NURS-B260 SPRING 2025
Exam 1 “Test Blueprint”
Content: Quality, Safety, Hygiene, Mobility, Infection Control/Isolation, Surgical Asepsis
Safety
Students should be able to define/understand things like sentinel events, near misses, etc. from day 1
lecture
- Sentinel event: something that was done to a patient that caused significant damage; or even
death
- adverse event: something was done that caused harm to a patient
- Patient safety event: an even occurs that could have caused harm, but didn’t. It was NOT
caused before the event occured
- Near miss event: an event ALMOST occured, but was caught right before the action was taken
-
-
Root cause analysis and event reporting
What is the problem? And collect data about it
look at possible causes and factors
look for solutions
FALL AND FALL ASSESSMENT
assessment of a patient’s risk factors for falling is essential in determining specific needs and
developing targeted interventions to prevent falls
MORSE FALL SCALE:
- history of falling
- secondary diagnosis
- ambulatory aid
- IV/Heparin Lock
- Gait/Transferring
- mental status
Review ATI and the posted slides. Please know about fire safety. (ie: RACE & PASS)
- RACE
- rescue
- alarm
- contain
- extinguish
- PASS
- Pull
- aim
- squeeze
- sweep
What does “safety” mean within the context of providing nursing care to patients? Think about things
like:
●
Medication errors
o
o
o
Check in patient
Proper reporting
5 rights of med administration
▪
Person
▪
Med
▪
Time
▪
Route
▪
●
Surgical errors
o Wrong site
o leaving object in site
o wrong technique
o anesthesia errors
o
●
Falls
o
o
o
o
o
●
most common adverse event
30% result in an injury
10% in serious injury
ensuring fall assessment is done and patients are wearing yellow socks, etc…
PREVENTING FALLS
▪
Fall risk assessment
▪
know how to use the call button
▪
fall risk alerts - socks, wristbands
▪
regular toileting
▪
hourly rounding
▪
bed in low position, lock brakes
▪
floor clear, dry, and no clutter
▪
gait belt
Pressure ulcers
o turn often
o stages
o pressure ulcer risk places
▪
●
head, shoulder, elbow, butt, heels, ears, shoulder, hips, sacrum
Hospital acquired infections
o Surgical site infection
o CAUTI - catheter assisted UTI
o CLABSI - central line ass blood stream infection
o burn or electrical shock
o blood transfusion incompatibility
o injury related falls
●
o
ineffective or unsafe insulin use
DVT
o
o
o
o
compression and blood thinners
typically in arms, legs, pelvis
can cause pulmonary embolism
sequential compression device
▪
●
inflates and deflates in calves to prevent DVT
Pneumonia/atelectasis
o Atelectasis
▪
collapsed alveoli
▪
caused from not moving, and not deep breaths, encourage movement!
▪
TURN, COUGH, DEEP BREATHE every 2 hours
▪
incentive spirometer
If any of these above things happened, what should be done next
- document
- treat them properly
- report to physician
What factors could put a patient at risk for injury, harm, errors, etc.?
- understaffed nurses
- older age
- younger age
- mobility problems
- cognitive and sensory awareness
- emotional state
- abliity to communicate
- lifestyle
- safety awareness
What are interventions should the nurse perform to ensure client safety?
- culture of safety
- Thourough assessment
- Monitor regularly
- Proper precautions
- HH
- Patient education
- Infection control
- Interprofessional collaboration
Restraints:
●
Why would restraints be necessary
o prescribed
o physical protection of the staff and client
o
o
pulling out IVs etc
patient safety: preventing falls, wandering, self-harm, etc
●
What are alternatives to restraints
o seclusion
o Adjusting environment to make it safer
o bed alarm for fall risks and wanderers
o someone watching them at all times
o personal assistance devices
o skin sleeves for IV removers
o rounding OFTEN
o frequent toileting
●
What safety considerations must be made for a patient who is requiring restraints/what are
potential complications of restraints
o Explain needs for restraints
o assess skin integrity and skin care
o food and fluid offered regularly
o provide hygiene and elimination
o monitor vitals
o ROM exercises
o Pad bony parts
o tie restraints to non movable part of bed
o two fingers
o remove frequently and ensure good ROM and circulation
o ongoing evaluation
Mobility
What does mobility look like, how would you know if your patient had optimal mobility vs. impaired
mobility?
- mobility is freedom and independence in purposeful movement
- our goal is to assist in preserving, maintaining, and restoring as much mobility as possible
-
You would know if they are immobile because they would have an inability to move one or more
body parts
ASSESSMENT TOOLS
- 1 - max assist
- use 2 or more assistive personnel
- 4 - no assist
- 0-1 assistive personnel
What are the risks/undesired effects of impaired mobility? Think of it from physical, mental, and
emotional standpoints.
- physical changes
- resp
- cardio
- musculoskeletal
- integumentary
- urinary and bowel
- metabolic
- psychosocial
- mental
- Can cause decreased independence and increased dependence on others
- loss of privacy
- inability to perform previous activities
- may lead to frustration, anxiety, depression and social isolation
- Emotional
- can be frustrating and sad for people to realize that they cannot do what they used to
be able to do before
What body systems/organs are affected? How? Think about a chain of events/ripple effect, if mobility
affects one body system/organ, are there other body systems that are in turn affected?
- Muscle atrophy and venous pooling
- muscle atrophy - weakness - falls - death
- muscles help pump venous blood back to the heart, this can lead to DVTs, edema, etc
- DVTs
- typically in legs, can be arms, pelvis, thighs
- from being immobile for too long
- can lead to pulmonary embolism in lungs
- can lead to stroke if it moves to the brain
- can lead to MI if it moves to the heart
- help by ambulating regularly and doing ROM activities
- elastic stockings - compression
- sequential compression devices - inflates and deflates on the calves to promote
venous return
- Atelectasis - collapsed alveoli
- can be caused from not moving or taking deep breaths
- encourage any movement in bed
- TURN, COUGH, DEEP BREATHE, every 2 hours minimum
- Use an incentive spirometer to promote deep breathing
- show them how to use
- Fecal impaction
- constipation and diarrhea
- use stool softeners as needed
- Gastroesophageal reflux
- GERD - elevate the bed
- Ensures that stomach acid doesn’t go up the lower esophageal sphincter
- NOT supine, this allows reflux
- Pressure injuries
- move in bed
- change positions
- can be all over the body
- inspect regularly
- can be on ears with O2 cannula
What interventions should the nurse perform for patients with impaired mobility? Think about this
ranging from just muscle weakness/joint stiffness, shortness of breath due to chronic diseases, all the
way to some sort of paralysis.
- see above i guess
- ROM
- ambulate as possible
- sequential compression devices
What are things that could be done to improve mobility and move the patient toward a better state of
mobility when it becomes impaired?
- encourage any movement
- ambulate regularly
- ROM exercises
- muscles need O2 and glucose
- eating and deep breathing
- make games to have movement
- puzzles etc
- pt and ot
How does mobility affect other concepts such as safety, infection control, etc?
- get immobile patients out first if there is an emergency because they cannot get out themselves
- infection control
- Normally they’re less healthy, therefore less ability to fight infection?
Also remember to review things like body mechanics, transfers, assistive walking devices, transfer
devices as well! ATI has a wealth of info in skills modules and Engage Fundamentals.
Infection Control/Isolation/Surgical Asepsis
What are common hospital acquired infections? What interventions should the nurse perform to
prevent each one of them? (don’t think of this as a long, overwhelming list of things to remember
because many of the interventions would apply in a number for all the infections, some do have
specific things to think about.)
-
-
-
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CLABSI
- wear gloves to prevent infection
- clean ports for at least 15 seconds
CAUTI
- bladder is sterile
- limit time having the catheter
- keep free of infection
Surgical site infection
- entry point for pathogens
- clean and covered always
- keep intact
Ventilator assisted pneumonias
- oral hygiene on pts
- special oral care
-
highway for bacteria to trachea and lungs
prevention
- HH
- medical asepsis - elimination of most pathogens
- surgical asepsis - 100% sterile and clean
- use infection control bundles
- cleanse insertion site and use the one with the least risk for infection
What are the principles of surgical asepsis?
●
Where to keep your hands at all times
o above your waist, in sight
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Watch your back
o Dont bump things or turn your back on the field
●
How to open packages
o away from the body, without touching sterile parts
●
What can be touched and still be considered sterile
o you can touch sterile with sterile
●
When is something considered contaminated
o touched with something unsterile
o out of sight
o below the waist
o reached over
o breathed on too hard
o any puncture, moisture, or tear
o if there’s any doubt about the sterility
o limit movement around the sterile field
●
Think about all the aspects of a sterile field
●
Know how to apply gloves, which hand is donned first? Do you pinch the inside of the
glove or scoop up the cuff?
o dominant hand first
o
▪ pinch bottom
second hand
▪
●
scoop the cuff, thumb away
What are ways that people contaminate their sterile gloves? What should you do if you do
one of those things?
o touch outside one inch of sterile dressing
o below waist
o touch unsterile item
o puncture or tear
o out of sight
▪
if you do these you should replace gloves and perform HH
What would the nurse do if there is a breach in sterility when performing a sterile procedure?
- stop and restart sterile procedure?
- notify team, reestablish sterile fields if it doesn’t compromise the patient’s health
What are the types of isolation?
●
What types of isolation would be used for specific illnesses?
o Contact
▪
o
▪ RSV
droplet
▪
o
●
influenza
▪ covid
airborne
▪
TB
▪
rubeola (measles)
▪
varicella
What PPE needs to be worn for each type?
o Contact
▪
o
o
gloves
▪ gown
droplet
▪
●
MRSA, C Diff
mask
▪ private room
airborne
▪
N95
▪
AIIR room
What does the term “standard precautions” mean and when are they applied?
o precautions used for all patients no matter if they are known to have an
infectious agent or not
What is THE most important thing a nurse should do to prevent infection and practice good infection
control?
- HH and hygiene
What can you throw in the regular trash can, and what should be thrown away in the biohazard
container?
- biohazard
- Blood products
- bodily fluids
- sharps in sharps container
What are the links in the chain of infection? How does the nurse prevent infection at each one of the
connecting links?
- presence of an infectious agent
- an available reservoir
- wipe off common surfaces
- a portal exit from the reservoir
- cover coughs
- wash hands to prevent indirect contact
- a mode of transmission from the reservoir to the host
- a portal of entry to enter a susceptible host
What are the stages of infection?
- incubation
- infection enters host and begins to multiple
- no symptoms yet
- prodromal
- client begins symptoms
- acute illness
- manifestations of the specific infectious disease process are obvious and may become
severe
- decline
- manifestations begin to wane as the degree of infectious disease decreases
- convalescence
- client returns to a normal or a new normal state of health
What are the types of infection? Think local vs systemic
- local
- confined to one area of the body
- treated with topical and/or oral antibiotics
- yeast infection
- athlete's foot
- systemic
- start as local infections and then spread to the blood stream and infect the whole body
- SEPSIS
- often happens with a central line infection. CAREFUL
What are factors that put patients at an increased risk of infection? Think about things like:
●
Type of illness
o Transplant
●
Overall health status
o immunocompromised
o chemo patients
o corticosteroids
●
Demographics
o People who dont have access to healthcare
o homeless
o
●
those without access to hygiene
Tubes/treatments/equipment, etc
o Increased risk for infection with central lines and other meds
How does infection relate to other concepts like hygiene, mobility, and safety?
- infection is decreased with better hygiene, mobility and safety
Hygiene
If you completed the pre-work for class and lab in a mindful manner, and didn’t just click through
without reading, you should be in good shape. Be sure you understand things like:
●
Why is hygiene important?
o decreases the spread or transmission of pathogens, thereby decreasing illness
o HH
●
Oral care
o brushing, flossing, mouthwash
o brushed twice a day with fluoride toothpaste and a soft toothbrush
o use battery operated when available
o clean tongue with brush or scraper
o can use penlight and tongue depressor if needed
o assist mouth while doing oral care
o VENT
o
▪ mouth rinses, gels, brushing teeth, suctioning
denture care
●
Perineal care
o use clean gloved
o give client option to do their own perineal care
o front to back
o uncircumcised, clean under the skin
o Urinary catheter cleaning and insertion
●
Complete vs partial bath, total care vs assist from pt.
o partial is face and hand, important things
●
Why is changing linens important
o can become soiled and contaminate and increased the risk for transmitting
pathogens to staff and others
o wear gloves when dealing with soiled linens
o place in correct bin to prevent cross contamination
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How do you provide patient centered care in terms of hygiene
o Preserving pt dignity
o Observing cultural/religious practices
o Pt education
o Obtaining pt permission and consent before doing anything
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Assessments that can/should be done during bath
o
Skin integrity, mobility, ADL assessment
Prioritization/Judgement/Reasoning
●
What are the steps to the nursing process?
o Assessment: objective and subjective data for client, history, etc
o analysis: determine the client problems
o planing: create a plan to address problems
o Implementation: take action to provide care as outlined in planning
o
●
▪ have evidence as to why you’re doing smthn and document it
evaluation: evaluate the effectiveness of the interventions provided and DOCUMENT
▪
if goal is met, yay
▪
if goal is not met, go back and change plan
What is the ABCDE method and how would it be applied in different situations?
o Airway
o breathing
o circulation
o disability
o exposure
▪
this whole ABCDE method establishes priorities for individuals and for groups of
clients
●
What does it mean to make a SMART goal? What are all the elements of a SMART goal?
o A smart goal is a goal for a patient that involves them and their planning, it gives them
autonomy and it is reasonable
o Specific
o measureable
o attainable
o realistic
o timely
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What is SBAR and SOAP notes
○ situation
○ background
○ assessment
○ recommendation
●
●
●
●
●
subjective
objective
assessment
plan
IDEAL discharge planning
○ include the client and caregivers
○ discuss 5 key areas
■ meds
■ home life
●
■ warning signs
■ test results
■ follow up
○ educate the client
■ condition
■ next steps
■ discharge process
○ assess effectiveness of the education
■ repeat back
○ listen to the clients goals and preferences
5 Rights of Delegation
○ task
○ circumstance
○ person
○ directions and communication
○ supervision and evaluation