Immobility Asepsis

An immobile postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? A. Pneumonia B. Hypothermia C. Fluid imbalance D. Pulmonary embolism

A. Pneumonia

The medical/surgical nurse watches a student nurse prepare a sterile field. Which of the following actions, if performed by the student nurse, requires further instruction? A. The student nurses laces he sterile drape, then turns to grab a packaged set of sterile gloves from the table behind her. B. The student nurses' hands, once in the sterile gloves, do not go above her head or below her waist. C. The student nurse drops the sterile gauze into the sterile field from a 6 inch height D. The student nurse performs hand hygiene prior to putting on sterile glove

A. The student nurses laces he sterile drape, then turns to grab a packaged set of sterile gloves from the table behind her.

Nocosomial condition

Any condition occurs in the hospital

4 Categories Responsible for Hospital Acquired Infections

Catheter-associated urinary tract infection (CAUTI) ●Surgical site infection (SSI) ●Central-line associated bloodstream infection (CLABSI) ●Ventilator-associated pneumonia (VAP)

contact precaution

In direct contact with the surface. Eg. C.diff

Metabolic Nursing Diagnosis and Care

Nutrition assessment Nutrition teaching Monitoring lipid and glucose levels

Use of Surgical Asepsis

Operating room, labor and delivery areas Certain diagnostic testing areas Patient bedside

The heart and immobility

Prolonged bed rest increases the heart rate 4 - 15 BPM Increases more with activity Heart works harder and less efficiently

Immobility

Rendering of a part incapable of being moved

4 essential steps when discovering a fire

Rescue Alarm Contain Extinguish (RACE)

Devices that in preventing DVT

TED (Thrombo-Embolic Deterrent) hose and Sequential Compression Device

Decreased Urinary Elimination from Immobility can cause

UTIs predispose them to renal calculi

Proper Term for Nursing Diagnosis of Orthostatic hypotension Blood dyscrasia: Thrombus/DVT

alteration of tissue perfusion

medical asepsis

clean technique

Doffing order of PPE

gloves, goggles, gown, mask

lateral recumbent

side lying position

surgical asepsis

sterile technique

Virchow's Triad

venous stasis, endothelial injury, hypercoagulability state

A primary health care provider writes a prescription of "Restraints PRN (as needed)" for a client who has a history of violent behavior. Which action would the nurse take? 1. Ask the health care provider to specify the type of restraint in the prescription. 2. Notify the provider that PRN prescriptions for restraints are unacceptable. 3. Implement the restraint prescription when the client begins to act out. 4. Ensure that the entire staff is aware of the prescription for the restraints.

2. Notify the provider that PRN prescriptions for restraints are unacceptable.

The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is incorrect to teach? 1. To prevent a confused client from pulling out an intravenous (IV) line 2. To prevent an adult client from getting up at night when there is insufficient staffing on the unit 3. To prevent ventilated patient from dislodging the ventilator 4. To keep an older adult client from falling out of bed after a surgical procedure

2. To prevent an adult client from getting up at night when there is insufficient staffing on the unit

Rules for Restraints

All restraints are required to be represcribed every 24 hours ●Cannot be PRN. ●Restraints should be removed and activity and skin care provided ●Tied to the bed frame

A nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which assessment finding, if present, is of greatest concern? A. The client is able to wiggle the fingers. B. The restraint is secured to the bed's frame. C. The skin of the hand feels cool to the touch and is pale. D. The nurse is able to insert two fingers under the restraints

C. The skin of the hand feels cool to the touch and is pale.

Orthostatic Hypotension

Decreased ability to equalize blood supply when moving from a lying to a standing position

Results of Orthostatic Hypotension

Decreased venous return Decreased cardiac output Decreased blood pressure

airborne precaution

Patients who have infections that spread through the air such as TB, varicella (chicken pox) and rubeola (measles). These patients get private negative pressure rooms, anyone entering the room must use a respirator

How to extinguish a Fire

Pull, Aim, Squeeze, Sweep (PASS)

Muscle Changes due to Immobility

Reduced muscle endurance for activity Muscle atrophy Decreased stability

Respiratory System Changes due to Immobility

Stasis and retention of secretions Generalized muscle weakness Decreased depth and rate of respirations

Donning order of PPE

gown, mask, goggles, gloves

Urinary stasis

stagnation of urinary flow; Urine formed by the kidneys must enter the bladder against gravity due to the shifting of anatomy when recumbent

Trendelenburg position

the body is laid supine, or flat on the back on a 15-30 degree incline with the feet elevated above the head.

Which point requires correction regarding the use of restraints? 1. Less restrictive interventions must have been unsuccessful before applying restraints. 2. All other alternatives must have been tried and exhausted before applying restraints. 3. Restraints may be applied to ensure the physical safety of the resident or other residents. 4. A written order for restraints is not required.

4. A written order for restraints is not required.

The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important?A. If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia.B. If you continue to breathe shallowly or cough ineffectively, this can lead to deep vein thrombosis (DVT) by preventing poor oxygen exchange in the cardiac and peripheral circulatory system.C. If you continue to breathe shallowly or cough ineffectively, this can lead to dizziness, falling, or an inability to ambulate because of shortness of breath.D. If you continue to breathe shallowly or cough ineffectively, this can lead to respiratory obstructive disease

A. If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia

Things to do to Prevent DVT

Ambulate ASAP Active vs. passive ROM Turn and reposition every 2 hrs. Change to a rising position slowly and monitor BP (lying; sitting; standing) Defecation-prevent constipation valsalva maneuver

Bone Changes due to Immobility

Bone resorption ●Hypercalcemia and hypercalciuria ●Bone less dense ●Osteoporosis

joint contracture

Caused by disuse, atrophy, and shortening of muscle fibers Usually due to immobility from things from stroke or motor vehicle accident

Assessment for Immobility

Detect risk of complications of immobility Determine amount of assistance the person will need

Nursing Care for Respiratory Complications

Exercise and activity Turn and reposition every 2 hrs. Deep breathe and cough every 2 hrs. Incentive spirometer Encourage fluids Careful use of narcotics and sedatives Respiratory assessment to note changes early Use of oxygen and mechanical ventilation as needed

droplet precaution

For patients with an infection that is spread by large particle droplets such as rubella, mump, influenza. These patients get private rooms, PPE upon entering the room.

Aseptic Technique

Includes all activities to prevent or break the chain of infection

Fowler's position

Semi sitting position; head of the bed is elevated to 45 to 60 degrees- promotes cardiac and respiratory functioning, providing the max space in thoracic cavity.

Prone position

lies on abdomen, head turned to side. Body is straight (shoulders, head, neck are all in erect position). Helps prevent flexion contractures of hip and knees. Contraindicated in people with spinal problems.

sims position

patient lie on their left side, left hip and lower extremity straight, and right hip and knee bent

restraints

physical or chemical means or device that restricts client's freedom to and ability to move about and cannot be easily removed or eliminated by the client