Chapter 24, 32 & 39 Flashcards
Safety
A basic human need concerning patient safety and personal safety
Body Mechanics for Staff Safety
Feet Spread Apart Minimize bending and twisting Bend knees (don't bend at waist) Lift with leg muscles Keep objects close Use both hands DON'T stand on tip toes If possible, avoid lifting! Push, slide, or pull Keep elbows bent
What is one of the leading causes of death in during patient safety?
Accidents that may lead to life changing injuries
Safety Factors
Developmental Status
Individual
Environment (Home, community, hospital)
Hospital Safety
Medication
Surgical
Communication
Physical
What are restraints meant to prevent?
Intentional self inflicted harm
Protective medical device harm
Staff harm
Restraints: Mechanical Devices
Belt Vest or Jacket Wrist or Ankle Mitt Enclosed bed (canopy bed or 4x rails up)
When using restraints for safety purposes, what measures should be taken first?
Less restrictive measures
When using restraints for safety purposes, what must be obtained?
Physician order (timing of order to be determined by facility protocol)
How often must the order be renewed and moved?
Renew at least every 24 hours
Remove ASAP and every 2 hours to assess patient and sites
When applying restraints,
Never tie to a movable parts of bed or chair
Secure with quick-release knot
Assess restraint site and distal to site
a RN mist be presence for the removal
Common Bed Positions
Semi-Fowlers
High-Fowlers
Trendelenberg
Revers Trendelenberg
Semi-Fowlers
Head of bed elevated to 45 degrees
High-Fowlers
Head of bed elevated to 90 degrees
Trendelenberg
Bed flat with feet elevated and head down
Reverse Trendelenberg
Bed flat with head elevated and feet down
Correct bed position is vital to
Promote comfort
Prevent injury
Provide sensation
Positioning for Semi-Fowler’s & High-Fowler’s
Small pillow Support arms and hands on pillows Small pillow under thighs Small pillow under ankles "Float" heels
Supine Position
Head of bed flat Small pillow under lumbar area Pillow under head, neck and shoulders Trochanter rolls parallel to lateral surface surface of thighs "Float" heels with pillow under ankle Use footboard or high top sneakers to prevent foot drop Pillows under forearms Hand rolls or splints
Prone
Roll patient to one side with arm alongside body
Roll client over arm
Position on abdomen in center of bed
Turn head to one side to support with one pillow
Place a small pillow under abdomen
Place arms i flexed position at shoulders
Support lower legs with pillows to elevate toes
30 degree lateral (side-lying)
Lower HOB Position client to side of bed opposite side being turned to Flex knees and turn patient on side Pillow under back to support Pillow under head and neck Bring dependent shoulder forward Position arms in slightly flexed position with pillow Place pillow under semi flexed upper leg
Sims’ (semiprone)
Lower HOB Place in supine postion Roll client on side Position on lateral side, lying partially on abdomen Lift dependent shoulder and place arm at side Small pillow under head Pillow under flexed upper arm Pillow under flexed upper leg
Logrolling
Requires 3 people
Small pillow between knees
Cross arms on chest
Use draw sheet
One nurse grasps draw sheet at lower hips and thigh area
Other nurse grasps draw sheet at shoulders and lower back
Roll as unit in one smooth continuous motion
“Single” nurse places pillow along length of patient for support or cleans patient
Gently lean the client as a unit back towards the pillow for support or back on the surface of the bed
Positioning aids
Trochanter roll
Hand roll
Cradle boots
Hip Abduction pillow
Transferring bed to stretcher
Get help!
Bend at knees when lifting
Keep siderail up on side patient moving towards
Use transfer board or friction reducing reducing device as appropriate
Keep bed locked
Keeps patient’s physical conditions in mind
Ambulating
Consider patient’s condition and gait
Allow patient to dangle before ambulating
Instruct patient to notify of any dizziness or discomfort
Use gait belt if available
Place chair close to bedside
Brace patient’s leg against your foot and knee
If patient falls, don’t try to stop.
Assistive devices when ambulating
Canes
Walkers
Crutcher
Canes
Hold stronger side
Move cane simultaneously with weaker side
Walker
Pick walker up to move as stepping forward
Don’t advance to far causing reaching
Crutches
Make triangle with crutches 6 inches ahead of body
Multiple gaits based on need
When using stairs: up-lead with strong leg and down-lead with weak leg
Gaits
Antalgic Gait Propulsive Gait Scissors Gait Spastic Gait Steppage Gait Waddling Gait
Antalgic Gait
Limp to avoid pain when bearing weight on the affected side
Propulsive Gait
Stooped, rigid posture with neck and head bent forward; movement forward is by small, shuffling steps with involuntary acceleration
Scissors Gait
Legs flexed slightly at the hips and knows with the thighs crossing in a scissor-like movement
Spactic Gait
A stiff, foot-dragging walk caused by one-sided, long-term, muscle contraction
Steppage Gait
An exaggerated motion of lifting the leg to avoid scraping the toes of a foot with foot drop
Waddling Gait
A distinctive rolling motion in which the opposite hip drops
Range of Motion
Maximum amount of motion possible
Can be active or passive
TCDB
Turn, Cough, Deep Breath
TCDB encourages
Lung expansion
Mobilizes secretions
TCDB Process
Place patient in Fowler’s
If abdominal or chest incision, provide pillow to splint and brace site
Teach patient to breath with diaphragm slowly
After 2-3 deep breaths, encourage patient to lean forward and cough
What helps patients take deep breaths after surgery to prevent respiratory complications?
Incentive Spirometer
What are TEDs and SCDs?
Thromboembolic devices
Sequential compressive devices
TEDs
Promote venous return by maintaining pressure on superficial veins and prevent venous pooling
Prevents passive dilation of veins & tears
SCDs
Air pump, connecting tubing, and sleeves that sequentially inflate & deflate
Drives superficial blood into deep veins & prevents venous stasis/pooling
Removal of TEDs
Remove when patient gets out of bed to prevent injury or use slippers if up briefly
Remove once a shift for 15-30 minutes
