300 exam 1

The Chain of Infection

• Infectious Agent: Bacteria, viruses, fungi, or protozoa.

• Reservoir: Where pathogens survive (e.g., food, water, oxygen, or human hands).

• Portal of Exit: How the pathogen leaves (e.g., skin, respiratory tract, urinary tract, blood).

• Mode of Transmission: Often the hands of healthcare workers. Routes include contact, droplet, or airborne.

• Portal of Entry: Same routes as exiting.

• Susceptible Host: Patients with invasive procedures (IVs, surgery) or who are immunocompromised (transplant patients, newborns, or premature infants).

Identification & Testing

• Specimens: Collected from sputum, blood, drainage, or urine (Urinalysis).

• Sensitivity Testing: Once the culture is grown, clinicians find which antimicrobials the organism is sensitive to for precise medication selection.

Airborne

• Measles, Varicella, Herpes Zoster (Shingles)

• private room; negative-pressure airflow.

• N95 Respirator.

Droplet

• Influenza (Flu), Pertussis, RSV

• Private room or cohort patients

• Mask or respirator.

Contact

• MRSA, VRE, C. diff, Scabies

• Private room or cohort patients.

• Gloves and Gown.

Contact (+)

• C. diff

• Must use soap and water for hand hygiene (Standard knowledge; sources specify "contact +").

• Gloves and Gown.

Infectious Disease

• AIDS, COVID-19, STIs, Pneumonia

• Standard/Transmission precautions as indicated by symptoms.

• Standard/Transmission precautions as indicated by symptoms.

Standard Precautions

used with every patient

• hand hygiene

• no artifical nails

• gloves when touching body fuilds or contaminayed items/surfaces

• ppe as needed for procedures

WHO’s Five Moments

1) Before touching a patient,

2) Before clean/aseptic procedures,

3) After body fluid exposure risk,

4) After touching a patient

5) After touching patient surroundings.

Isolation Considerations

• Psychological Impact: Isolation can cause loneliness, depression, and anxiety. Nurses must provide emotional support.

• Documentation: Infection status and required PPE must be documented and posted outside the room.

• Patient Transport: If an isolation patient must leave their room, the patient must wear appropriate PPE (e.g., a mask for droplet).

Absorption:

The passage of medication molecules into the blood.

• NURSING SCHOOL MUST KNOW: IV is the fastest route, followed by IM/SQ; skin and oral (PO) routes are the slowest.

• Patient Example: Factors like low blood pressure or Congestive Heart Failure (CHF) can impair circulation and slow down absorption.

Distribution

How the drug reaches tissues and organs

• Protein Binding: Low albumin levels in a patient can lead to medication toxicity because there is less protein for the drug to bind to.

• membrane permeability

Metabolism

Primarily occurs in the liver

• NURSING SCHOOL MUST KNOW: Patients with liver failure have impaired metabolism, leading to a high risk of toxicity; they often require lower doses

Excretion

Medications exit the body through the kidneys, liver, bowel, lungs, and exocrine glands.

• Need to Know: Impaired kidney function significantly increases the risk for medication toxicity.

Therapeutic Effect

The expected or predicted physiological response.

Adverse Effects:

Unintended and undesirable responses.

Toxic Effect vs side effect

Toxic Effect - Accumulation of medication in the blood

Side Effect - Predictable and unavoidable (e.g., vomiting).

Idiosyncratic Reaction

An unpredictable overreaction or underreaction.

Example: Giving Adderall to help a patient focus, but it causes the opposite effect, such as agitation

Timing of Responses: peak, trough, therapeutic range

• Peak: Highest level of the drug in the blood.

• Trough: Lowest level of the drug in the blood.

• Therapeutic Range: The goal is to keep the plasma drug concentration between the minimum effective concentration (MEC) and the toxic concentration.

The Seven Rights:

1. Medication, 2. Dose, 3. Patient (use two verifiers like name and DOB), 4. Route, 5. Time, 6. Documentation, 7. Indication.

Types of Orders: stat, now, prn

• STAT: Give immediately (usually a 30-minute window).

• Now: Needed quickly (up to a 90-minute window).

• PRN: Given "as needed" based on patient symptoms.

Topical/Skin Applications:

• NURSING SCHOOL MUST KNOW: Always wear clean gloves when removing or applying transdermal patches to prevent medication from absorbing into your own skin.

• Patient Safety: Always ask if the patient has an existing patch and remove the old patch before applying a new one to prevent a potential overdose.

• Documentation: Note the location of the patch on the Medication Administration Record (MAR) and document the removal of the old one.

Nasal Instillation:

• Need to Know: Caution patients about the rebound effect—excessive use of decongestant sprays can actually worsen congestion.

• Patient Example: In children, serious systemic effects can occur if excess decongestant solution is swallowed.

Ophthalmic (Eye) Instillation:

• Safety: Avoid touching the cornea and do not touch the eye or eyelid with the dropper to prevent infection.

• Patient Teaching: If using an intraocular disk (which resembles a contact lens), teach the patient how to insert and remove it and monitor for adverse effects.

Otic (Ear) Instillation:

• NURSING SCHOOL MUST KNOW: Instill eardrops at room temperature; cold drops can cause vertigo (dizziness) or nausea.

• Safety: Use sterile solutions in case the eardrum is ruptured, and never occlude the ear canal with the dropper.

Vaginal and Rectal Instillation:

• Vaginal: Inserted with a gloved hand (suppositories) or an applicator (foams/jellies/creams).

• Rectal: Rectal suppositories are bullet-shaped to prevent anal trauma.

• Patient Example: Use lubrication and place the patient in the left side-lying position for rectal administration.

Inhalation

pMDIs (Pressurized metered-dose inhalers): Require hand-breath coordination.

Need to Know: These are often used with a spacer to help deliver more medication to the lungs, especially for patients with poor coordination.

Equipment Basics - Syringes:

Luer-Lok syringes have threading that allows a needle to be "locked" on, while Non-Luer-Lok syringes use a plain tip.

Preparing Injections - Ampules

NURSING SCHOOL MUST KNOW: You must use a filter needle when withdrawing medication from an ampule to prevent glass shards from being drawn into the syringe.

Preparing Injections - Vials

You must inject air into the vial equal to the amount of medication you intend to withdraw to create the necessary pressure.

mixing insulin

• NURSING SCHOOL MUST KNOW: Never mix long-acting insulins (Glargine/Lantus or Detemir/Levemir) with any other types of insulin.

• "Clear before Cloudy": When mixing rapid/short-acting (clear) with intermediate (NPH/cloudy), draw the clear insulin into the syringe first.

Intradermal (ID):

Used for skin testing (TB, allergies). Use a 5 to 15-degree angle with the bevel up; a small bleb (bump) should form under the skin.

Subcutaneous (SQ)

Placed into loose connective tissue under the dermis (e.g., insulin). Inject at a 45 to 90-degree angle depending on the patient's weight and the amount of subcutaneous tissue.

Intramuscular (IM):

Faster absorption than SQ. Always inject at a 90-degree angle.

• Amounts:

  • adults: 2 to 5mL

  • children, other adults, and thin patients: up to 2mL

  • small children and older infants: up to 1mL

  • smaller infants: up to 0.5mL

IM Sites:

• Ventrogluteal: The safest and preferred site for all adults, children, and infants.

• Vastus Lateralis: Frequently used for infants and toddlers.

• Deltoid: Used for small volumes (less than 2 mL). It is not well-developed in many adults and is close to major nerves.

Factors Influencing Hygiene Practices

• Social & Cultural: Social practices (frequency of bathing), personal preferences (shower vs. bath), and cultural variables.

• Socioeconomic Status: Availability of products and facilities.

• Body Image: A patient’s subjective view of their own appearance.

• Physical Condition:

  • Arthritis: Affects dexterity, making grooming difficult.

  • Stroke: Can leave patients with significant physical impairments.

  • COPD: Patients may experience Shortness of Breath (SOB) during hygiene activities.

  • Casts: Cannot get wet, requiring specialized care.

Developmental Considerations

• Skin: As patients age, the skin starts to thin and becomes easy to break, leading to an increased risk of infection.

• Mouth: Considerations for teeth and the presence of dentures.

Nursing School "Must-Knows" & Safety Guidelines

1. identifiers before beginning care.

2. Clean to Dirty: Always move from the cleanest areas to the less clean areas to prevent cross-contamination.

3. Infection Control: Use clean gloves when in contact with non-intact skin, mucous membranes, blood, or any bodily secretions/excretions.

4. Temperature Safety: Always test the temperature of the water or cleaning solutions before they touch the patient.

5. Body Mechanics: Use proper body mechanics and safe patient-handling techniques to prevent injury to yourself and the patient.

6. Delegation: Provide clear and proper direction when delegating hygiene tasks to Nursing Assistive Personnel (NAP).

Patient Room Environment

• Bed Making: Do not bring extra linens into the room; keep the environment clean and organized to decrease the risk of falls.

• Comfort: Maintain a comfortable room temperature and minimize noise to promote rest.

• Health Promotion: Adapt your instructions based on the patient’s knowledge and motivation. Teach them how to avoid injury and reinforce infection control practices they can use at home.

Enteral Nutrition (EN) – Feeding via Tube

Must-Know: Used when a patient has a functional GI tract but cannot swallow (e.g., head/neck cancer, anorexia).

• Tube Types: Nasogastric (NG), Gastric, or Jejunal.

• Safety & Nursing Care:

  • Aspiration Risk: Keep the Head of Bed (HOB) at 30° minimum, preferably 45°.

  • Verification: Check gastric residuals to see how much formula is being absorbed.

  • Equipment: Use aseptic technique, label all equipment (patient name, formula, rate, time), and always use an infusion pump for continuous feedings.

  • ENFit: Ensure appropriate ENFit connectors are used to prevent tubing misconnections.

Parenteral Nutrition (PN) – Intravenous Feeding

Must-Know: Provided intravenously for patients unable to digest or absorb enteral nutrition (e.g., severe IBD, fistulas, or when GI rest is required).

• Access: Can be delivered via peripheral or central lines.

• Complications: Nurses must monitor for occlusion and infection.

• Nursing Requirements:

  • Placement must be confirmed by X-ray before use.

  • Always use a sterile technique and an infusion pump.

Nursing School "Must-Know" Safety Summary

• Standardized Practice: Follow the "right patient, right formula, right tube, right ENFit adapter".

• Tubing Safety: Trace all lines back to the patient to ensure enteral-to-enteral connections only.

• No Dyes: Do not add food coloring or dye to enteral feedings.

• Advancing Diets: Patients in acute care should experience a gradual progression of dietary intake (e.g., clear liquid to full liquid to solid) to manage illness recovery

Nutritional Needs Across the Lifespan

• Infants/Children: Focus on breastfeeding, formula, and the gradual introduction of solid foods.

• Pregnancy/Lactation:

  • Folic acid intake is critical for development.

  • Lactating women require an additional 500 kcal/day above their usual intake.

• Older Adults:

  • Metabolic rate slows with age.

  • Diminished sensations: Thirst, taste, and smell often decrease, which can lead to poor intake.

  • Barriers: Fixed income, limited transportation, and general health changes.

• Vegetarian Diets: Nurses must monitor for potential deficiencies in protein and Vitamin B12.

pressure injuries

• damage to the skin due to unrelieved pressure

• found on the bony proviences (butt, heel, elbows, etc)

• could be found on those with spinsl cord injuries, diabetes, stroke pt (all due to lack of mobilitiy)

risk factors pressure injuries

• impaired sensation or mobility

• alteration in LOC

  • dec awareness and communication skill

• shear - opposing force (ex: pts gravity is pulling down, bed is pulling up)

• friction - rubbing force

• moisture

ischemia

dec blood supply to an area

hyperemia (or erythema)

redness

blanchable

color lightens when pressure applied

non blanchable

stays red (hyperemia) despite pressure application

• Non-blanchable erythema is a stage 1 pressure ulcer

PU Classification

stage 1 - non balchable erthmea of intact skin

stage 2 - partial thickness skin loss w exposed dermis

• no visble fat (only pink or red)

stage 3 - full thickness skin loss

• exposed fat (yellow)

• could see sloth (greenish, yellow discharge or black dead eschar)

stage 4 - pressure injury: full thickness skin and tissue loss

• to muscle, bone, ligament, tendon

DTPI (deep tissure pressure injury)

• granulation tissue - new tissue (pink/red)

• slough

• eschar

• excudate drainage

wound classifications

• partial thickness wounds (epidermis, superficial layers)

• full thickness wounds (epidermis and dermis)

• primary intention - clean, approx/closed edges, edges of wound line up nicely, lower risk of infection (surgical wound, sutured, etc)

• secondary intention - edges not approx or line up nicely (ex: road rash, pressure ulcer, wound that got infected)

complications of wound healing

hemorrhage - bleeding

infection - pain, fever, heat to area, yellow pus (purulent), inc redness, odor

dehiscence - opening/seperation of wound layers (intervention: cover it with wet gauze)

evisceration - opens w something coming out

drainage terms (serous, purulent, sanguineous, serosanguinous)

serous - clear, watery, thin fluid

purulent - yellow, thick

sanguineous - blood

serosanguinous - watery, pink or red

prevention injury considerations

• prediction and prevention (reposition q2h)

• economic consequences (we don’t get paid and it costs money to treat them)

• factors influencing pressure injury formation and wound healing

  • nutrition

  • tissue perfusion (DM (high bp slow wound healing, PVD (dec circulation)

  • infection

  • age (dec function macrophages)

  • psychosocial impact of wounds

differences between ventilation, perfusion, diffusion

ventilation - movement of gasses into and out od lungs (inhale/exhale)

perfusion - cv system pumps oxygenated bloos to tissues and returns deoxygenated blood to lungs

diffusion - process of exchange of repiratoy gasses in avleoli

alterations in respiratory functining

hypoventilation - RR less than 12

hyperventilation - RR greater than 20

hypoxia - low O2, under 95% room air

modes of O2 delivery (NEED KNOW: CANNULA VS MASK, FLOW RATES)

nasal cannula (1-6L/min, if greater than 4 then humidify

• can still eat/talk

• hook up to sterile water or saline if greater than 4

• 6L/min MAX for nasal cannula

high flow nasal cannula - provides heated and humidified O2 via NC

oxygen mask (6-12L/min, want greater than 6 to avoid rebreathing exhaled CO2 in the mask)

• partial rebreather and nonrebreather have reservior bags (10-15L/min)

• venturi high flow (4-12L/min, usually for COPD)

Physiology of pain

• transduction - stimuli

• transmission - movement, communication

• perception - awareness: brain intercepts/processes

• modulation - inhibition of pain impluse

pain scales: numerical rating scale

• pt rates pain from 0-10

• best used for adults/older children who understand numbers

pain scales: verbal descriptive scale

• pt chooses words to describe pain such as no pain, mild, moderate, severe, very severe, worst possible pain

• best for pt who have diffficulty using numbers but can describe pain

pain scales: visual analog scale

• pt marks their pain on a straight line, usually from “no pain” to “worst pain”. The nurse measures where they marked

• pt who can understand visual/spartial concepts

wong baker faces pain rating

• pt choose a face that matches their pain lvl, ranging from happy to crying

• best for children, patients w language barriers, or pt who respond better to pictures

acute care: pharacological pain therapies

• patient controlled analgesia

• topical and transdermal analgesics

• local anesthesia via injection

• lock anesthetic infusion

• epidural

analgesics

• nonopiods

• opiods

• adjuvants

WHO 3 step ladder

step 1 - mild pain - non opiod

step 2 - moderate pain - weak opiod

step 3 - severe pain - strong opiod

benner’s stages of nursing proficiency

• novice - student, new grad

• advanced beginner

• competent - 2 to 3 years in setting

• proficient - greater than 2 to 3 years

• expert - diverse experience

professional responsibilities and roles

• autonomy and accountability

• care giver - maintain and regain health

• advocate - advocate for pt safety

• educator

• communciator

• Manager - established environment

florance nightingale

• established first nursing philosophy based on health maintenance and restoration

• organized the first school of nursing

• First practising epidemiologist

• reduced mortality rates

clara barton

• red cross

• cared for soilders in the civil war