EXAM 2 - Safety and Sensory Flashcards
What is the ANA’s definition of a culture of safety?
an organizational environment where “cores values and behaviors–resulting from a collective and sustained commitment by organizational leadership, manager, and workers—emphasize safety over competing goals’”
What are the attributes of a positive safety culture?
- Openness and trust, without individual blame;
- Appropriate resource allocation;
- A learning environment for health care professionals where errors are explored and systemic weaknesses identified;
- Transparency and accountability
How does QSEN minimize risk of harm to patients and providers?
- System effectiveness
- Individual performance
What accredited bodies creates the standards for nurses?
- ANA
- TJC
What are the outcomes of safety in the health care setting?
- Reduces the incidence of illness and injury
- Prevents extended length of treatment/stay
- Improves or maintains functional status
- Increases patient’s sense of well-being
What are the basic human needs?
- Oxygen
- Nutrition
- Temperature
What are some things to keep in mind with a patient on oxygen?
- highly flammable
- should not smoke around them
- furnaces and stoves need proper ventilation or carbon monoxide can build up
- low concentration of O2 causes: dizziness, nausea, fatigue and headache
What are some things to keep in mind with nutrition?
- improper food preparation and storage presents a r/f infection and food positioning
- fridge should be kept <40F
Who is at the highest risk for experiencing hypothermia?
- older adults
- the young
- those with CVD
- those with excessive drug/alcohol use
- the homeless
Who is at the highest risk for experiencing hyperthermia?
- chronically ill
- older adults
- infants
Who is carbon monoxide poisoning most common in?
toddlers
Who is MVA most common in?
young adults
What factors influence safety and quality in a patient?
- Developmental stages
- Individual risk factors
- Mobility, sensory, and cognitive status
- Impaired mobility
- Lifestyle choices
- Lack of safety awareness
- Risks in the health care agency
What are considered some serious reportable events?
- Surgical events
- Product or device events
- Patient protection events
- Care management events
- Environmental events
- Criminal events
What is the 8th leading COD in hospitals?
medication errors
What are some medical errors that often occur in the hospital?
- Medication errors-8th. Leading cause of death
- Infection-Hospital Acquired Infections- (CAUTI)
- Bed sores-Decubitus Ulcers-(HAPU)
- Failure to diagnose and treat in time
- Falls
What are some classifications of health care agency accidents?
- Patient-inherent accidents
> seizures
- Procedure-related accidents
> giving wrong meds
- Equipment-related accidents
> faulty equipmentHow do you report a SRE?
The nurse or provider involved completes an incident report. IR is a confidential document that describes any patient accident and focuses on the root cause of the event, not the person involved.
What are some examples of never events?
- pressure ulcers (stage 3 or 4)
- falls/trauma like fractures
- foreign objects in the body post-op
- CAUTIS
- blood incompatibility
- air embolism
- surgical site infection
- DVT/PE following ortho procedure
What increases a patients risk for falls?
- muscle weakness (lower body)
- paralysis
- abnormal gait/balance
- poor coordination
- poor vision
- problems with feet/shoes
- medications
- dizziness
- hazards/obstacles
What predisposes a patient to physical deconditioning and emotional hazards?
immobilization
What should you always do before using a restraint?
try restraint alternatives (restraint should ALWAYS be a LAST resort)
What are some ways to implement fall prevention?
- yellow wristbands = fall risk
- bedside commode (for those with urgency)
- safety bars near toilet
- 2 bed rails up
- remove tripping hazards
- call light within reach
- orient patient to room
- keep room well lit
- use non-slip socks
- bed alarms
When should discharge planning start?
on admission and it should include the family
What are some things that can be done to promote fire safety?
- keep equipment from blocking fire doors
- direct all ambulatory patients to walk themselves to a safe place
- move patients who cant get out of bed with a stretcher
What does PASS stand for?
- pull pin
- aim at base
- squeeze
- sweep from side to side
What does RACE stand for?
- rescue/remove
- alarm
- confine
- extinguish
What are some seizure precautions?
- never put anything in their mouths while seizing
- turn patient to the side and lower them to the ground
- do not restrain the patient
- loosen restrictive clothing
- if the seizure is longer than 5 minutes, call rapid response (status epilepticus)
- pad side rails
What are the different types of reception senses?
- Visual (Vision)
- Auditory (Hearing)
- Olfactory (Smell)
- Gustatory (Taste)
- Tactile (Touch)
What is stereognosis?
The perception of solidity, size, shape & texture of objects
What is kinesthetic?
The perception of body position & movement
What is visceral?
The perception of inner organ response
What is proprioception?
The subconscious level movement of the body-(limbs)
What are the 3 components of the sensory pathway?
- reception
- perception
- reaction
What is reception?
stimulation of a receptor such as light, touch, or sound. the nerve (receptor) is stimulated and travels to the spinal cord, then to the brain
What is perception?
integration and interpretation of stimuli. it is being aware of the stimuli occurring and happens when a person is conscious of the stimuli; each person integrates and interprets the stimuli based on past experience
What is reaction?
moving away from harm; only the most important stimuli will elicit a reaction
What factors affect sensory stimulation?
- Developmental considerations
- Cultural considerations
- Personality and lifestyle
- Stress and Illness
- Medications
- Consciousness
- Unconsciousness
What is locked in syndrome?
patient can see but cannot respond
What is vegetative state?
no brain activity
What is stupor?
unconscious but aroused with vigorous stimulation
What is coma?
unconscious and cant be aroused (one step closer to vegetative state)
What dBA is annoyingly loud?
70+ dBA
What dBA is during the day? What dBA is at night?
35 dB; 30 dB
What noise level can damage hearing if exposed too long?
> 80 dB
What factors affect sensory function?
- Age
- Number of stimuli
- Environmental factors
- Meaningful stimuli
- Social interaction
- Cultural factors
What is a sensory deficit?
Deficit in the normal function of sensory reception and perception
What is sensory deprivation?
Inadequate quality or quantity of stimulation
What is sensory overload?
Reception of multiple sensory stimuli
What area do most sensory deficits occur?
- Sight
- Hearing
- Balance
- Taste
- Speech
What is aphasia?
has varied degrees of inability to speak, interpret, or understand language.
What is expressive aphasia?
a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing
What is sensory or receptive aphasia?
the inability to understand written or spoken language (cant receive what is being said)
How should you care for a patient with aphasia?
- give them extra time to communicate
- do not shout or speak loudly
- use simple, short sentences
- ask simple yes/no questions
- offer pictures so they can point
- only one person speak at a time
- tell the patient when you don’t understand them
What is the nursing care provided when tending to a patient with sensory deprivation?
provide meaningful stimuli:
- provide stimulation with as many senses as possible
- encourage physical activity and ROM exercises
What are the effects of sensory deprivation?
- Perceptual
> person cant contain 5 senses (don’t know what a puzzle is) - Cognitive
> unable to to control direction of thought (confused; don’t know where to put puzzle piece) - Emotional Disturbances
> PTSD, fear, anger, pain
What is sensory overload?
when a person receives too much stimuli and the brain cannot process it all. patient may have a increased HR, inattention, anxiety and restlessness
What is the nursing care for a patient experiencing sensory overload?
- dim the lights, close the door, silence alarms early
- cluster care
- quiet time
- turn off bedside equipment not in use
- orient the person to patient, place or time
- decrease environmental noise
- encourage the patient to participate in nursing care
What factors can maintain orientation to person, place and time?
clock and a white board in patients room
What should your nursing care be for a patient with impaired vision?
- alert the patient when you enter the room
- explain what you are going to do before you do it (esp. if touching)
- orient them to the environment
- have safety bars near the toilet
- speak in a normal tone of voice
- keep call light within reach
- keep side rails in up position and have patient call for help
- assist with ambulation by walking slightly ahead of patient
- stay in field of vision for patients with partial vision
- provide diversion by using other senses
- tell them when interaction has ended and when your about to leave the room
What should your nursing care be for a patient with impaired hearing?
- do not approach from behind
- face the patient and stand/sit on their level
- check hearing aids
- use a lower tone of voice
- speak so they can see your mouth movement
- speak slowly and enunciate (do not yell)
- use an interpreter, NOT family/friend
- write down things if needed
- orient patient to your presence before speaking
- decrease background noises before speaking
- position yourself so that light is on your face
- talk directly to the patient while talking to them
- use sign language, as appropriate
What should your nursing care be for a patient with confusion?
- Use face to face contact to communicate social process
- Speak calmly, directly, & simply to patient***
- Orient & re-orient patient to environment
- Communicate expectations to patient
- Offer explanation for care delivered
- Reinforce reality if delusional***
What should your nursing care be for a patient who is unconscious?
- Be careful what is said in patient’s presence….Hearing is the LAST sense that is lost!***
- Assume patient can hear you. Talk in a normal voice
- Speak to patient before touching them
- Control environmental noises- low level
What should your nursing care be for a patient who has tactile alterations?
They have a reduced sensation/decrease in touch in extremities so they are at a increased risk for impaired skin integrity:
- temp. on home water heater should be no higher than 120F
- label hot and cold faucets if they also have a visual impairment
- discourage heating pads
- encourage wear of closed toed shoes
- inspect all body parts at risk
- protect the patients skin from temp. extremes
- assess the extremities for breaks in the skin, blisters, drainage or open wounds
- ensure that the patient is ambulating w/assistive devices
