

Safety considerations for adolescents

-Teach safe driving skills. -Teach avoidance of tobacco and alcohol. -Teach risk of infection with body piercing. -Teach about guns and violence. -Discuss dangers associated with the Internet

Therapeutic Communication

-foundation for nurse-pt relationship -purposeful use of communication to build and maintain helping relationships with clients, families, and significant others -age considerations- children and older adults -planning (minimize distractions and set priorities) -barriers to effective communication (offering sympathy, probing with personal questions, changing the topic -communication among health professionals (incivility, bullying, lateral violence) Characteristics: -pt centered. not social or reciprocal -purposeful, planned, and goal-directed Essential components: time, attentive behavior/ active listening, caring attitude, honesty, trust, empathy, nonjudgemental attitudex

Listeria

-gram-positive rod is distinguished by its tumbling motility -found in unpasteurized milk and -contaminated fruit

Physiological hazards associated with restraints

-inc possibility of serious injury due to fall -skin breakdown -contractures -incontinence -Assess CMS -Depression, delirium, anxiety, aspiration/rt difficulties, death

Factors affecting host suseptibility

-intact skin/ mucous membranes -normal pH levels -WBC -age, sex, race, hereditary factors -immunizations, natural or acquired -fatigue, climate, nutritional and gen. health status -stress -use of invasive or indwelling medical devices

Disruptive interpersonal behavior

-negative effect on clinical outcomes and interpersonal working relationships -Incivility & bullying (nurse to nurse, experienced nurse to new nurse, nurse to student nurse, negative communication between nurse and physician)

Nonverbal communication

-nurses should be aware of how they communicate nonverbally and should determine the meaning of clients nonverbal communication as well. -appearance, posture gait, facial expression, gestures, sounds, territoriality/personal space

VRE

-vancomycin resistant enterococcus -Pt at risk: kidney disease, diabetes, prior MRSA infection, presence of an IV, recent exposure to vanc., abd or chest surgery -Spread via: feces, urine, or blood

Distinguish between the stages of an infection.

1. incubation period (organism growing and multiplying) 2. Prodromal sage (person is most infectious, vague and nonspecific signs of disease) 3. full stage of illness (presence of specific signs and symptoms of disease) 4. convalescent period (recovery from infection)

Components of the Infection Cycle

1. infectious agent (bacteria, virus, fungi) 2. reservoir (natural habitat of the organism) 3. portal of exit (point of escape for the organism) 4. means of transmission (direct contact, indirect contact, airborne route) 5. portal of entry (point at which organism enters a new host) 6. susceptible host (must overcome resistance mounted by host's defenses) *Bacteria is most common in healthcare system*

safety event report

documentation describing any injury or potential for injury suffered by a patient in a health care agency details patient response and treatment not part of medical record

neonate/infant

dont smoke, no alcohol while pregnant doctor visits and prenatal vitamins never leaving the infant unattended, using crib rails, and monitoring the setting for objects that the infant could place in the mouth and swallow carseats/ seatbelts

adolescent safety

Peer influence Motor vehicle accidents- DUI, DWI Binge drinking Alcohol use more common Distracted driving- talking, texting, eating, self grooming Nurse+Parents collaboration for teaching Substance abuse-OTC, prescribed, street drugs Tobacco Body Piercing-very risky Tattoos- viruses and bacteria Guns- higher than any other age group, high suicide Internet- offenders reach out to vulnerable adolescents, cyberbullying

occupation

People who work in certain _______________ may experience exposure to health hazards, such as excessive noise, pollution, toxic chemicals or vapors, or infectious agents. Certain _____________ are also associated with increased risks of specific injuries (nurses=needlestick injuries)

Deontologic

An action is right or wrong based on a rule, independent of its consequences

knowledge

An awareness of safety and security precautions is crucial for promoting and maintaining wellness throughout the lifespan (managing new equipment) nurse teaching about safety are CRUCIAL

Moralizing

Children in this mode of value transmission are taught a complete value system by parents or an institution (church or school) that allows little opportunity for them to weight different values

Modeling

Children learn what is of high or low value by observing parents, peers, and significant others. May lead to socially acceptable or unacceptable behavior

chemical agents

Choking Lung/Pulmonary Agents Blood Agents Vesicants/Blister Agents Nerve Agents Incapacitating Agents

Bioethics

encompasses a number of fields of "life sciences" -application of ethics to health and life -addresses dilemmas (ie stem cell research, organ transplantation, gender reassignment, and reproductive technologies)

Bundles

evidence-based best practices that have proven positive outcomes when implemented together to prevent infection to reduce HAIs

Assessment of Wounds Laboratory Data (4)

Decreased leukocyte counts - delayed healing -Prolonged blood coagulation - results in excessive blood loss and prolonged clot formation -Protein analysis - indication of the body's nutritional reserves for rebuilding cells -Wound culture - confirms or rules out the presence of infection

Fideleity

fulfillment promises (Fidelity means being faithful to work-related commitments and obligations, such as reporting the incident. ) faithful to the client, who has the right to the truth. By not telling the client, the nurse is not being faithful to the client.

Assess the adequacy of hygiene practices and self-care behaviors using appropriate interview and physical assessment skills.

Hygiene practices include bathing and care of the skin and specific body areas, including the oral cavity, eyes, ears, nose, hair, nails, feet, and perineal and vaginal areas. Ask if the patient has noticed changes in or problems with these areas. Ask the patient about personal hygiene routines and products used. Inquire about any problems the patient may be experiencing related to completion of personal hygiene. Focused Assessment Guide 30-1.

plague

Expected attack most likely airborne (inhalation of bacilli) with sudden appearance in ED of multiple patients with respiratory symptoms Symptoms similar to a severe respiratory infection Progresses rapidly to severe pneumonia, sepsis, and death Standard precautions with droplet precautions until 48 hours after initiation of antibiotic therapy Antibiotic of choice: streptomycin (IM) or gentamicin sulfate (IM or IV). Possible use of oral antibiotics (effective when mass numbers of people are ill). Fatality rate of 100% for those not receiving treatment within 24 hours of onset of symptoms

Types of Dressings

Exudate Absorbers Provide a moist wound surface by interacting with exudate Absorb exudate Can be used to eliminate dead space or pack wounds Support debridement

poisoning

Factors that put children most at risk for exposure to toxic substances include unsafe storage in the home, spending time in environments other than the home, lack of attention on the part of the caregiver, the rise in multigenerational families that give children an opportunity to access grandparents' medications, and the presence of multiple pharmaceuticals and vitamins and dietary supplements in the home teens- experimenting with drugs "huffing" older adults- overdose on medication because they were confused household-gas, oil, and kerosene heaters CO

neglect

Failure to meet a child's basic needs including housing, food, clothing, education, and access to medical care.

older adult

Fall- MVA Interventions- maintain the automobile in optimal driving condition, schedule regular eye examinations, wear corrective lenses when necessary, and keep noise from the radio and other equipment to a minimum. Fires greater risk for burn injuries do they smoke? hot devices have to be monitored Medication accidental overdose prefilled trays Abuse <80yo- maltreatment family member abuse never reported nurses need to be aware of this upon assessment

Complications of Wound Healing (3)

Hemorrhage - Persistent bleeding Infection - Wound is infected with microorganisms at the time of injury, during surgery or pot-operatively Dehiscene - partial or total rupturing of a sutured wound

Risk Factors for Pressure Ulcers

Immobility Inadequate nutrition Fecal and/or urinary incontinence Decreased or altered mental status Diminished sensation Excessive body heat Advanced Age

Assess the condition of the patient's skin, oral cavity, hair, and nails using appropriate interview and physical assessment skills.

Mouth: How do you clean your teeth and gums? How often do you have a dental examination? Do you have any dental appliances? Are there any tender areas or lesions in your mouth? Eyes, ears, and nose: Do you wear glasses or contact lenses to improve your vision? Do you wear a hearing aid? Have you experienced any discharge or bleeding from or swelling of your eyes, ears, or nose? Hair: Have you noticed any unusual dryness of the scalp or changes in hair texture and amount? Feet and nails: Is the appearance of the nails normal? How do you normally care for and clean your nails? Is the skin intact on the feet? Have you noticed any swelling of one or both feet? Do you wear any special shoes? Perineum: Have you noticed any unusual discharge, swelling, itching, or inflammation? Are you able to complete your own perineal care? Do you follow any special hygiene practices during menstruation? What type of feminine hygiene products (e.g., pads, tampons, douches) do you use? Piercings/Tattoos: Do you have any body piercings on your face, neck, arms, legs, torso, navel, or genitals? Have you experienced any problems related to the procedure? Do you have any tattoos? Are the tattoos healed? How do you care for your piercing(s) and/or tattoo(s)? Focused Assessment Guide 30-1.

botulism

Possible release via airborne method, or contaminated food supplies Ocular symptoms such as blurred vision Skeletal muscle paralysis that progresses symmetrically and in a descending manner Muscle weakness that can result abruptly in respiratory failure Standard precautions Passive immunization with botulinum antitoxin Supportive respiratory care

Viral hemorrhagic fevers (e.g., Lassa, Ebola, Marburg, yellow, and dengue fevers)

Possible spread via aerosol infection Fever Myalgias Conjunctival symptoms Mild hypotension Petechial hemorrhages Progresses to shock and hemorrhage Standard, droplet, and contact precautions for the duration of illness; additional precautions, including use of negative-pressure room, N95 or higher respirator Use of personal protective equipment (PPE) (see Chap. 26) No proven treatment other than supportive care Avoidance of aspirin or other anticlotting drugs

Values Clarificaiton

Process by which people come to understand their own values and value system 1. Choosing 2. Prizing 3. Acting person who values something acts by combing choice into behavior

Proliferative Phase

Proliferative Phase - from 3- 4 to about 21 days Collagen synthesis Granulation tissue formation

Rescue anyone in immediate danger. Activate the fire code system and notify the appropriate person. Confine the fire by closing doors and windows. Evacuate patients and other people to a safe area.

RACE

Intact Skin

Refers to the presence of normal skin and skin layers uninterrupted by wounds or breaks or openings

Identify patients most at risk for injury.

Risk Tools -developmental considerations (teens) -lifestyle (exposure to loud noises) -mobility (elderly with unsteady gait) -sensory (vision impaired) -knowledge (lack of awareness) -health care workers (sleep deprivation) -Ability to communicate (language barrier) -physical health state (neuro impaired) -psychosocial state (stress) -risk for falls r/t medications

Factors influencing communication

level of development; gender; sociocultural differences; roles and responsibilities; space and territoriality; physical, mental, and emotional state; and environment.

diagnosis safety examples

Risk for Injury related to lack of awareness of environmental hazards; visual or auditory sensory deficits; history of falling; unsteady gait; substance abuse; refusal to use seat belt or child safety seat; effects of medication; age greater than 65 years; generalized weakness; biological, chemical, or nuclear exposure Risk for Poisoning related to impaired vision; medications stored in unlocked medicine cabinet that is accessible to a child; presence of poisonous plants; excess alcohol intake; use of illicit drugs; knowledge deficit; chemical contamination of food and water Risk for Suffocation related to a plastic bag that is accessible to a young child; child left unattended in bathtub; smoking in bed; placing an infant prone in a water bed; lack of safety precautions (door left on discarded refrigerator); unfamiliarity with fire prevention guidelines; household gas leaks Risk for Disuse Syndrome related to use of physical restraints Risk for Contamination related to chemical contamination of food or water, exposure to bioterrorism, exposure to radiation, flaking or peeling paint in presence of young children, playing in outdoor areas where environmental contaminants are used, smoking

anthrax

Symptoms variable based on form of anthrax: Cutaneous: skin lesion with local edema that progresses, enlarges, ulcerates, and becomes necrotic Gastrointestinal: nausea, vomiting, fever, abdominal pain, hematemesis, severe diarrhea Inhalational: fever, fatigue, cough, dyspnea, pain; may progress to meningitis, septicemia, shock, and death Standard precautions Decontamination possibly required for recent exposure Rapid administration of antimicrobial therapy Supportive therapy for shock, fluid volume deficit, and airway management Vaccine available; currently recommended only for high-risk populations

Risk Assessment Tool

Systematic means of identifying client at high risk for pressure ulcer development Bradens' Scale for Predicting Pressure Sore Risk Norton's Pressure Area Risk Assessment Form Scale

contractures

permanent contraction of a muscle

ability to communicate

The nurse must assess any factor that influences the patient's ability to receive and send messages. Fatigue, stress, medication, aphasia, and language barriers are examples of factors that can affect personal communication and prevent the patient from accurately perceiving events

tularemia

Transmission via contaminated water, food, and soil; most likely aerosolization of bacteria for use as a biological weapon Fever Nonproductive or productive cough Possible progression to respiratory failure Standard precautions Drug therapy such as streptomycin or gentamicin sulfate Fluid and respiratory support measures Vaccine under investigation

Types of Dressings

Transparent Adhesive Films - Provide protection against contamination and friction, maintain moist wound bed, and to facilitate wound assessment - Useful to superficial wounds (stage I), IV sites Impregnated Nonadherent Dressings - Cover and protect partial and full thickness wounds without exudate - Useful post - op and with superficial burns

Ethical Conduct

practice based on professional standards of ethical conduct as well as professional values Nurses should: -Cultivate the virtues of nursing -Understand ethical theories that dictate and justify professional conduct -Be familiar with codes of ethics for nurses and standards for professional nursing conduct

Assessment of the environment

requires the same attention to safety. Risks in the home, community, and health care agency may cause injury. Environmental safety hazards can result in falls, fires, poisoning, suffocation, and accidents involving motor vehicles, equipment, and procedures

describe strategies for implementing CDC guidelines for standard and transmission-based precautions when caring for patients

standard precautions: hand hygiene, clean gloves when needed, PPE, follow resp hygience/ cough etiquette, avoiding recapping used needles, safe injection practices, careful handling of patient care equipment, adequate environmental controls, carefully review room assignments transmission based precautions: STANDARD PRECAUTIONS AS WELL AS (for airborne:) prive negative pressure room, mask/respirator when entering room, transport pt out of room only when necessary and place mask on pt (for droplet:) private room, PPE, transport pt out of room only when necessary wearing a mask, visitors 3 ft away (for contact:) private room, PPE, limit movement of pt out of room, avoid sharing pt-care equipment

SUFFOCATION AND CHOKING

stoppage of breathing or the lack of air reaching the lungs; synonym for suffocation incidence greater in children drowning, chocking, gas or smoke poisoning

chemical terrorism

the deliberate release of a chemical compound that has the potential for harming people's health release in close space like stadium Choking/lung/pulmonary agents Blood agents Vesicants/blister Agents Nerve agents Incapacitating agents

Connotative

the implied or associated meaning of a word words have multiple meanings can cause miscommunication if people interpret them differently

***visual communication

the use of symbols to communicate

Purulent exudate

thicker, indicates the presence of pus, color varies with organism

Resonsibility

willingness to respect obligations and follow through on promises

The Helping Relationship

•Does not occur spontaneously •Characterized by an unequal sharing of information •Built on the patient's needs •The nurse is the helper, and the patient is the person being helped. •Communication is the means used to establish rapport and helping-trust relationships.

Blocks to communication

•Failure to perceive the patient as a human being •Failure to listen •Nontherapeutic comments and questions •Using clichés •Using closed questions •Using questions containing the words "why" and "how" •Using questions that probe for information -changing the subject -giving false assurance

Forms of communication

•Verbal (language) •Nonverbal (body language) -Facial expressions, touch, eye contact -Posture, gait, gestures -General physical appearance -Mode of dress and grooming -Sounds, silence -Electronic communication