Care of patient Flashcards
What are the different group of high risk patients available
Vulnerable group of patients:
1. Frail, dependent elderly patients
2. Person with disabilities
3. Children (below the age of 14) and young person (aged 14-16 years)
4. Victims of family violence which includes child abuse, elder abuse and neglect and spousal abuse
5. The following groups of patients:
* Oncology patients
* Bone marrow transplant patients
* Solid organ transplant patients
What is the management plan for patients admitted following suicide attempt
Ward nurse implements “suicide precaution”
Inform all staff every shift for patients who are on ‘Suicidal Precaution”
Nurse patient in cubicle/ room near the nurse station and away from window
Ward Doctor order suicide precaution and assess patient and makes referral to psychiatrist
Ward nurse makes referral to MSW
Management of physical restraints
-RN to initiate restrain order, indicate per protocol, no co-signed required
-Orders must be reviewed and reordered after 24hours if restraining intervention is to be continued
-Assess the need of physical restraint, only restraint if all attempts fail
-Patient must be monitored for complications of restraint used such as bruises, pressure related etc
-Monitored for nutrition needs too
-Application of restrainer is a clinical decision
-RN can initiate restraint by verbal order from Dr but a written order must be obtained within 2hr but no longer than 24hrs after initiation of restrainer
-Release at least 2 hourly or whenever possible
-Frequent assessment
-Document in the nursing e-docs and the physical restraint e-docs
- update family on reason for restraint ( consent not needed )
What is Braden Scale
A tool used is help assess a patient’s risk of developing pressure ulcer
What are the circumstances do you assess to determine patient’s risk of developing pressure ulcers
-Upon admission
-upon transter
-Changed in patient’s condition
-When new PI developed
When reassessment is done?
What are the braden scores?
Every Monday and Thursday
A low score indicates indicate high risk
-Very high risk :<10
-High risk: 10-12
-Medium risk :13-14
-At risk 15-18
-No risk 19-23
What are the circumstances do you determine patient’s fall risk assessment
-Upon admission
-Upon transfer
-Patient’s condition change
-Change in treatment
-Any incident event
When reassessment is done?
What are moarse fall risk scores
Every Monday and Thursday
Low risk 0-24
Medium risk 25-49
High risk more than 50
