Clinical Decision Making, Infection Control, and Mobility Review Flashcards

Flashcards covering key foundational nursing concepts including the nursing process, clinical judgment, infection control modes and precautions, medical/surgical asepsis, mobility effects, ambulation devices, range of motion, and fall safety.

Assessment (Nursing Process)

The step involving the collection of subjective and objective information about a client's present health status to identify needs and additional data to collect.

Analysis / Diagnosis (Nursing Process - RN Only)

The step where the nurse interprets or monitors the collected database to reach an appropriate nursing judgment about a client's health status and coping mechanisms.

Planning (Nursing Process)

The step where the nurse establishes priorities, identifies optimal client outcomes, and selects appropriate nursing interventions for inclusion in the plan of care.

Implementation (Nursing Process)

The step where the nurse provides care based on assessment data, analyses, and the established plan of care.

Evaluation (Nursing Process)

The step where the nurse examines a client's response to nursing interventions and forms a clinical judgment about whether goals and outcomes were met.

Data Collection (LPN Scope)

The LPN step involving the collection of subjective and objective client data and reporting changes to the RN.

Clinical Reasoning / Judgment

The visible or observed outcome of critical thinking and decision-making that considers nursing knowledge, client situations, and prioritization of client problems using evidence-based practice.

The Chain of Infection

A sequence of necessary pieces required for an infection to occur: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.

Standard Precautions

Infection prevention measures applying to all clients to protect healthcare workers from blood, body fluids, secretions, and excretions.

Contact Precautions

Isolation precautions used when microorganisms move from an infected person or object to another person; requires PPE including gloves (last on, first off) and gown (first on, last off).

Droplet Precautions

Isolation precautions used when airborne droplets from a client's respiratory tract travel into the mucosa of a host; requires a surgical mask.

Airborne Precautions

Isolation precautions used when small particles move into the airspace of another person; requires an N-95 mask/respirator, negative pressure air-flow exchanging air $6$ times an hour with HEPA filter, an ante room, and a private room.

Protective Precautions

Isolation precautions used for immunocompromised clients (e.g., stem cell transplant, cancer); requires a private room, surgical mask, HEPA filtration without negative air flow, and restriction of fresh flowers, plants, and fresh fruits/veggies.

Latex Sensitivity Manifestations

Reactions ranging from contact dermatitis (sensitivity) to hives, angioedema, pruritus, respiratory symptoms, and anaphylaxis (latex allergy).

Signs and Symptoms of the Inflammatory Response

Heat, erythema (redness), edema (swelling), pain, and loss of function.

Incubation Stage of Infection

The first stage of infection when an infectious agent enters the host and begins to multiply.

Prodromal Stage of Infection

The second stage of infection where the client begins having early, non-specific symptoms.

Acute Illness Stage of Infection

The third stage of infection where manifestations of the specific infectious disease process are obvious and may become severe.

Decline Stage of Infection

The fourth stage of infection where disease manifestations begin to wane as the degree of infection decreases.

Convalescence Stage of Infection

The final stage of infection where the client returns to a normal or a new normal state of health.

Local Infection

An infection confined to one specific area of the body, which can be treated with topical or oral antibiotics.

Systemic Infection

An infection that starts as a local infection and subsequently spreads to the bloodstream to infect the entire body.

Multidrug-Resistant Organisms (MDROs)

Bacteria resistant to one or more classes of existing antimicrobial agents (e.g., MRSA, VRE) that require standard or contact precautions.

Medical Asepsis

Clean technique focused on the reduction of disease-causing microorganisms through disinfection.

Surgical Asepsis

Sterile technique focused on the complete absence of disease-causing microorganisms through sterilization.

Handwashing with Antimicrobial Soap

Hand hygiene method performed using warm water for $15-30$ seconds when hands are visibly soiled or when caring for clients with C-diff.

Lipping a Sterile Solution

Pouring $1-2$ mL of solution off the bottle outside the sterile field prior to pouring onto the sterile field.

Immediate Action for Needlestick Injury

Immediately washing the injury site with soap and water and following facility policy.

Body Mechanics

The combined effort from the musculoskeletal and nervous systems to maintain posture, alignment, and balance during movement and daily activities.

Activity Intolerance

An inadequate amount of physical or physiological energy to undergo or complete a necessary activity.

Activity Tolerance

The capacity to successfully complete a necessary activity without distress.

Contractures

Fixation of a joint caused by changes in muscle and connective tissue, which can begin developing within $4$ days of immobility.

Foot Drop

A joint complication caused by immobility and lack of dorsiflexion, resulting in the toes dropping and dragging.

Cardiac Deconditioning

A cardiovascular effect of immobility occurring within $24$ hours, marked by decreased blood volume, increased blood viscosity, and heart muscle atrophy.

Orthostatic Hypotension Definition

A drop in systolic blood pressure $\\text{SBP} \ge 20\,mm\,Hg$ or diastolic blood pressure $\\text{DBP} \ge 10\,mm\,Hg$ within $3$ minutes of standing.

Gait Belt

An ambulation device placed over clothing at the waistline, snug enough for fingers to fit underneath, used for all transfers to assist with stability.

Cane Placement and Use

Positioned on the unaffected side with top level with the inside of the wrist, elbow bent $15-30^\circ$, moving forward simultaneously with the weaker leg.

Crutch Fitting Rules

Pad rests $1-2$ inches below the axilla with hand grips at hip/wrist level; client must not lean weight directly on the axilla.

Flexion

A range of motion movement that bends a joint and reduces the angle between the bones.

Extension

A range of motion movement that straightens a limb.

Abduction

Moving a body part or limb away from the midline or baseline.

Adduction

Bringing a body part or limb closer toward the midline or baseline.

Dorsiflexion

Drawing the toes and foot upward toward the body.

Plantarflexion

Pointing the toes and foot downward away from the body.

Universal Fall Precautions

Standard safety measures including non-skid footwear, bed in low position, locked wheels on beds/wheelchairs, clutter-free environment, adequate lighting, and call light within reach.

Discharge Planning Timeline

The discharge process that begins on admission and covers level of care, assistive devices, medications, restrictions, and verifying client understanding.