Chapter Thirteen Flashcards
SBARR
Situation
Background
Assessment
Resolution
Response
Ambulate
To Walk
The Joint Commission
The organization responsible for evaluation and accrediting health-care organizations and programs in the United States
Fall Assessment Rating Scales
Forms that when filled out, give a numerical rating for each patients risk for falls
Restraints
Vests, Jackets, or Bands that have connected traps that are tied to the bed chair or wheelchair to keep the patient in one place
Restraint Alternatives
Less restrictive ways to help patients remember to get up and to tru to walk, or to alert nursing staff that the patient is attempting to do so
Restraint Alternative (Monitor devices)
Monitors:
-Chair Monitor
-Bed Monitor
-Position Alarm
-Leg Monitor
Hypervigilant
to be on alert
Hyper - excessive (+) Vigilant - attentive to stimuli
Restraint Alternative (soft devices)
These can include bolsters that can be placed in the bed on either side of the patient to prevent them from slipping between or through the side rails
Restraint Alternative (Strategies)
Strategies:
-Placing patient who is a fall risk by the nurses station so it is easy to see if they attempt/ check on them
-Stay 1on1 with fall risk patients
-Keep bed at the lowest level at all times except if staff is bedside
-Place bedside table across chair to help patient remain seated
-Have high energy fall risks sit in a rocking chair to help relax and use up energy
-Offer regular opportunities to go to bathroom or get snacks or drinks
-Assess fall risks frequently for subjective complaints like nausea, pain, or other discomfort
-Provide back rubs and distractions
Restraints
Can be called protective devices or safety reminder devices. Sometimes can be called poseys after the brand name of the first restraints on the market.
Avoid using restraints if possible.
If an order for restraints has been placed, what guidelines do you need to follow:
-Check on patient every 30 min, making sure skin has no redness/chaffing and the extremities for warmth and color
-Remove restraint every 2 hours
While Removed do these things:
-Offer fluids
-Assist with toileting as needed
-Change position if in bed
-Assess for edema, cap refill, sensation, and function
-Assess skin over pressure points for integrity and erythema
-Assist the patient to ambulate if that is appropriate
-Stay with patient the entire time restraint is off
-Document all actions on the appropriate flow sheet
RACE
-Rescue: Remove patients from immediate danger to a safer area
-Alarm: Sound the fire alarm according to facility policy
-Confine: Confine the fire to one room or area.
-Extinguish: You should only attempt to extinguish a small fire with a fire extinguisher
PASS
Pull - the pin
Aim - the nozzle at the base of the flames
Squeeze - the handle together to release the contents
Sweep - side to side at the base of the flames to put it out
Types of Extinguishers
A
B
C
D
K
Type A
Paper Wood Fabric and Trash
Type B
Combustible liquids such as oil, gasoline, and other petroleum-based products and flammable gases
Type C
Electrical fires such as short circuits in wires, motor, or equipment
Type D
Powders, flakes, or shavings of combustible metals
Type K
Kitchen fires caused by combustible cooking fluids like oils and fats
Cardiopulmonary Resucitation
CPR
A set of actions used to restart the heart or breathing of an unresponsive victim without a pulse or respirations
Heimlich Maneuver
An action to relieve choking by thrusting just below a person’s xiphoid process
Rescue Breathing
Breathing for the patient in case of respirator arrest when the pulse still is palpable
Code Team
A group of specially trained personnel designated to respond to codes throughout the hospital
Mass Casualty Event
MCE
A public health or medical emergency involving thousands of victims
Body Mechanics
The movement of muscles of the body for balance and leverage
Center of Gravity
The middle point of the body, below the umbilicus and above the pubis, around which the body’s mass is distributed
Base of Support
This refers to your feet and lower legs
Ataxia
Unsteady Gate
Safety Data Sheet
SDS
Facility is required to have on file for every chemical
Contains information about potential harm caused by exposure and directions for what to do if the product gets in your eyes, on skin, or in mouth
