POD #1 Units 1 - 4 Flashcards
What are risk factors/hazards that pose a threat to patient safety?
Falling
Tripping
Obstruction
What would you include in a patient and bedside safety check?
Ensuring a minimum of 1 safety rail up; maximum of 3
Wheel brakes are on
Call button is accessible
Suction valve is functioning
Oxygen tank is functioning
Emergency kit is located
What is cultural safety?
Being Culturally Competent. The redistribution of power and resources in a relationship.
How can you incorporate cultural safety and humility into your clinical practice?
How can you incorporate anti-racism into your clinical practice?
Self-Reflective Practice
Building Knowledge Through Education
Anti-Racist Practice
Creating Safe Health Care Experiences
Person-Led Care
Strengths-Based & Trauma-Informed Practice
What are the links in the chain of infection and why is it important for Psychiatric Nurses to understand the infectious process?
Portal of Entry -> Susceptible Host -> Pathogen -> Reservoir -> Portals of Exit -> Mode of Transmission
Understanding where we can intervene and break the links in the chain
What is the difference between medical and surgical asepsis?
Medical: “Clean technique” Reduces number of pathogens, used in daily procedures
Surgical: “Sterile technique” Eliminates pathogens, used in surgical procedures
What is hand hygiene? What are the five key moments for hand hygiene?
Routine handwashing followed by hand sanitizer and prevents transmission of infection
- Before touching patient
- Before aseptic procedures
- After touching patient
- After touching patients surrounding
- After exposure to bodily fluids
What are the indications for hand washing versus alcohol-based gels/sanitizers?
Handwashing is required for heavily soiled hands, C Diff and norovirus, exposure to blood or bodily fluids
Sanitizer is required in between hand washing, kills majority of germs on hands, widely available
How long should hand washing be carried out?
15 seconds minimum, 40-60 maximum
Sanitized till absorbed
When should non-sterile clean gloves be utilized?
Contact with bodily fluids, Mucous membranes,
Surfaces contaminated with bodily fluids
What are routine practices/standard precautions?
Practices used by healthcare professionals to reduce modes of transmission and break chain of infection
Including and hygiene, wearing gloves where appropriate
What are additional/isolation precautions? What is a point of risk assessment?
Extra step added to routine practices for patients known or suspected to be infected with certain microorganisms
Ex. Additional PPE for contact, droplet, or airborne precautions: Clearly indicated outside patient door pertaining to specific pathogen and the mode of transmission
How does the psychiatric nurse make an occupied/unoccupied bed ensuring that the principles of medical asepsis and standards precautions are maintained?
Wearing gloves when appropriate
Applying gel sanitizer in between steps
After making an unoccupied/occupied bed, what actions would you take to ensure patient safety and comfort?
Ensuring top layers are untucked so patient can exit bed as needed
Bedside check (rails, brakes, call button)
Adjusting top fold by feet for patient mobility
What is the normal range of temperature for a healthy adult?
36 – 38 Degrees
What factors can affect the patient’s temperature?
Fever (Febrile)
Environment
Stress
Foods/Drinks
What are the sites used to assess body temperature?
Oral
Rectum
Armpit (Axillary)
Ear (Tympanic)
How does smoking, chewing gum, and ingesting hot/cold liquids or food affect a patient’s temperature? What are the nursing actions for assessing temperature in relation to these activities?
They can alter temperature in oral cavity giving an inaccurate reading.
Nursing Actions: Wait 20 mins after hot and cold liquids, 2 mins for smoking, and 5 mins after chewing
What do the following terms mean: core temperature, fever/pyrexia, and afebrile?
Core: body’s internal organs
Fever/Pyrexia: Abnormally high temperatures
Afebrile: Patient absent of fever (Normal)
What is the normal range of heart rate for a healthy adult?
60 – 100 BPM
What factors can affect the patient’s heart rate?
Diet, Exercise, Genetics
What do the terms rate, rhythm (irregular/regular), and quality (strength) mean in relation to assessing the pulse?
Rate: Time/Frequency
Rhythm: Steady, rapid (regular or irregular)
Quality: weak, strong
What do the terms tachycardia and bradycardia mean?
Bradycardia = slow heartbeat, lesser than 60 beats per minute
Tachycardia = fast heartbeat, greater than 100 beats per minute
What are the two common pulse sites used to assess the heart rate?
Neck – Carotid Artery
Wrist – Radial Artery
What is the normal respiratory rate range of a healthy adult?
12 – 20 Breaths (full inhalation and exhalation) per Minute
What factors affect the patient’s respiratory rate?
Smoking
Diet/Exercise
COPD
How does the psychiatric nurse assess the respiratory rate?
Observe Respirations for 30 Seconds x 2 (for 1 min total) OR 1 Full Minute if Irregular
What do the terms rate, rhythm, and depth mean in relation to respiration? What characteristics does the psychiatric nurse assess when observing respirations?
Rate: rapid, slow
Rhythm: regular or irregular
Depth: Deep? Shallow?
Checking if patient is sputtering, pursed lips or calm
What do the following terms mean: tachypnea, bradypnea, dyspnea, apnea, and orthopnea?
Tachypnea: Abnormally fast, greater than 20 breaths per minute
Bradypnea: Abnormally slow, less than 12 breaths per minute
Dyspnea: Shortness of breath
Apnea: Sudden stop of breathing
Orthopnea: sensation of breathlessness while laying down
What is a pulse oximeter? How does the pulse oximeter measure oxygen saturation?
Detects the amount of hemoglobin in arterial blood that is saturated with oxygen. By using cold light source through finger probe
How does the psychiatric nurse select an appropriate pulse oximeter site?
Finger, Toes, Nose, Earlobe
Choose the above based on factors that can affect reading
Anemia, impaired circulation, activity, jaundice, nail alterations/decorations, dark pigmentation, carbon Monoxide
What factors affect oxygen saturation readings?
Anemia, impaired circulation, activity, jaundice, nail alterations/decorations, dark pigmentation, carbon Monoxide
What is the normal range for oxygen saturation of a healthy adult? A patient experiencing COPD? A patient experiencing co-morbidities or an acute health challenge?
Healthy: 95 – 100%
COPD: 88 – 92 %
Co-Morbidity/Acute > greater than 92%
*Below 70% = Life threatening
What does blood pressure represent?
The force exerted on the walls of an artery by the pulsing blood under pressure from the heart
What is the normal range for the blood pressure of a healthy adult?
120/80 mmHg
100-139/60-89
What do the following terms mean: systolic, diastolic, pulse pressure, hypotension, hypertension, sphygmomanometer, and Korotkoff sounds?
Systolic: peak of maximum pressure when blood ejection occurs
Diastolic: minimum pressure exerted against the arterial walls when the ventricles relax
Pulse Pressure: difference between systolic vs diastolic. Used to indicate cardiovascular disease
Hypotension: low blood pressure, lower than 100/60 or 99/59 or below
Hypertension: high blood pressure, greater than 139/89 or 140/90 or above
Sphygmomanometer: blood pressure cuff
Korotkoff: sounds heard through stethoscope when blood pressure cuff is applied (occlusion)
What are common mistakes in blood pressure assessment?
Incorrect cuff size
Incorrect patient positioning
What does orthostatic/postural hypotension mean? How does the psychiatric nurse measure blood pressure to detect postural/orthostatic hypotension?
Experiencing low blood pressure/light headedness after standing up from sitting or laying down
Measure blood pressure laying down. Wait (1-3 minutes). Measure again standing up.
Why are proper body mechanics important in psychiatric nursing?
To ensure patient and nurse safety in clinical settings
What are the key principles relevant to body mechanics?
Use of correct muscles to complete activities (Client and Nurse)
Prevents unnecessary strain on any muscle or joint
To maintain body alignment, balance, and posture during activity or exercise
Reduces risk of injury to the nurse and the client during routine activities
Reduces fatigue of muscle groups
What five bed positions are used when performing activities of daily living?
Fowler’s
Semi-Fowler’s
Trendelenburg’s
Reverse Trendelenburg’s
Flat
What is the purpose of performing mouth care?
To assess condition of teeth, gums, lips, tongue, & buccal mucosa
What equipment would the nurse need to provide mouth care to the dependent patient? What equipment would the nurse need to provide mouth care to an independent patient?
Can use toothbrush, toothpaste, floss
Can use foam toothette swabs, tongue blade, mouth wash/chlorhexidine solution
How do you insert and remove dentures? What are important nursing considerations when caring for dentures?
Remove upper dentures followed by lower dentures
Moisten dentures, then insert upper denture followed by lower denture
Clean on a regular basis
Remove at night to give gums a rest and to prevent bacterial buildup
Keep covered in tepid water when not worn
Keep in an enclosed, labelled cup at patient’s bedside stand
DO NOT place on napkins, tissues, or food trays
What are important nursing considerations regarding a patient’s personal and cultural preferences related to hygiene/activities of daily living?
Social groups influence hygiene preferences/protocols (ex. types of products used, frequency, nature of care)
What are the key purposes of bathing?
Remove bacteria, increase blood circulation, decrease risk of infection and decrease skin breakdown
How does the psychiatric nurse perform a complete bed bath? What is a partial bed bath?
Complete: for patients who cannot bathe themselves, full body cleanse
Partial: cleansing areas that are hard to reach or cause discomfort for patients
While performing a bed bath, what areas of the skin could you assess on your patient?
Excessive dryness, rash, irritation, inflammation, wound status
Why does the psychiatric nurse wash extremities from distal to proximal?
Stimulates venous blood flow, preventing venous stasis (Use long firm strokes from hand to core)
What is meant by the term peri-care or perineal care?
Cleaning of genitalia and anal region
How does the psychiatric nurse provide perineal care for female and male patients?
Female: wash labia majoria from perinium to rectum, separate labia and wipe down in one smooth motion
Male: raise penis, wash tip with circular motion, from meatus outward
