Exam #2 Flashcards
What is the purpose of the joint commission?
To accredit hospitals based on their safety performance, policy, procedures, practice, and outcomes.
What are the National Patient Safety Goals?
- Identify Patients with two identifiers
- Improve staff communication: get important test results to the right person on time
- Use medications safely: label any nonlabeled medication before surgery, take extra caution for patients who use meds to thin their blood, document the meds administered, etc.
- Use alarms safely: make improvements to make sure alarms on machines are responded to on time
- Prevent infections: use hand cleaning guidelines provided by the CDC
- Identify Patient Safety risks: reduce the risk of suicide
- Prevent mistakes in surgery: make sure surgery is being performed on the right person and in the right location
Discuss interventions to prevent injury in the clinical setting.
2 identifiers, staff communication, medication safety, bed alarms, infection prevention, breaks in surgery, prevent fatigue, reduce stress, and fall reduction
Discuss Latex allergy.
-hospital workers are likely to develop an allergy over time due to exposure
-handwashing reduces irritants
-less likely to occur in powder-free gloves
Patient-inherent accidents
physical or psychosocial attributes such as seizures
Procedure-related accidents
caused by a healthcare provider such as a medication error or improper technique
Equipment-related accident
faulty equipment, injury/death from equipment failure are reportable to the FDA
RACE
R- Rescue and remove all people who are in immediate danger
A- activate the fire alarm
C- confine the fire by closing the doors
E- Extinguish the fire if safe to do so
PASS
P- Pull
A- Aim
S-Squeeze
S-Sweep
ABC fire extinguishers put out…
A (trash, wood, paper)
B (liquids and gases)
C (energized electrical sources)
How is a fall risk assessed?
Age, fall history, elimination pattern, high-risk medication, mobility, and cognition. Complete fall risk scale, changes in balance, orthostasis or dizziness
How is a fall risk prevented?
HRF bracelet, bed or chair alarm, non-skid footwear, frequent rounding, having patient items in reach
What is the nursing care for a client in restraints and guidelines that must be followed?
-must use least restrictive measures first
-HCP must asses face to face
-can be chemical (sedative)
-Physical: limb, belt, ,mitt, and hand
-must reevaluate q24h (can not be used as needed)
asses: hydration, elimination, circulation, ROM, nutrition, VS, skin integrity, and cognitive function
What is the nursing care for a client with seizures?
-make sure the patient is placed on their side
-all 4 bed rails up and padded
-time each seizure and stay with patient at time of seizure
-have 02, suction, oral airway at bedside and loosen clothing
Describe Nursing Sensitivity Quality indicators in general.
Structure- Where it’s happening?
Process- What is happening?
Outcome- Results
Quality Improvement
advancing the practice of health care through the use of objective, measurable information
Quality Assurance
Ongoing efforts of organizations outside the hospital that evaluate outcomes to ensure safety
Alignment
Relationship of a body part to another along a horizontal or vertical line. The body should be symmetrical while standing, sitting, or lying
Balance
Center of gravity over a low and wide stable base of support.
Posture
Position of the body in relation to the surrounding space. Requires the least amount of muscular work and strain.
Scoliosis
S curve of the spine
Kyphosis
convex curvature (rounded upper back)
Lordosis
Concave curvature of the spine inward at the lower back (commonly seen in pregnancy)
Congenital hip dysplasia
ball is loose in hip and socket and dislocates easily
Isotonic movement
Active movement that can control the needed movement speed and direction of bones and joints
What does isotonic movement help accomplish?
Improves circulation, and respiratory function, increases muscle mass, tone, and strength, prevents osteoporosis (walking, running, swimming, and biking)
Isometric movement
stretching, tightening or tensing the muscles without joint movement
What does Isometric movement accomplish?
improves circulation, increases muscle mass, tone, and strength, promotes osteoblastic activity, and increases respiratory rate and HR
Health Promotion
BMI < 25, Physical activity to be performed in moderate intensity for 150 minutes a week (5x 30 minutes a day)
What is the rule of 30?
keeping the head of the bed at 30 degrees to prevent shear injury
Friction Prevention:
-have the patient cross arms to reduce surface area before moving
-have patients bend their knees as you help them up in bed
-move patients’ pillow and have them lift their head off the bed
Shear injury Prevention:
-Rule of 30
- use transfer devices when moving patient
Examples of ADLs
bathing, brushing teeth, toileting, eating
Examples of Instrumental ADLs
driving, shopping, cooking
Flexion
bend, reduces the angle between the bones
extension
straighten the limb
abduction
move away from the baseline
adduction
bring closer to the baseline
pronation
turning to face backwards
supination
turning to face forward
circumduction
circular motion
rotation
side to side
inversion
turn inward
eversion
turn outward
dorsiflexion
Draw toes upward toward the body
plantarflexion
point toes downward away from the body
How often should ROM exercises be performed daily
2-3x daily (q8h), and you should do 5 reps per joint
Passive ROM
Use of a Continuous Passive Motion machine or motion preformed by a PT
Active ROM
walking, running, etc
Osteoporosis
reduction in bone density or mass (aging)
How can you prevent osteoporosis?
-weight-bearing exercises
-smoking cessation
-Increased intake of Calcium
-Isotonic exercises help the best
What are the adverse effects of the immobility of the respiratory system?
-poor lung expansion
-weak cough
-decreased capillary action
-atelectasis
-snap, crackle, pop lung sounds
-mucous collects and pools, causing hypostatic pneumonia
What are the nursing interventions for the immobility of the respiratory system?
-Turn deep breathe and cough q 1-2 h to mobilize static mucous
-Incentive spirometer q1h while awake (10 inhales)
-Chest physiotherapy - postural drainage
-Respiratory assessment every 2 hours
-Fluid intake 2L per day to thin out mucous
-monitor O2 sat
What are the adverse effects of immobility on metabolism?
-homeostasis
-balance of electrolytes
-acid-base balance
-hormones in the body
-decreased metabolic rate
-anorexia
-slow GI tract
-negative nitrogen balance (burning more than you are taking in)
What are nursing interventions for adverse effects on metabolism?
-Diets high in protein, calories, Vit B, Vit C, and Calcium
-Total Parenteral Nutrition
-Enteral/ GI feedings
What are the interventions that reduce the effects of GI/GU body systems?
-2L of non-caffeinated fluid to void large amounts of clear, yellow urine
-intake approx. = to output
-check for bladder distention
-promote urination
-Diet: high fiber, fresh fruits, veggies and fluid
-elevate HOB after meals to prevent esophageal reflux
What are the adverse effects of immobility on the cardiovascular system?
-orthostatic hypotension
-blood pools in immobility because of gravity
Interventions for adverse effects of immobility of the heart
-Raise HOB when sitting to encourage blood flow
-dangling at the bedside before transfer
-slow position changes
-early mobilization
-anti-embolism stockings
-check VS within 3 minutes of a position change
-discourage breath-holding
-encourage breathing out
Discuss nursing interventions for adverse effects of the integumentary system.
-proper positioning
-lift devices
-rule of 30
-skin assessment every 2h
-braden scale
-routine skin and perineal care
-turning every 1-2h
-limit chair time to 1h
-shift weight every 15 minutes
-pressure-reducing surfaces
-float or bridge heels
interventions for musculoskeletal adverse effects
-ROM 2-3 times a day every 8h, 5x per joint
-prone positioning
-CPM machine
-prevent foot drop
-isometric exercises QID
-sitting, ambulation
What are the safe practice guidelines to reduce injuries for nurses?
-get enough help when moving patients
-encourage the patient to assist
-keep a center of gravity
-tighten abdomen
-do not bend or twist
-bend hips and knees, keep feet wide apart
-do not use back
-if the person you are lifting can not do a share of the lifting, you will need assistance
-back brace for heavy lifting
What is the pacemaker of the heart? What rates does it produce?
The SA node. An intrinsic rate rate of 75 cardiac action potentials per minute.
What are some conditions affecting chest wall movement?
pregnancy, obesity, neuromuscular disease, musculoskeletal abnormalities
What are the factors affecting oxygenation in chronic diseases?
Barrel chest, flattened diaphragm, lung fields are overdistended, clubbing fingers and toes, RBCs increase to try and increase O2 carrying capacity
What are some ways you can implement airway management?
-early ambulation
-sit patient up (semi-fowlers 45 degrees)
-reduce pressure on the abdomen
-promote postural drainage
-chest percussion therapy
What is the teaching for an incentive spirometer?
Breathe into the machine every hour you are awake 10 breaths
Nasal Cannula
Least invasive
1 L per minute
Humidify if more than 4 L
What position best facilitates breathing?
Fowlers or Semi-Fowlers (you want them in the upright position
Simple Mask
6-10 L per minute
35-60%
short period of time (less than 12 hours)
good for blocked nasal passages and mouth breathers
partial rebreather mask
6-15 LPM
70-90%
Non-rebreather mask
6-15 LPM
60-100%
can be low-high flow
Venture Mask
4-10 LPM
24-55%
most precise concentration
How much oxygen is in room air?
22%
What are the signs of oxygen toxicity?
Chronic: atelectasis, coughing, dyspnea, pleuretic chest pain, chest heaviness
Acute: affects CNS: twitching of the hand muscles, nausea, generalized convulsions, dysphoria, tinnitus.
What are the purposes of a chest tube? And nursing guidelines?
To drain out air or blood from pleural space.
-do not knock over
-hang below the chest
-monitor water seal
-Mark the level of drainage
Describe the drive to breathe for healthy lungs vs COPD.
COPD patients have a hypoxic drive to breathe healthy lungs have a normal drive to breathe
Risk Management
The process reducing risk of errors by understanding the causes and beginning to change the culture with communication and collaboration of individual staff and management.
Incident Reports
Documentation of errors and the factors leading up to and including when an error occurs in the healthcare system
Root cause analysis
Follows the Joint Commission’s directive to investigate an incident to determine what happened and how to prevent it from happening again
Outcome indicators
Changes in a person’s health that occur due to an intervention
What is Direct Care?
-Treatments performed through interactions with patients
-Medication Administration
-Insertion of Intravenous
-counseling during times of grief
-ADL’s
-Lifesaving measures
What is indirect Care?
-treatments performed away on the behalf of the patient or group of patients
-managing the patient’s environment
-Documentation
-Interdisciplinary collaboration
-delegating, supervising, and evaluating the work of others
What is a SMART goal?
Specific, Measurable, Attainable, Realistic and Timed
Nurse initiated interventions
independent and do not require any supervision
Healthcare provider interventions
Dependent- require an order from a physician or other HCP. require specific nursing responsibilities and technical nursing knowledge.
Collaborative interventions
Interdependent- requires combined knowledge, skill, and expertise of multiple healthcare professionals
What is an SBAR?
Situation- Identify yourself and your position, the patient’s name, and the correct situation. Give a clear, concise overview of the pertinent issues.
Background: State the relevant history and physical assessment pertinent to the problem. treatment/clinical course summary and any pertinent changes
Assessment: Offer your conclusion about the present situation. Summarize facts and give your best assessment. What is going on? use your best judgment
Recommendations: Explain what you think needs to be done. what the patient needs and when
What education should be provided regarding oxygen use?
-no smoking around oxygen
-use prescribed drug and amount
-limit items that can cause static electricity, such as wool, nylon, and synthetics
-smoke alarms and fire extinguishers must be present
-keep nail polish remover and heating oil away from the O2
