Essentials in Nursing Exam 1

Sensory Order

1) Reception

2) Perception

3) Reaction

Nursing Process

1) Assessment

2) Diagnosis

3) Planning

4) Implementation

5) Evaluation

Maslow

1) Physiologic

2) Safety

3) Love + belonging

4) Self esteem

5) Self actualization

Nursing care plan

1) Problem

2) Goal

3) Interventions - what will we do?

Fall risk assessment

1) Stratify scale

2) Hendrich II fall risk

3) Morse fall scale

Partial Bath

1) Face

2) Hands

3) Axilla

4) Back

5) Perineal

Complete bath

1) Face

2) Hair

3) Arms

4) Torso

5) Legs

6) Back

7) Perineal

8) Hands

Purpose of cleansing pack

Reduce risk of gram - infection

Epidermis

• Prevents invasion of micro organisms

• Shields underlining tissue against H2O loss or injury

Dermis

• Bundles of collagen + elastic fibers

• Supports supports epidermis

• Nerve blood vessels, sweat glands, hair follicles

Subcutaneous

• Layer w bv, lymph nodes, connective tissue

Stages of Infection

1) Incubation

2) Prodromal stage

3) Full stage

4) Convalescent period

Vector Borne examples

1) Lyme disease

2) West Nile Virus

3) Rocky Mountain Spotted fever

4) Dengue fever

5) Malaria

Droplet precautions

1) Private room or cohort

2) Hand hygiene

3) Gown + gloves

4) Eyewear

Doffing PPE

1) Gloves

2) Goggles

3) Gown

4) Mask

Airborne Precaution

1) Private room w negative airflow + HEPA filter

2) Hand hygiene

3) N95 Respirator

Contact precautions

1) Private room or cohort patients

2) Hand hygiene

3) Gown

4) Gloves

Droplet examples

1) Influenza

2) RSV

3) Pertussusis

4) Bacterial meningitis

Airborne exmaples

1) TB

2) Measles

Contact exmaples

1) C Diff

Infectious Agent preventions

1) Hand hygiene

2) Sterilization

3) Antibiotics

Virulence

Ability to produce, degree damage to host

Viability

Ability to colonize

pH, temp, light/dark, moist

Reservoir prevention

1) Transmission based precautions

2) Sterilization

3) Dispose equipment

Portal of entry prevention

1) PPE

2) Hand hygiene

4) Disposal of needles

Portal of exit

1) PPE

2) Hand hygiene

3) Closed dry wound dressing

4) Cover nose/mouth when cough/sneeze

Mode of transmission prevention

1) Hand hygiene

2) Refrigerate food

3) Pesticides to eliminate vectors

Susceptible host intervention

1) Immunizations

2) Screening assessments

3) Patient placement/isolation

4) Clean to dirty