Fundamentals Exam 1

Normal Flora

Micro organisms that live on the skin and protects against pathogens

When does normal flora cause potential infection?

When it enters body from an opening

What are the signs of an infection?

Fever above 100.4, White Blood Cell Count above 10,000, redness, swelling, purulent exudate, odor, increased redness at the site

Serous drainage

Clear, no color

Sanguineous Drainage

Contains red blood cells, bloody drainage, dark red.

Serosanguinous Drainage

pink, Serous and sanguineous drainage together

What are the bodies defense systems?

Intact Skin- Acts as a barrier

Mechanical Actions- Coughing, sneezing, cilia movement, and urination flush pathogens out, eyes tearing

Mucous Membranes- Traps pathogens

What does smoking do to the bodies defense systems?

Smoking effects cilia lining making smokers more prone to infection

Why is meticulous management of central lines so important?

They provide a direct pathway into the body, making them high-risk entry points for infection

What do you clean insertion sites with?

CHG (chlorhexidine gluconate)

What is a iatrogenic infection?

Type of healthcare-associated infection that is caused by invasive diagnostic or therapeutic procedures ex. foley catheter insertion

What would you do after being exposed? (Post exposure protocol)

Immediately wash with soap and then report to management

What is a normal WBC?

5,000-10,000

What is a CBC and what is included in it?

Complete blood count. WBC, RBC, Platelet, hemoglobin, hematocrit.

What is a common vehicle for infection in healthcare?

Stethascope

What is a vehicle?

non-living items that carry infectious material

What are standard precautions? What PPE is worn?

These are precautions we take with EVERY patient at ALL times because we don’t know if they have an infectious disease. By implementing these practices, we help prevent transmission of infectious diseases from one to another (ex: patient to nurse, nurse to patient, or patient to patient).

-Hand hygiene

-Wearing appropriate PPE as needed

what is direct transmission?

immediate transfer of germs via close contact, ex. touching and droplets from coughs or sneezing

what is indirect transmission?

personal contact with a contaminated non-living object, e.g., doorknob, light switch.

What are droplet precautions? What PPE must be worn?

Infection control measures for illnesses spread by large respiratory droplets (like flu, pertussis, meningitis) that travel short distances (about 3 feet) from coughing, sneezing, or talking.

wear a surgical mask and eye protection when near the patient, perform frequent hand hygiene, and keep the patient in a private room if possible

When are contact precautions put in place?

When it is known that the patient is infectious

What are Airborne precautions? What PPE is used?

infection control measures used to prevent the spread of pathogens (e.g., tuberculosis, measles, chickenpox) that remain suspended in the air and travel long distances.

placing patients in a negative pressure AIIR room, using fit-tested N95 or higher-level respirators, and performing hand hygiene. Patients have their own designated equipment (stethoscope, BP Cuff)

What actions can be done to minimize HAIs?

Regular bathing, coughing hygiene, good oral hygiene, fluid intake, hand-washing, tissue disposal, nutritional status, moisturizing skin

What do you do when opening a bottle of saline?

-time

-date

-initials

When is sterile field compomised

when liquids enter the field

What is the normal aging process of the skin?

As you age the skin because less elastic and takes longer to heal due to diminished immune response

What is a pressure injury

Localized damage to the skin over boney prominences from pressure from medical devices

How do you blanch a pressure injury

when redness is pressed it becomes white

What does it mean when a hyperemia (bruise) cannot be blanched?

It is a deep tissue injury (DTI)

What is Shear force?

skin remains stationary (due to friction) while underlying bone and deep tissue slide in the opposite direction

What is Shear force caused by?

elevating the head of the bed (causing the body to slide), improper repositioning, and sitting for long periods.

What is a stage 1 pressure injury

intact skin that shows a localized area of non-blanchable redness

What is a stage 2 pressure injury

partial-thickness loss of skin, appearing as a shallow, open ulcer with a pink or red, moist wound bed

What is a stage 3 pressure injury

full-thickness loss of skin that extends through the dermis into the subcutaneous (fatty) tissue, creating a deep crater-like wound

What is a stage 4 pressure injury

most severe, full-thickness wound involving extensive tissue loss, where bone, tendon, muscle, or ligament is directly exposed or palpable

What is an unstageable pressure injury?

full-thickness wound where the base is completely covered by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black). Because the necrotic tissue obscures the wound bed, its true depth and stage cannot be determined.

What is granulation tissue and why is it important?

Granulation tissue is new, vascular connective tissue. It fills deep wounds, replacing necrotic tissue and helps in healing the wound

What is dehisence?

splitting open of a wound. can happen with surgery incisions when coughing or sneezing

What is eviseration?

Total separation of the skin and organs come out

What kind of patient is most at risk for dehiscence?

poor wound healing, poor nutrition, underlying conditions (diabetes, obesity)

How would you treat dehiscence and eviceration?

Keep the patient NPO, over exposed organs with warm, sterile saline-soaked dressings

What is a Hemovac and Jackson Pratt and how do they work

Both are used to drain wounds. They use suction to remove exudate from the wound

If a wound vac stopped draining what would that indicate?

A blockage in the tubing

What do you do before collecting a wound culture

clean the wound with saline, to remove debris and surface slough so they do not come up in the culture

When do you don sterile gloves in changing a dressing?

After removing the dressing and before cleaning the wound

What is a transparent dressing and when is it used

it is clear, breathable and allows you to see the wound. It is often used over IVs

What is a gauze dressing and when is it used?

Used to pack wounds, wicks away exudate, is covered with an abd pad

what is a hydrocolloid dressing and when is it used?

it forms a gel as it absorbs exudate, good for maintaining moisture and is impermeable to contaminants, can also be used for prevention methods

What is a Calcium algenate dressing and when is it used?

Calcium algenate dressing is made from seaweed, used when lots of exudate is present, makes a gel and not to be used on dry wounds.

What nutrients are important for wound healing?

Protein, Vitamin C, Vitamin A, Zinc