Fichas
Safe and Therapeutic Environment I and II
Fichas del conjunto (72)
- 1SafetyFreedom from psychological and physical harm.
- 2Patient Nurse RelationshipTrust, sensitivity, assisting in physical, emotional , and spiritual needs.
- 3Patient Nurse Relationship STEPSIntroduce yourself
Identify client by name
Ensure privacy when providing care
Actively listen
Maintain eye contact
Maintain professional boundaries Respect cultural differences - 4A safe environmentIncludes meeting basic needs
Reducing physical hazards
Reducing/eliminating the transmission of pathogens
Controlling pollution - 5Reasons for safety concerns in Older adults?Higher risk for falls
Deteriorating vision, hearing, mobility, reflexes, circulation
polypharmacy - 6poly pharmacyPatients are on a multitude of regular Rx medications.
- 7RACE (fire safety)Rescue, Alarm, Contain, Extinguish
- 8The nurse’s first action after discovering an electrical fire in a patient’s room is to…3. Remove all patient’s in immediate danger
- 9A client is being discharged with oxygen therapy via a cannula. Which of the following instructions should the nurse give to the client and family?3. Use cotton clothing to avoid static electricity
- 10Electrical SafetyMaintain all electrical equipment
Check electrical cords and outlets for exposed, frayed or damaged wires
Avoid overloading circuits
Disconnect a plug before cleaning
If client receives an electrical shock, turn off electricity before touching them - 11Radiation SafetyStrict guidelines
Be familiar and follow agency guidelines
Limit time near source of radiation and use shielding devices - 12Infectious WasteHandle all infectious waste as a hazard
Dispose of waste in designated areas, using proper containers
Dispose of all sharps immediately after use in closed, puncture-resistant disposable containers that are leak-proof and labeled or color coded
NEVER RECAP - 13Contributing factors that increase risk of fallsAge 65 or older
Reduced vision
Use of walking aids
Physical hazards also increase risk
Inadequate lighting
Barriers along normal walking areas
Lack of safety devices in the home - 14The nurse is completing admission histories for the newly admitted clients on the unit. The nurse is alert that the client with the greatest risk of injury…3. Has a history of falls
- 15RestraintsProtective devices used to limit the physical activity of a client or to immobilize a client or extremity
- 16Do you need an order from a HCP to administer a restraint?Yes
- 17What is the amount of slack needed for physical restraints?1-2 Fingers between the restraint and the patient.
- 18How often do you asses the skin integrity when a restraint is in place?Every 30 minutes
- 19How often do you have to remove the device?Every 2 hours
- 20Do you leave all 4 side rails up in a patient's bed to ensure the patients risk for falls is minimal?No. Having all 4 side rails in place is considered a physical restraint.
- 21What are some ways to occupy a patient or prevent them from leaving the bed?Give them wash clothes to fold.
Put the tray table up in front of them - 22Types of restraintsSide rails
Bed (Sleeping bag)
Jacket
Belt
Extremity - 23The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation by the nurse indicates unsafe application of the safety device by the UAP?2. Safely securing the safety device to the side rails
- 24HIPAAThe Health Insurance Portability and Accountability Act (HIPAA) describes how personal health information (PHI) may be used and how the client can obtain access to the information
- 25PHIindividually identifiable information that relates to the client’s past, present or future health treatment; and payment for health services
- 26infectionInvasion of host by pathogen/ microorganism resulting in a disease
- 27Colonizationgrowth of microorganisms without tissue invasion or damage.
- 28Communicable DiseaseDisease transmitted from one person to another
- 29Symptomaticpathogens multiply and cause clinical signs and symptoms
- 30Asymptomaticfree from clinical signs and symptoms. Can you think of a communicable disease that can be asymptomatic?
- 31Chain of InfectionAn infectious agent or pathogen
A reservoir for pathogen growth
A port of exit from the reservoir
A mode of transmission
A port of entry to a host
A susceptible host - 32Infectious agentmicroorganism-including bacteria, viruses, fungi, and protozoa
- 33ReservoirWhere the microorganism survives, multiplies, and awaits transfer to a host.
(humans, food, water, inanimate surfaces) - 34Port of ExitHow the microorganism transmits out of the reservoir-include blood, skin, mucous membranes, respiratory tract, GU tract, GI tract and transplacental
- 35Port of EntryOrganisms enter the body through the same routes they use for exiting
- 36Susceptible hostdepends on the individuals degree of resistance to pathogens
- 37PathogensBacteria
Viruses
Fungus
Protozoa/parasite - 38localizedlimited damage to host tissues
Effective host defense- leukocytes, containment, bacterial killing - 39SystemicEntire body is involved - can be a single organ- or throughout- can be fatal
organ injury- - 40Incubation PeriodInterval Between entrance of pathogen and symptoms
- 41Prodromal StageInterval from initial non-specific symptoms to specific symptoms
- 42Illness stageSymptoms specific to type of infection
- 43ConvalescenceAcute symptoms resolve- start to feel better
- 44Skin defense mechanismsMouth (saliva), eyes (blinking tearing), Respiratory Tract (Cilia, mucous lining), Urinary tract (urine flow, pH), GI tract (acidity), Vagina (pH, Flora)
- 45Immune ResponseInvolves specific reactions in the body to antigens or foreign material
- 46Requirements of healthy immune responseRequires intact skin, mucous membranes and blood cell production.
Lymphatic system and spleen.
Differentiate between self and foreign tissue - 47Natural KiIller cellsRelease Cytotoxic granulocyte
- 48Helathcare associated infection (HAI)Infection Obtained in relation to healthcare administration
- 49LatrogenicHealthcare system caused infection
(Ex. Dirty Catheter) - 50NosocomicalInfection spread from person to person
- 51Exogenousmicroorganisms found outside the individual
- 52EndogenousWhen the patient's flora becomes altered, E.g. after receiving antibiotics.
- 53NeutropenicImmuno-Suppressed- low white blood cell count- especially in older patients
- 54Older adults Immune responseless lymphocytes
poor nutrition
weight loss
low albumin
stress/ depression /confusion
decreased pain/inflammatory response
incontinence - 55Nurses roles in infectionDefense mechanisms
Patient susceptibility
Nutritional status
Stress
Specific disease
Medications
Physical symptoms/appearance
Lab data - 56How often do you wash your hands?Before and after seeing a patient
Or when there is bodily fluid contact - 57AsepsisThe absence of pathogenic microorganisms
- 58Aseptic techniquemeasures to help reduce the risk of infection. 2 types – medical and surgical
- 59Medical asepsisclean technique. HAND WASHING
- 60Surgical asepsissterile technique
- 61How can a sterile object become unsterile?Sterile objects become unsterile when touched by unsterile objects
Sterile items that are out of vision or below the waist level of the nurse are considered unsterile
Sterile objects can become unsterile by prolonged exposure to airborne microorganisms - 62The nurse observes a family member changing the dressing and recognizes that further education is needed after observing which of the following behaviors?1. Placing the sterile field on the over bed table with family members between the table and the wound
- 63A nurse has been assigned to care for four clients that are stable. Using the principle of medical sepsis, which client should be assessed first?3. A client who is severely neutropenic
- 64PPEPersonal protective equipment
- 65Gownif soiling of clothing is likely from blood or bodily fluid
- 66Masks/eye protectionif client activities may generate splashes of blood or other bodily fluids
- 67Dropletprivate room or cohort client, wear surgical mask, use proper hand hygiene, and some dedicated –care equipment
- 68Airborneprivate room, door must remain closed, respirator mask, mask on patient if they leave room
- 69Contactprivate room or cohort client, wear gown and gloves
- 70The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which item when performing this care?2. Particulate respirator, gown and gloves
- 71Contact precautions are initiated for a client with an nosocomial infection caused by methicillin-resistant staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?4. Gloves, gown, goggles and face shield
- 72Post Mortem CareAfter death, the body should be prepared in order to give a clean, peaceful impression for family members
Información
- Descripción
- NCLEX (Exam 1 ) NURSING 110 Fichas sobre Safe and Therapeutic Environment I and II, creado por Gwen Paparone el 20/09/2016.
- Creado por
- Gwen Paparone
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