Patient Restraint Protocols
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Questions and Answers

Which phase of wound healing involves the migration of white blood cells to the injured area?

  • Proliferation Phase
  • Maturation Phase
  • Secondary Intention
  • Inflammatory Phase (correct)

    • What is the primary distinction between secondary intention and tertiary intention in wound healing?

  • Secondary intention occurs without infection, while tertiary intention always includes pus.
  • Secondary intention is immediate closure, while tertiary intention involves primary closure.
  • Secondary intention requires granulation, while tertiary intention is a delayed closure. (correct)
  • Secondary intention involves skin edges being close together, while tertiary intention does not.

    • Which type of PPE should be donned first when entering a room with a suspected infectious disease?

  • Gown (correct)
  • Gloves
  • Goggles
  • Mask

    • In the maturation phase of wound healing, what primarily happens to the wound?

    <p>Collagen formation decreases and fibroblasts exit.</p> Signup and view all the answers

    Which of the following is least likely to be a risk factor for developing keloids?

    <p>Caucasian descent</p> Signup and view all the answers

    What is the proper order for removing PPE after caring for a patient suspected of having an infectious disease?

    <p>Gloves, Gown, Goggles, Mask</p> Signup and view all the answers

    Which fluid is characterized as containing pus?

    <p>Purulent fluid</p> Signup and view all the answers

    Collagen formation during the proliferation phase increases significantly between which post-operative days?

    <p>5-25 days</p> Signup and view all the answers

    What primarily causes a wound to be classified under primary intention?

    <p>Skin edges are approximated with minimal tissue loss</p> Signup and view all the answers

    What is the maximum flow rate for a Nasal Cannula?

    <p>6 liters per minute</p> Signup and view all the answers

    Which of the following is NOT a method of oxygen delivery?

    <p>Nebulizer</p> Signup and view all the answers

    What should be done if a patient refuses to be restrained?

    <p>Assess their mental function and notify the doctor</p> Signup and view all the answers

    What is the proper technique for wound irrigation?

    <p>Clean from the least contaminated area to the most contaminated area</p> Signup and view all the answers

    Which type of isolation precaution requires the use of a negative air pressure room?

    <p>Airborne precautions</p> Signup and view all the answers

    Which of the following is not appropriate for a wheelchair setup?

    <p>Securing tubing to the wheelchair</p> Signup and view all the answers

    During oxygen therapy, which of the following is a sign of oxygen toxicity?

    <p>Nasal congestion</p> Signup and view all the answers

    What is the correct position for a patient receiving an enema?

    <p>Left Sims position</p> Signup and view all the answers

    What is the primary purpose of the RACE acronym in fire safety?

    <p>Rescue patients in danger</p> Signup and view all the answers

    Which of the following types of face masks delivers the most precise amount of oxygen?

    <p>Venturi mask</p> Signup and view all the answers

    What should be done if a client refuses restraints?

    <p>Notify the doctor and responsible party about the refusal.</p> Signup and view all the answers

    Which of the following is true regarding safety reminder devices (SRDs)?

    <p>Nurses can apply SRDs in emergencies but must obtain a doctor's order within one hour.</p> Signup and view all the answers

    When using restraints, why should the client be positioned on their side?

    <p>To prevent aspiration during restraint application.</p> Signup and view all the answers

    How frequently should skin assessment be conducted for clients in restraints?

    <p>Every two hours for pressure points, tears, or scratches.</p> Signup and view all the answers

    What is the primary consideration before using restraints?

    <p>Exploring alternatives and less restrictive measures.</p> Signup and view all the answers

    What must be included in a doctor's order for safety reminder devices?

    <p>The type, location, duration, and behaviors prompting the use.</p> Signup and view all the answers

    What should a nurse do to ensure effective documentation when restraints are used?

    <p>Record precipitating events, alternative actions taken, and explanations from the client and family.</p> Signup and view all the answers

    What is a key aspect of mental status assessment before applying restraints?

    <p>Determining if the client is aware of their surroundings.</p> Signup and view all the answers

    When is seclusion an appropriate option for a client?

    <p>If the client requests it and it serves as a private area for calming down.</p> Signup and view all the answers

    What is the primary goal when utilizing restraints in healthcare?

    <p>To prevent the client from causing harm to themselves or others.</p> Signup and view all the answers

    What is the primary characteristic of the proliferation phase in wound healing?

    <p>Formation of new blood vessels and tissues</p> Signup and view all the answers

    Which type of wound healing occurs when a wound has not yet been contaminated and the edges are close together?

    <p>Primary intention</p> Signup and view all the answers

    During which phase of wound healing is collagen formation most rapid?

    <p>Proliferation phase</p> Signup and view all the answers

    What is the recommended order for doffing personal protective equipment (PPE)?

    <p>Gloves, gown, goggles, mask</p> Signup and view all the answers

    What is the maximum time duration for which an order for safety reminder devices must be rewritten?

    <p>24 hours</p> Signup and view all the answers

    Which term describes fluid that has been discharged from cells or blood through small pores?

    <p>Exudate</p> Signup and view all the answers

    What is required before applying safety reminder devices in an emergency?

    <p>Doctor's order within one hour</p> Signup and view all the answers

    Which of the following actions should be documented when restraints are used?

    <p>Precipitating events and alternative actions taken</p> Signup and view all the answers

    In what position should a client be placed to prevent aspiration when using restraints?

    <p>On their side</p> Signup and view all the answers

    What is the primary purpose of using alternative measures before applying restraints?

    <p>To minimize client distress and promote safety</p> Signup and view all the answers

    Which of the following is NOT a type of precaution while using safety reminder devices?

    <p>Documenting all client movements</p> Signup and view all the answers

    What must always be confirmed when considering the use of restraints?

    <p>Alternative measures have been attempted</p> Signup and view all the answers

    What should be done immediately when a client refuses restraints?

    <p>Notify the doctor and document the refusal thoroughly.</p> Signup and view all the answers

    What is the primary risk when using petroleum-based lubricants with oxygen equipment?

    <p>They increase the risk of combustion.</p> Signup and view all the answers

    How should the Venturi face mask be adjusted to deliver the correct oxygen concentration?

    <p>It must be adjusted snugly over the nose and chin.</p> Signup and view all the answers

    When caring for a patient in an oxygen tent, what is a crucial aspect to monitor?

    <p>The internal temperature of the tent.</p> Signup and view all the answers

    What is the recommended maximum flow rate for a nasal cannula?

    <p>6 L/min.</p> Signup and view all the answers

    For which type of precaution is it necessary to wear an N-95 mask or better?

    <p>Airborne precautions.</p> Signup and view all the answers

    What position should the patient be in when administering an enema?

    <p>Left Sims position.</p> Signup and view all the answers

    How frequently should skin condition assessments occur for clients in distal restraints?

    <p>Every 15-30 minutes.</p> Signup and view all the answers

    What essential action should a caregiver take prior to using a lift for patient transfer?

    <p>Always lock the lifts before use.</p> Signup and view all the answers

    In emergency fire situations, what does the 'A' in the RACE acronym stand for?

    <p>Alert the alarm.</p> Signup and view all the answers

    When are restraints considered an appropriate intervention?

    <p>When less restrictive measures have failed and safety is at risk.</p> Signup and view all the answers

    What must be done immediately if a client refuses the use of restraints?

    <p>Document the refusal and notify the healthcare team.</p> Signup and view all the answers

    What is the minimum frequency for skin assessment when a client is in restraints?

    <p>Every 2 hours.</p> Signup and view all the answers

    What characteristic is essential for consent regarding the use of restraints?

    <p>The client must have a stable mental status.</p> Signup and view all the answers

    What is required in a doctor's order for the use of Safety Reminder Devices (SRDs)?

    <p>Duration of use and client's behaviors prompting use.</p> Signup and view all the answers

    Which of the following is NOT a safety measure when using restraints?

    <p>Leaving restraints applied indefinitely.</p> Signup and view all the answers

    How should Safety Reminder Devices be attached when in use?

    <p>To an immovable part of the bed frame.</p> Signup and view all the answers

    What action should be taken for a client requesting seclusion?

    <p>Ensure the area is safe and private for the client.</p> Signup and view all the answers

    What should be monitored frequently while a client is in restraints?

    <p>The client's circulation, anxiety, and behavior.</p> Signup and view all the answers

    When should a doctor's order for Safety Reminder Devices usually be rewritten?

    <p>Every 24 hours.</p> Signup and view all the answers

    What role do myofibroblasts play during the proliferation phase of wound healing?

    <p>They produce collagen that adds strength to the wound.</p> Signup and view all the answers

    Which type of wound healing involves leaving a contaminated wound open until infection is controlled?

    <p>Tertiary intention</p> Signup and view all the answers

    In which phase of wound healing is the risk of wound dehiscence highest?

    <p>Proliferation Phase</p> Signup and view all the answers

    What is the primary characteristic of purulent fluid in a wound?

    <p>It contains or produces pus.</p> Signup and view all the answers

    Which statement best explains the significance of collagen formation during the proliferation phase?

    <p>It facilitates the contraction and sealing of the wound.</p> Signup and view all the answers

    What are common risk factors for the development of keloids?

    <p>Young women and dark-skinned individuals</p> Signup and view all the answers

    When is collagen formation most significantly increased post-operatively?

    <p>Between days 5-25</p> Signup and view all the answers

    What is the correct sequence for donning personal protective equipment (PPE)?

    <p>Gown, Gloves, Goggles, Mask</p> Signup and view all the answers

    Which phase of wound healing is primarily responsible for sealing the wound and protecting against contamination?

    <p>Proliferation Phase</p> Signup and view all the answers

    What does 'DOFF' mean in the context of PPE usage?

    <p>To take off PPE</p> Signup and view all the answers

    What is the primary method of maintaining patient safety when using a lift?

    <p>Ensure the base of the lift is correctly spread out</p> Signup and view all the answers

    What characteristic of oxygen therapy requires strict enforcement of safety measures?

    <p>Oxygen supports combustion</p> Signup and view all the answers

    When using a non-rebreather mask, what is a significant indication that oxygen flow needs to be increased?

    <p>The reservoir fully collapses</p> Signup and view all the answers

    Which of the following represents a critical consideration when documenting restraint refusal?

    <p>Notifying the doctor and responsible party</p> Signup and view all the answers

    What is the recommended oxygen flow rate for patients with chronic respiratory conditions?

    <p>1-2 liters per minute</p> Signup and view all the answers

    Which delivery method provides the most controlled oxygen levels?

    <p>Venturi mask</p> Signup and view all the answers

    What critical action must be taken when suctioning a tracheostomy?

    <p>Assess the patient's respiratory status before and after suctioning</p> Signup and view all the answers

    When is it permissible to use petroleum-based lubricants with oxygen equipment?

    <p>It is never permissible</p> Signup and view all the answers

    What is a key responsibility of caregivers regarding hygiene during tube feeding procedures?

    <p>Ensure the feeding tube placement is checked every time before feeding</p> Signup and view all the answers

    What is the appropriate action during an emergency fire situation according to the RACE protocol?

    <p>Sound the alarm as soon as possible</p> Signup and view all the answers

    What is the maximum oxygen flow rate for a nasal cannula?

    <p>6 liters per minute</p> Signup and view all the answers

    Which of the following symptoms indicates potential oxygen toxicity?

    <p>Nasal congestion</p> Signup and view all the answers

    What is the primary focus of isolation precautions for droplet transmission?

    <p>To limit patient transportation</p> Signup and view all the answers

    In a hyperbaric chamber, how much oxygen is delivered to the patient?

    <p>100% oxygen at three times the atmospheric pressure</p> Signup and view all the answers

    Which procedure is considered sterile when performing tracheostomy suctioning?

    <p>Nasopharyngeal suctioning</p> Signup and view all the answers

    What is required before using restraints on a client?

    <p>Ensure the client is informed and consents to the restraints</p> Signup and view all the answers

    How often should skin be assessed for clients who are restrained?

    <p>Every two hours for potential pressure points and injuries</p> Signup and view all the answers

    In the event of an emergency, what must a nurse do regarding the application of safety reminder devices (SRDs)?

    <p>Notify a doctor for an order within one hour after application</p> Signup and view all the answers

    What documentation is necessary when restraints are used on a client?

    <p>All preceding answers must be documented accurately</p> Signup and view all the answers

    What role does seclusion play in the context of managing a client's behavior?

    <p>It provides a safe, private area for clients to calm down voluntarily</p> Signup and view all the answers

    What is the protocol for documenting refusals when restraints are used?

    <p>Document the refusal, notify the doctor and the responsible party.</p> Signup and view all the answers

    How often should the skin be assessed for clients in restraints to check for pressure points?

    <p>Every two hours.</p> Signup and view all the answers

    What is a requirement for applying safety reminder devices in an emergency situation?

    <p>Obtain a doctor's order within one hour.</p> Signup and view all the answers

    What key factor should be assessed to ensure informed consent for the use of restraints?

    <p>The client's mental status.</p> Signup and view all the answers

    Which characteristic applies to safety reminder devices (SRDs) regarding their use?

    <p>They require a doctor's order including specific details of use.</p> Signup and view all the answers

    What is the maximum time duration an order for safety reminder devices must be rewritten?

    <p>24 hours</p> Signup and view all the answers

    Which of the following should be part of the documentation when restraints are used?

    <p>Alternative actions taken before restraint use</p> Signup and view all the answers

    In what situation can nurses apply safety reminder devices without a prior doctor's order?

    <p>In an emergency situation</p> Signup and view all the answers

    Which client behavior may prompt the use of safety reminder devices as indicated in a doctor's order?

    <p>Demonstrating severe anxiety or risk to self</p> Signup and view all the answers

    Why is it recommended to position the client on their side when using restraints?

    <p>To prevent aspiration</p> Signup and view all the answers

    Study Notes

    Restraints

    • Use restraints as a last resort, after less restrictive measures have failed
    • Obtain informed consent from the patient or responsible party if the patient cannot provide consent
    • Document any refusals, notify the doctor, and the responsible party when restraints are used. Assess their mental function.
    • Restraints can be physical or chemical
    • Position the patient on their side to prevent aspiration
    • Safety Reminder Devices (SRDs) require a doctor's order including type, location, duration of use, and client behaviors prompting their use
    • Nurses can apply SRDs in emergencies but must obtain an order within one hour
    • Orders for SRD use may need to be rewritten every 24 hours
    • While the client is in restraints, assess skin every two hours for pressure points, tears, or scratches
    • Monitor the client's circulation, anxiety, and behavior frequently
    • Document precipitating events, alternative actions taken, and client and family explanations.
    • Restraints should be attached to the movable part of the bed frame
    • Check every 15-30 minutes, release for toilet breaks, and perform Range of Motion (ROM) exercises every 2 hours

    Distal Restraint Safety

    • Check skin and circulation frequently where distal restraints are placed
    • If a client refuses restraints, assess their mental function, notify their doctor and responsible party, and document the refusal thoroughly

    Lifts

    • Always lock lifts before use
    • Ensure the base of the lift is correctly spread out
    • Carefully position the client in the center of the sling
    • Seek help if unsure about using a lift and never use it alone

    Wheelchairs

    • Lock the wheels of the wheelchair when stationary
    • Position the wheelchair on the client’s strong side
    • Never secure any tubing or lines to the wheelchair or any moveable part

    Oxygen Therapy

    • Oxygen is an odorless, tasteless, colorless, and non-flammable gas but it supports combustion
    • The Flow Meter regulates the oxygen flow rate
    • Oxygen is typically ordered in liters per minute (L/min)
    • Chronic respiratory illnesses require lower oxygen settings, generally no more than 1-2 L/min
    • Long-term oxygen use requires humidification
    • Enforce NO SMOKING signs strictly around oxygen
    • Know the location of all fire extinguishers
    • Only use water-soluble lubricants for oxygen equipment; petroleum-based lubricants can cause a combustion risk
    • Examples of combustible materials to avoid: grease, oil, Vaseline, alcohol, ether, or any ungrounded equipment

    Methods of Oxygen Delivery

    • Nasal Canula (Bi-prongs):
      • Documented as BNP or BNC
      • Delivers 24-40% concentration
      • Fits into the nares
      • Maximum flow rate of 6 liters
      • Turn oxygen on before placing the canula on the patient
      • Tubing goes over the ears and under the chin
      • Assess and document skin condition behind the ears and in the nares before, during, and after treatment
      • Only use water-soluble lubricants
    • Face Mask:
      • Provides greater control over oxygen levels
      • Concentration of 60-100% oxygen (required flow rate depends on the L/min) 6-10 L
      • Humidified oxygen should produce a fine mist
      • Adjust the mask snugly over the nose and chin
      • The reservoir should never fully collapse (increase oxygen flow if it does, but only with a doctor's permission)
    • Types of Face Masks:
      • Venturi: Delivers very precise amounts of oxygen
      • Non-rebreather: Delivers up to 100% oxygen
      • Simple: Delivers 40-60% oxygen
    • Oxygen Tent:
      • Delivers a fine mist, maintains a constant temperature, and provides high concentration
      • The canopy should cover at least the patient's torso
      • Keep the patient dry to prevent chilling and change linens frequently
      • The internal temperature should be at least 70 degrees
      • Adjust the oxygen flow rate to 10-12 L/min
      • Tuck the tent sides under the mattress if needed
      • Parents might have to get under the tent with a child
    • Hyperbaric Chamber:
      • Delivers 100% oxygen at 3 times the atmospheric pressure
      • Facilitates faster tissue regeneration, particularly beneficial for wound healing
    • Ambu Bag:
      • Delivers up to 100% oxygen depending on the presence of a reservoir
      • The mask must firmly cover the nose and mouth to create a seal
      • Deliver breaths every 5 seconds
      • Can be attached to an endotracheal tube (ET)

    Patient Teaching for Oxygen Therapy

    • Explain oxygen application and safety procedures

    • Discuss the signs and symptoms of oxygen toxicity:

      • Seen in concentrations over 50% for longer than 24-48 hours
      • Nonproductive cough
      • Substernal chest pain
      • Nasal stuffiness/congestion
      • Nausea/vomiting
      • Fatigue
      • Headache
      • Sore throat
      • Hypoventilation

    • Emphasize the importance of oral hygiene

    • Encourage fluid intake

    • Teach the patient about T C D B (Turn, Cough, Deep, Breath)

      Fire Safety

    • RACE:

      • Rescue Patients
      • Alert the alarm
      • Confine the fire
      • Extinguish the fire

    • PASS:

      • Pull the pin
      • Aim low
      • Squeeze the trigger
      • Sweep from side to side

    Types of Isolation

    • Airborne: Used for patients with confirmed or suspected serious illnesses transmitted by airborne droplet nuclei
      • Examples: Measles, Varicella zoster virus (Chickenpox), TB, COVID-19
    • Isolation Precautions:
      • Single-patient room
      • room with negative air pressure
      • Room vented to the outside
      • Door to the patient's room remains closed
      • N-95 mask or better
    • Droplet: Used for patients with known or suspected illnesses caused by large particle droplets
      • Examples of Illnesses:
        • Invasive Haemophilus Influenzae (meningitis, pneumonia, epiglottis, & sepsis)
        • Invasive Neisseria Meningitidis Disease (meningitis, pneumonia, & sepsis)
        • Serious Respiratory Illnesses:
          • Diphtheria (Pharyngeal)
          • Mycoplasma Pneumonia
          • Pertussis
          • Pneumonic Plague
          • Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children
        • Serious Viral Illnesses:
          • Adenovirus
          • Influenza
          • Mumps
          • Parvovirus B19
          • Rubella (German Measles)
      • Isolation for Droplet Precaution:
        • Standard PPE
        • Private room or at least 3 feet separation from roommates
        • Limited patient transportation, wear a mask during transport
    • Contact: Used for serious illnesses easily transmitted by direct patient contact or contact with objects in the patient's environment
      • Isolation for Contact Precaution:
        • Gloves and gown required when entering the room
        • Dedicated equipment for the patient
        • Careful hand hygiene

    Wound Irrigation

    • Sterile procedure
    • Promotes wound healing and comfort
    • Gentle cleansing technique to prevent further tissue damage
    • Clean from the least contaminated to the most contaminated area
    • Use a syringe alone or with an IV catheter or needle
    • Wash hands before and after the procedure
    • Use a collection device to catch irrigation fluid
    • Wear appropriate PPE

    Tracheostomy Care

    • Suctioning:
      • Nasopharyngeal/Tracheal: Sterile
      • Oropharyngeal: Clean
      • Suction only when withdrawing the catheter (coming out)
      • Assess respiratory status before and after suctioning

    Indwelling Urinary Catheter

    • Sterile procedure
    • Follow the same steps as the check-off procedure

    Enemas

    • Clean procedure
    • Types:
      • Fleet
      • Oil retention
      • Soap/Suds (SSE)
      • Tap water (TWE)
    • Steps to Perform an Enema:
      • Position the patient in left Sims position
      • Ensure the solution temperature is no higher than 105 degrees
      • Add soap only after the water has entered the rectum
      • Hold the container no higher than 18 inches from the patient's body
      • Typically, no more than 3 enemas are administered without a physician's permission
      • Review the procedure carefully

    Tube Feeding

    • Follow the same steps as the check-off procedure
    • Remember to check tube placement every time the patient is fed if on intermittent feeding, and every shift if on continuous feeding

    Hygiene

    • Do not use soap on the face unless the patient requests it
    • Rinse all soap from the body thoroughly to prevent skin irritation
    • Use long strokes when washing, moving towards the heart

    Baths

    • Tepid: Used to reduce fever
    • Sitz: Used for comfort after childbirth, rectal surgery, or hemorrhoids
    • Medicated: Used to moisturize and treat dry skin; monitor for skin breakdown

    Vital Signs

    • Pain is now considered the 5th vital sign
    • Always know the patient's baseline vital signs: weight, height, and temperature. Use the same scale, clothing, and time of day for daily weight measurements

    Wound Healing: Phases

    • Phase I: Inflammatory Phase:
      • Hemostasis: Immediately after injury, the blood vessels constrict and coagulate
      • Vasodilation: Blood vessels enlarge, increasing blood flow to the area.
      • Inflammation: The site is invaded by white blood cells.
    • Phase II: Proliferation Phase:
      • New cells and capillaries fill in the wound from the underlying tissue to the skin surface. This process seals the wound and protects from contamination
      • Collagen Formation: Occurs during reconstruction or proliferation phase. The wound contracts as new tissue is reconstructed.
      • Myofibroblasts: Produce collagen (glue-like substance) and adds strength to the wound and tissue
      • Collagen formation increases rapidly between post-op days 5-25
      • Wound dehiscence most frequently occurs during this phase
    • Phase IV: Maturation Phase:
      • Fibroblasts exit the wound, collagen forms, and tissue and skin become stronger
      • The wound will continue to gain strength but healing can take up to 1 year
      • Internal wounds (Stomach, Colon) regain faster than skin wounds
      • Keloid: Occasionally, an overgrowth of collagen at the site of the wound forms. African Americans, dark-skinned people of all races, and young women are at the highest risk for developing keloids.
    • Primary Intention: Skin edges of the wound are close together, and little tissue is lost
      • Primary intention healing begins in the inflammatory phase
    • Secondary Intention: When a wound must granulate during healing, and the edges are not approximate (come together), or when pus is visible
    • Tertiary Intention: Delayed primary intention. The provider will leave a contaminated wound open and close it later once the infection is controlled

    Wound Terminology

    • Purulent: Contains or produces pus
    • Exudate: Fluid, cells, or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes

    PPE (Personal Protective Equipment)

    • PPE should be worn for any patient with any suspicion of or known infectious disease.
    • Types of PPE:
      • Gown
      • Mask
      • Goggles (or other eye protection)
      • Gloves
    • PPE Removal Order:
      • Gloves
      • Gown
      • Goggles
      • Mask
    • DON - means to put on
    • DOFF - means to take off

    Restraints

    • Always obtain consent for restraints, ensure the client's mental status allows for informed consent
    • Document any refusals, notify the doctor, and the responsible party when restraints are used.
    • Assess their mental function.
    • Restraints are considered a last resort and alternatives should always be explored first.
    • Restraints can be physical or chemical
    • When using restraints, position the client on their side to prevent aspiration.
    • SRDs require a doctor's order including type, location, duration of use, and client behaviors prompting their use.
    • Nurses can apply SRDs in emergencies but must obtain an order within one hour.
    • Orders for SRD use may need to be rewritten every 24 hours.
    • While the client is in restraints, assess skin every two hours for pressure points, tears, or scratches.
    • Monitor the client's circulation, anxiety, and behavior frequently.
    • Document precipitating events, alternative actions taken, and client and family explanations.
    • Use quick-release ties and attach to the movable part of the bed frame.
    • Check every 15-30 minutes, release to the toilet, and perform ROM exercises every 2 hours

    Distal Restraint Safety

    • Check skin and circulation frequently where distal restraints are placed.
    • If a client refuses restraints, assess their mental function, notify their doctor and responsible party, and document the refusal thoroughly.

    ### Lifts

    • Always lock lifts before use
    • Ensure the base of the lift is correctly spread out
    • Carefully position the client in the center of the sling
    • Seek help if unsure about using a lift and never use it alone

    ### Wheelchairs

    • Lock the wheels of the wheelchair when stationary
    • Position the wheelchair on the client’s strong side
    • Never secure any tubing or lines to the wheelchair or any moveable part

    Oxygen Therapy

    • Oxygen is an odorless, tasteless, colorless, and non-flammable gas, but it supports combustion
    • The Flow Meter regulates the oxygen flow rate
    • Oxygen is typically ordered in liters per minute (L/min)
    • Chronic respiratory illnesses require lower oxygen settings, generally no more than 1-2 L/min
    • Long-term oxygen use requires humidification
    • Enforce NO SMOKING signs strictly around oxygen
    • Know the location of all fire extinguishers
    • Only use water-soluble lubricants for oxygen equipment; petroleum-based lubricants can cause a combustion risk
    • Examples of combustible materials to avoid: grease, oil, Vaseline, alcohol, ether, or any ungrounded equipment

    Methods of Oxygen Delivery

    Nasal Canula (Bi-prongs):

    • Documented as BNP or BNC
    • Fits into the nares
    • Delivers 24-40% concentration
    • Maximum flow rate of 6 liters
    • Turn oxygen on before placing the canula on the patient
    • Tubing goes over the ears and under the chin
    • Assess and document skin condition behind the ears and in the nares before, during, and after treatment
    • Only use water-soluble lubricants

    Face Mask:

    • Concentration of 60-100% oxygen (required flow rate depends on the L/min) 6-10 L
    • Humidified oxygen should produce a fine mist
    • Adjust the mask snugly over the nose and chin
    • The reservoir should never fully collapse (increase oxygen flow if it does, but only with a doctor's permission)

    Types of Face Masks:

    • Venturi: Delivers very precise amounts of oxygen
    • Non-rebreather: Delivers up to 100% oxygen
    • Simple: Delivers 40-60% oxygen

    Oxygen Tent:

    • Delivers a fine mist, maintains a constant temperature, and provides high concentration
    • The canopy should cover at least the patient's torso
    • Keep the patient dry to prevent chilling and change linens frequently
    • The internal temperature should be at least 70 degrees
    • Adjust the oxygen flow rate to 10-12 L/min
    • Tuck the tent sides under the mattress if needed
    • Parents might have to get under the tent with a child

    Hyperbaric Chamber:

    • Delivers 100% oxygen at 3 times the atmospheric pressure
    • Facilitates faster tissue regeneration, particularly beneficial for wound healing

    Ambu Bag:

    • Delivers up to 100% oxygen depending on the presence of a reservoir
    • The mask must firmly cover the nose and mouth to create a seal
    • Deliver breaths every 5 seconds
    • Can be attached to an endotracheal tube (ET)

    ### Patient Teaching for Oxygen Therapy

    • Explain oxygen application and safety procedures
    • Discuss the signs and symptoms of oxygen toxicity:
      • Seen in concentrations over 50% for longer than 24-48 hours
      • Nonproductive cough
      • Substernal chest pain
      • Nasal stuffiness/congestion
      • Nausea/vomiting
      • Fatigue
      • Headache
      • Sore throat
      • Hypoventilation
    • Emphasize the importance of oral hygiene
    • Encourage fluid intake
    • Teach the patient about T C D B (Turn, Cough, Deep, Breath)

    Fire Safety

    • RACE:
      • Rescue Patients
      • Alert the alarm
      • Confine the fire
      • Extinguish the fire
    • PASS:
      • Pull the pin
      • Aim low
      • Squeeze the trigger
      • Sweep from side to side

    ### Types of Isolation

    Airborne:

    • Used for patients with confirmed or suspected serious illnesses transmitted by airborne droplet nuclei
    • Examples: Measles, Varicella zoster virus (Chickenpox) , TB, COVID-19
    • Isolation Precautions:
      • Single-patient room
      • Room with negative air pressure
      • Room vented to the outside
      • Door to the patient's room remains closed
      • Wear N-95 mask or better.

    Droplet:

    • Used for patients with known or suspected illnesses caused by large particle droplets
    • Examples of Illnesses:
      • Invasive Haemophilus Influenzae
      • Invasive Neisseria Meningitidis Disease
      • Serious Respiratory Illnesses: Diphtheria, Mycoplasma Pneumonia, Pertussis, Pneumonic Plague, Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children
      • Serious Viral Illnesses: Adenovirus, Influenza, Mumps, Parvovirus B19, Rubella
    • Isolation for Droplet Precaution:
      • Standard PPE
      • Private room or at least 3 feet separation from roommates
      • Limited patient transportation, wear a mask during transport

    Contact:

    • Used for serious illnesses easily transmitted by direct patient contact or contact with objects in the patient's environment
    • Isolation for Contact Precaution:
      • Gloves and gown required when entering the room
      • Dedicated equipment for the patient
      • Careful hand hygiene

    ### Wound Irrigation

    • Sterile procedure
    • Promotes wound healing and comfort
    • Gentle cleansing technique to prevent further tissue damage
    • Clean from the least contaminated to the most contaminated area
    • Use a syringe alone or with an IV catheter or needle
    • Wash hands before and after the procedure
    • Use a collection device to catch irrigation fluid
    • Wear appropriate PPE

    ### Tracheostomy Care

    Suctioning:

    • Nasopharyngeal/Tracheal: Sterile
    • Oropharyngeal: Clean
    • Suction only when withdrawing the catheter (coming out)
    • Assess respiratory status before and after suctioning

    Indwelling Urinary Catheter

    • Sterile procedure
    • Follow the same steps as the check-off procedure

    ### Enemas

    • Clean procedure
    • Types:
      • Fleet
      • Oil retention
      • Soap/Suds (SSE)
      • Tap water (TWE)
    • Steps to Perform an Enema:
      • Position the patient in left Sims position
      • Ensure the solution temperature is no higher than 105 degrees
      • Add soap only after the water has entered the rectum
      • Hold the container no higher than 18 inches from the patient's body
      • Typically, no more than 3 enemas are administered without a physician's permission
      • Review the procedure carefully

    ### Tube Feeding

    • Follow the same steps as the check-off procedure
    • Remember to check tube placement every time the patient is fed if on intermittent feeding, and every shift if on continuous feeding

    Hygiene

    • Do not use soap on the face unless the patient requests it
    • Rinse all soap from the body thoroughly to prevent skin irritation
    • Use long strokes when washing, moving towards the heart

    Baths

    • Tepid: Used to reduce fever
    • Sitz: Used for comfort after childbirth, rectal surgery, or hemorrhoids
    • Medicated: Used to moisturize and treat dry skin; monitor for skin breakdown

    ### Vital Signs

    • Pain is now considered the 5th vital sign
    • Always know the patient's baseline vital signs: weight, height, and temperature.
    • Use the same scale, clothing, and time of day for daily weight measurements

    ### Wound Healing: Phases

    Phase I: Inflammatory Phase:

    • Hemostasis: Immediately after injury, the blood vessels constrict and coagulate.
    • Vasodilation: Blood vessels enlarge, increasing blood flow to the area.
    • Inflammation: The site is invaded by white blood cells.

    Phase II: Proliferation Phase:

    • New cells and capillaries fill in the wound from the underlying tissue to the skin surface. This process seals the wound and protects from contamination.
    • Collagen Formation: Occurs during reconstruction or proliferation phase. The would contracts as new tissue is reconstructed.
    • Myofibroblasts: Produce collagen (glue-like substance) and adds strength to the wound and tissue. Collagen formation increases rapidly between post-op days 5-25
    • Wound dehiscence most frequently occurs during this phase.

    Phase IV: Maturation Phase:

    • Fibroblasts exit the wound, collagen forms, and tissue and skin become stronger.
    • The wound will continue to gain strength but healing can take up to 1 year.
    • Internal wounds (Stomach, Colon) regain faster than skin wounds.
    • Keloid: Occasionally, an overgrowth of collagen at the site of the wound forms. African Americans, dark-skinned people of all races, and young women are at the highest risk for developing keloids.

    Wound Terminology

    • Purulent: Contains or produces pus.
    • Exudate: Fluid, cells, or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes.

    PPE (Personal Protective Equipment)

    • PPE should be worn for any patient with any suspicion of or known infectious disease.
    • Types of PPE:
      • Gown
      • Mask
      • Goggles (or other eye protection)
      • Gloves
    • PPE Removal Order:
      • Gloves
      • Gown
      • Goggles
      • Mask
    • DON- means to put on
    • DOFF - means to take off

    Restraints

    • Check skin and circulation regularly when restraints are used.
    • Obtain consent for restraints, ensuring the client’s mental status allows for informed consent.
    • Document refusals, notify the doctor, and the responsible party when restraints are used.
    • Assess their mental function.
    • Safety reminder devices should be used for the shortest amount of time possible and only after less restrictive measures have failed.
    • Seclusion can be requested by the client and is a safe, private area for them to calm down on their own.
    • Restraints are considered a last resort and alternatives should always be explored first.
    • Restraints can be physical or chemical.
    • When using restraints, position the client on their side to prevent aspiration.
    • SRDs (Safety Reminder Devices) require a doctor’s order including type, location, duration of use, and client behaviors prompting their use.
    • Nurses can apply SRDs in emergencies but must obtain an order within one hour.
    • Orders for SRD use may need to be rewritten every 24 hours.
    • While the client is in restraints, assess skin every two hours for pressure points, tears, or scratches.
    • Monitor the client’s circulation, anxiety, and behavior frequently.
    • Document precipitating events, alternative actions taken, and client and family explanations.
    • Use quick-release ties and attach to the movable part of the bed frame.
    • Check every 15-30 minutes, release to the toilet, and perform ROM exercises every 2 hours.

    Distal Restraint Safety

    • Check skin and circulation frequently where distal restraints are placed.
    • If a client refuses restraints, assess their mental function, notify their doctor and responsible party, and document the refusal thoroughly.

    Lifts

    • Always lock lifts before use.
    • Ensure the base of the lift is correctly spread out.
    • Carefully position the client in the center of the sling.
    • Seek help if unsure about using a lift and never use it alone.

    Wheelchairs

    • Lock the wheels of the wheelchair when stationary.
    • Position the wheelchair on the client’s strong side.
    • Never secure any tubing or lines to the wheelchair or any moveable part.

    Oxygen therapy

    • Oxygen is an odorless, tasteless, colorless, and non-flammable gas, but it supports combustion.
    • The Flow Meter regulates the oxygen flow rate.
    • Oxygen is typically ordered in liters per minute (L/min).
    • Chronic respiratory illnesses require lower oxygen settings, generally no more than 1-2 L/min.
    • Long-term oxygen use requires humidification.
    • Enforce NO SMOKING signs strictly around oxygen.
    • Know the location of all fire extinguishers.
    • Only use water-soluble lubricants for oxygen equipment; petroleum-based lubricants can cause a combustion risk.
    • Examples of combustible materials to avoid: grease, oil, Vaseline, alcohol, ether, or any ungrounded equipment.

    Methods of Oxygen Delivery

    Nasal Canula (Bi-prongs)

    • Documented as BNP or BNC
    • Fits into the nares
    • Delivers 24-40% concentration
    • Maximum flow rate of 6 liters
    • Turn oxygen on before placing the canula on the patient
    • Tubing goes over the ears and under the chin
    • Assess and document skin condition behind the ears and in the nares before, during, and after treatment
    • Only use water-soluble lubricants

    Face Mask

    • Provides greater control over oxygen levels
    • Concentration of 60-100% oxygen (required flow rate depends on the L/min) 6-10 L
    • Humidified oxygen should produce a fine mist
    • Adjust the mask snugly over the nose and chin
    • The reservoir should never fully collapse (increase oxygen flow if it does, but only with a doctor’s permission)
    Types of Face Masks
    • Venturi: Delivers very precise amounts of oxygen
    • Non-rebreather: Delivers up to 100% oxygen
    • Simple: Delivers 40-60% oxygen

    Oxygen Tent

    • Delivers a fine mist, maintains a constant temperature, and provides high concentration
    • The canopy should cover at least the patient’s torso
    • Keep the patient dry to prevent chilling and change linens frequently
    • The internal temperature should be at least 70 degrees
    • Adjust the oxygen flow rate to 10-12 L/min
    • Tuck the tent sides under the mattress if needed
    • Parents might have to get under the tent with a child

    Hyperbaric chamber

    • Delivers 100% oxygen at 3 times the atmospheric pressure
    • Facilitates faster tissue regeneration, particularly beneficial for wound healing

    Ambu Bag

    • Delivers up to 100% oxygen depending on the presence of a reservoir
    • The mask must firmly cover the nose and mouth to create a seal
    • Deliver breaths every 5 seconds
    • Can be attached to an endotracheal tube (ET)

    Patient Teaching for Oxygen Therapy

    • Explain oxygen application and safety procedures
    • Discuss the signs and symptoms of oxygen toxicity
      • Seen in concentrations over 50% for longer than 24-48 hours
      • Nonproductive cough
      • Substernal chest pain
      • Nasal stuffiness/congestion
      • Nausea/vomiting
      • Fatigue
      • Headache
      • Sore throat
      • Hypoventilation
    • Emphasize the importance of oral hygiene
    • Encourage fluid intake
    • Teach the patient about T C D B (Turn, Cough, Deep, Breath).

    Fire Safety

    RACE

    • Rescue Patients
    • Alert the alarm
    • Confine the fire
    • Extinguish the fire

    PASS

    • Pull the pin
    • Aim low
    • Squeeze the trigger
    • Sweep from side to side

    Types of Isolation

    Airborne: Used for patients with confirmed or suspected serious illnesses transmitted by airborne droplet nuclei

    • Examples: Measles, Varicella zoster virus (Chickenpox), TB, COVID-19
    Isolation Precautions
    • Single-patient room
    • Room with negative air pressure
    • Room vented to the outside
    • Door to the patient's room remains closed
    • N-95 mask or better

    Droplet: Used for patients with known or suspected illnesses caused by large particle droplets

    Examples of Illnesses
    • Invasive Haemophilus Influenzae (meningitis, pneumonia, epiglottis, & sepsis)
    • Invasive Neisseria Meningitidis Disease (meningitis, pneumonia, & sepsis)
    • Serious Respiratory Illnesses
      • Diphtheria (Pharyngeal)
      • Mycoplasma Pneumonia
      • Pertussis
      • Pneumonic Plague
      • Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children
    • Serious Viral Illnesses
      • Adenovirus
      • Influenza
      • Mumps
      • Parvovirus B19
      • Rubella (German Measles)
    Isolation for Droplet Precaution
    • Standard PPE
    • Private room or at least 3 feet separation from roommates
    • Limited patient transportation, wear a mask during transport

    Contact: Used for serious illnesses easily transmitted by direct patient contact or contact with objects in the patient’s environment

    Isolation for Contact Precaution
    • Gloves and gown required when entering the room
    • Dedicated equipment for the patient
    • Careful hand hygiene

    Wound Irrigation

    • Sterile procedure
    • Promotes wound healing and comfort
    • Gentle cleansing technique to prevent further tissue damage
    • Clean from the least contaminated to the most contaminated area
    • Use a syringe alone or with an IV catheter or needle
    • Wash hands before and after the procedure
    • Use a collection device to catch irrigation fluid
    • Wear appropriate PPE

    Tracheostomy Care

    Suctioning

    • Nasopharyngeal/Tracheal: Sterile
    • Oropharyngeal: Clean
    • Suction only when withdrawing the catheter (coming out)
    • Assess respiratory status before and after suctioning

    Indwelling Urinary Catheter

    • Sterile procedure
    • Follow the same steps as the check-off procedure

    Enemas

    • Clean procedure
    Types
    • Fleet
    • Oil retention
    • Soap/Suds (SSE)
    • Tap water (TWE)

    Steps to Perform an Enema

    • Position the patient in left Sims position
    • Ensure the solution temperature is no higher than 105 degrees
    • Add soap only after the water has entered the rectum
    • Hold the container no higher than 18 inches from the patient’s body
    • Typically, no more than 3 enemas are administered without a physician's permission
    • Review the procedure carefully

    Tube Feeding

    • Follow the same steps as the check-off procedure
    • Remember to check tube placement every time the patient is fed if on intermittent feeding, and every shift if on continuous feeding

    Hygiene

    • Do not use soap on the face unless the patient requests it
    • Rinse all soap from the body thoroughly to prevent skin irritation
    • Use long strokes when washing, moving towards the heart

    Baths

    • Tepid: Used to reduce fever
    • Sitz: Used for comfort after childbirth, rectal surgery, or hemorrhoids
    • Medicated: Used to moisturize and treat dry skin; monitor for skin breakdown

    Vital Signs

    • Pain is now considered the 5th vital sign
    • Always know the patient’s baseline vital signs: weight, height, and temperature.
    • Use the same scale, clothing, and time of day for daily weight measurements

    Wound Healing: Phases

    Phase I: Inflammatory Phase

    • Hemostasis: Immediately after injury, the blood vessels constrict and coagulate.
    • Vasodilation: Blood vessels enlarge, increasing blood flow to the area.
    • Inflammation: The site is invaded by white blood cells.

    Phase II: Proliferation Phase

    • New cells and capillaries fill in the wound from the underlying tissue to the skin surface. This process seals the wound and protects from contamination.
    • Collagen Formation: Occurs during reconstruction or proliferation phase. The wound contracts as new tissue is reconstructed.
    • Myofibroblasts: Produce collagen (glue-like substance) and adds strength to the wound and tissue.
    • Collagen formation increases rapidly between post-op days 5-25.
    • Wound dehiscence most frequently occurs during this phase.

    Phase IV: Maturation Phase

    • Fibroblasts exit the wound, collagen forms, and tissue and skin become stronger.
    • The wound will continue to gain strength but healing can take up to 1 year.
    • Internal wounds (Stomach, Colon) regain faster than skin wounds.
    • Keloid: Occasionally, an overgrowth of collagen at the site of the wound forms. African Americans, dark-skinned people of all races, and young women are at the highest risk for developing keloids.

    Wound Terminology

    • Purulent: Contains or produces pus.
    • Exudate: Fluid, cells, or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes.

    PPE (Personal Protective Equipment)

    • PPE should be worn for any patient with any suspicion of or known infectious disease.
    Types of PPE
    • Gown
    • Mask
    • Goggles (or other eye protection)
    • Gloves
    PPE Removal Order

    • Gloves

    • Gown

    • Goggles

    • Mask

    • DON- means to put on

    • DOFF- means to take off

    Restraints

    • Use restraints only after less restrictive measures have failed.
    • Obtain consent for restraints, ensure the client's mental status allows for informed consent and document any refusals.
    • Restraints can be physical or chemical.
    • Physical restraints require a doctor's order including type, location, duration of use, and client behaviors prompting their use.
    • Nurses can apply restraints in emergencies but must obtain an order within one hour.
    • Orders for restraint use may need to be rewritten every 24 hours.
    • Assess skin every two hours for pressure points, tears, or scratches.
    • Monitor the client's circulation, anxiety, and behavior frequently.
    • Document precipitating events, alternative actions taken, and client and family explanations.
    • Use quick-release ties and attach to the movable part of the bed frame.
    • Check every 15-30 minutes, release to the toilet, and perform ROM exercises every 2 hours.
    • Position the client on their side to prevent aspiration.

    Distal Restraint Safety

    • Check skin and circulation frequently where distal restraints are placed.
    • If a client refuses restraints, assess their mental function, notify their doctor and responsible party, and document the refusal thoroughly.

    Lifts

    • Always lock lifts before use.
    • Ensure the base of the lift is correctly spread out.
    • Carefully position the client in the center of the sling.
    • Seek help if unsure about using a lift and never use it alone.

    Wheelchairs

    • Lock the wheels of the wheelchair when stationary.
    • Position the wheelchair on the client's strong side.
    • Never secure any tubing or lines to the wheelchair or any moveable part.

    Oxygen Therapy

    • Oxygen is an odorless, tasteless, colorless, and non-flammable gas, but it supports combustion.
    • The Flow Meter regulates the oxygen flow rate.
    • Oxygen is typically ordered in liters per minute (L/min).
    • Chronic respiratory illnesses require lower oxygen settings, generally no more than 1-2 L/min.
    • Long-term oxygen use requires humidification.
    • Enforce NO SMOKING signs strictly around oxygen.
    • Know the location of all fire extinguishers.
    • Only use water-soluble lubricants for oxygen equipment; petroleum-based lubricants can cause a combustion risk.
    • Examples of combustible materials to avoid: grease, oil, Vaseline, alcohol, ether, or any ungrounded equipment.

    Methods of Oxygen Delivery

    Nasal Canula (Bi-prongs)

    • Documented as BNP or BNC.
    • Fits into the nares.
    • Delivers 24-40% concentration.
    • Maximum flow rate of 6 liters.
    • Turn oxygen on before placing the canula on the patient.
    • Tubing goes over the ears and under the chin.
    • Assess and document skin condition behind the ears and in the nares before, during, and after treatment.
    • Only use water-soluble lubricants.

    Face Mask

    • Provides greater control over oxygen levels.
    • Concentration of 60-100% oxygen (required flow rate depends on the L/min) 6-10 L.
    • Humidified oxygen should produce a fine mist.
    • Adjust the mask snugly over the nose and chin.
    • The reservoir should never fully collapse (increase oxygen flow if it does, but only with a doctor's permission).

    Types of Face Masks:

    • Venturi: Delivers very precise amounts of oxygen.
    • Non-rebreather: Delivers up to 100% oxygen.
    • Simple: Delivers 40-60% oxygen.

    Oxygen Tent

    • Delivers a fine mist, maintains a constant temperature, and provides high concentration.
    • The canopy should cover at least the patient's torso.
    • Keep the patient dry to prevent chilling and change linens frequently.
    • The internal temperature should be at least 70 degrees.
    • Adjust the oxygen flow rate to 10-12 L/min
    • Tuck the tent sides under the mattress if needed.
    • Parents might have to get under the tent with a child.

    Hyperbaric Chamber

    • Delivers 100% oxygen at 3 times the atmospheric pressure.
    • Facilitates faster tissue regeneration, particularly beneficial for wound healing.

    Ambu Bag

    • Delivers up to 100% oxygen depending on the presence of a reservoir.
    • The mask must firmly cover the nose and mouth to create a seal.
    • Deliver breaths every 5 seconds.
    • Can be attached to an endotracheal tube (ET).

    Patient Teaching for Oxygen Therapy

    • Explain oxygen application and safety procedures.
    • Discuss the signs and symptoms of oxygen toxicity:
      • Seen in concentrations over 50% for longer than 24-48 hours.
      • Nonproductive cough.
      • Substernal chest pain.
      • Nasal stuffiness/congestion.
      • Nausea/vomiting.
      • Fatigue.
      • Headache.
      • Sore throat.
      • Hypoventilation.
    • Emphasize the importance of oral hygiene.
    • Encourage fluid intake.
    • Teach the patient about T C D B (Turn, Cough, Deep, Breath).

    Fire Safety

    RACE:

    • Rescue Patients
    • Alert the alarm
    • Confine the fire
    • Extinguish the fire

    PASS:

    • Pull the pin
    • Aim low
    • Squeeze the trigger
    • Sweep from side to side

    Types of Isolation

    Airborne:

    • Used for patients with confirmed or suspected serious illnesses transmitted by airborne droplet nuclei.
    • Examples: Measles, Varicella zoster virus (Chickenpox), TB, COVID-19.

    Isolation Precautions:

    • Single-patient room.
    • Room with negative air pressure.
    • Room vented to the outside.
    • Door to the patient's room remains closed.
    • N-95 mask or better.

    Droplet:

    • Used for patients with known or suspected illnesses caused by large particle droplets.

    Examples of Illnesses:

    • Invasive Haemophilus Influenzae (meningitis, pneumonia, epiglottis, & sepsis).
    • Invasive Neisseria Meningitidis Disease (meningitis, pneumonia, & sepsis).
    • Serious Respiratory Illnesses
      • Diphtheria (Pharyngeal).
      • Mycoplasma Pneumonia.
      • Pertussis.
      • Pneumonic Plague.
      • Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children.
    • Serious Viral Illnesses
      • Adenovirus.
      • Influenza.
      • Mumps.
      • Parvovirus B19.
      • Rubella (German Measles).

    Isolation for Droplet Precaution:

    • Standard PPE.
    • Private room or at least 3 feet separation from roommates.
    • Limited patient transportation, wear a mask during transport.

    Contact:

    • Used for serious illnesses easily transmitted by direct patient contact or contact with objects in the patient's environment.

    Isolation for Contact Precaution:

    • Gloves and gown required when entering the room.
    • Dedicated equipment for the patient.
    • Careful hand hygiene.

    Wound Irrigation

    • Sterile procedure.
    • Promotes wound healing and comfort.
    • Gentle cleansing technique to prevent further tissue damage.
    • Clean from the least contaminated to the most contaminated area.
    • Use a syringe alone or with an IV catheter or needle.
    • Wash hands before and after the procedure.
    • Use a collection device to catch irrigation fluid.
    • Wear appropriate PPE.

    Tracheostomy Care

    Suctioning:

    • Nasopharyngeal/Tracheal: Sterile.
    • Oropharyngeal: Clean.
    • Suction only when withdrawing the catheter (coming out).
    • Assess respiratory status before and after suctioning.

    Indwelling Urinary Catheter

    • Sterile procedure.
    • Follow the same steps as the check-off procedure.

    Enemas

    • Clean procedure.
    • Types:
      • Fleet.
      • Oil retention.
      • Soap/Suds (SSE).
      • Tap water (TWE).

    Steps to Perform an Enema:

    • Position the patient in left Sims position.
    • Ensure the solution temperature is no higher than 105 degrees.
    • Add soap only after the water has entered the rectum.
    • Hold the container no higher than 18 inches from the patient's body.
    • Typically, no more than 3 enemas are administered without a physician's permission.
    • Review the procedure carefully.

    Tube Feeding

    • Follow the same steps as the check-off procedure.
    • Remember to check tube placement every time the patient is fed if on intermittent feeding, and every shift if on continuous feeding.

    Hygiene

    • Do not use soap on the face unless the patient requests it.
    • Rinse all soap from the body thoroughly to prevent skin irritation.
    • Use long strokes when washing, moving towards the heart.

    Baths

    • Tepid: Used to reduce fever.
    • Sitz: Used for comfort after childbirth, rectal surgery, or hemorrhoids.
    • Medicated: Used to moisturize and treat dry skin; monitor for skin breakdown.

    Vital Signs

    • Pain is now considered the 5th vital sign.
    • Always know the patient's baseline vital signs: weight, height, and temperature.
    • Use the same scale, clothing, and time of day for daily weight measurements.

    Wound Healing: Phases

    Phase I: Inflammatory Phase:

    • Hemostasis: Immediately after injury, the blood vessels constrict and coagulate.
    • Vasodilation: Blood vessels enlarge, increasing blood flow to the area.
    • Inflammation: The site is invaded by white blood cells.

    Phase II: Proliferation Phase:

    • New cells and capillaries fill in the wound from the underlying tissue to the skin surface.
    • This process seals the wound and protects from contamination.

    Collagen Formation:

    • Occurs during reconstruction or proliferation phase.
    • The would contracts as new tissue is reconstructed.
    • Myofibroblasts: Produce collagen (glue-like substance) and adds strength to the wound and tissue.
    • Collagen formation increases rapidly between post-op days 5-25.
    • Wound dehiscence most frequently occurs during this phase.

    Phase IV: Maturation Phase:

    • Fibroblasts exit the wound, collagen forms, and tissue and skin become stronger.
    • The wound will continue to gain strength but healing can take up to 1 year.
    • Internal wounds (Stomach, Colon) regain faster than skin wounds.
    • Keloid: Occasionally, an overgrowth of collagen at the site of the wound forms. African Americans, dark-skinned people of all races, and young women are at the highest risk for developing keloids.

    Wound Terminology

    • Purulent: Contains or produces pus.
    • Exudate: Fluid, cells, or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes.

    PPE (Personal Protective Equipment)

    • PPE should be worn for any patient with any suspicion of or known infectious disease.

    Types of PPE:

    • Gown
    • Mask
    • Goggles (or other eye protection)
    • Gloves

    PPE Removal Order:

    • Gloves

    • Gown

    • Goggles

    • Mask

    • DON- means to put on.

    • DOFF - means to take off.

    Restraints

    • Check skin and circulation regularly when restraints are used.
    • Always obtain consent for restraints, ensure the client's mental status allows for informed consent.
    • Document any refusals, notify the doctor, and the responsible party when restraints are used. Assess their mental function.
    • Safety reminder devices should be used for the shortest amount of time possible and only after less restrictive measures have failed.
    • Seclusion can be requested by the client and is a safe, private area for them to calm down on their own.
    • Restraints are considered a last resort and alternatives should always be explored first.
    • Restraints can be physical or chemical.
    • When using restraints, position the client on their side to prevent aspiration.
    • SRDs require a doctor's order including type, location, duration of use, and client behaviors prompting their use.
    • Nurses can apply SRDs in emergencies but must obtain an order within one hour.
    • Orders for SRD use may need to be rewritten every 24 hours.
    • While the client is in restraints, assess skin every two hours for pressure points, tears, or scratches.
    • Monitor the client's circulation, anxiety, and behavior frequently.
    • Document precipitating events, alternative actions taken, and client and family explanations.
    • Use quick-release ties and attach to the movable part of the bed frame.
    • Check every 15-30 minutes, release to the toilet, and perform ROM exercises every 2 hours.

    Distal Restraint Safety

    • Check skin and circulation frequently where distal restraints are placed.
    • If a client refuses restraints, assess their mental function, notify their doctor and responsible party, and document the refusal thoroughly.

    Lifts

    • Always lock lifts before use.
    • Ensure the base of the lift is correctly spread out.
    • Carefully position the client in the center of the sling.
    • Seek help if unsure about using a lift and never use it alone.

    Wheelchairs

    • Lock the wheels of the wheelchair when stationary.
    • Position the wheelchair on the client's strong side.
    • Never secure any tubing or lines to the wheelchair or any moveable part.

    Oxygen Therapy

    • Oxygen is an odorless, tasteless, colorless, and non-flammable gas, but it supports combustion.
    • The Flow Meter regulates the oxygen flow rate.
    • Oxygen is typically ordered in liters per minute (L/min).
    • Chronic respiratory illnesses require lower oxygen settings, generally no more than 1-2 L/min.
    • Long-term oxygen use requires humidification.
    • Enforce NO SMOKING signs strictly around oxygen.
    • Know the location of all fire extinguishers.
    • Only use water-soluble lubricants for oxygen equipment; petroleum-based lubricants can cause a combustion risk.

    Examples of combustible materials to avoid:

    • Grease
    • Oil
    • Vaseline
    • Alcohol
    • Ether
    • Any ungrounded equipment

    Methods Of Oxygen Delivery

    Nasal Canula (Bi-prongs):

    • Documented as BNP or BNC.
    • Fits into the nares.
    • Delivers 24-40% concentration.
    • Maximum flow rate of 6 liters.
    • Turn oxygen on before placing the canula on the patient.
    • Tubing goes over the ears and under the chin.
    • Assess and document skin condition behind the ears and in the nares before, during, and after treatment.
    • Only use water-soluble lubricants.

    Face Mask

    • Provides greater control over oxygen levels.
    • Concentration of 60-100% oxygen (required flow rate depends on the L/min). 6-10 L.
    • Humidified oxygen should produce a fine mist.
    • Adjust the mask snugly over the nose and chin.
    • The reservoir should never fully collapse (increase oxygen flow if it does, but only with a doctor's permission).

    Types of Face Masks:

    • Venturi: Delivers very precise amounts of oxygen.
    • Non-rebreather: Delivers up to 100% oxygen.
    • Simple: Delivers 40-60% oxygen.

    Oxygen Tent

    • Delivers a fine mist, maintains a constant temperature, and provides high concentration.
    • The canopy should cover at least the patient's torso.
    • Keep the patient dry to prevent chilling and change linens frequently.
    • The internal temperature should be at least 70 degrees.
    • Adjust the oxygen flow rate to 10-12 L/min.
    • Tuck the tent sides under the mattress if needed.
    • Parents might have to get under the tent with a child.

    Hyperbaric Chamber

    • Delivers 100% oxygen at 3 times the atmospheric pressure.
    • Facilitates faster tissue regeneration, particularly beneficial for wound healing.

    Ambu Bag

    • Delivers up to 100% oxygen depending on the presence of a reservoir.
    • The mask must firmly cover the nose and mouth to create a seal.
    • Deliver breaths every 5 seconds.
    • Can be attached to an endotracheal tube (ET).

    Patient Teaching for Oxygen Therapy

    • Explain oxygen application and safety procedures.
    • Discuss the signs and symptoms of oxygen toxicity:
      • Seen in concentrations over 50% for longer than 24-48 hours.
      • Nonproductive cough.
      • Substernal chest pain.
      • Nasal stuffiness/congestion.
      • Nausea/vomiting.
      • Fatigue.
      • Headache.
      • Sore throat.
      • Hypoventilation.
    • Emphasize the importance of oral hygiene.
    • Encourage fluid intake.
    • Teach the patient about T C D B (Turn, Cough, Deep, Breath).

    Fire Safety

    RACE:

    • Rescue Patients
    • Alert the alarm
    • Confine the fire
    • Extinguish the fire

    PASS:

    • Pull the pin
    • Aim low
    • Squeeze the trigger
    • Sweep from side to side

    Types of Isolation

    Airborne:

    • Used for patients with confirmed or suspected serious illnesses transmitted by airborne droplet nuclei.
    • Examples: Measles, Varicella zoster virus (Chickenpox), TB, COVID-19.

    Isolation Precautions:

    • Single-patient room.
    • Room with negative air pressure.
    • Room vented to the outside.
    • Door to the patient's room remains closed.
    • N-95 mask or better.

    Droplet:

    • Used for patients with known or suspected illnesses caused by large particle droplets.

    Examples of Illnesses:

    • Invasive Haemophilus Influenzae (meningitis, pneumonia, epiglottis, & sepsis)
    • Invasive Neisseria Meningitidis Disease (meningitis, pneumonia, & sepsis)
    • Serious Respiratory Illnesses:
      • Diphtheria (Pharyngeal)
      • Mycoplasma Pneumonia
      • Pertussis
      • Pneumonic Plague
      • Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children
    • Serious Viral Illnesses:
      • Adenovirus
      • Influenza
      • Mumps
      • Parvovirus B19
      • Rubella (German Measles)

    Isolation for Droplet Precaution:

    • Standard PPE.
    • Private room or at least 3 feet separation from roommates.
    • Limited patient transportation, wear a mask during transport.

    Contact:

    • Used for serious illnesses easily transmitted by direct patient contact or contact with objects in the patient's environment.

    Isolation for Contact Precaution:

    • Gloves and gown required when entering the room.
    • Dedicated equipment for the patient.
    • Careful hand hygiene.

    Wound Irrigation

    • Sterile procedure.
    • Promotes wound healing and comfort.
    • Gentle cleansing technique to prevent further tissue damage.
    • Clean from the least contaminated to the most contaminated area.
    • Use a syringe alone or with an IV catheter or needle.
    • Wash hands before and after the procedure.
    • Use a collection device to catch irrigation fluid.
    • Wear appropriate PPE.

    Tracheostomy Care

    Suctioning:

    • Nasopharyngeal/Tracheal: Sterile.
    • Oropharyngeal: Clean.
    • Suction only when withdrawing the catheter (coming out).
    • Assess respiratory status before and after suctioning.

    Indwelling Urinary Catheter

    • Sterile procedure.
    • Follow the same steps as the check-off procedure.

    Enemas

    • Clean procedure.

    Types:

    • Fleet
    • Oil retention
    • Soap/Suds (SSE)
    • Tap Water (TWE)

    Steps to Perform an Enema:

    • Position the patient in left Sims position.
    • Ensure the solution temperature is no higher than 105 degrees.
    • Add soap only after the water has entered the rectum.
    • Hold the container no higher than 18 inches from the patient's body.
    • Typically, no more than 3 enemas are administered without a physician's permission.
    • Review the procedure carefully.

    Tube Feeding

    • Follow the same steps as the check-off procedure.
    • Remember to check tube placement every time the patient is fed if on intermittent feeding, and every shift if on continuous feeding.

    Hygiene

    • Do not use soap on the face unless the patient requests it.
    • Rinse all soap from the body thoroughly to prevent skin irritation.
    • Use long strokes when washing, moving towards the heart.

    Baths

    • Tepid: Used to reduce fever.
    • Sitz: Used for comfort after childbirth, rectal surgery, or hemorrhoids.
    • Medicated: Used to moisturize and treat dry skin; monitor for skin breakdown.

    Vital Signs

    • Pain is now considered the 5th vital sign.
    • Always know the patient's baseline vital signs: weight, height, and temperature.
    • Use the same scale, clothing, and time of day for daily weight measurements.

    Wound Healing: Phases

    Phase I: Inflammatory Phase:

    • Hemostasis: Immediately after injury, the blood vessels constrict and coagulate.
    • Vasodilation: Blood vessels enlarge, increasing blood flow to the area.
    • Inflammation: The site is invaded by white blood cells.

    Phase II: Proliferation Phase:

    • New cells and capillaries fill in the wound from the underlying tissue to the skin surface. This process seals the wound and protects from contamination.
    • Collagen Formation: Occurs during reconstruction or proliferation phase. The wound contracts as new tissue is reconstructed.
    • Myofibroblasts: Produce collagen (glue-like substance) and adds strength to the wound and tissue. Collagen formation increases rapidly between post-op days 5-25. Wound dehiscence most frequently occurs during this phase.

    Phase IV: Maturation Phase:

    • Fibroblasts exit the wound, collagen forms, and tissue and skin become stronger. The wound will continue to gain strength but healing can take up to 1 year. Internal wounds (Stomach, Colon) regain faster than skin wounds.
    • Keloid: Occasionally, an overgrowth of collagen at the site of the wound forms. African Americans, dark-skinned people of all races, and young women are at the highest risk for developing keloids.

    Wound Terminology

    • Purulent: Contains or produces pus.
    • Exudate: Fluid, cells, or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes.

    PPE (Personal Protective Equipment)

    • PPE should be worn for any patient with any suspicion of or known infectious disease.

    Types of PPE:

    • Gown
    • Mask
    • Goggles (or other eye protection)
    • Gloves

    PPE Removal Order:

    • Gloves

    • Gown

    • Goggles

    • Mask

    • DON - means to put on

    • DOFF - means to take off

    Restraints

    • Check skin and circulation regularly when restraints are in use.
    • Always obtain informed consent for restraints.
    • Document refusals, notify the doctor, and the responsible party.
    • Safety reminder devices (SRDs) should be used for the shortest amount of time possible and only after less restrictive measures have failed.
    • Seclusion can be requested by the client and is a safe, private area for them to calm down.
    • Restraints can be physical or chemical.
    • When using restraints, position the client on their side to prevent aspiration.
    • SRDs require a doctor's order including type, location, duration of use, and the reason for use.
    • Nurses can apply SRDs in emergencies but must obtain an order within one hour.
    • Orders for SRD use may need to be rewritten every 24 hours.
    • While the client is in restraints, assess skin every two hours for pressure points, tears, or scratches.
    • Monitor the client's circulation, anxiety, and behavior frequently.
    • Document precipitating events, alternative actions taken, and client and family explanations.
    • Use quick-release ties and attach to the movable part of the bed frame.
    • Check every 15-30 minutes, release to the toilet, and perform ROM exercises every 2 hours.

    Distal Restraint Safety

    • Check skin and circulation frequently where distal restraints are placed.
    • If a client refuses restraints, assess their mental function, notify their doctor and responsible party, and document the refusal thoroughly.

    Lifts

    • Always lock lifts before use.
    • Ensure the base of the lift is correctly spread out.
    • Carefully position the client in the center of the sling.
    • Seek help if unsure about using a lift and never use it alone.

    Wheelchairs

    • Lock the wheels of the wheelchair when stationary.
    • Position the wheelchair on the client's strong side.
    • Never secure any tubing or lines to the wheelchair or any movable part.

    Oxygen Therapy

    • Oxygen is an odorless, tasteless, colorless, and non-flammable gas, but it supports combustion.
    • The Flow Meter regulates the oxygen flow rate.
    • Oxygen is typically ordered in liters per minute (L/min).
    • Chronic respiratory illnesses require lower oxygen settings, generally no more than 1-2 L/min.
    • Long-term oxygen use requires humidification.
    • Enforce NO SMOKING signs strictly around oxygen.
    • Know the location of all fire extinguishers.
    • Only use water-soluble lubricants for oxygen equipment; petroleum-based lubricants can cause a combustion risk.
    • Examples of combustible materials to avoid: grease, oil, Vaseline, alcohol, ether, or any ungrounded equipment.

    Methods of Oxygen Delivery

    • Nasal Canula (Bi-prongs):
      • Documented as BNP or BNC.
      • Fits into the nares.
      • Delivers 24-40% concentration.
      • Maximum flow rate of 6 liters.
      • Turn oxygen on before placing the canula on the patient.
      • Tubing goes over the ears and under the chin.
      • Assess and document skin condition behind the ears and in the nares before, during, and after treatment.
      • Only use water-soluble lubricants.
    • Face Mask:
      • Provides greater control over oxygen levels.
      • Concentration of 60-100% oxygen (required flow rate depends on the L/min) 6-10 L
      • Humidified oxygen should produce a fine mist.
      • Adjust the mask snugly over the nose and chin.
      • The reservoir should never fully collapse (increase oxygen flow if it does, but only with a doctor's permission).
      • Types of Face Masks:
        • Venturi: Delivers very precise amounts of oxygen.
        • Non-rebreather: Delivers up to 100% oxygen.
        • Simple: Delivers 40-60% oxygen.
    • Oxygen Tent:
      • Delivers a fine mist, maintains a constant temperature, and provides high concentration.
      • The canopy should cover at least the patient's torso.
      • Keep the patient dry to prevent chilling and change linens frequently.
      • The internal temperature should be at least 70 degrees.
      • Adjust the oxygen flow rate to 10-12 L/min.
      • Tuck the tent sides under the mattress if needed.
      • Parents might have to get under the tent with a child.
    • Hyperbaric Chamber:
      • Delivers 100% oxygen at 3 times the atmospheric pressure.
      • Facilitates faster tissue regeneration, particularly beneficial for wound healing.
    • Ambu Bag:
      • Delivers up to 100% oxygen depending on the presence of a reservoir.
      • The mask must firmly cover the nose and mouth to create a seal.
      • Deliver breaths every 5 seconds.
      • Can be attached to an endotracheal tube (ET).

    Patient Teaching for Oxygen Therapy

    • Explain oxygen application and safety procedures.
    • Discuss the signs and symptoms of oxygen toxicity:
      • Seen in concentrations over 50% for longer than 24-48 hours.
      • Nonproductive cough.
      • Substernal chest pain.
      • Nasal stuffiness/congestion.
      • Nausea/vomiting.
      • Fatigue.
      • Headache.
      • Sore throat.
      • Hypoventilation.
    • Emphasize the importance of oral hygiene.
    • Encourage fluid intake.
    • Teach the patient about T C D B (Turn, Cough, Deep, Breath).

    Fire Safety

    • RACE:
      • Rescue Patients
      • Alert the alarm
      • Confine the fire
      • Extinguish the fire
    • PASS:
      • Pull the pin
      • Aim low
      • Squeeze the trigger
      • Sweep from side to side

    Types of Isolation

    • Airborne: Used for patients with confirmed or suspected serious illnesses transmitted by airborne droplet nuclei.
      • Examples: Measles, Varicella zoster virus (Chickenpox), TB, COVID-19.
      • Isolation Precautions:
        • Single-patient room.
        • Room with negative air pressure.
        • Room vented to the outside.
        • Door to the patient's room remains closed.
        • N-95 mask or better.
    • Droplet: Used for patients with known or suspected illnesses caused by large particle droplets.
      • Examples of Illnesses:
        • Invasive Haemophilus Influenzae (meningitis, pneumonia, epiglottis, & sepsis).
        • Invasive Neisseria Meningitidis Disease (meningitis, pneumonia, & sepsis).
        • Serious Respiratory Illnesses:
          • Diphtheria (Pharyngeal).
          • Mycoplasma Pneumonia.
          • Pertussis.
          • Pneumonic Plague.
          • Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children.
        • Serious Viral Illnesses:
          • Adenovirus.
          • Influenza.
          • Mumps.
          • Parvovirus B19.
          • Rubella (German Measles).
      • Isolation for Droplet Precaution:
        • Standard PPE.
        • Private room or at least 3 feet separation from roommates.
        • Limited patient transportation, wear a mask during transport.
    • Contact: Used for serious illnesses easily transmitted by direct patient contact or contact with objects in the patient's environment.
      • Isolation for Contact Precaution:
        • Gloves and gown required when entering the room.
        • Dedicated equipment for the patient.
        • Careful hand hygiene.

    Wound Irrigation

    • Sterile procedure.
    • Promotes wound healing and comfort.
    • Gentle cleansing technique to prevent further tissue damage.
    • Clean from the least contaminated to the most contaminated area.
    • Use a syringe alone or with an IV catheter or needle.
    • Wash hands before and after the procedure.
    • Use a collection device to catch irrigation fluid.
    • Wear appropriate PPE.

    Tracheostomy Care

    • Suctioning:
      • Nasopharyngeal/Tracheal: Sterile
      • Oropharyngeal: Clean
      • Suction only when withdrawing the catheter (coming out).
      • Assess respiratory status before and after suctioning.

    Indwelling Urinary Catheter

    • Sterile procedure.
    • Follow the same steps as the check-off procedure.

    Enemas

    • Clean procedure.
    • Types:
      • Fleet.
      • Oil retention.
      • Soap/Suds (SSE).
      • Tap water (TWE).
    • Steps to Perform an Enema:
      • Position the patient in left Sims position.
      • Ensure the solution temperature is no higher than 105 degrees.
      • Add soap only after the water has entered the rectum.
      • Hold the container no higher than 18 inches from the patient's body.
      • Typically, no more than 3 enemas are administered without a physician's permission.
      • Review the procedure carefully.

    Tube Feeding

    • Follow the same steps as the check-off procedure.
    • Remember to check tube placement every time the patient is fed if on intermittent feeding, and every shift if on continuous feeding.

    Hygiene

    • Do not use soap on the face unless the patient requests it.
    • Rinse all soap from the body thoroughly to prevent skin irritation.
    • Use long strokes when washing, moving towards the heart.

    Baths

    • Tepid: Used to reduce fever.
    • Sitz: Used for comfort after childbirth, rectal surgery, or hemorrhoids.
    • Medicated: Used to moisturize and treat dry skin; monitor for skin breakdown.

    Vital Signs

    • Pain is now considered the 5th vital sign.
    • Always know the patient's baseline vital signs: weight, height, and temperature.
    • Use the same scale, clothing, and time of day for daily weight measurements.

    Wound Healing: Phases

    • Phase I: Inflammatory Phase:
      • Hemostasis: Immediately after injury, the blood vessels constrict and coagulate.
      • Vasodilation: Blood vessels enlarge, increasing blood flow to the area.
      • Inflammation: The site is invaded by white blood cells.
    • Phase II: Proliferation Phase:
      • New cells and capillaries fill in the wound from the underlying tissue to the skin surface. This process seals the wound and protects from contamination.
      • Collagen Formation: Occurs during reconstruction or proliferation phase. The wound contracts as new tissue is reconstructed.
      • Myofibroblasts: Produce collagen (glue-like substance) and adds strength to the wound and tissue. Collagen formation increases rapidly between post-op days 5-25. Wound dehiscence most frequently occurs during this phase.
    • Phase IV: Maturation Phase:
      • Fibroblasts exit the wound, collagen forms, and tissue and skin become stronger. The wound will continue to gain strength but healing can take up to 1 year. Internal wounds (Stomach, Colon) regain faster than skin wounds.
      • Keloid: Occasionally, an overgrowth of collagen at the site of the wound forms. African Americans, dark-skinned people of all races, and young women are at the highest risk for developing keloids.
    • Primary Intention: Skin edges of the wound are close together, and little tissue is lost. Primary intention healing begins in the inflammatory phase.
    • Secondary Intention: When a wound must granulate during healing, and the edges are not approximate (come together), or when pus is visible.
    • Tertiary Intention: Delayed primary intention. The provider will leave a contaminated wound open and close it later once the infection is controlled.

    Wound Terminology

    • Purulent: Contains or produces pus.
    • Exudate: Fluid, cells, or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes.

    PPE (Personal Protective Equipment)

    • PPE should be worn for any patient with any suspicion of or known infectious disease.
    • Types of PPE:
      • Gown.
      • Mask.
      • Goggles (or other eye protection).
      • Gloves.
    • PPE Removal Order:
      • Gloves.
      • Gown.
      • Goggles.
      • Mask.
    • DON- means to put on.
    • DOFF - means to take off.

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    Description

    This quiz covers essential protocols regarding the application of restraints in a healthcare setting. Understand the procedures for obtaining consent, documenting usage, and ensuring patient safety. Test your knowledge on both physical and chemical restraints, as well as the responsibilities of medical personnel.

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