final Flashcards
What factors must the psychiatric nurse consider when evaluating the patient’s ability to mobilize?
Body alignment/posture
Gait
Activity tolerance
Motor strength/control
Level of assistance
Use of mobility
Assess cooperation, behaviour, current medical status, pain, vital signs
What is the difference between passive and active range of motion exercises?
Passive: patient is unable to move independently, nurse moves joint through range of motion
Active: patient can move all joints through range of motion unassisted
Limited range of motion: can move some, can go through some range of motions but not all
What safety issues are present for the nurse and the patient when ambulating, positioning, and/or transferring patients?
Fall risks
Injury
fatigue
What are safety issues related to the use of hydraulic and ceiling lifts?
Proper use of equipment
Is it within your scope of practice
Client safety/concern
Correct application
What assistive devices can the psychiatric nurse utilize to make lifting, transferring, and moving patients safer and easier?
Transfer sheet
Transfer belt
Equipment aids (wheelchair, walker, cane)
Health care providers/caregivers
Mechanical lifts (not in scope of practice)
Slider board
What is important to consider when repositioning a patient in bed? When would you reposition a patient in bed?
- Make sure the patient’s ankles, knees, and elbows are not resting on top of each other. Make sure the head and neck are in line with the spine, not stretched forward, back, or to the side. Return the bed to a comfortable position with the side rails up. Check with the patient to make sure the patient is comfortable
- every 2 hours to keep blood flowing
What is important to consider when transferring a patient to and from bed to chair/wheelchair/toilet?
- make sure the chair is close and you guide the patient into the chair
- make sure their heels are all the way back, touching the device and the locks are on
When should a psychiatric nurse assess a patient’s risk for falls? What are specific risk factors that increase a patient’s risk for falls?
- on admission, on transfer from one unit to another, with a significant change in a patient’s condition, or after a fall.
History of previous falls
Gait disturbances
Balance/mobility issues
Postural hypotension
Medications
Urinary incontinence
Cognitive impairment
Communication
Safety awareness
Environmental hazards
Age
polypharmacy
What nursing interventions would a psychiatric nurse implement to reduce the risk for falls?
Secure locks on beds, stretcher, & wheel chair. Keep floors clutter/obstacle free (especially the path between bed and bathroom/commode). Place call light & frequently needed objects within patient reach. Answer call light promptly.
What nursing interventions would a psychiatric nurse implement if a patient had an unwitnessed? What nursing interventions would a psychiatric nurse implement if a patient had witnessed a fall?
Rapid assessment: BLS, VS, NVS, CWMS, injuries, LOC, blood glucose level, Transfer to bed, Ongoing assessment: unwitnessed/head impact, Management: clean + dress wounds, pain management, Communication, reporting & documentation: contact doctor & family, team meeting
(Unwitnessed/head impact: VS/NVS Q15 min x 4, if stable, Q1H x 4, if stable Q4H x 24 h)
(Witnessed/no head impact: VS/NVS Q1h x 2, if stable VS Q4H x 24 hrs)
If a patient was going to fall, how would the psychiatric nurse safely lower the patient to the ground?
Move behind the patient, take one step back
Support patient’s waist/hip, put your leg b/w patient’s legs
Slide patient down your leg lowering yourself at the same time
Assess patient for injuries before moving them
Reassure patient and seek help
Document per agency policy
Oral:
in the mouth
Sublingual:
under the tongue
Buccal:
between gums and cheek
Parenteral:
injecting a medication into body tissues
Intradermal:
injection into the dermis
Subcutaneous:
injection under the skin
Intramuscular:
injection into the muscle
Intravenous:
injection into the veins
Topical:
applying on the skin (lotions, gels, patches, ointments)
Transdermal:
apply patch to skin to (nitro: 12hr & nicotine: 24hr)
Inhalation:
form of a gas or aerosol—via the mouth or the nose (insufflation), enabling it to reach the body tissues rapidly.
Intraocular
through the eye
What are the seven essential components of a medication order?
Date and time order was written
Name of client
Name of medication (generic or trade name)
Dosage
Route
Frequency
Signature of prescriber
What actions should the psychiatric nurse take if they are unable to read a medication order?
Call the doctor and get them to clarify
document efforts of contacting prescriber
If can’t reach doctor, consult with other healthcare professionals (charge nurse)
What assessments should the psychiatric nurse perform prior to medication preparation and administration?
- allergy history
- diet history
- patient medical history
- patients current condition
- perceptual or coordination problems
- medication data
- attitude toward medication use
- knowledge & understanding of medication therapy
- learning needs
Where can the psychiatric nurse find patient allergy information?
on the MAR
What are the rights of medication administration
Right medication
Right dose
Right patient
Right route
Right time and frequency
Right documentation
Right reason
What are two patient identifiers?
DOB
Name of patient
What are the 3 medication checks?
The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times: When the medication is taken out of the drawer. When the medication is being poured. When the medication is being put away/or at bedside.
What do you need to know about the medication that you are administering?
- reason the client is receiving medication
- drug classification
- drug action
- contraindications
- usual dosage range
- side effects
- special nursing considerations
What is the procedure for administering oral medications? How do you maintain aseptic technique while preparing and administering medications?
-Identify the patient by using at least two patient identifiers, Compare labels of the medications with the MAR, Explain to the patient the purpose of each medication and its action, Assist the patient to a sitting position, Administer med, Stay at the bedside until the patient has completely swallowed each med
- work on a clean surface
- hand hygiene
- avoid touching the medications with your fingers
What are the five essential components of a Medication Administration Record?
- 2 patient identifiers
- date
- allergies
- RN/RPN signature
- medication name, dose, route, frequency, time
What could constitute a medication error? What is the procedure for reporting and documenting medication errors?
any event that could cause or lead to a patient either receiving inappropriate medication therapy or failing to receive appropriate medication
- omission, incorrect time, drug, dose, route, patient, preparation
- acknowledge & take responsibility for error, patient safety is top priority: assess patient, notify physician, document incident, report incident, reflect
What are the conversions for grams, milligrams, and micrograms?
1g to 1000mg to 1000mcg
What are the guidelines for decimal point placement in relation to medication calculations and orders?
When designating a metric dosage, do not write a zero alone after a decimal point (e.g., write 5 mg, not 5.0 mg) and always include a zero before the decimal point (e.g., 0.1 mg) to comply with current guidelines
What is the sequence for writing a medication order? What is the difference between generic and brand names for medications?
Date and Time the medication order was written. Generic Drug Name (unless the product is a combination product). Dosage (correctly formatted with appropriate pharmaceutical dosage units). Route of Administration.
(generic name: active ingredient)
(brand name: company gives)
What essential information is included on the drug label?
- name of medication
- type of medication (tablet)
- dosage of packaged drug
What is the formula for calculating medication dosages?
desired amount / available dosage X quality
What is meant by the term enteric coated tablets? What is meant by the term sustained release/controlled release/long acting?
- Coated tablet that does not dissolve in stomach; coatings dissolve in intestine, where medication is absorbed
-Sustained release= Tablet or capsule that contains small particles of a medication coated with material that requires time to dissolve
What are nursing considerations for before, during, and after feeding to promote safe intake of food and fluids?
before: assess for risk of aspiration, dietary restrictions, ability to feed self, position upright position, perform oral hygiene, apply clothing protector, hearing aids, glasses, dentures
during: use rocking motion on tongue, give small bites & offer drinks, allow 5-10 secs for each bite, assess for dysphagia
after: patient should remain upright for 30 mins, perform oral hygiene
What do the terms dysphagia, aspiration, and choking mean?
dysphagia = Difficulty swallowing
aspiration = to draw in or out using a sucking motion. It has two meanings: Breathing in a foreign object (sucking food into the airway). A medical procedure that removes something from an area of the body.
choking = object lodges in the throat or windpipe blocking the flow of air
What are clinical manifestations of dysphagia, aspiration, and choking?
dysphagia = coughing or choking when eating or drinking, bringing food back up, sometimes through the nose, a sensation that food is stuck in your throat or chest, persistent drooling of saliva.
aspiration = Feel something stuck in your throat, Hurt when you swallow, or it’s hard to do, Cough while or after you eat or drink
choking = Skin, lips and nails that change color turning blue or gray, Inability to talk.
How does the psychiatric nurse determine how well an individual can swallow?
Assess ability to swallow by positioning examiner’s thumb and index finger on patient’s laryngeal protuberance. Ask patient to swallow; feel larynx elevate. Ask patient to cough; test for a gag reflex on both sides of posterior pharyngeal wall (lingual surface) with a tongue blade.
What nursing interventions are implemented for a choking individual? What nursing interventions are implemented for a patient who is showing signs of aspiration? *This may require you to consult another source!
- abdominal thrusts & back blows
- Keep suctioning equipment at the bedside, Performing suctioning as necessary, Keep the head of the bed elevated after feeding, Implement other feeding techniques, position properly
What modifications are made when assisting individuals with a visual impairment?
- vocalizing everything to let them know where things are
- having their belongings close by
- having the call bell near so you can assist them
- Make sure pt glasses/contacts are clean and in place
- Identify location of food on plate as if it were a clock
- Tell pt where beverage is in relation to plate
Why should the psychiatric nurse assess the patient’s diet type and texture before feeding?
- to make sure they aren’t on any specific type of diet because of their eating restrictions or potential for choking or aspiration
What is the purpose of elastic stockings?
- aid in maintaining external pressure on the muscles of the lower extremities and thus promote venous return
How do you apply elastic stockings?
- The nurse will need to measure the patient’s legs with a tape measure to determine proper stocking size.
- Turn elastic stocking inside out up to the heel.
- Place patient’s toes into the foot of the elastic stocking
- Slide remaining portion of sock over the patient’s foot, being sure that the toes are covered
What nursing assessments would the psychiatric nurse make in relation to the application of elastic stockings?
- assess circulation at the toes to ensure that the hose are not too tight
- Record condition of skin and circulatory assessment
What nursing assessments would the psychiatric nurse make in relation to the application of a disposable brief?
- skin assessment to see if there is any skin breakdown
- see if theres rashes
- pressure ulcers
How does the psychiatric nurse apply and remove a bedpan?
- Slide the bedpan beneath the patient’s buttocks with the curved edge of the bedpan facing the back. If the patient can lift their hips: Slide the bedpan underneath the buttocks and instruct the patient to ease down onto it, using your support hand to guide them.
- To remove the pan, the nurse can ask the patient to roll off to the side or to raise the hips. The pan should be held steady to avoid spilling. It is important to avoid pulling or shoving the pan from under the patient’s hips; these actions can pull the patient’s skin and cause tissue injury
- After the pan is removed, while wearing gloves, the nurse cleans the anal and perineal areas and assists the patient with hand hygiene.
When would a patient require the use of a bedpan? What type of patient would use the fracture/slipper type of bedpan?
- unable to get out of bed may need to use a bedpan
- designed for patients with body or leg casts
