fundamentals Flashcards
decubitus
STAGE 1:
- intact skin
- no blanching
- massage
STAGE 2:
-blistering
STAGE 3:
-dermis to muscle
STAGE 4:
- muscle to bone
- wound vac system
*turn the pt every 2 hours
latex allergy
- apples
- avacado
- banana
- celery
- cherry
- chestnuts
- figs
- grapes
- kiwi
- mangos
- passion fruit
- peaches
- pears
- pistachios
- potatoes
- ragweed
- strawberry
- tomatoes
maslow’s hierachy
PHYSIOLOGICAL NEEDS:
- food
- water
- sleep
- sex
SERCURITY & SAFETY:
- employment
- money
- security
LOVE AND BELONGING:
- friendship
- family
- relationship
SELF ESTEEM:
- confidence
- respect for self
- respect from others
SELF ACTUALIZATION:
- accepting facts
- problem solving
- morals
floating
- must be assigned to STABLE pt
- assignment must be based on their practice
- should not admit or discharge pt
- do not refuse compromise acceptable task
priorities of care
- life threatening are priority
- actual concerns before potential concerns
- check ABC followed by safety and infections
- use maslows hierarchy of needs
- check UNSTABLE pt before STABLE
- check pt before equipment
reporting to authorities
ABUSE:
- elderly : adult services
- child : child services
- hospital: social servies
- nursing home: ombudsman
- agency : adult or child services
COMMUNICABLE DISEASE: -TB -HIV -HEP B local department of health
GUNSHOT WOUND KNIFE OR STAB WOUND VEHICULAR ACCIDENT ASSAULT & HOMICIDES SUSPICIOUS DEATH -police or 911
torts
INTENTIONAL TORTS:
-assault:
yelling at pt
-battery:
procedure without consent
-false imprisonment
restraints
QUASI-INTENTIONAL TORTS
-breach of confidentiality
sharing info of pt
-defamation of character
adding un needed info
UNINTENTIONAL TORT
-negligence
-malpractice
doing things out of scope
unethical nursing practice
-med errors
-burning a pt
check temp of food and water
-falls
side rails up
-mistaken identity
-pt abuse
-breach of privacy
-withholding treatment
-providing care under the influence
informed consent
-DR is legally responsible
-nurse may sign as a witness
-person under the influence can’t sign
-parents or legal guardians but sign for under age 18
-emancipated minors can sign
pregnant
seeking treatment for STD
married
-during emergency consent may be waived
-vaild for only 24 hrs
-1 consent for each invasive procedure
-withdrawal of consent can be done by pt at any time verbal or written
advance directives
written document that provides directions concerning the provision of the care when pt is unable to make his or her own treatment choices
LIVING WILL:
- health decisions made when pt if terminally ill or permanently unconscious
- PERMANENT
- reviewed with dr yearly
- between dr and pt
DURABLE POWER OF ATTORNEY: (health care proxy) -allows pt to appoint someone they trust to make health care decisions with the pt cant make decisions -usually spouse, family, friend -CAN BE CHANGED AT ANY TIME -between pt and someone close to pt
PMD
-DNR
-cpr
make sure to check status of pt before preforming
restraints
- requires written consent from relatives
- consent is required each time
- PRN orders and legally unacceptable
- use soft restraints
- secure to BED FRAME not side rails
- check pt every 15-20 mins
- release every 2 hours for 30 mins
- change order every 24 hrs
- confused pt
- pt harming self or others
- leave doors open
- semi fowlers
hand washing
- wash hands for 1-3 mins when 1st arriving to unit
- wet hands
- soap
- lather 20 secs
- rinse 10 sec
- dry hands
- use paper towel to turn off water
-anti bacterial soap doesnt kill germs
alcohol kills germs
-wash hands 20-40 sec between pt
PPE
personal protective equipment
PUTTING ON:
- gown
- mask
- goggles/face shield
- gloves
TAKING OFF:
- gloves
- goggles/face shield
- gown
- mask-take mask off OUTSIDE of room for airborn or immuno compromise
infection control
NON CONTAGIOUS:
-pt without infection
-infection that CAN'T be transmitted by
sneezing
talking
coughing
-pt with low WBC
-immune compromised
CONTAGIOUS:
-pt with infection that CAN be transmitted by
sneezing
talking
coughing
touch
-airborne
-droplet
-same room same disease or infection
-same bacteria virus age gender
-airborn and low WBC should be in PRIVATE room
combative or radiation pt
-immune compromise and non contagious can be in the same room and long as infection is not contagious
