Nursing Fundamentals: Infection Control, Wound Care, and Clinical Interventions

Practice flashcards covering core nursing lecture concepts including infection control precautions, wound stages, drainage types, positioning, and clinical assessment parameters.

What is a contracture, and what is the recommended schedule for range of motion (ROM) patient teaching to prevent them?

A contracture is the shortening and tightening of muscles due to disuse; patient teaching for ROM should be performed every $8\,\text{hours}$.

What is dorsiflexion, and what complication does it prevent?

Dorsiflexion is the bending of the foot in an upward direction, which prevents permanent footdrop (an inability to put heels on the ground).

What precautions and personal protective equipment (PPE) are required for droplet precautions versus airborne precautions?

Droplet precautions require a private room and a mask; airborne precautions require a negative pressure ventilation room, an N95 respirator, and keeping the door closed.

Which specific infections require airborne precautions?

Tuberculosis (TB), measles, chickenpox, and Herpes zoster.

How do the hand hygiene and room requirements differ between MRSA and CDIFF under contact precautions?

For MRSA, an alcohol-based rub or soap and water may be used and patients may be cohorted; for CDIFF, hand hygiene must be performed with soap and water, and the patient requires a single room with a dedicated toilet.

What are the six links in the chain of infection?

Infectious agent, reservoir (place where the organism grows), portal of exit, mode of transmission, portal of entry, and susceptible host.

How does a healthcare-associated infection (HAI) differ from a nosocomial infection?

A nosocomial infection is acquired specifically inside a hospital when admitted for something else without prior signs, whereas HAI is a broader term extending to any healthcare setting, including outpatient clinics, nursing homes, dialysis centers, and home healthcare.

What defines a secondary infection?

An infection that develops during or after treatment for an initial infection because the primary illness or its treatment weakens the body's immune system or alters its natural bacterial balance.

What is a systemic infection, and what clinical signs indicate it?

An infection that has spread through the entire body via the bloodstream or lymphatic system; it triggers generalized symptoms such as high fevers, chills, rapid heart rate, or low blood pressure, and can progress into sepsis.

What is the required hand hygiene duration under medical asepsis?

Hand hygiene should be performed for $45\,\text{seconds}$.

What is a trochanter roll, and what is its specific purpose?

A tightly rolled sheet or blanket placed against the lateral side of the thigh to prevent outward motion of the hip and leg.

What is atelectasis, and what nursing interventions prevent it?

Atelectasis is the collapse of air sacs; it is prevented by having the patient cough and deep breathe every $2\,\text{hours}$ and use incentive spirometry.

How do weight-bearing exercises prevent the formation of kidney stones?

Weight-bearing exercises keep calcium in the bones, preventing it from leaving the bones, entering the blood, and filtering through the kidneys to form stones.

What are the characteristics of wound healing by first, second, and third intention?

First intention involves a clean wound with little tissue loss and approximated edges sutured closed; second intention involves greater tissue loss with irregular edges left open; third intention involves leaving the wound open to form granulation tissue before suturing it closed.

How do active drains differ from passive drains, and which category does a Penrose drain fall into?

Hemovac and Jackson-Pratt drains are active drains that use suction, while a T-tube is a passive drain that uses gravity; a Penrose drain is an open drain that is not commonly used because it provides a pathway for pathogens.

How is serosanguineous wound drainage described, and where is it typically seen?

A thin, watery, pink mixture of clear and bloody fluid; it is the most common drainage found in surgical wounds and active surgical drains during the first few days of recovery.

What are the characteristics and clinical significance of purulent versus seropurulent drainage?

Purulent drainage is thick, opaque, foul-smelling fluid (yellow, green, tan, or brown) indicating bacterial infection; seropurulent drainage is thin but cloudy or yellow-tinged fluid serving as an early warning sign of developing infection.

What distinguishes a colonized wound from an infected wound?

A colonized wound contains multiplying microorganisms on the surface that do not cause tissue damage or an immune response, whereas an infected wound involves bacteria invading deep tissue and provoking localized or systemic immune responses.

What emergency actions should a nurse take if wound evisceration occurs?

Stay calm and call for help, place the patient in a low Fowler's position with knees slightly flexed, cover the wound, monitor vitals, notify the physician immediately, and keep the patient NPO.

What four complications are associated with chronic venous insufficiency (CVI)?

Venous stasis ulcers, stasis dermatitis, deep vein thrombosis (DVT), and cellulitis.

What temperature value is considered normal, and at what threshold is a body temperature considered a fever?

Normal body temperature is $98.6$, and a temperature of $100.4$ or higher is generally considered a fever.

What immediate nursing interventions are required for a patient experiencing severe anaphylaxis?

Call for emergency assistance, administer epinephrine, maintain the patient's airway, provide oxygen, monitor breathing, pulse, and blood pressure, prepare for emergency airway support, and do not leave the patient alone.

What is the characteristic rash and standard antibiotic treatment for Lyme disease?

A bull's-eye shaped rash; it is treated with prescribed antibiotics, generally doxycycline.

What are the characteristic rash pattern and prescribed antibiotic for Rocky Mountain spotted fever?

A rash that begins on the wrists and ankles and can spread to the palms and soles; it is treated with prescribed doxycycline.

What is the orthopneic position, and when is it indicated?

The patient sits upright and leans forward over a bedside table or pillows with arms supported; it is indicated to expand the lungs and improve breathing for patients with shortness of breath, COPD, or respiratory distress.

What is the Trendelenburg position, and why is it not routinely recommended for shock?

The patient lies on their back with the entire bed tilted so the head is lower than the feet; it is not routinely recommended for shock because it increases respiratory difficulty and aspiration risk.

What are the angles of bed elevation for Semi-Fowler's, Fowler's, and High Fowler's positions?

Semi-Fowler's is elevated approximately $30^\circ\text{--}45^\circ$, Fowler's is elevated approximately $45^\circ\text{--}60^\circ$, and High Fowler's is elevated approximately $60^\circ\text{--}90^\circ$.

What is the clinical purpose of a footboard?

A firm board placed at the foot of the bed that maintains the feet in proper neutral alignment, supports the feet, and prevents plantar flexion contractures (foot drop).

What blood pressure criteria define orthostatic hypotension?

A drop in systolic blood pressure of at least $20\,\text{mmHg}$ or a drop in diastolic blood pressure of at least $10\,\text{mmHg}$ when moving from lying down to sitting or standing.

What three primary factors contribute to deep vein thrombosis (DVT), and what action is contraindicated?

Venous stasis (slow blood flow), endothelial injury (damage to blood vessels), and hypercoagulability (increased tendency to clot); nurses must never massage a suspected DVT.

What is shearing, and how does it affect bodily tissues?

Shearing occurs when the skin stays in place while underlying tissues and bones move (such as sliding down in bed); it stretches and damages blood vessels, decreases tissue circulation, and causes deep tissue damage or pressure injuries.

How do Stage 1 and Stage 2 pressure injuries differ clinically?

Stage 1 features intact skin with localized, non-blanchable persistent redness; Stage 2 features partial-thickness skin loss with exposed dermis, presenting as a shallow open wound or a serum-filled blister without visible fat.

How do Stage 3 and Stage 4 pressure injuries differ regarding exposed tissues?

Stage 3 involves full-thickness skin loss where adipose (fat) tissue and granulation tissue may be visible without exposed bone, tendon, or muscle; Stage 4 involves full-thickness skin and tissue loss with exposed or directly palpable bone, cartilage, tendon, or muscle.

What defines an unstageable pressure injury?

A wound where eschar (or slough) covers the wound bed, making it impossible to determine the actual depth of tissue destruction.

How are tunneling, undermining, and sinus tracts differentiated in wound care?

Tunneling is a passage extending from the wound into surrounding tissue; undermining is tissue destruction underneath wound edges creating a shelf-like space; a sinus tract is a narrow channel connecting a deeper area or infected cavity to an opening at the skin surface.

What is a contracture, and what is the recommended schedule for range of motion (ROM) patient teaching to prevent them?

A contracture is the shortening and tightening of muscles due to disuse; patient teaching for ROM exercises must be performed every $8\,\text{hours}$ to maintain joint mobility.

What is dorsiflexion, and what complication does it prevent?

Dorsiflexion is the bending of the foot in an upward direction, which prevents permanent footdrop (the inability to put the heels on the ground).

What are standard precautions, and what specific personal protective equipment (PPE) may be utilized?

Standard precautions are a group of safety measures performed to prevent transmission of pathogens found in blood and body fluids (including hand hygiene, cough etiquette, and PPE based on exposure risk); PPE includes gloves, gowns, masks, eye protection, face shields, and puncture-resistant sharps containers.

Which clinical infections require droplet precautions, and what room and PPE measures are mandatory?

Infections spread via large respiratory droplets from coughing, sneezing, or talking, including influenza, meningitis, mumps, and rubella; they require a private room and the use of a standard surgical mask.

Which specific infections require airborne precautions, and what room and PPE specifications are required?

Tuberculosis (TB), measles, chickenpox, and Herpes zoster; these require a negative pressure ventilation room, an N95 respirator, and keeping the door closed at all times.

When are contact precautions indicated, which common pathogens require them, and what barrier protections are necessary?

Indicated for pathogens spread through direct patient contact or indirect contact with objects (e.g., MRSA, C. difficile, RSV); they require a private room, clean gloves, and a protective gown upon room entry.

How do the hand hygiene and room requirements differ between MRSA and CDIFF under contact precautions?

For MRSA, hand hygiene may be performed with an alcohol-based rub or soap and water, and patients may be cohorted; for CDIFF, hand hygiene must be performed strictly with soap and water, and the patient requires a private room with a dedicated toilet.

What are the six links in the chain of infection?

The six links are infectious agent, reservoir (place where the organism grows), portal of exit, mode of transmission, portal of entry, and susceptible host.

How does a healthcare-associated infection (HAI) differ from a nosocomial infection?

A nosocomial infection is acquired specifically inside a hospital when admitted for another condition without prior signs, whereas HAI is a broader term encompassing infections caught across all healthcare settings (outpatient clinics, nursing homes, dialysis centers, and home healthcare).

What are the most common healthcare-associated infections (HAIs), and what key nursing interventions prevent them?

Common HAIs include UTIs, pneumonia, surgical site infections, bloodstream infections related to IV lines, and C. difficile; prevention includes proper hand hygiene, PPE, sterile technique, cleaning and disinfecting medical equipment, avoiding unnecessary urinary catheters/IV lines, and timely device removal.

What defines a secondary infection?

An infection that develops during or after treatment for an initial infection because the primary illness or its treatment weakens the body's immune defenses or disrupts its natural normal bacterial flora.

What is a systemic infection, and what clinical signs indicate it?

An infection that has spread through the entire body via the bloodstream or lymphatic system rather than staying localized; it triggers body-wide symptoms such as high fevers, chills, tachycardia, or hypotension, and can progress into life-threatening sepsis.

How do medical asepsis, surgical asepsis, and sterile technique differ in nursing practice?

Medical asepsis relies on clean practices (hand hygiene for $45\,\text{seconds}$, grouping care, clean environments) to reduce pathogen spread; surgical asepsis maintains an entirely sterile environment (such as in an operating room); sterile technique involves specific procedures ensuring no microorganisms enter the body during invasive tasks like catheter insertion or injections.

What is a thromboembolism, where does it originate, and where can it travel?

A blood clot (thromboembolism) that forms from stagnant blood and breaks free to travel through the bloodstream, where it can lodge in the lungs, brain, or heart.

What is a trochanter roll, and what is its specific purpose?

A tightly rolled sheet or blanket placed against the lateral aspect of the thigh to prevent outward external rotation of the hip and leg.

What is atelectasis, and what nursing interventions prevent it?

Atelectasis is the collapse of pulmonary air sacs (alveoli); it is prevented by instructing the patient to perform coughing and deep breathing exercises every $2\,\text{hours}$ and routinely use an incentive spirometer.

How do weight-bearing exercises prevent the formation of kidney stones?

Weight-bearing exercises keep calcium deposited in the bones, preventing excessive calcium from leaching into the bloodstream and filtering through the kidneys where it can form stones.

What are the three distinct phases of wound healing and their key events?

1. Inflammatory phase: begins immediately upon injury, involving hemostasis and phagocytosis (can be inhibited by NSAIDs); 2. Reconstruction (proliferation) phase: begins healing and tissue rebuilding roughly $21\,\text{days}$ post-injury; 3. Maturation (remodeling) phase: the wound contracts and scar tissue gains tensile strength.

What are the characteristics of wound healing by first, second, and third intention?

First intention involves a clean wound with minimal tissue loss and approximated edges sutured closed; second intention involves greater tissue loss with irregular edges left open to heal by granulation; third intention involves leaving the wound open initially to granulate before delayed surgical closure.

What is the recommended schedule for routine wound assessment, and when should the provider be notified?

Wounds must be inspected and assessed every $8\,\text{hours}$, and the physician or provider must be notified immediately upon identifying any clinical signs of infection.

How does wound dehiscence differ from wound evisceration?

Dehiscence is the partial or complete separation of the outer surgical wound layers, whereas evisceration is the total separation of all wound layers accompanied by the protrusion of internal visceral organs through the open incision.

What emergency actions should a nurse take if wound evisceration occurs?

Stay calm and call for immediate assistance, place the patient in a low Fowler's position with knees slightly flexed, cover the exposed organs with sterile dressings moistened with saline, monitor vital signs, notify the physician immediately, and keep the patient NPO.

What immediate nursing actions are required if an acute wound hemorrhage occurs?

Notify the physician immediately, place the patient in Fowler's position with knees flexed, apply direct firm pressure over the bleeding site, and administer supplemental oxygen.

How do active drains differ from passive drains, and which category does a Penrose drain fall into?

Hemovac and Jackson-Pratt drains are active closed drains utilizing negative suction, whereas a T-tube is a passive drain operating by gravity; a Penrose drain is an open drain that is rarely used because it creates a potential conduit for external pathogens.

How are serous and sanguineous wound drainages characterized and clinically interpreted?

Serous drainage is clean, thin, watery, straw-colored fluid containing plasma and proteins (normal during inflammatory healing); sanguineous drainage is thick, bright red fresh blood indicating active bleeding from deep tissue or damaged blood vessels.

How is serosanguineous wound drainage described, and where is it typically seen?

A thin, watery, pink mixture of clear serous and bloody fluid; it is the most common drainage observed in surgical wounds and active surgical drains during the initial postoperative recovery days.

What are the clinical characteristics of purulent, seropurulent, and bilious wound drainages?

Purulent drainage is thick, opaque, foul-smelling yellow, green, tan, or brown pus signaling infection; seropurulent drainage is thin, cloudy, yellow-tinged fluid representing an early infection warning; bilious drainage is dark green to brownish-yellow fluid with bile, normal from abdominal/GI drains but abnormal in general skin wounds.

What defines necrotic and closed wounds, and what care is required for each?

A necrotic wound contains dead black, brown, yellow, or tan tissue that halts healing and requires debridement and moisture control; a closed wound features intact skin over damaged deeper structures, requiring protective padding, comfort measures, and close monitoring.

What distinguishes a colonized wound from an infected wound?

A colonized wound contains multiplying surface microorganisms without causing tissue damage or an immune response, whereas an infected wound features bacterial invasion into deep tissues that triggers localized inflammation, purulent exudate, or systemic immune responses.

What is chronic venous insufficiency (CVI), and what four major complications are associated with it?

CVI occurs when damaged leg vein valves impair venous return, leading to blood pooling and elevated venous pressure; its four primary complications are venous stasis ulcers (shallow ankle sores with heavy drainage), stasis dermatitis (iron release from broken RBCs causing discoloration), deep vein thrombosis (DVT), and cellulitis.

What temperature value is considered normal, and at what threshold is a body temperature considered a fever?

Normal body temperature is $98.6^\circ\text{F}$, and a core temperature of $100.4^\circ\text{F}$ or higher is clinically defined as a fever.

How should a nurse care for a febrile patient, and what clinical signs represent urgent red flags?

Interventions include monitoring vitals, encouraging oral hydration, lightweight bedding, keeping room temperature comfortable, rest, and antipyretics; red flags requiring prompt escalation include dyspnea, confusion, stiff neck, severe dehydration, hypotension, and fever in immunocompromised hosts.

What are the clinical manifestations and nursing interventions for a mild allergic reaction versus severe anaphylaxis?

Mild reactions produce itching, hives, rash, and watery eyes (managed by stopping exposure, monitoring vitals, and administering antihistamines like diphenhydramine); anaphylaxis involves airway swelling, wheezing, hypotension, and collapse, requiring immediate emergency response, epinephrine administration, airway maintenance, supplemental oxygen, and staying with the patient.

What causes Lyme disease, what are its manifestations, and how is it medically managed?

A tick-borne bacterial infection characterized by an expanding bull's-eye shaped rash, fever, headache, and joint pain; if untreated it can cause chronic arthritis, facial palsy, and carditis; it is treated with prescribed antibiotics (typically doxycycline) and prevented with protective outdoor clothing and prompt tick checks.

What is Rocky Mountain spotted fever (RMSF), what rash pattern distinguishes it, and what are its potential complications?

A severe tick-borne bacterial infection causing high fevers, severe headache, and vomiting; its rash characteristically begins on the wrists and ankles before spreading to the palms and soles; treated promptly with doxycycline to avoid complications like renal failure, encephalitis, shock, or death.

What are the clinical characteristics and uses of the supine, Sims, and dorsal recumbent positions?

Supine: lying flat on the back facing up (monitor heels, sacrum, and occiput for breakdown); Sims: lying on the side (usually left) with the lower arm behind and upper leg flexed (used for rectal exams, enemas, and suppositories); Dorsal recumbent: lying on the back with knees bent and feet flat on the mattress.

What are the clinical purposes and precautions for the orthopneic and Trendelenburg positions?

The orthopneic position involves sitting upright and leaning forward over a bedside table supported by pillows to expand lung capacity during severe dyspnea; the Trendelenburg position tilts the bed with the head lower than the feet, which is contraindicated as routine shock treatment due to increased aspiration risk and respiratory compromise.

What are the angles of bed elevation for Semi-Fowler's, Fowler's, and High Fowler's positions?

Semi-Fowler's is elevated approximately $30^\circ\text{--}45^\circ$, Fowler's is elevated approximately $45^\circ\text{--}60^\circ$, and High Fowler's is elevated approximately $60^\circ\text{--}90^\circ$.

What is the clinical purpose of a footboard, and what must nurses assess when using it?

A rigid board positioned at the foot of the bed that keeps the feet in neutral dorsiflexion alignment to prevent plantar flexion contractures (foot drop); nurses must routinely inspect the heels and ankles to prevent localized pressure injury development.

What defines osteoporosis, what are its primary risk factors, and what nursing care is indicated?

A systemic condition in which bones become porous, weak, and susceptible to fragility fractures (especially hip, wrist, spine); risk factors include older age, postmenopausal women, corticosteroid use, smoking, and lack of exercise; nursing care includes fall precautions, encouraging weight-bearing exercises, calcium and vitamin D supplementation, and safe transfer mechanics.

What causes a urinary tract infection (UTI), what are its characteristic symptoms, and how is it prevented?

Caused by bacterial entry, poor perineal hygiene, urinary retention, dehydration, or indwelling catheterization; symptoms include dysuria, frequency, urgency, cloudy/foul urine, lower abdominal pain, and hematuria; prevention involves wiping front to back, promoting hydration, regular voiding, and avoiding unnecessary or prolonged catheterization.

What factors contribute to skin breakdown in immobile patients, and what core nursing interventions prevent it?

Contributed to by pressure, friction, shear, excess moisture, incontinence, dehydration, and impaired circulation; prevented by regular skin assessments, scheduled repositioning, pressure-redistribution surfaces, barrier creams, optimizing nutritional protein, and using draw sheets instead of dragging.

What blood pressure criteria define orthostatic hypotension, and what nursing actions prevent falls?

A decrease in systolic blood pressure of at least $20\,\text{mmHg}$ or diastolic blood pressure of at least $10\,\text{mmHg}$ upon moving from supine to sitting or standing; nursing care includes slow position changes, having the patient dangle at the bedside before standing, assisting with ambulation, and removing environmental trip hazards.

What three factors constitute Virchow's triad for deep vein thrombosis (DVT), and what nursing intervention is strictly contraindicated?

Venous stasis (sluggish blood flow), endothelial injury (vascular wall damage), and hypercoagulability (increased clotting tendency); nurses must never massage an extremity with suspected or diagnosed DVT due to the risk of dislodging a pulmonary embolus.

What clinical manifestations suggest that a deep vein thrombosis (DVT) has progressed to a pulmonary embolism (PE), and what action is required?

Sudden onset of dyspnea, pleuritic chest pain, tachypnea, tachycardia, hemoptysis (coughing up blood), and acute syncope; this is a medical emergency requiring immediate activation of emergency response protocols.

What is shearing, how does it damage tissue, and how do nurses prevent it?

Shearing occurs when stationary surface skin remains fixed while underlying bone and deep tissues slide down in bed; it stretches and tears microvasculature, decreasing perfusion; prevented by using lift equipment, draw sheets, keeping the head of the bed as low as appropriate, and avoiding dragging.

How do Stage 1 and Stage 2 pressure injuries differ clinically?

Stage 1 features intact skin with localized non-blanchable persistent erythema; Stage 2 features partial-thickness skin loss with exposed dermis presenting as a shallow pink open wound or an intact or ruptured serum-filled blister without visible adipose tissue.

How do Stage 3, Stage 4, and Unstageable pressure injuries differ regarding tissue depth and visibility?

Stage 3 involves full-thickness skin loss where subcutaneous fat and granulation tissue may be visible without exposed bone or muscle; Stage 4 involves full-thickness skin and tissue loss with exposed or directly palpable bone, tendon, cartilage, or muscle; Unstageable injuries have their base fully covered by slough or eschar, obscuring true tissue depth.

How are tunneling, undermining, and sinus tracts differentiated and managed during wound care?

Tunneling is a linear channel extending from the wound bed into deeper tissue; undermining is tissue destruction extending beneath intact skin edges to create a shelf-like margin; a sinus tract is a narrow channel connecting a deep infection focus to the skin surface; nurses must never forcefully probe or tightly pack these tracts.

What are the defining characteristics of contusions, abrasions, lacerations, and penetrating wounds?

A contusion is closed tissue damage (bruise) with intact epidermis; an abrasion is a superficial friction scrape (like a rug burn); a laceration is an accidental jagged cutting or tearing of tissue; a penetrating wound is an open injury where an offending foreign body remains embedded or passes through tissue.

What underlying physiological mechanisms cause pallor, erythema, and jaundice during skin assessment?

Pallor reflects impaired arterial perfusion or severe blood loss; erythema reflects increased capillary blood flow driven by localized inflammation or vasodilation; jaundice reflects elevated serum bilirubin levels, which makes skin tissue fragile and prone to breakdown.