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51 Cards in this Set
- Front
- Back
What is the single most important method of controlling an preventing spread of infections?
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Proper hand washing and hand hygiene
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Describe 4 nursing interventions that can be used when a patient starts to fall.
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1. Put both arms around client's waist or grasp gait belt
2. Stand with feet apart to provide broad base of support 3. Extend one leg and let client stand against it to the floor 4. Bend knees to lower body as client slides to floor. |
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What kind of circulatory and skin assessment needs of the restrained patient?
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Provide appropriate skin therapy
Reassess need for restraint Consider alternatives to restraint Inspect area where restraint is to be placed Note any nearby tubing or devices Assess condition of skin Assess sensation Assess adequacy of circulation Assess range of motion |
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Describe 5 nursing interventions to implement for a restraint-free environment
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1. Orient client and family to surroundings. Introduce staff. Explain all treatment and procedures.
2. Meet client's basic needs (toileting, relief from hunger) 3. Use stress reduction techniques such as massage and imagery. 4. Place client in a room that is easily accessible to caregivers.w |
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Name the 6 elements in the chain of infection
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1. Infectious agent (pathogenic organism capable of causing disease)
2. Reservoir (site or source of microorganism growth) 3. Portal of Exit (means organism leaves site) 4. Mode of Transmission (means of spread) 5. Portal of entry 6. Susceptible host (client) **Review Elkin 63 for medical aseptic practices to reduce microorganism spread for each element.** |
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Why do we pad side rails and headboard of a patient with a seizure disorder?
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Modifications to environment minimize risks associated with seizure activity. Padding reduces risk for traumatic injury. (Don 't use pillows to pad side rails because of suffocation risk)
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What is PPE?
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Personal Protective Equipment
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Give examples of PPE
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mask
cap eyewear gown gloves |
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Is recording and reporting required for applying PPE?
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Nope, just use them appropriately and discard properly as necessary
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Symptoms of Type 1 allergic reaction to latex gloves
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hives. generalized edema, itching
rash, wheezing, brachiospasm, difficulty breathing laryngeal edema, diarrhea, nausea hypotension, tachycardia respiratory arrest, cardiac arrest **Reactions vary based on type of latex protein and degree of individual sensitivity.** |
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Nosocomial or Health-care associated infection
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infection acquired in the health care setting (usually defined by an infection acquired at least 72 hours after hospitalization)
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Isolation procedures- Airborne precautions
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Private room, negative-pressure airflow of at least 6 to 12 exchanges per hours, mask or respiratory protection device
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Isolation procedures- Droplet precautions
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Private room or cohort clients, mask
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Isolation procedures- Contact precautions
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Private room or cohort clients, gloves, gowns
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Isolation procedures- Protective Equipment
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Private room, positive airflow with 12 or more air exchanges per hour, gloves, gowns
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What is logrolling?
How and why is it done? |
Logrolling is the rolling of a patient in one smooth, continuous motion.
Usually requires a minimum of 3 people to assist. Prevents injury to client and caregivers Maintains neck and spinal alignment |
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What is a gait belt?
Why is it used? |
A gait belt (transfer belt) is a device that wraps around the torso to assist movement.
It is safe technique for transferring and ambulating patients. Gait belt allows nurse to maintain stability of client during ambulation and reduces risk of falling. |
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Preventing lift injuries
(4 Principles & Rationales) |
1. When planning to move a client arrange for adequate help. Use lift team if avail. (trained on techniques to prevent injury)
2. Encourage client to assist as much as possible. (Promotes client's abilities and strength while minimizing caregiver workload) 3. Use arms & legs, not back. (Leg muscles are stronger, larger muscles, Proper Body Mechanics) 4. Position self close to client or object being lifted (reduces horizontal reach and stress on back) |
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5 complications that immobilized, chronically ill, and older patients are at risk for
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Loss of Bone Mass
Urinary Stasis Pressure Ulcers Joint Contractures Constipation |
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Active ROM exercises
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Patient able to perform exercises independently
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Passive ROM exercises
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Performed by nurse or Physical Therapist
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Active Assisted ROM exercises
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ROM exercises achieved by caregiver and client together
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Why is a cane positioned on a patient's stronger side?
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The cane offers most support when on stronger side of body. Cane and weaker leg work together with each step.
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Describe how you would teach a patient to use a walker
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too much for flashcard... look in the book!
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Semi-Fowler's
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head position raised 60 degrees
Facilitates visiting/diversional activities, Improves breathing by decreasing pressure on the diaphragm as gravity pulls abdominal contents downward |
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High Fowler
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head of bed raised 90 degrees
recommended for eating |
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Lateral (side laying)
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30 degrees lateral
Removes pressure from bony prominences of back |
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Sims (semi prone)
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alternative to lateral position
client lies somewhat forward onto abdomen |
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Supine (dorsal recumbent)
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lying horizontally on back
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Prone
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being in horizontal position when lying face downward
improves oxygenation in client's with severe pulmonary problems Prevents foot drop, maintains proper body allignement |
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Trendelenburg
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head is low and body and legs are on an inclined plane
used in pelvic surgery to displace organs upward or to increase blood flow in hypotension and shock |
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Reverse Trendelenburg
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Lower extremities are placed lower than the body and head, which are elevated on an inclined bed
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Lithotomy
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position in operating room in which the patient is supine with legs raised and abducted to expose perineal region. The legs are placed in stirrups to maintain position
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abduct
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to draw away (as a limb) from the midline of the body
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adduct
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to bring toward the midline of body
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center of gravity
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midpoint or center of the weight of a body or object (In standing adult human, center of gravity is midpelvic cavity between symphysis pubis and umbilicus)
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Continuous passive motion (CPM)
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a technique for maintaining or increasing the amount of movement in a joint, using a mechanical device that applies force to produce joint motion without normal muscle function
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Contracture
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a permanent shortening (as of a muscle, tendon, or scar tissue)
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Dangle
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sit or lie at edge of bed so feet can hang down, improves blood flow to legs
Prevents fainting, dizziness |
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Distal
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situated away from point of origin or attachment
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Extension
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"straightening" movement allowed by certain joints of the skeleton that increases angle between two adjoining bones, such as extending the leg
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External rotation
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turning outwardly or away from the midline of the body
ex- when leg is externally rotated with toes turned outward, away from midline |
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Flexion
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movement by certain joints that decreases angle between two adjoining bones such as bending the elbow
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Foot Drop
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abnormal neuromuscular condition of lower leg and foot characterized by an inability to dorsiflex, or evert the foot, caused by damage to common peroneal nerve
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Internal rotation
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turning of a limb about its axis of rotation toward midline of body
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Pivot
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pivot joint- (trochoid joint) synovial joint where movement is limited to rotation
Pivot transfer- movement of a person from one site to another such as bed to wheelchair (one side immobile) |
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Pronation
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rotation of hand or forearm so surface of palm is facing downward or toward back
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Proximal
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Close to midline of body
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Rotation
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gyration of a bone around its central axis
one of four basic movements allowed by various joints of the skeleton |
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Supination.
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rotation allowed by certain skeletal joints such as elbow and wrist joints, which permit palm of hand to turn up
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List 5 nursing diagnoses related to safety skills
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1. Risk for fall due to alteration in mental status
2. Risk for injury due to application of restraint 3. Risk for impaired skin integrity due to inability to reposition 4. Risk for infection related to nosocomial infections 5. Risk for infection related to alteration in skin integrity |