Download Evidence-Based Primary Health Nursing for Chronic Illness: Exam 1 Study Guide and more Exams Nursing in PDF only on Docsity!
Mount Saint Joseph University
NUR 501 LATEST EXAM 1 2024 - 2025 (WEEK
1 - 4) ACCURATE FALL-SPRING GRADED A
Weeks 1- 4 Infection the invasion of a susceptible host by pathogens or microorganisms; results in disease. Colonization presence and growth of microorganisms within a host without tissue invasion or damage. Communicable disease the infectious process transmitted from one person to another. Virulence is the ability to produce disease. Chain of infection
Mount Saint Joseph University Infectious agent or pathogen, Reservoir or source for pathogen growth, Portal of exit, Mode of transmission, Portal of entry, susceptible host. Modes of transmission Unwashed hands, Indirect contact, Droplet, Airborne, Vehicles, Vector. Infectious Process Four Stages: Incubation period, Prodromal Stage, Illness Stage, Convalescence. Localizes versus systemic infection. What are the four types of isolation precautions? ◦Contact- require a gown and gloves ◦Droplet- require surgical mask within 3 feet from the patient, proper hand hygiene and some dedicated equipment ◦Airborne- special negative air flow and N95 respirator when enter the room ◦Protective environment- requires specialized room with positive airflow
Mount Saint Joseph University Endogenous-When the person’s flora becomes altered and an overgrowth occurs- i.e. when a person gets antibiotics that alter normal floras Risk of Infection: Older Adults Age-related deterioration of the immune system function, Poor nutrition, unintentional weight loss, lack of exercise. Antigen Any substance that provokes an adaptive immune response. Innate Immunity Non-specific defense mechanisms such as skin, cough reflex, mucus, enzymes, and acid in the GI tract that prevent harmful substances from entering the body. Acute Infections Infections that develop and run their course rapidly, examples include colds and ear infections. Chronic Infections
Mount Saint Joseph University Infections that may persist for months or longer, examples include mononucleosis, wound infections, bone infections, and hepatitis. Localized Infections Infections characterized by redness, swelling, warmth, pain, tenderness, numbness or tingling, and loss of function in the affected area. Systemic Infections Infections that infiltrate the bloodstream, leading to symptoms like fever, increased heart rate, increased respiratory rate, lethargy, anorexia, and lymph node tenderness or enlargement. Actual Nursing Analysis: 3 parts (PES) ◦(1) The patient’s identified need or problem ◦(2) The etiology or underlying cause ◦(3) Signs and symptoms Risk Nursing Analysis: 2 parts ◦(1) The patient's identified need or problem
Mount Saint Joseph University Droplet Precautions Used when contagious diseases can be transmitted through large droplets suspended in the air, generated by coughing, sneezing, or talking. Protective Isolation Used for patients with compromised immune systems to protect them from microorganisms in the environment. Isolation Documentation concerns Includes documenting when isolation begins and ends, patient and family education, marking charts, placing signs, and following institutional policies if isolation is broken. What does it mean that a goal needs to be "SMART"? Use SMART acronym ◦Specific ◦Measurable ◦Attainable ◦Realistic ◦Timed
Mount Saint Joseph University What's the difference between an independent and dependent nursing action? An independent action is nurse initiated A dependent action is provider initiated & requires an order from a physician What is direct vs indirect care? Direct care refers to interventions that are carried out by having personal contact with patients. (i.e. ADLs, teaching, reassessments) Indirect care: nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients. (i.e. advocacy, referrals, research, prevention-orientated interventions) What are the "ABCDE's" of prioritization? Airway ◦Compromised airway requires immediate intervention to prevent illness and death Breathing ◦Once airway is established assessment of breathing
Mount Saint Joseph University CHILDREN: Dry mouth and tongue No tear when cry No wet diapers for 3 or more hrs Sunken eyes or cheeks or soft spot High fever Listlessness or irritability What is a fecal occult blood test? How do you obtain one? Measures for microscopic amounts of blood in the feces and can be a sign of a growth in the colon or rectum.
- Collect a stool sample in a clean, dry container
- Use a wooden applicator to smear a small amount of stool onto the test card
- Seal the sample and label it with your name and date
- Repeat for the next two stools, or as directed Give some examples of ostomy care Empty the pouch when 1/3 to ½ full Change pouching system every 3-7 days
Mount Saint Joseph University Assess stoma color- should be pink and red Skin assessed each pouch change Name and explain three coughing techniques cascade cough the patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then the patient opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum. huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. With practice the patient inhales more air and is able to progress to the cascade cough. quad cough technique is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough What are the advantages and disadvantages of using a non rebreather mask? Advantages:
Mount Saint Joseph University Nocturia excessive urination at night Dysuria painful urination Hematuria blood in the urine What are potential causes of urinary retention? An obstruction in the urinary tract or a neurologic disorder. Characteristics: ◦Difficulty starting a stream or emptying the bladder ◦Weak urine flow ◦Chronic or acute pain ◦Chronic = mild but constant discomfort ◦Acute = medical emergency
Mount Saint Joseph University What are potential complication of urinary retention? Urinary tract infections (UTIs) Urine that stays in the bladder can cause a breeding ground for bacteria, which can lead to UTIs that can spread to the kidneys. Urinary incontinence When the bladder doesn't fully drain, it can lead to accidentally leaking urine. Kidney damage If urine backs up towards the kidneys, it can cause inflammation and swelling that can damage the kidneys and lead to kidney disease. Bladder damage When urine stays in the bladder, it can overstretch and damage the bladder muscles. Bladder stones When urine stays in the bladder, it could lead to bladder stones
Mount Saint Joseph University What are possible respiratory complications due to immobility? ◦Lack of movement leads to pneumonia, atelectasis (secretions block bronchus =lung collapse) ◦At some point in development of these complications there is a proportional decline in the patients ability to productively cough What are some common complications of immobility? ◦Foot Drop- foot is permanently in plantar flexion from joint contraction- pt is unable to lift toes off the ground ◦Osteoporosis: immobility can accelerate this disease process (immobility results in bone resorption, the bone tissue becomes less dense and disuse osteoporosis results). ◦Joint contracture: an abnormal and possibly permanent condition characterized by fixation the joint when this occurs the joint can not achieve full ROM ◦Pressure ulcers: a result of decreased blood supply (ischemia) will see inflammation at the site must turn and reposition patient every one to two hours and/or encourage position changes older adults at greater risk What are some interventions to prevent immobility related complications for a pt in the supine position?
- trochanter rolls: helps alleviate pressure points
Mount Saint Joseph University
- Supporting the foot: prevents foot drop
- passive ROM: helps maintain range of motion
- Towels under hands: prevents joint contracture Passive range of motion the process of putting a joint through its full extent of movement by someone other than the patient Active range of motion the process whereby a patient puts a joint through its full extent of movement What factors influence a fall risk assessment? This evaluation could include a resident's fall history; review of medications and alcohol consumption; gait and balance screening; assessment of walking aids, assistive technologies, and protective devices; and environmental assessments. Some interventions include: ◦Keeping a call light within patient's reach ◦Keeping frequently used items close to the patient
Mount Saint Joseph University ◦Prevent infection. ◦Identify patient safety risks. (ligature, infection, fall, etc.) ◦Prevent mistakes in surgery. (time-outs and safety checks; mark surgical site, two identifiers, etc.) What are two types of restraints and what is required for their use? Physical ◦Any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move arms, legs, body, or head. Chemical ◦Medications used to manage a patients behavior and are not standard treatment or dosage for the patients condition. Purpose ◦Physical restraints can be applied only with a physician or health care provider order and only after all reasonable alternatives to restraint use have failed. ◦Physical restraints can be applied for either or both of two reasons: ◦Medical necessity ◦Behavioral or mental health issues ◦Examples of common reasons for the use of physical restraints are as follows: ◦To immobilize an extremity
Mount Saint Joseph University ◦To prevent harmful patient behavior ◦To allow treatments or procedures to proceed without patient interference What is a sequential compression device? Sequential compression devices (SCDs) are used to: ◦Prevent edema to the lower extremities. ◦Prevent deep vein thrombosis (DVT) and venous stasis. ◦Promote blood flow of venous return. ◦Ultimately, prevent pulmonary emboli. How do you assess for DVT? Ultrasonography to find clot or d-dimer test that detects a substance in the blood that appears when a clot breaks up Diaphramatic breathing breathing that promotes the use of the diaphragm rather than the upper chest muscles pursed lip breathing a technique of exhaling against pursed lips to prolong exhalation, preventing bronchiolar collapse and air trapping; done to increase expiratory airway pressure, improve oxygenation of the blood, and help prevent early airway closure.
