FINAL EXAM Units 9-12 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 Aids
** Assess cooperation, behavior, current medical status, pain & comfort, and vital signs **
What is Passive ROM
Patient is unable to move independently
Nurse moves joint manually
What is Active ROM
Patient is able to move all joints through ROM unassisted
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 (provides support for nurse when mobilizing patient)
Equipment aids (Wheelchair, walker, cane etc)
Health care providers/caregivers
Mechanical Lifts
Slider Board
What nursing interventions would a psychiatric nurse implement if a patient had an unwitnessed fall?
Call for help
Ask and inspect for head injury (head impact)
Transfer to bed
Pain Management
Communicate and report (agency policy)
What nursing interventions would a psychiatric nurse implement if a patient had witnessed?
Witnessed: LOC, CWMS, Vitals, Injuries, Blood glucose levels
Transfer to bed
Pain Management
Communicate and report (agency policy)
If a patient was going to fall, how would the psychiatric nurse safely lower the patient to the ground?
Move behind patient. Take one step back
Support patient’s waist/hip. Put your leg between 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.
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?
Do not administer!
Clarify with doctor first
What assessments should the psychiatric nurse perform prior to medication preparation and administration?
Allergy history
Diet history
Patient’s medical history
Patient’s current condition
Perceptual or coordination problems
Medication data
Attitude toward medication use
Knowledge and understanding of medication therapy
Learning needs
Where can the psychiatric nurse find patient allergy information?
Chart, noted on MAR or patient identifier
What are the 3 medication checks?
Before
During
After
What are the rights of medication administration?
The right medication
The right dose
The right patient
The right route
The right time and frequency
The right documentation
The right reason
The right to refuse*
The right patient education*
The right evaluation*
What are two patient identifiers?
Name
Hospital Number
DOB
