NUR215 exam 1

know the order of donning(put on) and doffing (take off) PPE

*HAND HYGIENE 1. Gown 2. surgical mask (or respirator) 3. Goggles / face shield (only if bodily fluids) 4. Gloves Doffing/ Remove: 1. gloves 2. face shield or goggles 3. gown 4. mask (or respirator) *HAND HYGIENE

discuss and define evidenced base practice

- providing current/up to date/ and effective ways to give patient-centered care -result in the best patient outcomes provides the basis for sound clinical practice guidelines and associated recommendations that improves quality of care -remain competent in your ability to provide clinical care; the will develop trust amount other HCPs -good communication between the HCPs builds trust and is related to the acceptance of your role in the healthcare team -understand the roles of the HCP and what each can contribute to a patient's care

describe what the nurse does for an inflammatory response

-administers antibiotics -monitors the response to drug therapy -hand hygiene & standard precautions -providing adequate nutrition

describe what makes up environmental safety including basic needs (temperate, oxygen and nutrition), physical hazards, transmission of pathogens and pollution

-environmental safety= factors that affect the life and survival of a patient (physical factors and psychological factors) BASIC NEED: OXYGEN: O2 is combustile; carbon monoxide is dangerous NUTRITION: FDA approved; food borne illnesses- compromised immune systems, children, pregnant women, older people TEMPERATURE: between 18.3-23.9 degrees c (65-75 F); frostbite and hypothermia (homeless, older adults, young patients, people with cardiovascular conditions, people on drugs and alcohol); extreme heat: changes electrolyte balance, raising core temperature, leading to heatstroke/heat exhaustion (chronically ill, older adults, infants)

what is the purpose of evaluation of nursing care?

-evaluate the appropriateness of the interventions selected -was the correct application of the intervention

second tier

-for patients who are known/suspected to be infected -4 types: airborne, droplet, contact, protective environment precautions

review the nurse's priority interventions when a patient's condition changes

-involve patients in priority -est priorities in relation to their ongoing clinical importance 1ST LEVEL: ABC Airway problems Breathing problems Cardiac/Circulation problems -signs(vital signs concerns) 2ND LEVEL: -mental status change -acute pain -acute urinary elimination problems -untreated medical problems w/immediate attention (ex: a diabetic who hasn't had insulin) -abnormal lab values -risks of infection - safety/security(for patient and others) 3RD LEVEL: -health problems that don't fit into the above categories (ex: problems with lack of knowledge, activity, rest, family coping)

discuss what might the nurse do when there is a change in patient condition

-the order of priories changes as a patient's condition and needs change -at each start of care reprioritize -prioritize nursing interventions -involve patients in priority setting

know sterile technique an examples of what procedures require sterile technique

1. A sterile object remains sterile only when touched by another sterile object a. Sterile touching sterile = sterile i. Sterile gloves on sterile forceps b. Sterile touching clean =contaminated i. Tip of a syringe touches surface of a clean disposable glove c. Sterile touching contaminated =contaminated i. Sterile object touched with ungloved hand d. Sterile state questionable=discard of it i. Tear found/break in coverage of object 2. Only sterile objects may be paced on a sterile field 3. A sterile object/field out of the range of vision or an object held below a person's waist is contaminated 4. A sterile object/ field becomes contaminated by prolonged exposure to air 5. When a sterile surface comes in contact w/ a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action 6. Fluid flows in the direction of gravity 7. The edges of a sterile field or container are considered to be contaminated

describe standard precautions, airborne precautions, droplet precautions, and contact precautions including the type of infection and PPE items to be worn or placed in the room

1. AIRBORNE PRECAUTIONS: -disease transmitted by smaller droplets (smaller than 5 microns) (remain in air for longer) -Private room: "airborne infection isolation room" (special room w/ neg. air flow) -wear N95 respirator when every time they enter room -ex) measles, chickenpox, TB 2. DROPLET PRECAUTIONS : -diseases transmitted by larger droplets (bigger than 5 microns) in air & w/in 3 feet of patient -wear surgical mask when w/in 3 feet -proper hand hygiene -dedicated - care equipment -ex) meningitis 3. CONTACT PRECAUTIONS: -used for direct or indirect contact w/ patients & their environments -direct= handling contaminated body fluids -Direct= touching patents' poop then touching my inner mouth, or contaminated food -require gown & gloves -direct ex) blood or body fluids from infected patient that enter the HCP's body through direct contact w/ compromised skin or mucous membranes -indirect=involves the transfer of an infectious agent through a contaminated object Indirect= needles, dressings, environment, sharp objects -if hand hygiene is bad, HCP can transmit germs from one patient cite to another --gloves, gown, -ex) MRSA -Vehicles: Contaminated items Water Drugs, solutions Blood Food (improperly handled, stored, or cooked, fresh or thawed meats) -Vector: External mechanical transfer ex) flies Internal transmission such as a parasitic condition between vector & host: Ex) mosquito, louse, flea, tick 4. PROTECTIVE ENVIRONMENT: -positive airflow -patients wear masks when out of the room -stem cell transplant

review the national patient safety goals

1. Identify patient's correctly 2. Improve staff communication 3. Use medicines safely 4. Use alarms safely 5. Prevent infection 6. Prevent mistakes in surgery

open gloving

1. Preform thorough hand hygiene 2. remove outer glove package wrapper by carefully separating & peeling apart sides 3. grasp inner package & lay it on clean, flat surface just above wrist level 4. open package keeping gloves on wrappers inside surface 5. Identify right & left glove. Dominant hand first 6. With thumb & first 2 fingers of non-dominant hand grasp edge of cuff of glove for dominant hand touch only inside surface of glove 7.carefully pull glove over dominant hand, leaving cuff & being sure that it doesn't roll up wrist. Make sure fingers are in proper spaces 8. w/ gloved dominant hand, slip fingers underneath cuff of 2nd glove 9. carefully pull 2nd glove over other hand 10. after 2nd glove is on interlock fingers of gloved hands& hold away from body above waist level until beginning procedure

write nursing interventions and rationale for the following nursing diagnoses: risk for falls risk for injury, deficient knowledge related to safety in acute care

1. RISK FOR FALLS: (is associated with altered mobility) Interventions: a. Range of motion (ROM) exercises i. Strengthening & working out muscles decreases falls b. Evaluating the home environment for risk factors i. This highlights factors that lead to falls that can be changed c. More frequent supervised ambulation i. Helping the patient will prevent the patient from falling & further complications d. Teaching the proper use of safety devices such as side rails, canes or crutches i. Knowledge of how to use equipment reduces falls e. Keep area well lit, orienting the them to the surrounding, keeping glasses clean/handy/protected (if visual impairment is a risk factor) i. Improved vison reduces instances of falls f. Evaluate medications that could be causing falls i. Certain medications increase a patient's risk for falls *Also consult w/ a physician about a referral for physical therapy 2. RISK FOR INJURY: a. Educate the patient about call light & place it near them i. This will help HCPs get to them when they need something b. Educate patient on surrounding i. If they're used to the layout, they will avoid accidents c. Avoid use of restraints i. This can lead to further injuries d. Keep room clutter free of all items i. Decrease the chance of falling e. Remove all hazardous objects from room 3. DEFICIENT KNOWLEDGE RELATE TO SAFETY IN ACUTE CARE: a. Assess barriers to learning i. Understanding the issue will help you teach b. Identify who needs to learn i. Ex) patient or caregiver

know the chain of infection

1. Vascular and cellular response: -rapid vasodilation-allowing more blood near the injury -increased blood = redness & warmth at site of inflammation -edema=chemicals that make vessel more permeable enters interstitial spaces -pain=swelling of inflamed tissues that increase pressure on nerve endings -loss of function -WBCs arrive at site -fever 2. Inflammatory exudate (pus/serum) -accumulation of fluid, dead cells, & WBCs accumulate -puss/serum 3. Tissue repair

know the order of the nursing process (assessment, nursing diagnosis, planning (goals), implementation, and evaluation)

1. assessment 2. nursing diagnosis 3. planning (goals) 4. implementation 5. evaluation

what are the components of evaluation?

1. examination of condition/situation 2. judgment as to whether change has occurred

define the problem-oriented approach to nursing assessment. Be able to determine, who in a given scenario, you would assess first (ASK QUESTIONS ON)

1. nature of pain 2. precipitating factors 3. severity

discus interpreting and validating assessment data

1st validate: -comparing data from another source to ensure accuracy -validate inferences -ask patients to validate unclear info interview/history (fam/friends can also) 2nd interpreting: -determine the presence of abnormal findings -recognize that further observations are needed to clarify information -begin to identify a patient's health problems -begin to see patterns of data that direct you to collect more info & clarify what you have -formation of data clusters-which clarify patient's health problem

know the 3 types of nursing diagnoses (actual, risk for, health promotion)

ACTUAL RISK FOR HEALTH PROMOTION

discuss the factors influencing infection prevention and control including age, nutrition, stress, and diseases

AGE: -infant: immature defense against infection. Breastfed=higher immunity -older adults: more susceptible, lower immune system NUTRITION:: -low intake of protein & carbs = impairs wound healing & fighting infection STRESS: -elevated cortisone levels=decreased resistance to infection -continued stress=exhaustion=depletion in energy stores=no resistance to invading organisms DISEASES: -diseases of immune system=at risk for infection -leukemia -AIDS -lymphoma -aplastic anemia -diabetes mellitus -MS -emphysema -bronchitis -cancer -burns

describe medical and surgical asepsis

Asepsis: absence of disease producing microorganisms. Helps reduce the risk for infection MEDICAL ASEPSIS: (Clean) -break the chain for infection -use for all patients, even when no diagnosed infection -hand hygiene -barrier techniques -routine environmental cleaning SURGICAL ASEPSIS: (sterile technique) -prevents contamination of open wound -serves to isolate an operative area from unsterile environment -eliminate microorganisms from object or area (Object is considered contaminated if touched by any object that is not sterile) -insertion of IVs & catheters -when skin integrity is broken from trauma, surgical incision, burns -applying PPE

review cognitive, interpersonal, and psychomotor interventions and be able to recognize examples of each

COGNITIVE: -critical thinking -decision-making skills -good judgment -sound clinical decision ***this ensures that no nursing action is automatic -Know the rationale for therapeutic interventions -understand normal and abnormal physiological and psychological responses -know the evidence in nursing science to ensure that you deliver current and relevant nursing interventions INTERPERONAL: -develop a trusting relationship -express a level of caring -communicate clearly w/ patients and family (this keeps them informed and engaged in decision making, provides individualized instruction, supports patients who have challenging emotional needs, enables you to be perceptive of their verbal and nonverbal communication) PSYCHOMOTOR: -require the integration of cognitive and motor activities -(examples: giving an injection- understand anatomy and pharmacology(cognitive) and use good coordination and precision to administer the injection correctly (motor)

define collaborative, independent, and dependent nursing interventions. what makes them such?

COLLABORATIVE -the indirect intervention of consolation is a collaborative -carried out with another HCP INDEPENDENT -actions that don't require direction or order from another HCP DEPENDENT -require an order from another HCP

define direct and indirect nursing interventions

DIRECT: -any treatment that is preformed through interaction w/patient -managing a patient's environment (e.g. safety and infection control), documentation, and interdisciplinary collaboration INDIRECT: -preformed away from patient, but on behalf of them -(example: medication administration, insertion of a urinary catheter, discharge instruction or counseling during a time of grief)

define defining characteristic, etiology, and diagnostic labeling. Be able to look at a nursing diagnosis and determine the parts

ETIOLOGY: related to (related factor) DEFINING CHARACTERISTIC: observable assessment cues such as patient behavior, physical signs DIAGNOSTIC LABELING: the NANDA labels

define exogenous, endogenous and iatrogenic infections. know examples of each

EXOGENEOUS INFECTION: -comes from microorganisms found outside the individual -salmonella, clostridium tetani (tetanus), aspergillus -don't exist as normal floras ENDOGENOUS INFECTION: -occurs when part of the patient's flora becomes altered & overgrowth occurs -staphylococci, enterococci, yeast, streptococci -happens when given broad spectrum antibiotics IATROGENIC INFECTION: -caused by invasive diagnostic/therapeutic procedure -bronchoscopy & treatment w/ antibiotics

describe hand hygiene in terms of washing with soap and water and using alcohol-based gel and when each should be used

GEL: *when hands are not visibly soiled or contaminated with blood or bodily fluids 1. inspect surface of your hands for breaks or cuts in skin or cuticles. Cover all lesions w/ dressing before providing care 2. inspect hand for visible soiling 3. inspect condition of nails. Neutral tips, short, no polish 4. push watch & sleeves above wrist 5. antiseptic hand rub (hand sanitizer) WITH ASEPTIC SOAP: *Preform when: -before, after & between direct contact with patients -after contact with fluids -after touching objects from their room -after removing gloves -after contact with spores 1. turn on water, don't splash uniform 2. wet hands & wrists thoroughly under running water. Keeps hands & wrists lower than elbows 3. apply soap & rub hands together. 15 seconds, interlace fingers, under nails, 4. rinse hands & wrists, keep hands under elbows 5. dry hands: from fingers, wrists & forearms 6. turn off water

define goal and outcomes (and know the difference)

GOAL: -broad statement that describes a desired change in a patient's condition, perceptions or behavior (example patient WILL understand post-op risks) -uses the word "will" OUTCOME: -the measurable change that must be achieved to reach the goal (example:patient identifies signs and symptoms of wound infection before discharge) -expresses that the patient "reports" "describes" "remains" etc

review items the nurse would assess for a home safety assessment

HOME HAZARD ASSESSMENT(lighting, furniture placement (can create a barrier), safety in kitchen/bathroom, knowing where cleaning supplies are, knowing where meds are, locks on doors) FOOD INSPECTION FOR INFECTION AND POISONING (assessing their knowledge of food preparation and storage) ENVIRONMENTAL COMFORT INSPECTION (heating, air systems, carbon monoxide detectors, fire extinguisher) OLD HOMES (encourage them to have it inspected for lead(in paint, dust, water and soil))

compare acute care measures of infection control with home measures of infection control.

IN HOME MEASURES: hand hygiene: -before cooking -after bathroom -after touching dirty objects ACUTE CARE MEASURES: -collect specimens of fluids -maintain fluid intake -IV nutrition/ fluids -removal of debris -draining wound sites -changing dressing -use aseptic techniques -repositioning -cleaning oral cavity -bathing

discuss risks ate developmental stages, list an example of each and describe how the nurse will combat each

INFANT, TODDLER AND PRESCHOOLER (highly preventable, EDUCATION OF PARENTS NEEDED, exploring environment, put things in their mouths , oral activity increased, risk of choking, risk of poisoning, risk of fire and falls, drowning, head trauma) SCHOOL AGED CHILD (learning to perform more complicated motor activates, uncoordinated, TEACHERS, PARENTS AND NURSES NEED TO TEACH(what to do if approached by strangers, the safety rules for sports and safety equipment), head injuries are the major cause of death, seatbelts) ADOLESCENT: (greater independence, develop sense of identity/values, smoking, drinking, drugs (increased drowning, car accidents, overdosing) , separate emotionally from family-peers become greatest influence, CHECKING FOR(drug magazines, beer, liquor bottles, blood on clothes, long sleeve shirts/ sunglasses inside, failing grades, change in dress, isolation, increased aggressiveness, changes in interpersonal relationships), STDs, car crashes ADULTS: alcohol usage(greater risk for car accidents), smoking(cardiovascular and pulmonary disease), stress (accidents, illness (headaches, GI, infections) OLDER ADULT: increased risk of falls/accidents from (psychological effects of aging, multiple meds, cognitive factors, acute/chronic disease) wandering, REGULAR EXERCISE REDUCES RISK OF FALLS AND DECREASE THE HAZARD IN HOME

discuss a patient at risk for falling. what interventions will you take as a nurse? what conditions make our adults more at risk?

Interventions: 1. Adjust bed to low position & lock wheels *place nonslip padded floor mats at exit side of bed 2. Encourage the use of properly fitted skin-proof footwear 3. Orient patient to surroundings 4. Call light: place near, & explain using it to patient & family 5. Provide glasses & hearing aids 6. Clear instructions given to patient & family regarding mobility restrictions 8. Make environment safe: -remove excess equipment/supplies/furniture -keep floors clutter & obstacle free *especially to bathroom -coil tubing & cords -ensure glare free lighting -have assistive devices on exit side of bed -arrange personal items near patient & in logical way -secure locks on bed/stretcher/wheelchair Conditions making older adults at risk: · History of falling · Being age 65 or older · Reduced vision · Orthostatic hypotension · Lower extremity weakness · Gait (manner of walking) & balance problems · Urinary incomitance · Improper use of walking aids · Various medications · Physical hazards · Poor lighting · High bed position

describe individual risk factors for patient safety, list an example of each and describe how the nurse will combat each

LIFESTYLE (drive/operate heavy machinery while on drugs/alcohol, have dangerous jobs, risk takers, stress, anxiety, fatigue, alcohol/drugs withdrawal, taking prescription med) IMPAIRED MOBILITY (muscle weakness, paralysis, poor coordination/balance=falls, buildings/ cars that aren't handicap friendly, immobilization-physiological, emotional, independence and mobility issues) SENSORY/COMMUNICATION IMPAIRMENT: cognitive impairment(delirium, dementia, depression), visual, hearing tactical, communication impairment LACK OF SAFETY AWARENESS(nursing assessment-including home inspection helps identify patient's leave of knowledge about home safety

discuss the difference between a medical and nursing diagnosis

MEDICAL DIAGNOSIS: the identification of disease/condition bases on a specific evaluation of physical signs and symptoms, a patient's medical history, and the results of tests/procedures stays constant as a condition remains NURSING DIAGNOSIS: clinical judgment concerning a human response to health conditions/ life process or vulnerability for that response by an individual, fam or community acute pain is a response to an injury such as surgery can be problem focused or a state of health promotion or potential risk patients are actively involved ever changing on the basis of patient needs

describe what makes up environmental safety including physical hazard

MOTOR VEHICLE ACCIDENTS:leading cause of death (teens (16-19);older adults(75-80)) POISON: any substance that impairs health or destroys life (HCPs: cleaning supplies; toddler, kids (poison control is best resource for patients and parents needing information about treatments for accidental poisonings); Lead: fetus and infants=most vulnerable. In: soil, water, soil, water, older homes FALLS: history of falling, being over age of 65, reduced vision, orthostatic hypotension, lower extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, effects of medications, physical environment(bad lighting, high bed position, improper equipment), person's risky behavior(unwilling to call for assistance when getting up) FIRE: smoking = leading cause of fire, space heaters, improper use of cooking equipment/ appliances (stoves) DISASTER: cause death and homelessness (floods, tsunamis, hurricanes, tornadoes, wildfires, bioterrorism)

describe what makes up environmental safety including pollution

POLLUTION: harmful chemical or waste material discharged into the air(pulmonary disease), land (improper disposal of radioactive/bioactive products), water (contamination in lakes, rivers, streams)

describe HAIs (healthcare acquired infections) and give an example of the cause of each. with what procedures are patients placed at risk for HAIs?

Result from: -invasive procedures -antibiotic administration -the presence of multidrug-resistant organisms -breaks in infection prevention & control activities 1. URINARY TRACT -unsterile insertion of catheter -improper positioning of drainage tubing -open drainage system -catheter & tube becoming disconnected -drainage bag port touching contaminates surface -improper specimen collection technique -obstructing or interfering w/ urinary drainage -urine in catheter/drainage tube allowed to reenter bladder (reflux) -repeated catheter irrigations -improper perineal hygiene 2. SURGICAL/TRAUMATIC WOUNDS: -Improper skin penetration before surgery (shaving vs clipping hair) (no preoperative bath) -failure to clean skin surface properly --failure to use aseptic technique during operative procedures & dressing changes -use of contaminated antiseptic solutions 3. RESPIRATORY TRACT: -contaminated respiratory therapy equipment -failure to use aseptic technique while suctioning airway -improper disposal of secretions 4. BLOODSTREAM -contamination of IV fluids by tubing -insertion of drug additives to IV fluid -addition of connecting tube or stopcocks to IV system -improper care of needle insertion site -contaminated needles/catheters -failure to change IV access at 1st sign of infections/ at recommended intervals -improper technique during administration of multiple blood products -improper care of peritoneal/hemodialysis shunts -improperly accessing an IV port

know all 7 guidelines in writing goals with patients (observable, measurable, etc.)

SMART: Specific+singular Measurable(observable) Attainable Realistic Timed +patient centered +mutually set

define and discuss the different types of data collected in an assessment (subjective and objective). Be able to determine which are subjective and which are objective

SUBJECTIVE -patients verbal description of their health problems -feelings, pain... OBJECTIVE -my observations and measurements of patient -BP, inspecting, noticing mood

Review skill 29-1 and 29-5, Hand Hygiene and Open Gloving (Sterile gloving). 29-5

Specific questions to ask patient & family related to risk for infection/disease · AIDS/TB patients: have psychological & social issues from self-isolations o Ask how the infection affects the ability to maintain relationships o Can they still preform daily activities? o How are they financially? o What are their expectations for healthcare? o How much do they want to be involved w/ planning care 1. RISK FACTORS o Do you have any recent cuts/lacerations? o Show me the location o Describe for me any illness or diseases that you have & those for which you receive treatment o Tell me about any recent diagnostic testing you've undergone, such as colonoscopy or cystoscopy 2. POSSIBLE EXISTING INFECTIONS o Do you have or feel like you have a fever? o Do you have any cuts or wounds with drainage? o Do you have any pain/ burning during urination? o Do you have a cough? Is there any sputum? 3. RECENT TRAVEL HISTORY o Have you traveled outside the US in the past 6 months? o Are you a resident of or have you traveled w/in in the last 21 says to a country where an Ebola outbreak is occurring? o Were any of the people you visited or traveled w/ ill? 4. MEDICATION HISTORY o List for me the medications you are currently taking o Describe any over the counter meds or herbals that you're currently taking 5. STRESSORS o Tell me about your major lifestyle change occurring such as the loss of employment or place of residence, divorce, or disability

befinde standard precautions

Standard precautions apply to blood, blood produces, all bodily fluids, secretions, excretions (except sweat), nonintact skin, mucous membranes

describe what makes up environmental safety including transmission of pathogens

TRANSMISSION OF PATHOGENS: hands: most common means of transmission of pathogens hand hygiene=most effective way to limit transmission HIV & HEP B: through blood and fluids immunization: reduces and sometimes prevents transmission of disease

review normal and abnormal lab values/findings in patients with a suspected infection

WBC count: 5,000-10,000 mm^3

review the use of restraints. when will we use them? why do we use them? how do you tie them? what can we do to try and NOT use them? what can the RN delegate? define "never events" and review what events the nurse would report immediately

When: · Confused/disoriented patients · Wander · Repeated fall · Try to remove medical devices Why: · Reduce the risk of patient injury from falls · Prevent interruption of therapy such as IVs, NG tubes, Foleys · Prevents confused or combative patients from removing lifesaving equipment · Reduces risk of injury to others by patient Alternatives: · More frequent observations · Distracting · Social interactions (involvement of family during visitation) · Frequent reorientation · Regular exercise · Introduction of familiar and meaningful stimuli · Electronic devices: ex) weight & motion sensor beds Assessment steps: 1. Identify patient w/ 2 identifiers -name & birthday -name & medical record # 2. Assess behavior -Confusion? -Disorienting? -Agitation? -Restlessness? -Combativeness? -Inability to follow directions/repeated removal of tubing/dressing/therapeutic devices -Are they a risk to other patients? 3. Determine failure of restraint alternatives 4. Review facility policies 5. Check for current healthcare providers order (assessed within 1 hour of order) (order must have purpose, type, location, & time/duration of restraint) 4. Review manufacture's instructions for application & size needed before entering Planning steps: 1. Gather equipment 2. Hand hygiene 3. Explain what you plan to do 4. Provide privacy 5. Make sure they're comfortable & in correct anatomical position Implementation: 1. Adjust bed to proper height & lower side rail on side of patient contact 2. Be sure patient is comfortable & in correct position 3. Inspect area where restraint is to be placed: any nearby tubing? How is the skin-sensation, adequacy of circulation & range of motion? 4. Pad skin & body prominences (prn) that will be under restraint 5. Apply proper size 6. Attach restraint to portion of bedframe that moves when raising or lowering head of bed NOT TO SIDE RAILS 7. Assure tie is out of patients reach 8. Secure restraints w/ quick release buckle DON'T TIE IN KNOT, buckle bust be out of reach 9. Double check & insert 2 fingers under secured restraint 10. Assess proper placement of restraint 11. Assess skin integrity, pulses, temp, color, sensation 12. Remove restraint every 2 hours (or more frequently) 13. Reposition patient 14. Give comfort & toileting measures 15. Evaluate condition each time 16. If violet take one off at a time or get help 17. Leave bed/chair wheels locked & in lowest position 18. Preform hand hygiene · Belt restraint: o Have patient sitting o Apply over clothes/gown o Place at waist (not chest or abdomen) o Remove wrinkles/creases o Bring ties through slots in belt o Have patient lie down o Have patient role to 1 side & avoid applying too tightly · Extremity (ankle or wrist) restraint: o Wrap around wrist w/ soft part & secure tightly w/ Velcro/buckle o Insert 2 fingers under secured restraint to check for constriction · Mitten restraint: o Put hand in mitten & out Velcro around wrist NOT forearm · Elbow restraint: o Insert arm so elbow joint rests against padded area, keep joint extended o Clam upper end's hook to sleeve on their gown Evaluation: 1. Check for signs of injury every 15 mins (circulation, vital signs, ROM, physical & phycological status, readiness for discontinuation) If too agitated to approach do visual check 2. Check for need for bathroom, nutrition, fluids, hygiene, elimination & release from restraint every two hours 3. Check for complications with immobility 4. HCP writing restraint must come reassess after 24 hours 5. Check IV, Foleys, drainage tube's position & therapy is uninterrupted 6. Observe patient's behavior & reaction to presence of restraint

first tier

apply to contact w/ blood, body fluid, nonintact skin, mucous membranes -protect patients & HCPs -for all patients, regardless of risk or presumed infection -primary stages -barrier precautions

critical thinking approach to assessment

critical thinking is a vital part of assessment knowledge from the physical, biological, and social sciences allows relevant questions and collect relevant history and physical assessment data related to a patient's presenting health care needs

discus diagnostic errors

error occur during: -data collection -interpretation and analysis of data -data clustering -diagnostic statement (only the patient's response(not medical diagnosis), identify treatable etiology, remain patient centered, one diagnosis per problem)

define the problem-oriented approach to nursing assessment. Be able to determine, who in a given scenario, you would assess first

focus on a patient's presenting situation and begin with problematic areas (incisional pain, then limited understanding of postoperative recovery) ask patient follow-up questions to clarify and expand assessment to understand the full nature of the problem later your physical examination focuses on the same problem areas to further confirm your observations

define the acronym RACE

in case of fire Rescue & removal of all patients in immediate danger Activate the alarm. always do this before attempting to extinguish even more fire Confine the fire: close doors and windows and turn off O2 and electrical equipment Extinguish the fire with an appropriate extinguisher

list what is included in an assessment database. How do we make a database?

information from a patient and secondary sources(health care providers, family members) interpreting and validating the information to form a complete database -nursing interventions -management -education -history

what are patient safety risks for people while admitted in the hospital and what will you do to prevent each while practicing as a nurse?

medical errors risk of falls (ASSESSMENT AND COMMUNICATION ABOUT PATIENT'S RISKS, STAFF ASSIGNMENTS IN CLOSE PROXIMITY, SIGNAGE, IMPROVED PATIENT HAND-OFFS, NURSE TOILET, COMFORT SAFERY ROUNDS, INVOLVING PATIENT AND FAMILY, PUTTING HAND RAILS UP INCREASES RISK OF ALL BECAUSE THEY WILL TRY TO CLIMB OVER) patient inherent accidents: accidents other than falls in which a patient is primarily the reason for the accident procedure related accidents: caused by HCPs PREVENTION: ADHERING TO ORGANIZATIONAL POLICY, PROCEDURES AND STANDARDS PREVENTION: BE AWARE OF DISTRACTIONS AND INTERRUPTIONS THAT LEAD TO ERRORS AVOID RAPID IV FLUIDS: IV PUMPS MUST HAVE FLOW PROTECTION DEVICES AVOID ACCIDENTS: DON'T OPERATE EQUIPMENT WITHOUT INSTRUCTION PLACE TAG ON FAULTY EQUIPMENT ASSESS POTENTIAL ELECTORAL HAZARDS TO DECREASE FIRES, ELECTROCUTION AND INJURY

describe the three-part diagnostic statement. Be able to accurately write a 3-part (NANDA label, etiology, as evidenced by) nursing diagnostic statement

patient's need/problem = NANDA statement (ex acute pain) related to (r/t) (ex a surgical incision) as evidence by (AEB) (patient rates pain 7/10) if RISK FOR: you don't need AEB because hasn't happened yet PES P: problem E: etiology S: symptoms

discuss who should be involved in planning nursing care for all patients

patients their families if appropriate other HCPs

critical thinking approach to assessment (gathering patient data)

synthesize relevant knowledge recall prior clinical experiences apply critical thinking standards and attitudes use professional standards of practice to direct assessment in meaningful/purposeful way

discuss why nurses use the nursing process, more importantly nursing diagnoses

to form clinical decisions necessary for safe and effective nursing practice improves selection of nursing interventions Provides a precise definition of a patient's responses to health problems that gives nurses and other members of the health care team a common language for understanding a patient's needs 1. Allows nurses to communicate (e.g., written and electronic) what they do among themselves with other health care professionals and the public 2. Distinguishes the nurse's role from that of other health care providers 3. Helps nurses focus on the scope of nursing practice 4. Fosters the development of nursing knowledge 5. Promotes creation of practice guidelines that reflect the essence and science of nursing

define nursing interventions. Be able to use critical thinking to assign nursing interventions to nursing diagnoses

treatments based on clinical judgment and knowledge nurses performs to better patient outcomes: -evidence based -provides current, up to date, and effective approaches for delivering patient centered care

what are the signs and symptoms of a systemic of an inflammatory response?

· Fever · Increased WBCs · Fatigue · Anorexia · Vomiting · Malaise · Lymph nodes enlarged/swollen/tender · Decreased level of activity & alertness · Increased HR & lowered BP Organ failure

describe how smoking affects the body when it comes to infection control

· Harmful in fighting infection · Respiratory tract: smoke affects cilia lining upper airway · Affects macrophages

List and describe the signs and symptoms of a localized inflammatory response

· Redness · Warmth · Swelling · Drainage-green yellow, brown Ask about pain or tenderness around site, Edema=tightness or pain around site

review skills that can and cannot be delegated to Nursing Assistive Personnel (NAP)

· The skill of assessing & communicating a patient's risk for falling (however, skills used to prevent falls can be) · The skill of palpation of blood pressure · The skill of assessing a patient's behavior, orientation to the environment, need for restraints, and appropriate use (however, the application and routine checking of a restraint can be delegated to nursing assistive personnel) The skill of preparing a sterile field cannot