NURS 3005 Concepts - Exam 1 Review
ADPIE - ✅✅-Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment - ✅✅-always step one; asses the situation and the patient
Diagnosis - ✅✅-interpret data, analyze, formula
example: pt who might chronic lung disease might have a nursing diagnosis of
impaired gas exchange due to narrowed bronchial passages
Plan - ✅✅-outcome identification; what goal do you want to accomplish?
example: breath more effectively demonstrated by improving O2 saturation
Implementation - ✅✅-nursing interventions
example: apply O2 cannula, have the pt sit up, administer medication, etc.
Evaluation - ✅✅-did the patient reach the goal? if not, start over and go back to
planning
Question: which of the following is the most significant and commonly found
infection-causing agent in healthcare institutions?
a. bacteria
b. fungi
✅✅
c. viruses
d. mold - -a. bacteria
Asepsis - ✅✅-activities to prevent infection or prevent the spread of infection
medical asepsis vs. surgical asepsis - ✅✅-medical asepsis: "cleaning technique"
surgical asepsis: "sterile technique"
chain of infection (infection cycle) - ✅✅-> infectious agent (HIV, E. coli, MRSA,
C.diff, etc)
> reservoir (person, object, animal, food, water,etc.)
,> portal of exit from reservoir (respiratory, GI, blood, open wound, etc.)
> means of transmission (direct or indirect)
> portals of entry (urinary, respiratory, GI tract, etc.)
> susceptible host (elderly, young children, those who are immunocompromised)
infectious agent: ways to break the chain of infection - ✅✅-hand hygiene
sterilization
antibiotics/ antimicrobials
reservoir: ways to break the chain of infection - ✅✅-transmission based
precautions
sterilization
use of disposable supplies
portal of exit from reservoir: ways to break the chain of infection - ✅✅-dry intact
dressings
hand hygiene
wearing gloves if in contact with body fluids
cover nose/mouth when sneezing
means of transmission: ways to break the chain of infection - ✅✅-hand hygiene
use pesticides to eliminate vectors
adequate refrigeration
portals of entry: ways to break the chain of infection - ✅✅-hand hygiene
wearing gloves
use masks and appropriate PPE
proper disposal of needles/sharps
*** getting a catheter increases the chances of getting a UTI***
susceptible host: ways to break the chain of infection - ✅✅-immunizations
screen healthcare workers and other patients
susceptible hosts of infection - ✅✅ -> patients with wounds, cracked/dry oral
tissues
> older/ very young persons
> those not current with their immunizations
> those with invasive devices (catheters, central lines, etc.)
> those with low WBC count (5,000-10,000 is the normal range)
,> those who are immunocompromised (HIV patients and those who received an
organ transplant)
> those who are fatigued, stressed, etc.
> those with pre-existing illnesses (diabetes, peripheral vascular disease)
Question: the patient is a chronic carrier for infection. to prevent the spread of
infection to other patients or healthcare providers, the nurse emphasizes intervention
that do which of the following?
a. eliminate the reservoir
b. block the portal of exit from the reservoir
✅✅
c. block the portal of entry into the host
d. decrease susceptibility of the host - -b. block the portal of exit into the host
rationale: stopping the way in which the carrier spreads infection prevents
transmission
Hospital Associated Infections (HAIs) - ✅✅ -> used to be known as nosocomial
infections
> direct result from delivery of health services
> approximately 2 million infections annually
> preventable!
> occur due to poor infection control, during surgery, use of invasive medical
devices, poor medical asepsis, etc.
Medicare and Medicaid will NOT pay for - ✅✅ -> UTI (CAUTI- catheter associated
urinary tract infection)
> vascular catheter associated infection (VACI)
> surgical site infection
> blood incompatibility
> air embolism
> objects left in the body
> pressure ulcers (stage III and IV)
> mediastinitis after CABG
HITECH - ✅✅ -Health Information Technology for Economic and Clinical Health Act
of 2009: concerned with the use of electronic medical records to improve care
coordination and public health
✅✅
can only discuss protected health information (PHI) if it is
___________________________ - -directly related to treatment
HIPAA: exceptions to the privacy rule include__________________ - ✅✅-vitals
stats
, communicable diseases
adverse rxn to drugs or medical devices
industrial accidents
cases of child/elder/domestic abuse
GSWs
stabbings
poisonings associated with criminal activities
unknown cause of death
HIPPPA: Privacy - ✅✅ -the right of the pt to keep information about him or herself
from being divulged to others, including healthcare workers, insurance companies,
employers, and even family members unless they give permission
HIPPAA: confidentiality - ✅✅ -providers will hold secret all protected health
information relating to pt unless they give consent
The Joint Commission (TJC) - ✅✅ -> accreditation and certification body of
hospitals
> establishes standards to improve performance
> follows sentinel events (e.g. an unexpected occurrence involving death or serious
physical or psychological injury )
> publishes National Patient Safety Goals every year
> prevention is always the goal!
Hospital National Patient Safety Goals - ✅✅-> identify patient correctly
> improve staff communication
> use medicines safely; use alarms safely
> prevent infection
> identify patient safety risks
> prevent mistakes in surgery
Resistant organisms - ✅✅-MRSA
VRSA
VISA
VRE
CRE
C. diff
MRSA - ✅✅-methicillin-resistant staphylococcus aureus
> found in nasal passages, skin, and respiratory tract
> main mode of transmission: hands of healthcare workers
> treatment: vancomycin, linezolid, daptomycin
ADPIE - ✅✅-Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment - ✅✅-always step one; asses the situation and the patient
Diagnosis - ✅✅-interpret data, analyze, formula
example: pt who might chronic lung disease might have a nursing diagnosis of
impaired gas exchange due to narrowed bronchial passages
Plan - ✅✅-outcome identification; what goal do you want to accomplish?
example: breath more effectively demonstrated by improving O2 saturation
Implementation - ✅✅-nursing interventions
example: apply O2 cannula, have the pt sit up, administer medication, etc.
Evaluation - ✅✅-did the patient reach the goal? if not, start over and go back to
planning
Question: which of the following is the most significant and commonly found
infection-causing agent in healthcare institutions?
a. bacteria
b. fungi
✅✅
c. viruses
d. mold - -a. bacteria
Asepsis - ✅✅-activities to prevent infection or prevent the spread of infection
medical asepsis vs. surgical asepsis - ✅✅-medical asepsis: "cleaning technique"
surgical asepsis: "sterile technique"
chain of infection (infection cycle) - ✅✅-> infectious agent (HIV, E. coli, MRSA,
C.diff, etc)
> reservoir (person, object, animal, food, water,etc.)
,> portal of exit from reservoir (respiratory, GI, blood, open wound, etc.)
> means of transmission (direct or indirect)
> portals of entry (urinary, respiratory, GI tract, etc.)
> susceptible host (elderly, young children, those who are immunocompromised)
infectious agent: ways to break the chain of infection - ✅✅-hand hygiene
sterilization
antibiotics/ antimicrobials
reservoir: ways to break the chain of infection - ✅✅-transmission based
precautions
sterilization
use of disposable supplies
portal of exit from reservoir: ways to break the chain of infection - ✅✅-dry intact
dressings
hand hygiene
wearing gloves if in contact with body fluids
cover nose/mouth when sneezing
means of transmission: ways to break the chain of infection - ✅✅-hand hygiene
use pesticides to eliminate vectors
adequate refrigeration
portals of entry: ways to break the chain of infection - ✅✅-hand hygiene
wearing gloves
use masks and appropriate PPE
proper disposal of needles/sharps
*** getting a catheter increases the chances of getting a UTI***
susceptible host: ways to break the chain of infection - ✅✅-immunizations
screen healthcare workers and other patients
susceptible hosts of infection - ✅✅ -> patients with wounds, cracked/dry oral
tissues
> older/ very young persons
> those not current with their immunizations
> those with invasive devices (catheters, central lines, etc.)
> those with low WBC count (5,000-10,000 is the normal range)
,> those who are immunocompromised (HIV patients and those who received an
organ transplant)
> those who are fatigued, stressed, etc.
> those with pre-existing illnesses (diabetes, peripheral vascular disease)
Question: the patient is a chronic carrier for infection. to prevent the spread of
infection to other patients or healthcare providers, the nurse emphasizes intervention
that do which of the following?
a. eliminate the reservoir
b. block the portal of exit from the reservoir
✅✅
c. block the portal of entry into the host
d. decrease susceptibility of the host - -b. block the portal of exit into the host
rationale: stopping the way in which the carrier spreads infection prevents
transmission
Hospital Associated Infections (HAIs) - ✅✅ -> used to be known as nosocomial
infections
> direct result from delivery of health services
> approximately 2 million infections annually
> preventable!
> occur due to poor infection control, during surgery, use of invasive medical
devices, poor medical asepsis, etc.
Medicare and Medicaid will NOT pay for - ✅✅ -> UTI (CAUTI- catheter associated
urinary tract infection)
> vascular catheter associated infection (VACI)
> surgical site infection
> blood incompatibility
> air embolism
> objects left in the body
> pressure ulcers (stage III and IV)
> mediastinitis after CABG
HITECH - ✅✅ -Health Information Technology for Economic and Clinical Health Act
of 2009: concerned with the use of electronic medical records to improve care
coordination and public health
✅✅
can only discuss protected health information (PHI) if it is
___________________________ - -directly related to treatment
HIPAA: exceptions to the privacy rule include__________________ - ✅✅-vitals
stats
, communicable diseases
adverse rxn to drugs or medical devices
industrial accidents
cases of child/elder/domestic abuse
GSWs
stabbings
poisonings associated with criminal activities
unknown cause of death
HIPPPA: Privacy - ✅✅ -the right of the pt to keep information about him or herself
from being divulged to others, including healthcare workers, insurance companies,
employers, and even family members unless they give permission
HIPPAA: confidentiality - ✅✅ -providers will hold secret all protected health
information relating to pt unless they give consent
The Joint Commission (TJC) - ✅✅ -> accreditation and certification body of
hospitals
> establishes standards to improve performance
> follows sentinel events (e.g. an unexpected occurrence involving death or serious
physical or psychological injury )
> publishes National Patient Safety Goals every year
> prevention is always the goal!
Hospital National Patient Safety Goals - ✅✅-> identify patient correctly
> improve staff communication
> use medicines safely; use alarms safely
> prevent infection
> identify patient safety risks
> prevent mistakes in surgery
Resistant organisms - ✅✅-MRSA
VRSA
VISA
VRE
CRE
C. diff
MRSA - ✅✅-methicillin-resistant staphylococcus aureus
> found in nasal passages, skin, and respiratory tract
> main mode of transmission: hands of healthcare workers
> treatment: vancomycin, linezolid, daptomycin
