Fundamentals of Nursing, Chapter 27, set 2, Temple College
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nursing history
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This includes data about a person's level of Wellness to determine if any underlying conditions exist that pose threats to safety. Ex., lower body muscle strength
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Emesis
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Vomiting
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Federal Emergency Management agency
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FEMA
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Range of motion
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ROM
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Assessment
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- Through the patient's eyes, - nursing history, - Healthcare environment which includes risk for Falls, risk for medical errors, disasters, - patients home environment.
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Nursing process
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Assessment, diagnosis, planning, implementation, evaluation
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Critical thinking model for the nursing process
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Knowledge, experience, standard, attitudes - kesa What is your knowledge? What is your experience? What are the standards? What attitude should you have?
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Kyphosis
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excessive outward curvature of the spine, causing hunching of the back.
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SBAR
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A standard approach to communication -situation, background, assessment, recommendation - this helps to obtain and organize information.
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90 million
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# Americans have low health literacy
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Extinguishers
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Type a - used for ordinary combustibles. Type b - used for flammable Type c - used for electrical equipment
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PASS
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Extinguisher Process P - pull pin A - aim at base of fire S - squeeze handles S - sweep from side to side
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RACE
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Fire - know phone number for reporting fires, know evacuation and drill, know locations of extinguishers, turn off Oxy, R - rescue and remove A - activate the alarm C - confine fire, shut doors E - extinguish fire
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Poison control number
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800-222-1222
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Safety expected outcomes
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- A Safe physical environment - a patient whose expectations have been met - a patient who is knowledgeable about safety factors and precautions - a patient free of injury
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Safe environment
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An environment that basic needs are met, physical hazards are reduced, transmission of pathogens is reduced, sanitation is maintained, pollution is controlled.
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Medical asepsis
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Includes hand hygiene and environmental cleanliness, reduces the transfer of organisms. Aseptic practice, can teach to patients.
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Fall Risk
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Poor Vision, cognitive dysfunction, impaired gait or balance and difficulty walking, difficulty getting in and out of bed, orthostatic hypotension, urinary frequency or receiving diuretics, weakness from disease process or therapy, current medication.
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Safety risks in health care agency
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Chemical used, medical errors, Falls, accidents
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National patient safety goals
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Identify patients correctly, improve staff communication, use medicines safely, use alarms safely, prevent infection, prevent mistakes in surgery.
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MSDS
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Required in health care. Provides detailed information about the chemical, health hazards from post, first aid guidelines, and precautions for Safe Handling and use. They give information on the steps to take in case material is released or spilled.
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Aura
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Is often a bright light, smell, or taste.
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Seizure
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Hyper excitation and disorderly discharge of neurons in the brain leading to a sudden, Violent, involuntary series of muscle contractions that is paroxysmal and episodic, causing loss of consciousness, falling, tonicity, and clonicity.
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Tonicity
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Rigidity of muscles
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Clonicity
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Jerking of muscles
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Status epilepticus
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A medical emergency that requires intensive monitoring and treatment. Prolonged or repeated seizures indicate this.
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Seizure precautions
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These Encompass all nursing interventions to protect a patient from traumatic injury, position for adequate ventilation and drainage of oral secretions, and provide privacy and support following a seizure.
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Tonic clonic seizure
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Insert a bite block or oral Airway in advance if you recognize the possibility of this type of seizure.
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5 Ps
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Pain, potty, position, possessions, and plan of care - hourly rounding and checking these help prevent falls and call light response
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Fall prevention
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- Fall risk assessment tool - hospital bed with side rails, low bed - call light, intercom system - gait belt - wheelchair, walker, non skid footwear - bed alarm pad, wedge cushion
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SPLATT
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- symptoms at time of fall - previous fall - location of fall - activity at time of fall - time at fall - trauma After Fall
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Fall inducing meds
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Sedatives, hypnotics, tranquilizers, analgesics, diuretics
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Timed get up and go
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Tug for fall assessment,
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CMS
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Circulation, movement, sensation - check restraints for
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Types of restraints
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Chemical, elbow, mitt, 4 point, extremity, physical, belt
