NURS 100 - Final Exam Study Guide.
Chapter 10: Medical and Surgical Asepsis -Hand Hygiene: Use antimicrobial soap and water when your hands are visibly soiled, before you eat, after using the bathroom, and after contact of bodily fluid. Scrub your hands for 15 seconds -Alcohol based product use 3-5ml of the product -Stand 3 feet away from those coughing -Keep nails short -No gel polish because it increases risk of microbes -Remove jewelry from hands and wrist -Never shake linens -Clean the least soiled area first and the worst last How to set up a sterile field: -Position it so the top flap is facing away from you and open it away from you -Open the right flap with your right hand and the left flap with the left hand and the last flap open towards you -If you need to use a sterile solution, remove the bottle cap and place it face it up on a clean surface not the sterile surface, hold the bottle so that the label is against your palm, and you want to pour 1-2 ml out, and then pour the solution on the site
-Do not cough, sneeze, or talk over sterile field -The 1 inch outer edge of the sterile field is not sterile -Any object help below the waste or above the chest is considered contaminated -Any objects that need to be added to the sterile field should be added 6 inches above and dropped into -Never turn your back or reach across a sterile field -Any sterile field item that comes in contact with moisture is not considered sterile Chapter 11: Immunity Nonspecific innate immunity vs. Specific Adaptive Immunity Nonspecific innate immunity : our bodies defense mechanisms or barriers that respond immediately to all antigens Ex: skin, mucous membranes, stomach acid
Specific adaptive immunity: your body produces antibodies in response to a specific antigen to through the actions of B and T lymphocytes. It requires more time, but in the future the immune response will be more specific and effective through this specific adaptive immunity
Active Natural immunity : the body produces antibodies in response to exposure to a life pathogen. Ex: when you get exposed to a cold virus and get sick, your body produces antibodies that when you exposed to that same cold virus again, your body can really defend it off more quickly. Active Artificial Immunity : when your body produces antibodies in response to a vaccine
Passive natural immunity: when the antibodies are passed from tge mom to the baby through the breast milk or through the placenta.
Passive artificial immunity : patient would get immunoglobulins administered to them after they have been exposed to a pathogen. Ex: someone who has a compromised immunity and can’t mount to a proper immune response, so they get ready made immunoglobulins in them.
Infections (6 components) 1)Causative agent like a bacteria and a toxin 2)A reservoir- where the causative agent lives (human or environment)
3)Portal of exit- how that pathogen leaves the host 4)Mode of transmission- it is transmitted through airborne, droplet, or contact 5)Portal of entry-how the pathogen enters the host
6)Susceptible host- how a pathogen goes from the reservoir to the host RISK FACTORS for Infection
-compromised immunity
- chronic or acute disease -poor personal and hand hygiene -crowded living environment -IV drug use -unprotected sex -poor sanitation Virulence: ability of a pathogen to produce a disease Different stages of infection 1.Incubation- time from when the pathogen enters the body until the first symptom appears 2.Prodromal stage- time from the onset of general symptoms such as fatigue and fever until
the patient exhibits specific symptoms to that particular infection
3.Illness stage- time from when specific symptoms occur that are specific to that particular illness
4.Convalescence- time from when the symptoms disappear to complete recovery occurs, this can take several months
Systemic Infection: symptoms such as fever, chills, fatigue, increased respiratory rate, increased pulse, and large lymph nodes Local infection- edema, pain at a specific place in your body, warmth Inflammation- the bodies local response to an injury or infection (3 stages)
1)When the patient exhibits erythema, warmth, edema, and pain at the site of injury 2)When white blood cells kill the microorganisms and exudate containing those WBC’s as well as the dead tissue cells that accumulate at the site of the injury. This exudate can take many forms. Serous exudate or drainage which is clear, sanguineous drainage is bloody, serous sanguineous, may be pink tint, it is in-between, purulent drainage contains
leukocytes and bacteria 3)This is when damaged tissue is replaced by scar tissue Lab tests that indicate an infection 1)WBC count should be between 5,000 and 10,000… it is over 10,000 there is an infection 2)Left shit in the WBC count means when you are fighting off a bad infection and your immune system is working really hard, when it gets overwhelmed it starts releasing immature WBC’s… releasing immature WBC’s because we are overwhelmed by an infection 3)ESR- Erythrocyte sedimentation rate is a good indicator that there is inflammation in the body 4)CRP- C- reactive protein is a good indicator that there is inflammation in the body 5)Positive culture result- indicate infection, you want to collect all the culture before the patient starts any antibiotics Precautions: 1)Standard precautions are used for ALL patients, hand hygiene, use alcohol based antiseptic rather than soap and water unless your hands are visabily soiled, always use face masks whenever there is splashing of bodily fluids, clean cloves whenever you touch
anything in the room, and use a moisture resistance bag for soiked items and proper sharps disposal
2)Air borne precautions: Measles, Varicella (chicken pox) TB (MTV is airborne) the room must have negative airflow . Any visitors must wear a N95 mask 3)Droplet precautions: Influenza, Pneumonia, Putrescence, Sepsis, Mumps, Bacterial meningitis, rubella….. patient will get a private room and caregivers and visitors will need to wear masks 4)Contact precautions- impetigo, scabies, mersa, Cdiff, other enteric infection, RSV, wound
infections … usually given a private room, visitors and caregivers need to wear gowns and gloves Herpes Zoster: This is shingles, it is caused by the reactivation of chicken pox, if you had chicken pox as a kid you are at risk
-Risk factors: compromised immune system, stress, fatigue, and poor nutrition Chapter 12: Patient Safety How to prevent falls? -Patients with orthostatic hypotension advise them to get up slowly -Provide our patients with regular toileting for those that require assistance -Round on patients hourly -Put frequently used items in reach -Always position the bed in the lowest position and lock the breaks -Don not put up all 4 side rails, leave at least 1 side down
Seizures
-During seizures make sure you lower the patient to the floor or the bed and turn the patient on to their side -Loosen any restrictive clothing -Do not restrain patient or put anything in their mouth -Note the onset and duration of the seizure -After the seizure take patients vital signs, do neurological check, implement seizure precautions Restraints -Physical restraints like a vest, belt, or mittens -Chemical restraints like sedatives or psychotics -If you can’t calm the patient down, in an emergency the RN can place the patient in restraints but you must get a prescription from the doctor in the next hour
-Orders can be written for up to 4 hours for adults -Remove restraints one at a time and check every 2 hours -Always use the least restrictive restraint like mittens -Apply restraints so that 2 fingers can fit between the restraint and the patient -Always use a quick release knot Fire Safety -Use acronym RACE (rescue: do a horizontal then a lateral evacuation) (A: alarm) (C- contain, close doors and windows and turn off O2 sources) (E- Extinguish) -PASS (use of a fire extinguisher) P: pull the pin, A: aim at the base of the fire, S: squeeze
the handle, S: sweep side to side Chapter 14: Safe Patient Movement -When lifting an object, you should hold it as close to your body as close as possible -Avoid twisting and bending at the waist -Always gen help when repositioning the patient
Moving patient from the gurney to the bed: -Position the bed slightly lower than the gurney, lower the head of the bed so its flat, have them tuck their chin in to their chest and cross their arms over their chest and you slide them across
