Infection Control
Name the stages in the chain of infection.
Host, transmission, reservoir, entry, infectious agent and portal of exit
Name the steps for a 24-hour urine collection.
Hang a sign on the wall.
Have the client void and discard the first urine.
Record the starting time.
Collect urine in a special container and keep refrigerated.
Remind the client that ALL urine must be collected
Full-thickness skin loss with visible adipose tissue
What is stage III pressure injury?
Prescription:
Potassium 30mEq in 1000 ml of normal saline, to be administered over 10 hours.
Available is 40mEq/20 ml.
The nurse prepares how many ml of potassium chloride to administer the correct dose?
30mEq / 40mEq x 20 ml = 15ml
Incubation
Prodromal
Illness
Convalescent
Client education for preventing constipation.
Increase fluid intake.
Increase fiber in diet.
Encourage mobility.
Limit pain medication
The surgical incision closed with sutures.
What is primary healing?
Solumedrol 2.5 mg/kg is ordered for a child weighing 29kg.
Available: Solumedrol 125mg / 2ml is available. How many ml must the nurse administer?
2.5 mg x 29 = 72.5
72.5mg / 125mg x 2ml = 1.16 ml
What is the difference between local and systemic s/s of infection?
Local - redness, edema, purulent drainage, loss of movement, and pain.
Systemic- Fever, increased WBCs, malaise, elevated ESR, and enlarged lymph nodes.
Name the different types of urinary incontinences.
Incont - transient- sudden 6 months or less ,
stress- r/t an increase in intra abdominal pressure.
Mixed- 2 or more
Overflow- retention
Functional- inability to get there in time
Reflex- no urge (spinal cord)
Total- continuous and unpredictable
13-day-old wound that has scabbed over.
What is the proliferation phase?
Solumedrol 1.5 mg/kg is ordered for a child weighing 68 lb. Solumedrol is available as 75 mg / 1 mL is available. How many mL must the nurse administer?
68lbs / 2.2= 30.9091kg
1.5 mg x 30.9091 kg =46.36 mg
46.36mg / 75mg x 1 ml = 0.618 = 0.62
This process of cleaning removes all microorganisms EXCEPT spores.
Disinfection
Your client has changes in the color of urine. What medications are associated with these changes
1. Red urine output
2. Brown or black urine output
3. orange-red urine output
4. Pale yellow urine output
5. Blue-green urine output
1. Anticoagulants
2. Levodopa
3. Phenazopyridine
4. Diuretics
5. Amitriptyline
What are the risk factors for delayed wound healing?
Diabetes, infection, drugs, nutritional problems, tissue necrosis, hypoxia, extensive tension, another wound, low temperatures
There is an order for 5,000 mg of Ampicillin. Ampicillin is available as 11,000 mg tablets. What should the nurse administer?
5000mg / 11,000 mg =0.45= 0.5 tablets
This process of cleaning removes all microorganisms including spores.
Sterilizing
List principles for enema administration.
Position client in left sims with upper leg flexed
Hang enema bag 12-18 inches
Insert 3-4 inches
Solution room temperature
Slowly infuse over 5-10 minutes
Encourage the client to retain/hold the solution
Actions to take for an eviscerated wound.
Notify the surgeon
Cover with a moist sterile dressing
Position client in low fowlers with knees bent
apply oxygen
NPO
Lay patient with HOB slightly elevated and knees bent, apply moist sterile gauze, prepare for OR
Order Morphine sulfate 8 mg IV
Available: Morphine sulfate 10mg/ml
8mg / 10 mg x 1 ml = 0.8ml
Name principles of maintaining a sterile field.
The last flap is opened toward the nurse.
The 1-inch border is considered unsterile.
Sterile items remain sterile until it touches something not sterile.
Place only sterile objects on the sterile field.
The sterile field must stay in your eye sight at all times.
Describe the appearance of a healthy stoma
Bright red (beefy)
Moist
Non-painful
May bleed when touched/clean.
No open areas
-response from client-
Braden ?? (Sensory, Moisture, Act, mobility, Nutrition and shear)
Pt responds to verbal commands but has difficulty communicating pain. Linen must be changed once a shift. Make frequent slight changes in bed but unable to bear weight out of bed. Eats approximately 50% of meals and requires max assistance to move up in bed.
Sensory 3
Moisture 2
Activity 2
Mobility 3
Nutrition 2
Shear/friction 1
Total 13
Infuse NS 1000ml over 8 hours what should the nurse set the infusion pump?
1000ml/ 8 + 125ml/hr