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Nursing > TAFE - Sem 1 Labs > Flashcards

TAFE - Sem 1 Labs Flashcards

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1
Q

When is it appropriate to wash your hands in the clinical setting?

A

5 points of contact.

Pg. 6

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2
Q

How long should you wash your hands for?

A

Social: 15 - 30 seconds
Clinical: 1 - 2 minutes

Pg. 6

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3
Q

What is the difference between a social and a clinical hand wash?

A

Social to wrist
Clinical to elbow

Pg. 6

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4
Q

When should you wear gloves?

A

When there is the possibility of bodily fluid contact.

Pg. 6

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5
Q

When should you change your gloves?

A

When you finish with each patient and procedure.

Pg. 6

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6
Q

In what order do we put our PPE on and take it off?

A

Donning: Gown, mask, eyewear, gloves
Doffing: Gown, gloves, eyewear, mask

Pg. 6

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7
Q

What goes in general waste?

A

Packaging, flowers & newspapers

Pg. 6

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8
Q

What goes in clinical waste?

A

Things contaminated with bodily fluids, dressings, infectious materials and waste.

Pg. 6

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9
Q

Where would a used needle be disposed?

A

Sharps disposal.

Pg. 6

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10
Q

What are the 5 moments of contact?

A
  1. Before touching a patient
  2. Before a procedure
  3. After a procedure or body fluid exposure risk
  4. After touching a patient
  5. After touching a patient’s surroundings.

Pg. 9

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11
Q

What is one thing you can do to increase patient trust?

A

Build rapport, converse.

Pg. 10

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12
Q

What information do you need to check before you perform a sponge?

A

Client’s autonomy & comfort, checking for any obvious excretions.

Pg. 11

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13
Q

What questions should you ask your patient prior to performing a sponge?

A

How they are feeling, if they have any pain etc.

Pg. 11

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14
Q

What are the most important points to consider during a sponge?

A

Bodily discharges and secretions, ensuring you are wearing correct PPE.

Pg. 11

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15
Q

How do you ensure client safety during the procedure?

A

Ensuring you have enough staff in relation to the patient’s autonomy

Pg. 11

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16
Q

What do you need to do before leaving a patient?

A

Ensure they have all the things they may require, and that they are comfortable.

Pg. 11

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17
Q

What are the legal requirements of a progress note?

A
  1. Date and Time (Using 24 hour format)
  2. Nursing Entry: (You must identify which stream of health care you are with)
  3. Black pen
  4. No spaces
  5. Errors (Cross out with one line and initial beside)
  6. Signature [SIGNATURE (SURNAME) EN Facility or Organisation]
  7. Check ID of patient

Pg. 12

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18
Q

What is ISBAR, what does it stand for and how do you perform it?

A

ISBAR is a verbal handover technique that can also be utilised for progress notes.

I : Identity - Who are you handing over? (Introduce Pt/Nurse & build rapport)
S : Situation - What is the situation?
B : Background - What is the clinical relevant history?
A : Assessment - What is the problem?
R : Recommendation - What do I recommend/request to be done?

Pg. 13

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19
Q

In what direction do we wash genitals?

A

“Clean” to dirty, front to back

Pg. 14

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20
Q

What must we do when cleaning eyes?

A

Start at the tear duct, fold cloth each time

Pg. 14

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21
Q

When do we take our gloves off when doing a sponge?

A

Before touching clean sheets, if we come in contact and must rewatch, and upon completion of task

Pg. 14

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22
Q

When do we change water during a sponge?

A

If it becomes dirty, cold, contaminated or soapy

Pg. 14

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23
Q

What is a CVA?

A

A Cerebral Vascular Accident

  • A lack of blood flow to the brain causing death of tissue.
  • a stroke

Pg. 15

24
Q

Why are TEDS used?

A

Primary use is to prevent DVT.
For patients with a reduction in mobility, or with cardiac issues that may cause oedema.

Pg. 15

25
Q

If a patient has CVA with Left hemiplegia, which arm will you undress first and redress first?

A

Undress the unaffected arm first to assist with undressing and redress with the affected arm first.

Pg. 15

26
Q

What is hemiplegia?

A

Half body weakness

Pg. 15

27
Q

What questions should you ask your patient prior to performing a shower?

A

For their consent, whether they would like to use the toilet first, if they want their hair washed, what outfit they’d like.

It is also important to consult the care plan and be aware of their mobility level.

Pg. 15

28
Q

Name 2 things that promote safety during a shower?

A

Make sure they’re seated safely, hand rails, non-slip mats, non-slip shoes, water temperature (check on self first), allergies, care plan.

Pg. 15

29
Q

What must we ensure when we have a patient on a shower chair?

A

Chair is clean, they are never alone, are sitting correctly and are afforded dignity.

Pg. 16

30
Q

What must we ensure when we leave a patient’s room?

A

They have everything they require and are comfortable.
They have the call button, and the bed is at an appropriate height.

Pg. 16

31
Q

Why do you need to use 2 slide sheets?

A

Using two slide sheets is necessary to make use of low friction.

Pg. 17

32
Q

Do we use brakes on a hoist?

A

Brakes should only be used during storage or when lifting a person from the floor.

Pg. 17

33
Q

Name two things that promote safety during mobilisation?

A

The patient is not alone whilst elevated, the correct sling size for the person is being utilised, the destination is prepared, the equipment is functional, the care plan has been checked, appropriate footwear, good communication and no hooking.

Pg. 17

34
Q

How many people are required to operate a hoist?

A

Two.

Pg. 17

35
Q

What do you do if a patient falls? Name your immediate actions.

A

Press the assist button, assess for injury, organise a visit by a qualified person, DRSABCD & COWS, keep the patient still.

Pg. 17

36
Q

What does COWS stand for?

A

Can you hear me?
Open your eyes.
What’s your name?
Squeeze my hand.

37
Q

What does DRSABCD stand for?

A

Danger - Check the surrounding area for dangers.
Response - COWS, if there is a response make them comfortable and monitor for changes in responsiveness
Send for help - Ask a person to call for an ambulance
Airway - Open mouth and check for possible obstructions. If foreign material is present, place into recovery position and clear airway with fingers.
Breathing - Look, listen, feel; if there is normal breathing place into recovery position and monitor their breathing.
CPR - 30 chest compressions + 2 breaths; 100-120bpm. Continue until help arrives or individual recovers.
Defibrillation - Apply defibrillator and follow prompts.

38
Q

How do we measure a hoist sling?

A

From over the tip of the head (by at least 2cm) to the end of the coccyx.
Hoist slings are identified by colour.

Pg. 17 & 18

39
Q

Are the legs if the hoist open or closed when lifting a patient?

A

Open for balance as this provides a wider more stable base.

Pg. 18

40
Q

When using slide sheets would you place the smaller sheet on the top or bottom and why?

A

The smaller sheet is on the bottom as a smaller area is needed for frictionless movement and so the patient is covered from head to toe.

Pg. 18

41
Q

When choosing bed height, is it measured with tallest or shortest person?

A

The shortest persons hip height.

Pg. 18

42
Q

If a patient has dysphagia, how will that affect their eating and drinking?

A

Dysphagia means the patient will have difficulty swallowing or cannot swallow.

Pg. 19

43
Q

What is Dysphasia?

A

Dysphasia is difficulty with speech.

Pg. 19

44
Q

How do you assist a patient with dysphagia to eat and drink?

A

Sit the patient up to eat and alter the texture of food and drink.

Pg. 19

45
Q

What are some signs and symptoms (clinical manifestations) of aspiration?

A
  • Watery eyes
  • coughing, choking
  • SOB or fatigue while eating
  • fever within half an hour of eating
46
Q

What are the different levels of fluid thickness (viscosity)

A
  1. Thin / Normal
  2. Clear fluids
  3. 150 mildly thickened
  4. 400 moderately thickened
  5. 900 extremely thickened

Pg. 19

47
Q

What are the stages of food presentation?

A
  1. NWD - Normal ward diet
  2. Cut up / soft
  3. Minced & Moist (gravy)
  4. Purée

Pg. 19

48
Q

What are ways to reduce reduce pressure areas?

A
  1. Change the patients position
  2. Change the mattress
  3. Pillows to protect areas likely to rub and bony prominences
  4. Maintain skin integrity - moisturise
  5. Bed cradle - also adding pleats or loosening the top sheet to prevent tension
  6. Ensure patient is dry and not sweaty

Pg. 19

49
Q

What are some risk factors for pressure areas?

A
  1. Immobility
  2. Incontinence
  3. Lack of sensory perception
  4. Poor nutrition & hydration
  5. Conditions that affect blood flow

Pg. 19

50
Q

What is the purpose of a Waterlow Pressure Ulcer Continuous Risk Assessment?

A

To assess the level of risk your patient is at of developing pressure injuries.

Pg. 19

51
Q

How do you calculate BMI?

A

Weight(in Kg) divided by height (in metres) squared.

52
Q

If you are hoisting a pt to the shower chair, are their pants on or off?

A

Off, as removal is difficult once they are seated.

Pg. 20

53
Q

Name two things to ensure pt safety?

A

Waterlow assessment, falls risk assessment, putting items in reach, & on their unaffected side if they have hemiplegia.
Pg. 20

54
Q

What should you check before feeding a pt?

A

Their viscosity requirements, and if they are allowed to eat (NBM)

55
Q

What is a “normal “ blood pressure range and what is the terminology for “abnormal” ranges?

A

“Normal” BP is 100-140 systolic and 60-90 diastolic.
If a blood pressure is above this range the patient is hypertensive or have hypertension, if it is below they are hypotensive or have hypotension.
Pg. 21

56
Q

What is a “normal” pulse rate and what is the terminology for “abnormal” rates?

A

A “normal” pulse rate is 60-100 beats per minute.
If the pulse rate is above this they have tachycardia or are tachycardic. If it is below this range they are bradycardic or have bradycardia.
Pg. 21

Nursing (23 decks)

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