Module A Study Guide

Module A Study Guide (Potter & Perry Ch. 27, 28, 38, 39) ●​ Identify safety risk factors ○​ Falls ■​ Older clients, decreased visual activity, generalized weakness, urinary frequency, gait and blaance problems, cognitive dysfunction, and adverse effects of medications increase risk of falls ○​ Seizures precautions ■​ Make sure the equipments needed is at bedside (O2, oral airway, suction, padding) and inspect clients environment for items that could cause injury during a seizure ■​ Do not restrain patient ○​ Physcial hazards ■​ Motor vehicle accidents: adolesents are at increased risk; ages 16-19 ■​ Posion: toddlers, school aged and preschoolers are at increased risk; can be inhaled, ingested, or absorbed; poison control center is the best resource ■​ Falls: Older Adults(65+) ■​ Fires: RACE and PASS ●​ Extinguishers ○​ Class A: paper, wood, rags, trash ○​ Class B: flammable liquids and gas fires ○​ Class C: electrical fires ●​ Smoking in bed, smoking while on oxygen, using gasoline to burn yard rubbish, overloading extension cords, improper use of cooking equipment and appliances, space heaters ●​ ●​ ●​ ●​ ●​ ■​ Disasters: ABCDE princible Explain body mechanics risk factors. Explain positioning, transfer, and ambulation. ○​ Safety is first priority, ask patient to help as much as possible, determine if pt, comprehends what is expected, pt, comfort level, determine if you need assisstance Define environmental hazards. ○​ Carbon monoxide: binds to the hemoglobin and reduces the o2 supply to the tissues ■​ Cannot be seen, tasted, or smelled ■​ Symptoms: Nausea, vomiting, headache, weakness, and unconsciousness ●​ Encourage carbon monoxide monitors in the home ○​ Food posioning: Improper storage, prep and provision of food ■​ Posioning from norovirus or E coli, salmonella, listeria ■​ Risk clients: very old, very young, immunocompromised and pregnant ■​ Clean, separate, cook, chill ○​ Temperauture: 65 to 75; frostnip and frostbite; heat stroke(do not give anything to drink) Identify safety restraints. ○​ Chemical or physical Explain guidelines and risk factors for using safety restraints. ○​ Nurse must know federal, state, and facility policies for restraints ○​ Last resort ○​ Perscription cannot be PRN and allows only 4 hours for an adult, 2 hrs for ages 9-17, and 1hr for ages under 9; the ●​ ●​ ●​ ●​ ●​ provider must have done a face to face assessment with the client ○​ Restraints should : interfere with treatment, restrict movement as little as necessary, fit properly and be as discrete as possible, be easy to remove or change Explain the process of using safety restraints. ○​ Restraints must: reduce risk if patient injury from fall, prevent interruption of therapy, prevent patients who are confused or combative from removing life support equipment, and reduce the risk of injury to others by patient ○​ Explain the need ofr restraints to the client and family, ask client pr gaurdian to sign consent form, pad bony prominences, secure restraints to a moveable part of the bed frame(never side rails), make sure loose enough for two fingers ○​ Assess: sin integrity every 2 hrs, offer food and fluid, provide means for hygeiene and elimination, monitor vitals, offer ROM extercises Identify the nurse’s role in disaster management. ○​ triage Identify issues related to risk management. Identify types of asepsis. ○​ Cleaning, disinfection, protection of the susceptible host, control and elimination of reservoirs of infection, control portals of exit/entry, cough etiquette, control of transmission, hand hygiene Explain medical and surgical aseptic procedures. ○​ Medical asepsis- clean technique, eleimination of and the absence of disease causing microorganisims ○​ Sterile- preparing sterile fields ●​ Identify OSHA guidelines for healthcare providers. ○​ Needlestick injury ○​ HAIs ■​ Central line bloodsteam, catheter, surgical site, pneumonia/ventilator assisted ●​ Identify standard precautions. ●​ Identify measures that insure a secure environment. ○​ Performance improvement, risk management, safety reports, providing reliable tech, use evidence based practice, providing safe enviorment ●​ Define documentation processes for safety and security. ●​ Explain the process of reporting preaches in safety and security ●​ Systemic effects of immobility ○​ Metabolic ■​ Decrease in metabolic rate, causes GI disturbances ■​ Height, weight, skinfold, I+O for fluid balance ■​ Intervention: provide high protein, high calorie diet with vitamin B+C ○​ Cardiovascular ■​ Orthostatic hypotension, increased heart rate and edema, venous thromboembolism, DVT, and pulmonary embolus(blood clot that breaks free) ■​ Assess: calf circumference, painlevel, wells score, blood pressure, reddness, warmth, tenderness, venous stasis ■​ Interventions: SCDs, reduce cardiac workload, descreaase orthrostatic hypotension ○​ Urinary elimination ■​ Urinary stasis, renal calculi, and infection ■​ Assess: I&Os, fluid and electrolyte imbalances, bowel sounds, dehydration ■​ Interventions: hydration(1100-1400 adult), diet rich in fruits, fluids, vegtable, and fiber ○​ Respiratory ■​ Atelectasis(collapse of alveoli), hypostatic pneumonia ■​ Assess: lung expansion, ascultate, asses cough for color and production, incentive spirometer(q2h) ■​ Interventions: cough and deep breathe g1-2h, increase fluid intake, report green yellow sputum ○​ Musculoskeletal ■​ Lean body mass loss, muscl weakness, osteoporosis, joint contracture ■​ Assess: decrease in muscle tone and strength, contracture, early assessment of ROM ■​ Interventions: ROM, walking, extercise and activity ○​ Integumentary ■​ Pressure injuries ■​ Assess: braden scale, asses skin g1h, skin breakdown, color changes ■​ Intervention: position changes 1-2 hours, skin care ●​ Vacabulary ○​ Root cause analysis- follows the joint commissions directive to investigate an incident and determine what happened and how to prevent it from happening agian ○​ Most common sitenial events ■​ Falls, unintended retention of a foreign object, suicide, wrong surgery, delay in treatment ○​ Never events- medical errors that are identifiable and preventable ○​ Sarcopinia- gradual loss of muscle mass, strength and function ○​ Foot drop ○​ Kyphosis ○​ Gait belt ○​ Gait ○​ Ambulate ○​ Orthostatic hypotension ○​ SCDs ○​ ROM ●​ Things to remember ○​ FACT- for charting ○​ SMART- for patients education ○​ SURETY- for theraputic education ○​ RACE- the presence of smoke or fires ○​ PASS- for fire extinguishers ○​ WHOS for hand hygiene