chapter 13 and 16 nursing

Cardiopulmonary resuscitation

- CPR, which is a set of actions used to restart the heart or breathing of an unresponsive victim without a pulse or respirations

Orthostatic hypotension

- Decrease in blood pressure that occurs when a patient changes from a reclining or flat position to an upright position, such as standing or sitting, it is common after a person has been restricted to bedrest

Base of support

- Feet and lower legs - Give the body stability and balance - The wider one's base of support, the lower the center of gravity

Restraint alternatives

- Less restrictive ways to help patients remember not to get up and try to walk, or to alert nursing staff that the patient is attempting to do so

Dorsiflexion

- Lying in supine position, patient's ankles should be flexed approximately 90 degrees so that the toes point toward the celling

prone position

- Lying on one's stomach with the head turned to the side

Sims' position

- Lying on the back with arms at the side

Center of gravity

- Middle point of the body, below the umbilicus and above the pubis, around which the body's mass is distributed.

Transfer

- Movement of a patient from one place to another in a way that it is safe for both the patient and for health care personnel

Position of function

- Placement of the extremities in an alignment to maintain the potential for their use and movement

Semi-fowler's position

- Position in which head of the bed is elevated 45 degrees

Mass casualty event

- Public health or medical emergency involving thousands of victims

Contracture

- Shortening and tightening of the muscles because of disuse

Orthopneic position

- Sitting upright with the head of the bed elevated 90 degrees or sitting on the side of the bed with ones' feet flat on the floor; in this position, the individual leans slightly forward with arms raised and elbows flexed, supported on an over-bed table

Shearing

- Situation in which the skin layer is pulled across muscle and bone in one direction while the skin slides over another surface, such as a bed sheet, in an opposite direction

what is ambulate

- To walk - Patients who are unsteady on their feet or unable to bear full weight are at particular risk for injury if they attempt to walk without help.

Logroll

- Turning a patient's body as one unit after the patient has had spinal surgery or a spinal injury

Difference between active and passive ROM

Active range of motion- performed by patient without physical nursing assistance Passive range of motion- exercises are done with the nurse performing the exercising of the patients joints, while providing proper support

What are safety measures that must be used when moving a patient? (example: moving a patient from the bed to chair or from the bed to a stretcher)

Always make sure wheels are locked, elevate bed to a comfortable working height

What is a restraint

Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his arms, legs, body or head freely

What is the difference between a bed alarm, chair alarm, personal alarm and leg monitor

Bed alarm and chair alarm- pressure sensitive device that generates an alarm when patient's weight is not sensed Leg monitor- another type of chair alarm, attaches to patients leg

What specific nursing interventions must be implemented when a restraint is in use

Check on patient every 30 min Check the extremity for warmth and color Check skin for redness or chafing under the restraint Remove every 2 hours

What is the difference between a chemical and a physical restraint?

Chemical restraints are medications prescribed to prevent restlessness and anxiety in the patient who may be in an unsafe situation Physical restraints are like vests or jackets, mitts, waist, wrist

What do you do if a patient fall?

Do not move the patient, check patient for obvious injuries, level of consciousness, call for help do not leave patient alone, take full set of vitals, notify health care provider of the patient's, document, and an incident report must be made

Safety data sheet

Form that provides printed information regarding the hazards of materials that contain chemicals

Fall assessment rating scales

Forms that, when filled out, give a numerical rating for each patient's risk for falls. The higher the number, the greater the patient's risk.

What is 1:1

Someone stays in the room with patient at all times

Body mechanics

The movement of muscles of the body for balance and leverage

How often do you check on a patient in a restraint?

30 minutes

How is a restraint properly applied?

You should be able to insert two fingers between the patients body and restraint

Rescue breathing

breathing for a person who is not breathing on his or her own - Breathing for patient in case respiratory arrest when the pulse still is palpable

Supine position

lying on back, facing upward

Footdrop

permanent plantar flexion of the foot

Heimlich maneuver

procedure that removes food or other obstacles from a choking person's airway

Define various terms associated with safety

safety is a concept that includes all measures and practices taken to preserve the life, health, and bodily integrity of individuals.

Lateral position

side lying position

Discuss the roles of nurses in a mass casualty event

· A student nurse's responsibility as a student and as a nurse will be to know and follow his or her facility's disaster plan. A student nurse should expect to be called in to work as an extra if a disaster occurs. · It is appropriate for the student nurse to ensure the safety of family first and then assist at his or her place of work. Some facilities have a plan for calling in extra help according to needs, rather than having a barrage of off-duty employees arriving at once.

Describe six factors that contribute to an unsafe patient environment

· Age and ability to understand · Impaired mobility · Communication · Pain and discomfort · Delayed assistance · Equipment

Discuss assisting patients with ambulation and potential complications

· Be sure patient is wearing nonskid foot wear. Place your feet in front of patients feet and you knees against your patient knees to provide stability when he or she is moving from a sitting position to a standing position. If patient becomes dizzy, place patient back to sitting position. If patient begins to fall when ambulating pull him or her towards your body and allow the patient to slide down your leg to the floor, as you lower the patient, bend your knees, keep your back straight as you lower the patient to the floor.

Describe the effects of immobility on seven body systems

· Blood clots · Pneumonia · Bone demineralization · Kidney stones · Constipation · Pressure injuries · Urinary retention depression

Determine actions to take when patient is unresponsive

· CPR (cardiopulmonary resuscitation) · Heimlich maneuver · Rescue breathing

Identify requirements for use of restraints and release of restraints

· Check on patient every 30 minutes, making sure to check skin for redness or chafing under the restraint and the extremities for warmth and color · Remove the restraint every 2 hours (While the restraint is off) · Offer them fluids · Assists with toileting as needed · Change patient's position if he or she is in bed · Assess the extremities for edema, capillary refill time, sensation, and function · Assess skin over pressure points for integrity and erythema · Assists the patient to ambulate if that is appropriate · Stay with patient the entire time the restraint is off

Identify the purpose of a safety data sheet

· Contains information about potential harm caused by exposer and directions for what to do if the product gets into your eyes, on your skin, or in your mouth.

Plantar flexion

- Downward pointing of the foot

What are restraint alternatives---give examples?

Bed, chair, or leg monitor or even a personal alarm.

Syncope

fainting

Explain areas addressed by the national patient safety goals

· Identifying patients correctly · Improving staff communication · Using medicine safely · Using alarms safely · Preventing infections · Identifying patient safety risks · Preventing mistakes in surgery

Identify commonly used patient positions

· Supine, dorsal recumbent, Trendelenburg, Reverse Trendelenburg, Lateral, Left sims, Right sims, Fowler's, Low fowler's, Semi-Fowler's, high Fowler's, Orthopneic, Prone, Lithotomy

When is a restraint used?

When it is absolutely necessary, to keep the patient safe

Code team

A group of specially trained personnel designated to respond to codes throughout the hospital.

Leg monitor

A type of chair monitor; it attaches to the patient's leg like a large bandage and generates an alarm when the leg is in a dependent position, indicating that the patient is attempting to stand.

what are the differences between and what is included in Level I, Level II, Level III, Fall Precautions

Level 1 is based off if the patient is given a 0-24 on the scale. Bed will be in lowest position, side rails up, have nonskid footwear, call bell in reach and floor free of clutter Level 2 is if the patient was given a 25-50 on the scale. It will have all of level 1's precautions and it will include fall risk armband, fall risk identified on chart, you will need to stay with patient in bathroom, and do not allow patient out of bed without supervision. Level 3 is if the patient was given a 51 or greater on the scale. It includes all of level 1 and 2 and there will be an identification above patient's bed or doorway, and use of restraints alternatives

What special precautions do you take when oxygen is in use?

No open flames in the same room as the oxygen source No smoking, no burning candles, no open flames heaters, no wool blankets or sweaters, no electrical appliances

What is a fall assessment rating scale and how does it work?

Numerical rating for each patient's risk for falls The fall assessment rating scale is filled out when a patient is admitted to the hospital. It's filled out the start of your shift. Works by rating the patient on a scale from a history of falling, if there is a secondary diagnosis, an ambulatory aid, Iv or saline lock, if there is a gait/ transferring, and by mental status.

Understand National Patient Safety Goals and their purpose

Patient Safety. The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them

What are fall prevention strategies

Place patient in room next to nurse's station, place overbed table in front of chair, offer regular opportunities to toilet, provide distractions

What is a position of function?

Placing the extremities in alignment to maintain the potential for their use and movement

Understand proper body mechanics

Plan your work carefully think through how to do it safely Elevate your work to comfortable level Keep feet shoulder width apart Avoid twisting When lifting heavy objects, hold it close to your body with elbows bent When lifting objects from a lower level, have knees bent, squat

Chair or bed monitor

Pressure-sensitive device that generates an alarm when the patient's weight is no longer sensed

Trochanter roll

Rolled towel support placed against the hips and upper leg to prevent external rotation of the legs.

Fowler's position

Semi-sitting position with various degrees of head elevation with the knees slightly elevated

What factors contribute to an unsafe patient environment

Unfamiliar setting Loss of privacy Age and ability to understand Impaired mobility (weakness, blood loss) Communication (language barrier) Pain and discomfort Delayed assistance Equipment (tubing, alarms)

Discuss strategies for preventing falls, including assessment rating scales and restraint alternatives

· Fall production program · Be on alert at all times · Place a patient who is at risk for falls in a room near the nurse's station to make it easier for more people to see and check on him or her · Stay with patients at risks for falls when they are in the bathroom or on the bedside commode · Keep bed at lowest position at all times expect when nursing staff is at the bedside · Place over-bed table across the wheelchair like a tray to help patients remain seated in the chair · Assess your fall risk patients frequently for subjective complaints such as nausea, pain, or other discomfort · Provide back rubs as distractions · Some patients who are at risk for falls seem to have a lot of energy and are looking for ways to stay busy, try having them sit in a rocking chair near the nurses' station, often motion of rocking seems to help them relax as well use pent-up energy

Ø Explain how lack of rest and substance use or abuse can contribute to unsafe patient care

· Fatigue can contribute to conditions that result in injury · If you are exhausted you may not think as clearly as you would if you were well rested · It is important to get enough rest to function safely as a nurse

Identify proper body mechanics for protecting yourself and the patient

· Have good posture, Stand with your feet apart. Create a small hallow in your lower back by tucking the tailbone in and tilting your pelvic bone slightly forward. This is done by tightening the muscles of the buttocks and thus, rotating the pelvis into the neutral position. Be careful not to arch too much. Pull the shoulders back and lift your chest. Lift your chin until it is level and relax your jaw and mouth. · Standing, avoid standing in one position for prolonged periods of time. Change your position as often as you can. This will not only help relieve stress on your spine, it also helps increase circulation and decrease muscle fatigue. When you can, stretch. Gentle stretching exercises during a break can help ease muscle tightness. · Sitting, place your buttocks at the back of the seat while maintaining a small space between the back of your knees and the seat of the chair. Place your feet flat on the floor with your knees bent at a 90° angle. Pull your shoulders back and lift your chest. · Lifting, Place the load immediately in front of you. Bend the knees to a full squat or lunge position. Bring the load towards your chest. Assume a neutral position with your back. Tighten the lumbar and buttocks muscles to "lock" the back. Lift now from the legs to the standing position. · DO NOT: Lift from a twisted / sideways position. Lift from a forward stooped / imbalanced position

Enumerate nursing measures to prevent compactions of immobility in these body systems

· It is important to recognize that complications resulting from bed rest and immobility although numerous are preventable

Discuss safe handling of chemicals and gases

· Know the location of the safety data sheet in your facility and be aware of the hazards of the chemicals with which you work

Describe the psychological effects of immobility and nursing measures to prevent psychological complications

· Musculoskeletal: (decreased muscle strength and muscle mass; shortening and tightening of connective tissue) potential complications: Muscle atrophy, Footdrop, Contractures, Osteoporosis · Cardiovascular system: (decreased cardiac output; pooling of blood in the extremities; increased cardiac workload) potential complications: orthostatic hypotension, blood clots in extremities, blood clots traveling to the lugs, heart and brain. · Respiratory system: (decreased respiratory muscle strength and decreased lung expansion; impaired oxygen and carbon dioxide exchange; pooling of respiratory secretions) Potential complications: Atelectasis, Hypoxemia, Hypostatic pneumonia · Gastrointestinal system: (decreased peristalsis; decreased appetite; increased intestinal gas) Potential complications: Constipation, Flatulence, Distention · Urinary system: (pooling of urine in the renal pelvis; incomplete emptying of the bladder; increased calcium in the blood to be filtered by the kidneys) Potential complications: urinary tract infection, Renal calculi. · Integumentary system: (decreased oxygen and nutrients to tissues; skin and capillaries compressed between the bed and bony prominences) Potential complications: Pressure injuries · Neurological system: (Decreased oxygenated blood circulating to nerves trapped between the bed and bone; decreased in normal cues and activities; decreased balance when initially out of bed) Potential complications: Compression neuropathy, Impaired level of consciousness, confusion · Psychological effects: (decrease in normal social interaction; decrease in independent activity) potential complications: Depression, Anxiety, Impaired sleep Pt 2 Nursing measures to prevent psychological complications: · Minimize sensory deprivation by ensuring that the patient has distractions to keep himself or herself occupied · When you are with the patient try to involve his or her senses with pleasant smells, tastes, sounds · Help improve patient sleep pattern · Encourage and allow patient to do as much as possible for himself or herself during patient care · Allow patient to express concerns · Encourage visits with family and friends

Identify specific safety information

· Never recap a used needle, and always use puncture-proof, labeled containers for disposing of used needs and other sharps

Identify ways to use body mechanics to prevent injury when caring for patient's

· Plan your work carefully, think through how to do it safely · Elevate your work to a comfortable level. Raise bed so that you do not have to bend over to work, which will cause strain to your back · Avoid twisting, turn your whole body or pivot on one foot instead of twisting · When carrying an object hold it close to your body with elbows bent · When possible push, pull, or slide heavy objects rather than lifting them · Get help when you need to move or lift a patient

Discuss the importance of positioning patients correctly and performing frequent position changes

· Positioning of function will help prevent undue pressure on nerves and help prevent discomfort, pain, and nerve damage. It is important to preform frequent position changes because if a person is on bed rest they need their position change to be every 2 hours at least, if a patient is confined to a wheelchair you'll need to reposition them every hour, patients who are at risk for skin breakdown will may need even more frequent position changes

Explain the acronyms PASS

· Pull: the pin found between the handles · Aim: nozzle of the fire extinguisher at the base of the flames · Squeeze: handles together to release the contents of the extinguisher · Sweep: nozzle back and forth at the base of the flames to extinguish the fire

Explain the acronyms RACE

· Rescue: remove patients from immediate danger to a safer area of the hospital · Alarm: Sound the fire alarm according t the facility policy. This may involve dialing an extension or pulling a fire alarm box · Confine: Confine the fire to one room or area. Close the doors according to hospital policy. Fire doors automatically close to help confine the fire to one wing of the hospital · Extinguish: You should only attempt to extinguish a small fire with a fire extinguisher

What are types of specialty beds and their purposes

· Support surfaces (mattress overlays)- applied to the top of the mattress; may be filled with air or gel, or made of foam · Specialized mattress- mattresses containing special foam such as "memory foam" or chambers containing air that can be controlled with a dial · Specialty bed (Air- fluidized bed)- encased mattress filled with small round beads coated in silicone to prevent clumping, air is pumped through the bed, which caused the beads to mimic liquid; patient rests on a thin sheet within the air-fluidized compartment · Surface/ bed (Combination low-air-loss and lateral rotation bed)- combination bed is a low-air-loss type of bed with lateral rotation to prevent pressure on any one area; each pocket is filled with air that can be inflated or deflated; can be utilized with a ventilator-assisted patient. · Continuous lateral-rotation bed- special type of bed frame that allows the entire bed to turn from side to side; mattress is low air loss; bed can be programmed to turn by degrees at set intervals.

Define various terms associated with moving and positioning patient's

· The human body is intended to move in order for a person to remain healthy, and every organ in the body depends on movement for optimal function

Explain the purposes and focus of the handle with care campaign established by the American Nurses Association

· To build an industry-wide program in health care to prevent musculoskeletal injuries · Prevention of musculoskeletal disorders

Summarize the importance of assisting a patient to dangle prior to transfer or ambulation

· To see if the patient will have any adverse reactions like dizziness, and if the patient becomes dizzy while dangling, assist him or her back to the fowler's or semi fowler's position on the bed

Describe devices available to increase safety and ease of transferring patients

· Transfer belts, nylon friction reducing devices, and slide boards, as well as partial- or full- weight bearing devices, including sling-type, battery-operated patient lifts.

Describe the types of fires and extinguishers

· Type: A, B, C, D, or K · Type A: is for paper, wood, fabric and trash · Type B: is for combustible liquids, such as oils, gasoline, and other petroleum-based products and flammable gases · Type C: is used for electrical fires such as short circuits in wires, motors, or equipment fires · Type D: is used for powders, flakes, or shavings of combustible metals · Type K: used for kitchen fires due to combustible cooking fluids such as oils and fats

Enumerate guidelines for performing a manual patient transfer.

· Using a wide base of support and standing close to an object being, keeping your back straight, and avoiding twisting your torso. Use your thigh muscles instead of your muscles in your back. Remember to explain to the patients what you will be doing and instruct him or her about what to do during transfer

Explain ways to protect yourself from biological hazards

· Wash hands before and after all patient contact and wear gloves when any risk of exposer to blood or body fluids is present

Describe ways to protect yourself from radiation hazards

· Wear a lead apron during procedures involving X-Rays and fluoroscopy. Wear a film badge if you work in radiology area on a regular basis