Nursing Trial prep

Chain of Infection

A series of events that allows infections to occur, including infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.

Infectious Agent

The pathogen causing infection, such as bacteria, viruses, fungi, parasites, or prions.

Reservoir

The natural habitat where a pathogen lives and multiplies, which can include humans, animals, or the environment.

Portal of Exit

The path by which a pathogen leaves its host, such as through respiratory secretions, blood, or other bodily fluids.

Mode of Transmission

The method by which a pathogen spreads from one host to another. This can include contact, droplet, airborne, vehicle-borne, or vector-borne transmission.

Portal of Entry

The route through which a pathogen enters a new host, such as via the respiratory tract, gastrointestinal tract, or broken skin.

Susceptible Host

An individual who is at risk of infection due to factors such as age, immune status, and existing health conditions.

Standard Precautions

Infection prevention practices applied to all patients, including hand hygiene and the use of personal protective equipment (PPE).

Hand Hygiene - The 5 Moments

The key times for handwashing:

1. before patient contact

2. before clean procedures

3. after body fluid exposure

4. after patient contact

5. after touching patient surroundings

Personal Protective Equipment (PPE)

Gear worn to prevent exposure to hazards, including gloves, gowns, masks, and eye protection.

Contact Precautions

Infection control measures used when infections are spread by direct or indirect contact.

wear gown and gloves

Droplet Precautions

Measures taken to prevent transmission of pathogens spread by large droplets that are expelled during coughing, sneezing, or talking.

gown, gloves, face visor, mask

Airborne Precautions

Infection control measures used to prevent the spread of diseases that are transmitted through small airborne particles.

gown, gloves, mask, eye visor/goggles

Aseptic Technique

A specific practice aimed at preventing contamination by pathogens during invasive procedures, involving maintaining a sterile field.

Clinical Waste

Waste that poses an infection risk, including items contaminated with blood or body fluids.

Sharps Waste

Items that can puncture skin, including needles, blades, and broken glass, requiring special disposal methods.

Braden Scale

A risk assessment tool for predicting pressure injury risk based on sensory perception, moisture, activity, mobility, nutrition, and friction.

DRSABCD Protocol

A first aid procedure: Danger, Response, Send for help, Airway, Breathing, CPR, Defibrillation.

BGL Monitoring

Blood Glucose Level monitoring, important for managing diabetic patients.

Palliative Care

Specialized medical care focusing on providing relief from symptoms and stress of a serious illness, ensuring quality of life.

Cultural Safety

An environment that is safe for patients of diverse backgrounds, where their cultural identity is respected and valued.

Validation Therapy

Therapeutic approach used with dementia patients focusing on acknowledging their feelings and experiences without correcting their reality.

Education and Training

Essential components for ensuring the health care staff are equipped with the knowledge and skills to provide safe and effective patient care.

WHS Legislation

Laws governing workplace health and safety, ensuring the safety of all worksites and staff.

Empowerment of Older People

Supporting older individuals to make their own choices regarding their care and activities, promoting dignity and independence.

Dementia Care

Specialized care focusing on supporting individuals with dementia to maintain their dignity and independence.

Adult normal temperature range

36.0–37.5 °C Pyrexia (fever): >37.5°C Hypothermia: <36.0°C

Adult normal pulse range

60–100 bpm Tachycardia: >100 bpm Bradycardia: <60 bpm

Adult normal respiratory rate

12–20 breaths per minute Tachypnoea: >20 bpm Bradypnoea: <12 bpm

Adult normal blood pressure range

90/60 – 120/80 mmHg Hypertension: >140/90 mmHg Hypotension: <90/60 mmHg

Adult normal SpO₂ range

95–100% Hypoxaemia: <95% Critical: <90%

Normal BGL (fasting)

4.0–6.0 mmol/L Hypoglycaemia:

Minimum normal urine output (adult)

≥0.5 mL/kg/hour Oliguria: <0.5 mL/kg/hr Anuria: <100 mL/24 hrs

DRSABCD — what does each letter stand for?

D — Danger R — Response S — Send for help A — Airway B — Breathing C — CPR D — Defibrillation

AVPU — conscious state assessment

A — Alert V — Voice (responds to verbal stimuli) P — Pain (responds to painful stimuli) U — Unresponsive

PQRST pain assessment

P — Provokes/Palliates Q — Quality R — Radiates/Region S — Severity T — Timing

TILEO — manual handling risk assessment

T — Task I — Individual (your capability) L — Load (patient) E — Environment O — Other (extra staff, time)

ISBAR clinical handover

I — Identify (self + patient) S — Situation (current concern) B — Background (history) A — Assessment (what you think) R — Recommendation (next steps)

RACE fire response

R — Rescue (remove patients from danger) A — Alarm (activate alarm, call 000) C — Contain (close doors/windows) E — Evacuate

FAST stroke assessment

F — Facial droop (smile — one side droops?) A — Arm drift (arms out — one drifts down?) S — Slurred speech (can they speak clearly?) T — Time (time of onset — call 000)

Braden Scale — 6 subscales

1. Sensory perception

2. Moisture

3. Activity

4. Mobility

5. Nutrition

6. Friction/shear Scored 6–23; lower = higher risk

5 Moments of Hand Hygiene

1. Before touching patient

2. Before clean/aseptic procedure

3. After body fluid exposure risk

4. After touching patient

5. After touching patient surroundings

Chain of Infection — 6 links

1. Infectious agent

2. Reservoir

3. Portal of exit

4. Mode of transmission

5. Portal of entry

6. Susceptible host Break any link = prevent infection

PPE donning order

Gown → Mask → Eye protection → Gloves (Gown first, gloves last)

PPE doffing order

Gloves → Gown → Eye protection → Mask (Gloves first, mask last. Hand hygiene after each step)

Contact precautions — when and what PPE?

When: MRSA, VRE, C. diff, wound infections PPE: Gown + gloves on entry Room: Single room, green signage Equipment: Dedicated or clean between patients

Droplet precautions — when and what PPE?

When: Influenza, meningococcal, COVID-19, pertussis PPE: Surgical mask + eye protection within 1m Room: Single room, blue signage Patient: Surgical mask if leaving room

Airborne precautions — when and what PPE?

When: TB, measles, chickenpox PPE: N95/P2 respirator (fit-tested) + gown + gloves + eye protection Room: Negative pressure room, red signage Door closed at all times

6 steps of hand hygiene (20–30 secs)

1. Palm to palm

2. Right palm over left dorsum (vice versa)

3. Palm to palm fingers interlaced

4. Backs of fingers to opposing palms

5. Rotational rubbing of thumbs

6. Rotational rubbing of fingertips into palms

When to use soap and water vs ABHR

Soap + water: Visibly soiled hands, C. diff, norovirus (spores) ABHR: All other clinical situations (60–80% alcohol)

Sharps disposal rules (3 rules)

1. Dispose immediately after use — do not leave on trolley

2. Do NOT recap, bend, or break needles

3. Do not fill past 3/4 full line

Clinical waste — definition and examples

Definition: Waste that poses infection risk — contaminated with blood/body fluids Examples: Used dressings, gloves, swabs, IV tubing, urine bags, soiled continence aids Disposal: Yellow biohazard bags/bins

4 principles of aseptic technique

1. All items must be sterile (check expiry + integrity)

2. Sterile items only contact sterile items (key parts + key sites)

3. Keep sterile items above waist level

4. If in doubt about sterility — consider it contaminated, discard

Pulse sites — name 5

Radial (wrist), Brachial (inner elbow), Carotid (neck), Apical (chest), Dorsalis pedis (foot)

What is pulse deficit?

Difference between apical pulse and radial pulse Indicates ineffective heart contractions (common in atrial fibrillation)

3 things to assess about pulse (beyond rate)

1. Rhythm (regular vs irregular)

2. Volume/amplitude (bounding, weak/thready)

3. Symmetry (compare both sides)

Postural hypotension — definition

Drop of ≥20 mmHg systolic OR ≥10 mmHg diastolic within 3 minutes of standing Significant falls risk — report to RN

5 pressure injury prevention strategies

1. Reposition 2-hourly (30° lateral tilt)

2. Daily skin inspection (sacrum, heels, elbows, occiput)

3. Moisture management (barrier cream, dry skin)

4. Pressure-relieving devices (alternating pressure mattress, heel boots)

5. Nutrition (protein, fluids, Vit C, zinc)

5 principles of body mechanics

1. Stable base (feet shoulder-width)

2. Bend knees, not back (use leg muscles)

3. Keep load close (centre of gravity)

4. No twisting — pivot with feet

5. Maintain natural spinal curves

Hierarchy of controls (most to least effective)

1. Elimination (use hoist, don't lift manually)

2. Substitution (replace with safer method)

3. Engineering controls (slide sheets, hoists)

4. Administrative controls (training, policies)

5. PPE (last resort)

CPR adult — compression rate, depth, ratio

Rate: 100–120 per minute Depth: 5–6 cm Ratio: 30 compressions: 2 breaths

Choking — severe (adult) — what to do?

5 back blows (between shoulder blades) → 5 abdominal thrusts (Heimlich) → Alternate until obstruction clears or patient collapses If unconscious → start CPR

Burns first aid — what to do?

Cool running water for 20 minutes (within 3 hours of injury) Remove jewellery/clothing (if not stuck) Cover with non-stick dressing or cling wrap Do NOT apply ice, butter, cream

Anaphylaxis — first 3 actions

1. Call 000 immediately

2. Position: sit upright (or lie flat if hypotensive)

3. Administer adrenaline auto-injector (EpiPen) IM outer mid-thigh Can repeat after 5 minutes if no improvement

Stroke — FAST assessment

F — Facial droop (smile) A — Arm drift (arms out) S — Slurred speech T — Time of onset → call 000 Thrombolysis window: 4.5 hours from symptom onset

Needlestick injury — immediate actions

1. Encourage bleeding (do NOT suck)

2. Wash with soap and running water

3. Apply antiseptic, cover with waterproof dressing

4. Report immediately to RN/NUM

5. Attend ED for risk assessment (HIV, Hep B, Hep C)

6. Complete incident report

STRATIFY — 5 items

1. Previous falls (1 pt)

2. Agitated/confused (1 pt)

3. Visual impairment (1 pt)

4. Toileting frequency ≥6/day (1 pt)

5. Transfer/mobility score 3–4 (1 pt) Score ≥2 = high falls risk

post fall protocol

1. do not move the patient

2. call for help - RN or MET

3. assess for injury (head, limbs, hips)

4. if unconscious → DRSABC, call 000

5. if safe, assist to sit up slowly (monitor for postural hypotension)

fowlers position- angle and use

use: breathing, eating, NG feeding
angle: head of bed elevated 45-60 degrees

semi-fowler’s position- angle and use

use: general comfort, post-surgery, pressure relief
angle: Head of bed elevated 30 degrees

30 degrees lateral tilt- why used?

preferred position for pressure injury prevention, relieves pressure on sacrum and trochanters

used for repositioning every 2 hours

Order of washing a patient

face→arms→chest→ abdomen→legs→back→perineal area

Change water after washing top half

dressing a hemiplegic patient- which side first?

Dressing: affected side first then unaffected
Undressing: affected side last unaffected side first

Denture care→key points

• clean over basin of water

• brush with soft toothbrush and denture cleaner

• store in labelled container with water/denture solution

• reinsert or store safely

aspiration precautions during feeding

• sit patient upright (Fowler’s position)

• small amounts

• allow time to chew/swallow

• check mouth empty before next mouthful

• observe for: coughing, choking, wet voice

• report any concerns to RN immediately

4 types of dementia

1. Alzheimer’s → progressive memory loss, most common

2. Vascular→ stepwise decline, reduced blood flow to brain

3. Lewy body→ hallucinations, fluctuating cognition, Parkinson-like

4. Frontotemporal→ personality/behaviour changes, language

Sundowning→ what is it and how to respond?

Increased agitation/confusion in later afternoon/evening

Response: reduce stimulation, calm environment, maintain routine, check unmet needs (pain, hunger, toileting)

Validation therapy→ what is it?

Acknowledge and validate emotions rather than correcting facts = reduces anxiety, builds trust

Person-centred care in dementia→ 3 key principles

1. see the person, not the diagnosis

2. know their life story (occupation, interests, family)

3. maintain routines and familiar surroundings

code red meaning

fire

code blue

medical emergency

code black

personal threat

code yellow

internal emergency

code orange

external disaster

AIN scope→ what can you NOT do?

administer medications, calculate or draw up doses, give injections, diagnose or make clinical decisions, perform tasks you are not trained for.

normal range for temperature

36.0-37.5 degrees celsius

abnormally low temperature

<36 degrees = hypothermia

abnormally high temperature

>37.5 degrees = pyrexia

normal range for pulse

60-100 bpm

abnormally low pulse

<60= bradycardia

abnormally high pulse

>100= tachycardia

normal range respiration

12-20 breaths per minute

abnormally low respiration

<12= bradypnoea

abnormally high respiration

>20= tachypnoea

normal range blood pressure

90/60 - 120/80

abnormally low blood pressure

<90/60= hypotension

abnormally high blood pressure

>140/90 = hypertension

normal range SpO2

95-100%

abnormally low SpO2

<95%= hypoxaemia

normal range BGL

4.0-6.0 mmol/L