POD quiz (1-4) Flashcards
What are risk factors/hazards that pose a threat to patient safety?
Cognitive risk factors, ABCCS, Patient position in bed, Bed rails (min 1 & max 3), Bed breaks, Bed in lowest position, Bed/chair alarm on, safety belt on in chair, Environmental risk factors (clutter, sharps, spills)
What would you include in a patient and bedside safety check?
ABCCS, bed rails, brakes, bed is in lowest position, call-bell within reach, clutter free
Suction meter testing (suction meter, suction liner, plastic suction canister, tubing, yankauer
Oxygen meter testing (oxygen meter, white nipple), Nasal prongs, simple oxygen mask, suction catheter kit,
Make sure safety equipment bag is located near bed/patient
What is cultural safety?
provide care in an appropriate manner through 6 standards: self-evaluation, education, anti-racism, safe environments, relational care, and trauma-informed practice
How can you incorporate cultural safety and humility into your clinical practice?
through self-reflection practice, examine your beliefs, values and how they present
How can you incorporate anti-racism into your clinical practice?
through anti-racism practice, supporting individuals who have been exposed to racism
What are the links in the chain of infection and why is it important for Psychiatric Nurses to understand the infectious process?
Infectious agent (pathogen causing infection)
Reservoir (source for pathogen survive, may or may not multiply)
Portal of exit from reservoir (point of escape)
Mode of transmission (vehicle on or by which microorganism can travel) (direct contact, indirect: vehicle or vector, airborne, droplet)
Portal of entry to host (point of entry into susceptible host)
Susceptible host
Important because want to keep ourselves safe and the patients safe as well
What is the difference between medical and surgical asepsis?
Medical asepsis = “clean technique” aimed at controlling microorganisms & used for all clinical patient care activities (reduces # of pathogens)
Surgical asepsis = “sterile technique” aimed at removing all microorganisms and is used for all surgical/sterile procedures (eliminates ALL pathogens)
What is hand hygiene?
Most important and basic technique in preventing the transmission of infections, includes using an instant alcohol hand antiseptic before and after providing patient care
What are the five key moments for hand hygiene?
Before touching patient, before clean/aseptic procedures, after body fluid exposure, after touching patient, after touching patient surroundings
What are the indications for hand washing versus alcohol-based gels/sanitizers?
Handwashing:
Visibly soiled/dirty
Working with patients who have C. diff or norovirus
If hands exposed to blood or body fluids
How long should hand washing be carried out?
15 seconds of the actual washing the hands (scrubbing of hands)
40 - 60 seconds total for whole procedure
When should non-sterile clean gloves be utilized?
Before aseptic procedure, when anticipating contact with blood or body fluid, non-intact skin, mucous membranes, or equipment or environmental surfaces contaminated with blood or body fluids, when in contact with patient or equipment or environment during additional precautions
What are routine practices/standard precautions?
Based on the premise that all patients are potentially infectious, even when asymptomatic, and IPAC routine practices should be used to prevent exposure to blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, or soiled items
What are additional/isolation precautions? What is a point of risk assessment?
Point of risk assessment is first step in routine practices, involves assessing the infection risk posed to themselves and others by the patient, a procedure or a situation
Precautions implemented in addition to routine practices for patients with known or suspected to be infected with certain microorganisms, Mode of transmission will direct type of additional precaution
After making an unoccupied/occupied bed, what actions would you take to ensure patient safety and comfort?
use of bed rails for support while turning/positioning, call bell in reach, bed proper position, tighten linens, adjust patient often
What is the normal range of temperature for a healthy adult?
36-38C
What factors can affect the patient’s temperature?
Age, exercise, hormone level, circadian rhythm, stress, environment, fever, hyperthermia, heatstroke, hypothermia,
What are the sites used to assess body temperature?
tympanic membrane, oral, axillary, temporal sites
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?
Effect the oral cavity and give an inaccurate reading
Hot & cold: 20 mins
Gum: 5 mins
Smoking: 2 mins
What do the following terms mean: core temperature, fever/pyrexia, and afebrile?
Core temperature: temperature of structures deep within the body
Fever / pyrexia: heat-loss mechanisms unable to keep pace with excess heat production; resulting = body temperature rises to abnormal level
Afebrile: when the fever breaks
What is the normal range of heart rate for a healthy adult?
60 - 100 beats per min
What factors can affect the patient’s heart rate?
Exercise, temperature, emotions, pain, medications, hemorrhage, postural changes, pulmonary conditions
What do the terms rate, rhythm (irregular/regular), and quality (strength) mean in relation to assessing the pulse?
Rate: number of pulsing sensations occurring in 1 min
Irregular rhythm: abnormality of heart’s rhythm
Regular rhythm: normal sinus rhythm = 60 – 100 b/min
Quality (strength): strength in regard to blood volume and heart contraction
What do the terms tachycardia and bradycardia mean?
Tachycardia: abnormally fast heart rate = > 100 b/min
Bradycardia: slow heart rate, < 60 b/min
What are the two common pulse sites used to assess the heart rate?
Radial (thumb side of forearm at wrist) & apical (4th-5th intercostal space at left mid-clavicular line)
What is the normal respiratory rate range of a healthy adult?
12 - 20 breaths / min inhalation & exhalation is one breath
What factors affect the patient’s respiratory rate? (8)
Exercise, acute pain, anxiety, smoking, body position, medications, neurological injury, hemoglobin function
How does the psychiatric nurse assess the respiratory rate?
Right after measuring the pulse while hand remains on patient’s wrist as it rests over abdomen or chest
Observation respirations for 30 seconds and multiply by 2
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: carbon dioxide exits the lungs at the same rate that the body produces it
Rhythm: determined by observing the chest or abdomen, diaphragmatic breathing results from contraction & relaxation of diaphragm & best observed by watching abdomen (men & children) & women use thoracic muscles to breathe = best observation is upper chest
Depth: assessed by observing degree of excursion or movement of the chest wall, deep = full expansion of the lungs with full exhalation
What do the following terms mean: tachypnea, bradypnea, dyspnea, apnea, and orthopnea?
Tachypnea: rate of breathing is regular but abnormally rapid (> 20 breaths/min)
Bradypnea: rate of breathing is regular but abnormally slow (< 12 breaths/min)
Dyspnea: uncomfortable abnormal awareness of breathing (shortness of breath)
Apnea: respirations cease for several seconds then resume, persistent cessation results in respiratory arrest
Orthopnea: sensation of breathlessness in the recumbent (laying down) positions relieved by sitting or standing
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
Sites to take = finger, toe, nose, & earlobe
How does the psychiatric nurse select an appropriate pulse oximeter site?
Assessing capillary refill and skin condition
What factors affect oxygen saturation readings?
Anemia, impaired circulation, activity, jaundice, nail polish/artifical nails, dark pigmentation, carbon monoxide poisoning
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?
95 - 100%
88 - 92%
> 92%
SpO2 > 92% (as presented in lecture due to being in hospital setting)
What is the SpO2 percentage of someone in hospital… > 92%
What does blood pressure represent?
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?
Systolic: 100 - 139 mmHg
Diastolic: 60 - 89 mmHg
What do the following terms mean: systolic, diastolic, pulse pressure, hypotension, hypertension, sphygmomanometer
Systolic: maximum pressure when ejection occurs
Diastolic: ventricles relax, the blood remaining in arteries – minimal pressure exerted against arterial walls
Pulse pressure: difference between systolic & diastolic
Hypotension: blood pressure lower than 100/60 be specific during exam - give number
Hypertension: blood pressure higher than or equal to 140/90
Sphygmomanometer: instrument for measuring blood pressure
what are Korotkoff sounds?
1st: clear rhythmical tapping that corresponds to pulse rate & gradually increases in intensity systolic
2nd: blowing or swishing sound occurs as the cuff continues to deflate (as artery distends, blood flow becomes turbulent)
3rd: crisper and more intense tapping
4th: muffled and low-pitched as the cuff is further deflated diastolic
5th: disappearance of sound
What are common mistakes in blood pressure assessment?
Bladder or cuff too wide, bladder or cuff too narrow or too short, cuff wrapped too loosely or unevenly, deflating cuff too slowly, deflating cuff to quickly, arm below heart level, arm above heart level, arm not supported, stethoscope fits poorly or impairment of the examiner’s hearing, causing sounds to be muffled, stethoscope applied too firmly against antecubital fossa, cuff inflating too slowly, repeating assessments too quickly, inadequate inflation level, multiple examiners using different korotkoff sounds for diastolic readings
What does orthostatic/postural hypotension mean? How does the psychiatric nurse measure blood pressure to detect postural/orthostatic hypotension?
Normotensive person (person with normal blood pressure) develops symptoms of low blood pressure when rising to an upright position developing symptoms like dizziness,
Blood pressure and pulse are obtained with the patient supine, sitting, and standing (readings obtained 1 to 3 minutes after patient changes positions)
Why are proper body mechanics important in psychiatric nursing?
reduces risk of injury, prevents unnecessary strains, maintains body alignment/balance/posture, and reduces fatigue of muscles
What are the key principles relevant to body mechanics?
Wide base of support
Low center of gravity
Face direction of movement
Prevent abnormal twisting
Avoid lifting (roll, turn, or pivot instead)
What five bed positions are used when performing activities of daily living?
Fowler’s (sitting) (45-60 degrees)
Semi-fowler’s (35-45 degrees)
high fowler (60-90 degrees)
Trendelenburg’s (laying on back, head below feet – diagonal)
Reverse trendelenburg’s
Flat
What is the purpose of performing mouth care?
maintains healthy state of mouth, decreased gum disease, removes food/plaque/bacteria. decreased risk of aspiration pneumonia
Asses the 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?
Dependent: use foam toothette swabs, tongue blade, mouth wash/chlorhexidine solution
Independent: do themselves with toothbrush, toothpaste, floss
How do you insert and remove dentures? What are important nursing considerations when caring for dentures?
Grasp upper plate at front with thumb & index finger and pull downwards, lift lower denture from jaw and rotate one side downward to remove, moisten upper denture and press firmly to seal
clean dentures, remove at night, soak in tepid water, keep in closed container (labelled)
What are important nursing considerations regarding a patient’s personal and cultural preferences related to hygiene/activities of daily living?
Be careful of intruding in someone’s personal space and touch, ask what would make the patient feel most comfortable, for hygiene, patient may not want it done, be understanding and try to work out a compromise with patient as hygiene is important to prevent infection and skin breakdown
What are the key purposes of bathing?
Clean and deodorize skin, stimulate circulation, promote sense of well-being, and promote relaxation/comfort
How does the psychiatric nurse perform a complete bed bath? What is a partial bed bath?
washing all body parts including perineum (dependent)
Partial: bathing only those parts that would cause discomfort or odour if not cleaned – including perineal care and areas hard to reach
While performing a bed bath, what areas of the skin could you assess on your patient?
skin folds and creases, bony prominences (ears, shoulders, hips, outer knees, between knees, between ankles, outer ankles), wounds
Why does the psychiatric nurse wash extremities from distal to proximal?
Stimulates venous blood flow which prevents venous stasis
What is meant by the term peri-care or perineal care?
Perineal care: washing the genital and rectal areas of body especially for someone who is more susceptible to infection like someone with in-dwelling catheters, recovering from rectal or genital surgery or childbirth, uncircumcised males
How does the psychiatric nurse provide perineal care for female and male patients?
Female: wash labia majora – wiping from perineum to rectum, separate labia exposing urethral meatus & vaginal orifice, wash downward from pubic area toward rectum in one smooth stroke, cleanse thoroughly around labia minora, clitoris, and vaginal orifice, assist patient back into comfortable position
Male: gently raise penis & place bath towel underneath, gently grasp shaft of penis (patient uncircumcised, retract the foreskin), wash tip at urethral meatus first (using circular motion, clean outward), wash shaft with gentle but firm downward strokes, gently clean scrotum (making sure to wash underlying skin folds), assist back to comfortable position
bed making ensuring medical asepsis/standards
inspection of linens - clean/dry/wrinkle free, keep soiled linens away from uniform, and placed into hamper, do not shake or put on floor
