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)