Unit 4 Flashcards
Environment, basic needs, physical hazards, age/development
Safety factors
A basic human need ; Freedom from psychological and physical injury
Definition of safety
Home, community, school, hospital
Environments
Oxygen, nutrition, temp/humidity, cognitive awareness, emotional state
Basic needs
Enforce no smoking ; be aware of a decrease in oxygen availability
Basic need - oxygen
Lighting, obstacles, bathroom hazards, security, pathogens
Physical hazards
injuries are the leading causes of death in ages_____
1-25 years old
_______ _______ changes as the patients age
teaching purposes
in the event of a fire you will be expected to perform _____
R-A-C-E
Risk for physical violence and work related accidents
safety hazard for working in healthcare setting
rescue those who are in immediate danger
R in RACE
Pull the fire ALARM and call it in
A In race
contain or confine the fire ( close doors)
C in Race
Extinguish if its a small fire
E in Race
Pull Pin, Aim at base of fire, Squeeze and Sweep
PASS
harm to your patient, fellow worker or yourself; liability suit ; loss of licensure
violations in safety could result in…
lifestyle, neuro function, mobility function, cardiopulmonary function
health history data the nurse should gather
ask about the home environment and daily activities; meds they take
lifestyle
ask about balance and coordination
neuro function
ask about ambulatory aids, ex walkers canes, etc…
mobility function
ask about SOB or fatigue
cardiopulmonary function
unexplained bruises or cuts, LOC, how well they make decisions, Musculoskeletal assessment , changes in vitals signs with activity
important subjective and objective data that the nurse should gather
risk for injury, risk for poisoning, risk for aspiration, risk for impaired home maintenance
nursing diagnosis related to safety
variance and fall reports do not go into the chart because of _____ ______
legal reasons
free from injury, free from poisoning, etc..
Goals for safety
individualized for each pt ; focus on prevention, holistic in nature
Guidelines for nursing interventions relating to safety
wiping up spills, pick up packaging, putting equipment away
Ways to reduce physical hazards
physical hazards are reduced, basic needs are met, psychological status is not jeopardized, and transmission of infections are reduced
safe environment for patients
offer toileting and fluids frequently
Make sure basic needs are met
step in when any type of abuse is witnessed
psychological status is not jeopardized
hand washing and wearing gloves
Refusing transmission of infection
quality safety of education nursing
QSEN
demonstrate effective use of technology and standardized practices that support safety and quality
QSEN safety standards
demonstrate affective use of strategies to reduce risk of harm to others and self
QSEN safety Standards
use appropriate strategies to reduce reliance on memory
QSEN Safety standards
use of biological agents to create fear and threat; most likely form of terrorist attack
Bioterrorism
recognizing changes in trends in emergency rooms and urgent care, know policy and procedures, be familiar with syndromes associated with bio-terrorist acts
roles and responsibilities of a nurse in emergency management
restriction of freedom of movement or normal access to a person body that is not an usual part of treatment
restraints
meds such as anxiolytics and sedatives use to manage a patients behavior that is not a standard treatment
chemical restraints
manual, physical or mechanical device that reduce ability of a patient to move freely
physical restraints
Know agency policies, ongoing assessments are needed, must be clinically justified
legal implications for restraints use
reduce the risk of patient injury, prevent interruption of therapy such as IV, NG, Foleys, prevents patients from removing life supporting equipment , reduce risk of injury to others by the patient
objectives for use of restraints
weight sensitive mats, posey beds, side rails, alarms, and one on one
alternative to restraints
be aware of who is present, be cautious when leaving at night, do not share personal info, reports suspicious behaviors
Guidelines for keeping yourself safe
environmental factors, developmental needs, alternative food patterns, lifestyle, religious practice, economics
factors that affect nutrition
lifestyle, work schedule, poor meal choices, lack of access to full service grocery store
environmental factors that affect nutrition
food budget, infection, surgery,alcohol/ drug abuse, loss of energy , changes in bowel habits, inadequate diet for more than three days
cues for poor nutrition
past nutritional problems, eating habits, sociocultural patterns, perceived nutritional problems, medicine and supplementary intakes
health history data that is necessary for the nurse to gather
alert/ responsive, normal weight, well developed muscle tone, good attention span, bright clear eyes, normal heart rate and rhythm
signs of good nutrition
obesity, anorexia, rapid heart rate, easily fatigued, no energy , flaccid muscle tone
signs of poor nutrition
percent of the total blood volume made up of RBC
Hematocrit blood test
Measures the total amount of hemoglobin in the peripheral blood
hemoglobin blood test
hemoglobin and hematocrit
H and H
measures plasma protein in the blood
albumin blood test
to identify patients who are at risk for ASHD
Cholesterol blood test
risk for aspiration, deficient knowledge , imbalanced nutrition, risk for imbalanced nutrition, readiness for enhance nutrition, impaired swallowing, feeding self care deficit
nursing diagnosis related to nutrition
often done in collaboration with the physician/ dietician, should include patient teaching, provides assistance to create an atmosphere that encourages eating, explain special diets
nursing interventions relating to nutrition
NPO, clear liquid/ full liquid , soft mechanical and puree, low residue, low fiber, low fat, low sodium,
types of diets
daily activities , activity tolerance, health status, physical problems, mental status, age/ developmental influences,
Data gathered by nurse during assessment
body alignment, muscle mass and strength , ROM, ability to accomplish ADLs
parts of a physical exam relating to activity
impaired physical mobility, risk for disuse syndrome, ineffective airway clearance, risk for injury, insomnia
nursing diagnosis related to activity
if pt is experiencing any mobility problems goals and inspected outcomes are directed towards the _____ ______ ______ ______
promotion of physical activity
if a patient has problems related to decrease mobility the goals and expected outcomes are directed towards…
maintaining present function, preventing further muscle weakness, promoting optimal mobility prom
assess/ monitor health promotion activities, promote restorative care, promote fitness
nursing intervention related to activity
limited bed rest, good body alignment, ROM
assess/monitor pt health promotion activity
ambulation assistance, physical therapy
promote restorative care
aerobic, isometric, isokinetic, isotonic,
types of fitness
sustaines muscle movement, promotes cardiovascular functions and regulates weight control ex.. running, swimming, zumba
aerobic exercise
dynamic, active muscle movement, maintains tone and strength, promotes joint and bone health ex… ROM, swimming
Isotonic exercise
conditioning :used in rehab
isokinetic exercise
static movement , increases heart rate and cardiac output, muscle contractions with joint movement, used with hospital pts
isometric exercise
cyclical physiological process that alternates with longer periods of wakefulness, prevents fatigue for mind and body
sleep
state of being mentally relaxed, free from anxiety, and physically calm
Rest
to reduce stress, to restore biological process for the next period of wakefulness, to conserve and restore energy, to restore cognitive function, to dream
functions of sleep
NREM, REM
stages of sleep
non Rapid Eye Movement
NREM
Rapid Eye Movement
REM
day dreaming, 70-80 % of NREM sleep
Stage 1 NREM sleep
50% of total sleep ; 10-15 min
stage 2 of NREM sleep
more easily aroused in these stages
Stage 1 and 2 of NREM of sleep
deep sleep; there is rarely movement
stage 3 Of NREM
greatest depth of sleep where all functions slow down
Stage 4 Of NREM
deeper sleep; slow wave
Stages 3 and 4 of NREM
end of each sleep cycle; lasts 5-30 min ; dream state; distinct eye movement
REM Sleep
8-10 hrs at night, 15 hrs total, 30% of sleep time is in REM, 40-50 min sleep cycles
infants
12 hrs total, still need daytime naps up until the age 3
toddlers
12 hrs 20% REM sleep, night mares ; might need night light
Preschoolers
11-12 hrs
school age
7 1/2 hrs of sleep
adolescents
6-8 1/2 hrs , insomnia starts to occur because of stress
young adult
number of hrs decline, insomnia is common
middle adult
50% report sleeping problems, takes more time to fall asleep, less REM sleep, Difficult to restore themselves cognitively
elderly adult
drugs/ substances, lifestyle, sleep patterns, emotional stress, environment, exercise/fatigue,food intake
factors affecting sleep
meds and antidepressants, caffeine, alcohol
drug/substances that affect sleep
daily routines, patterns, traveling in different time zones, shift work, night or day, late night life
lifestyle
chronic insomnia, falling asleep driving
usual sleep patterns
ventilation, mattress, snoring , tv
environment
if you exercise it does help with sleep
exercise and fatigue
poor sleep, nocturnal syndrome
emotional stress
develop good eating habits, do not eat large meals, or spicy meals before sleep, alcohol
food/ calorie intake that affects sleep
chronic difficulty falling asleep, most common sleep disorder, nonrestorative sleep
insomnia
cessation of breathing or stopping of breathing for a time during sleep
sleep apnea
Headaches, constipation can be caused by
Circadian rhythm
genetic, excess of daytime sleeping
hypersomnia
falling asleep whenever
narcolepsy
somabulism, sleep talking, sleep walking, enuresis, nightmares, night terrors, errections
parasomnias
most common in children as trying to get into REM sleep
somabulism
occurs during non REM and the beginning of REM cycle
Sleep walking
bed wetting
enuresis
form of seizure , involuntary response
night terrors
Restless Leg Syndrome
RLS
Periodic Limb Movement
PLM
Teeth Grinding, possible seizure
Bruxism
genetics, sleep pattern, narcolepsy, some insomnia & somabulism, lifespan , consideration, age, developmental factors
other factors affecting sleep
actual intolerance, sleep pattern disturbance, fatigue , anxiety
nursing diagnosis applicable to sleep
support rituals, create a restful environment, decrease distractions, try alternative supplements
Nursing interventions relating to sleep
if possible avoid sleeping pills
should be non pharm
