Week Two Flashcards
What are the most common safety hazards occurring through the life cycle?
age and development, lifestyle, mobility and health status, sensory perceptual alterations, cognitive awareness, emotional state, ability to communicate, safety awareness, environmental factors
What is the purpose of the NAtional Patient Safety Goals?
System wide solutions. bar coding medication patient identification, number of times you ask about surgery
Bioterrorism
intentional attack using weapons of viruses, bacteria, and other germs
What is an adult home hazard appraisal?
Assessing the home for potential causes of falls, fires, poisoning, suffocation, and other accidents
Four specific phases of disaster planning
mitigation, preparedness, response, recovery
RACE
Remove clients from danger, activate fire alarm, contain the fire, extinguish the fire when confinable and evacuate the area as directed
Hendrich Assessment
get up and go test - fall assessment
Safety Monitoring Device
Leg Band Alarm, Bed Exit Monitoring Alarm. side rails do not protect all clients from falls
Restraints
protective devices used to limit the physical activity of the client or a part of the body
Physical Restraint
any manual method or physical or mechanical device, material, or equipment attached to the client’s body. They cannot be moved easily and they restrict the client’s movement
Chemical Restraint
Medication
Reasons for restraint use acceptable
to avoid and/or prevent purposeful or accidental harm to the client, to do what is required to provide medically necessary treatment that could not be provided by any other means
How long after applying restraints must the RN have to practitioner see the client face-to-face?
1 hour for evaluation
How long is a written restraint order valid for?
4 hours
Surgical Care- How long after applying restraints must the RN recieve the primary care’s written order?
12 hours
Surgical Care - How often must the restraint order be renewed?
daily
What do both standard of restraints require?
reason, time frame, type of restraint, continual monitoring, RN documentation that the need for the restraint was made clear both to client and support person, clients have a right to be free from restraints that are not medically necessary, restraints cannot be used for staff convenience or client punishment, restraints use only after every possible means of ensuring safety are unsuccessful and documented
Alternatives to restraints
buddy systems take turns staying with and observing client, place unstable client sin an area that is constantly or closely supervised, prepare clients before a move to limit relocation shock and confusion, stay with client using a bedside commode or bathroom if client is confused or sedated or has a fait disturbance or a high risk score for falling, monitor meds, lowest position beds, use 1/2-3/4 rather than full length side rails, removable lap table, wedge pillows or pads against the sides of wheelchairs, relaxation techniques, personal items, ongoing assessment
Jacket (vest)
safety of confused or sedated clients
Extremity Restraint
immobilize limb for therapeutic reasons
Waist/Belt Restraint
used when moved on stretcher or wheelchair
Elbow Restraints
used to prevent infants and small children from flexing elbow
Mitt Restraint
prevent confused client from using hands or fingers to scratch or injure themselves or pulling medical equipment out
Four basic elements for body alignment and mobility
alignment and posture, joint mobility, balance, coordinated movement
Alignment and Posture
bring body parts into position in a manner that promotes optimal balance and max body function whether the individual is standing, sitting, or lying down
Three important principles of alignment and posture
center of gravity, line of gravity, base of support
Center of Gravity
point at which all of the body’s mass is centered
Line of Gravity
imaginary line drawn through the body’s center of gravity
Posture
position of the body in relationship to the surrounding space.
Base of Support
foundation on which the body rests, the broader the base of support and the lower the center of gravity, the greater the stability and balance
Joint Mobility
functional unit of the musculoskeletal system
ROM
maximum movement that is possible for a joint
Pronation
moving the bones of the forearm so that the palm of the hand faces downward when held in front of the body
Eversion
turning the sole of the foot outward by moving the ankle joint
Extension
increasing the angle at the joint
supination
moving the bones of the forearm so the the palm of the hand faces upward when held in front of the body
Internal Rotation
inward movement of the bone around it’s central axis
Abduction
movement of the bone away from the midline of the body
Adduction
movement of the bone toward the midline of the body
Flexion
Decreasing the angle of the joint
Dorsi-flexion
point the toes of each foot upward
inversion
turning the sole of the foot inward by moving ankle joint
hyperextension
further extension or straightening of the joint
plantar flexion
point the toes of each foot downward
external rotation
external movement of the bone around its central axis
Balance
mechanisms involved in maintaing balance and posture.
Balance body parts
labyrinth (inner ear), vision, stretch receptors of muscles and tendons
Proprioception
awareness of posture, movement, changes in equilibrium, knowledge of position, weight, resistance of objects in relation to body
Coordinated Movement
balanced, smooth, purposeful movement is the result of proper functioning of cerebral cortex, cerebellum
Cerebral Cortex
initiates voluntary motor activity
Cerebellum
coordinates the muscles involved in voluntary movement
Isometric Exercise
muscle contraction without moving the joint (no change is muscle length), exerting pressure against a solid object, mild increase in HR and cardiac output, no apparent increase in blood flow to other parts of the body, strengthening abdominals, gluteal, and quads, maintaining strength in immobilized muscles in casts or traction, endurance training
Isotonic Exercise
Muscle shortening to produce muscle contraction and active movement, HR and cardiac output increase to increase blood flow to all parts of the boy, useful for increasing muscle tone, mass, and strength, running, walking, swimming, cycling
Isokinetic Exercise
resistive exercise, an increase in BP and blood flow to muscle occurs, muscle contraction or tension against resistance, used in physical conditioning and build up certain muscle groups, lifting weights
Example Isokinetic
weight lifting
Example Isotonic
swimming, walking, running, cycling
Example Isometric
quad sets
Aerobic Exercise
activity during which the amount of oxygen taken in the body is greater than that used to perform the activity. use large muscle groups that move repetitively, improve cardiovascular conditioning and physical fitness
Anaerobic Exercise
involved activity in which muscles cannot draw out enough oxygen from the blood stream and anaerobic pathways are used to provide additional energy for a short time. endurance training, weight lifting, sprinting
Preambulatory exercises
strengthen muscles for walking for clients who have been immobilized for a prolonged period. Quad drills or sets
Passive ROM
another person moves each of a client’s joints through complete range of movement as ordered while awake to maintain joint flexibility
Active ROM
isotonic exercises in which the client moves each joint in the body through its complete range of motion to maintain or increase muscle strength and endurance, help to maintain cardiorespiratory function in immobilized client, prevent deterioration at joint capsules and contractures
Active Assistive ROM
client uses stronger opposite arm or leg to move each joint of a limb incapable of active motion and continues movement passively to its max degree to learn to support and move the weak arm or leg and increase active movement on the strong side and maintain joint flexibility on the weak side
stance phase
hell of one foot strikes the ground, body weight is spread over that foot while the other heel pushes off and leaves the ground
swing phase
leg from behind moves in front of the body
friction
a force acting parallel to the skin surface
how much are we allowed to lift
35 pounds
bad things body mechanics
twisting, stooping
Purpose of transfer gait belt
safety device used for moving of transferring a client
Hydraulic lift device
used for clients who cannot help themselves or who are too heavy for others to lift
Lateral Assist Device
reduce client surface friction during side to side transfers. roller boards, slide boards, transfer boards
Supine Position
back lying position
Supine and dorsal recumbent positions purpose
provide comfort and facilitate healing following certain surgeries or anesthetics
dorsal recumbent position
back lying with head and shoulders slightly elevated on a small pillow
Prone position
lies on abdomen with head turned to one side
prone purpose
to prevent hip and knee flexion contractures, promotes drainage from the mouth and useful for unconscious clients or clients recovering from surgery of mouth or throat
Lateral/Side Lying
lies on one side of body
lateral side lying purpose
used for resting and sleeping clients, relieves pressure on scrum and heels in individuals who sit for much of the day or who are confined to bed
Sim’s (semi-prone)
assumes posture halfway between lateral and prone position
sim’s purpose
facilitate drainage from mouth, prevent aspiration of fluids
Paraplegia
paralysis of the legs
quadriplegia
paralysis or the legs, arm, trunk, of the body below the level of associated injury to the spinal cord
Semi-Fowler’s
15-45 degree with or without knee flexion
Fowler’s
45-60 degrees with or without knee flexion
High Fowler’s
60-90 degrees with or without knee flexion
Fowlers’ positions purpose
difficult breathing and some people with heart problems
Pressure ulcer
injury to the skin and/or underlying tissue usually over a bony prominence as a result of force alone or in combination with movement
Pressure Area
compressing downward force on a body area
Ischemia
a deficiency in the blood supply to the tissue
Reactive Hyperemia
bright red flush of skin
Vasodilation
extra blood floods to the area to compensate for the preceding period of impeded blood flow
Pressure Duration
low pressure over a prolonged period causes tissue damage, as well as high intensity pressure over a short period of time
Tissue Tolerance
ability of the tissue to endure pressure depends upon the integrity of the tissue and the supporting structures
Risk factors that contribute to the formation of pressure ulcers?
friction, shearing force, immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, chronic medical condition, other factors
Shearing Force
a combination of friction and pressure that occurs when a client assumes a sitting position in bed because the body tends to slide downward toward the foot of the bed because the deeper tissues and the superficial tissues meet which causes damage to the blood vessels and tissues in the area
Nutrition for pressure ulcers
2,500 mL fluid daily, high protein, A C B1 B5 zinc
Braden Scale for predicting pressure sore risk
sensory perception, moisture, activity, mobility, nutrition, friction and shear
braden scale scoring
lower the number, higher the risk
norton’s pressure area risk
general physical condition, mental status, activity, mobility, incontinence
Pressure Ulcer definition
localized injury to the skin and or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction
Suspected Deep Tissue Injury
purple or maroon localized area of discolored, intact skin or blood filled blister due to damage of underlying soft tissue from pressure and or shear. the area may be preceded by tissue that is painful firm mushy body warmer or cooler as compared to adjacent tissues
Stage 1 Pressure Ulcer
intact skin with non-blanchable redness of localized area usually over a bony prominence. darkly pigmented skin may not have visible blanching, its color may differ from the surrounding area. may be painful, firm, soft, warmer or cooler. may be difficult in niggers
Stage 2 Pressure Ulcer
partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough may also present as an intact or open/ruptured serum-filled blister. shiny or dry shallow ulcer without slough or bruising
Stage 3 Pressure Ulcer
full thickness tissue loss. subcut fat may be visible but bone tendon or muscle are not exposed. slough may be present but does not obscure the depth of tissue loss. may have tunneling
Stage 4 Pressure Ulcer
full thickness tissue loss with exposed bone tendon or muscle. slough or eschar may be present on some parts of the wound bed often includes undermining or tunneling
Unstageable Pressure Ulcer
full thickness tissue loss in which the base of the ulcer is covered by slough and or eschar in the wound bed
What must be documented for pressure ulcers?
location, size, presence of undermining or tunneling, stage of the ulcer, color of the wound bed, condition of the wound, condition of exudates
Serous
serum, clear, watery
Sanguineous
hemmorhagic, large amounts of red blood cells, seen in open wounds
Serosanguineous
clear and blood tinged drainage
purulent
thicker, pus, blue, green, yellow
Diagnosis Impaired Skin Integrity
stage one or stage two pressure ulcers, applies to pressure ulcers and wound extending through the epidermis but not through the dermis
Diagnosis impaired tissue integrity
stage three or four pressure ulcers and suspected deep tissue injury, applies to pressure ulcers and to wounds extending in subcut tissue muscle or bone
Trapeze
Triangular metal apparatus above a bed to assist in moving and turning clients, patient can grasp the bar with one or both hands and then raise the trunk from the bed when moving the client, makes moving and turning easier
Overbed cradle
metal frame that supports the bed linens away from the patient while providing privacy and warmth
Egg Crate Mattress
provides comfort and helps to distribute body weight evenly, pressure reduction for high risk clients, reduces pressure on bony prominences
Water Bed
filled with water, controls temp of water to prevent or treat pressure ulcers, high risk client, stage one or two pressure ulcer, prevents or treats ulcers by equalizing pt weight against the support
air fluidized static high air loss bed
forced temp controlled air circulated around millions of tiny silicone coated beads producing a fluid like movement, uniform support to body contours, decreases skin maceration by its drying effect
static low airloss bed
air filled cushions divided into four or five sections, separate control permits each section to be inflated to a diff level, prevention of skin breakdown in clients who cannot turn themselves or have existing skin breakdown
alternating pressure mattress
composed of a number of cells in which the pressure alternately increases and decreases, uses a pump, pressure can be reduced over bony prominences
gel floatation pads
filled with a gelatinous substance similar to fat to distribute weight over entire flotation pad, when sitting the weight is distributed evenly
Sheepskins
natural and artificial pads that limit pressure to affected areas, limit pressure on area of skin when the client is in bed
Yellow wound
cleanse
Red Wound
protect
Black Wound
debride
Granulation Phase
tissue needs to be protected to avoid disturbance of regeneration tissue
Debridement
removal of nonviable tissue (necrotic tissue) from a wound
Why do you debride a wound?
remove: tissue contaminated by bacteria and foreign bodies thereby preventing the client from invasion of bacteria, devitalized tissue or burn eschar in preparation for grafting and wound healing
Sharp Debridement
scalpel or scissors is used to separate and remove dead tissue, contraindicated for bleeding disorders
Mechanical Debridement
moist to moist dressings or scrubbing force of moist dressings, wide mesh gauze most common, saline, whirlpool
Chemical Debridement
more selective, collagenase enzyme agents are more recommended for this use
Autolytic Debridement
contain wound moisture such as hydrocolloid and clear absorbent acrylic dressings, trap the wound drainage against the eschar, body’s own enzymes in the drainage break down the necrotic tissue, takes longest but is the most selective causing the least damage to healthy and healing tissue, dressings should be changed as soon as they begin to leak or strike through
Exudate Absorbers
non-adherent, dressing of powder, beads, granules, ropes, sheets, paste, that conform to the wound surface and absorb exudate, to provide a moist wound surface by interacting with exudate, facilitates debridement and rehydrates dead tissue, provides cool moist wound surface by interacting with exudate by assisting in the removal of slough
Gauzes
cover surgical incisions, absorbs exudate, wet-to-dry debrides the wound, protect from trauma and infection, wound is debrided when the dressing is removed
Hydrocolloids
moist, healing environment that allows clean wounds to granulate and in necrotic wounds it facilitates autolytic debridement, waterproof adhesive wafers, pastes, powders
Hydrogels
facilitate autolytic debridement, add moisture to wounds, used for pressure ulders, skin tears, partial thickness wound, glycerin or water based nonadhesive jellylike sheets, granules, or gels that are oxygen permeable, unless covered by a plastic film, require secondary occulsive dressing
Impregnated nonadherent dressings
woven or nonwoven cotton or synthetic materials impregnated with petrolatum, saline, zinc-saline, antimicrobials, require secondary dressings to secure in place, to cover, soothe, protect partial and full thickness wounds without exudate, provide wound protection and retain moisture of wound, used postop dressing over staple or sutures and superficial burns
Polyurethane foams
nonadherent hydrocolloid dressings, need to have their edges taped down or sealed, light to highly exudating wounds, pressure ulcers, skin tears, venous stasis ulcers, surgical wounds, chemical debridement
Transparent adhesive films
adhesive, plastic, semipermeable, nonabsorbent dressings allow exchange of oxygen, impermeable to bacteria and water, used for iv dressing, central line dressing, superficial wounds and pressure ulcers stage 1
Factors to consider when securing a dressing
location, size, type of wound, amount of exudates, whether the wound requires debridement or is infected, freq of dressing change, ease of difficulty of dressing application and cost
Hydrogen peroxide
soften and remove crusted exudate and debris
Normal Saline
irrigation of clean or noninfected wounds, safest and most appropriate solution for open wounds
Povidone idodine (betadine)
broad spectrum effectiveness against bacteria, spores, fungi, viruses when used on intact skin or small clean wounds
Lactated Ringer’s
irrigation of clean or noninfected wounds
Water
cleansing of clean or noninfected wounds
What stage ulcers are considered partial thickness
stage 2
what stage ulcers are considered full thickness
stage three and stage four
Circular Technique
anchor bandages or terminate bandage, cover small area finger or toe
Spiral Technique
bandage parts of the body that are fairly uniform in circumference such as upper arm or leg
Recurrent Technique
cover distal parts of the body, such as the end of a finger, the skull, or the stump of an amputation
Figure of Eight Technique
bandage elbow, knee, or ankle because they permit some movement after application
How should you bandage?
distal to proximal
Alopecia
loss of hair
callus
thickened skin on your hands or the soles of your feet
corn
thickened skin on the top or side of a toe, usually from shoes that do not fit properly
cyanosis
blue color to the skin, lack of oxygen
diaphoresis
profuse sweating
ecchymosis
bruising, purple, ruptured blood vessels
edema
swelling
erythema
redness or rash
excoriation
an injury to a surface of the body caused by trauma, such as scratching, abrasion, or a chemical or thermal burn
gingivitis
Inflammation of the gums, characterized by redness and swelling.
halitosis
bad breath
hirsutism
abnormal hair growth, excessive hair growth
jaundice
yellowing of skin, sclera,
pallor
pale color
pediculosis
infestation with lice
petchia
small purplish spot on a body surface, such as the skin or a mucous membrane, caused by a minute hemorrhage and often seen in typhus.
pruritus
itching
tartar
A hard, yellowish deposit on the teeth, consisting of organic secretions and food particles deposited in various salts, such as calcium carbonate.
plaque
a soft thin film of food debris, mucin, and dead epithelial cells on the teeth, providing the medium for bacterial growth. It contains calcium, phosphorus, and other salts, polysaccharides, proteins, carbohydrates, and lipids, and plays a role in the development of caries, dental calculus, and periodontal and gingival diseases.
