Nursing Past Paper PDF

2.Put on gown 3.Put on mask/N95 respirator 4.Put on eye protection 5.Put on gloves https://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng201 2.pdf Taking off PPE 1.Remove gloves 2.Remove gown 3.Perform hand hygiene 4.Remove eye pr...

2.Put on gown 3.Put on mask/N95 respirator 4.Put on eye protection 5.Put on gloves https://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng201 2.pdf Taking off PPE 1.Remove gloves 2.Remove gown 3.Perform hand hygiene 4.Remove eye protection 5.Remove mask/N95 respirator 6.Perform hand hygiene (WEEK 4) Class 4: Tuesday, Oct 1 - Transfers, Mobility, and Comfort Measures 1. Recognize safe client handling and how the nurse uses body mechanics to prevent musculoskeletal injuries while moving, transferring, and ambulating a client. 2. Describe the benefits of activity and exercise and how the concepts of mobility and immobility relate. 3. Describe how body alignment, balance, friction, shear and gravity influence body movement. 4. Identify the factors that influence activity, exercise, mobility, immobility. 5. Identify how the nurse can promote mobility and exercise in the hospitalized client to promote optimal health outcomes. 6. Discuss the role of the nursing process and clinical judgement play in transferring and ambulating patients to minimize the effects of immobility. 7. Demonstrate the nursing process and clinical judgement related to safe and effective transfer techniques: bed to chair, bed to stretcher, and mechanical lifts. 8. Demonstrate the nursing process and clinical judgement related to safe and effective ambulation techniques: assisting a client to walk with and without mobility aids. Movement,Exercise & Body Mechanics Body Mechanics The coordinated efforts of the MSK & nervous systems to maintain balance, posture & body alignment during lifting, bending, moving & ADLs, injury, facilitates mobility & allows for efficient use of energy. Principles of Body Mechanics Body Alignment Body balance - center of gravity 1. Friction 2. Pathological Influences on Body Mechanics& Movement 3. Congenital abnormalities  4. Degenerative disorders 5. Other chronic diseases 6. Episodic illness Principles of Body Mechanics Wider base of support=greater stability Lower center of gravity=greater stability Equilibrium of an object is maintained as long as the line of gravity passes through its base of support Facing direction of movement reduces twisting Dividing balanced activity between arms & legs back injury Principles of Body Mechanics 1. Leverage, rolling, turning, pivoting less work than lifting 2. When friction is reduced, less force is required to move it 3. Reducing force of work ↓ risk of injury 4. Good body mechanics reduces fatigue 5. Alternating periods of rest and activity reduces fatigue Proper Lifting he image you’ve uploaded appears to demonstrate the concept of proper lifting techniques, which is an important topic in nursing and other healthcare-related fields. The purpose of teaching proper lifting is to prevent injury to both healthcare workers and patients, especially in settings where lifting and moving patients or heavy objects is a regular task. Here are the basic steps of proper lifting as shown in the image: 1.Bend at the knees, not the waist: Squat down, keeping your back straight. This allows you to use the stronger muscles in your legs rather than putting strain on your back. 2.Hold the object close to your body: Keeping the object near your center of gravity helps maintain balance and reduces the risk of strain. 3.Lift with your legs: Use your leg muscles to stand up, keeping your back as straight as possible during the motion. 4.Avoid twisting: When turning, move your feet instead of twisting your back or torso, which could lead to injury. 5.Keep the load balanced: Ensure that the load is stable and manageable. In nursing, lifting is particularly relevant for patient care, whether it’s assisting patients in moving from beds to chairs, helping with ambulation, or lifting equipment. Proper lifting techniques help reduce the risk of musculoskeletal disorders, which are common in healthcare workers due to the physical demands of the job. In your class, you are likely learning these techniques to prevent injuries such as back strains, which are a leading cause of work-related injuries in healthcare settings. Preventing Lift Injuries 1. Arrange for help when moving clients, use a lift team 2..Use patient handling equipment (ceiling-lifts, slide sheets, air-mattress on maximum inflate, adjust height of bed) 3..Encourage client to help as much as possible (AFTER your assessment) 4.Keep back, neck, pelvis & feet aligned 5.Avoid twisting Preventing Lift Injuries Flex knees, keep feet wide apart Position yourself close to client, use arms & legs (not your back) Use a pull sheet to move pt towards you, & slide board to move client from bed-stretcher The person with the heaviest load coordinates efforts by counting to 3, then move client together. Perform manual lifting as a last resort & only if it doesn’t involve lifting most or all of a client’sweight. Positioning Assessment of the Mobile or Partially Mobile Client 1.Body Alignment: standing, sitting, recumbent 2.Mobility: ROM, gait, exercise, activity tolerance 3.Patient Expectations: Motivation, expectation of pain or undue fatigue with movement, perception of need for activity Range of Motion (ROM) 1.The maximum amount of movement available at a joint in one of the 4 planes of the body 2.Nurse assesses ROM before mobilizing client, while laying in bed 3.Active ROM: client performs the exercises, is able to move all joint through motions Passive ROM: nurse performs for the client, who is weak or unable to move the joints Positioning client for comfort Fowler’s position: HOB 45-60 degrees Increases comfort, improves ventilation, promotes relaxation Prone position: Pillow under head reduces flexion or hyperextension of cervical vertebrae Pillow under abdomen reduces pressure on breasts and reduces hyperextension of lumbar-reducing low back strain  Pillow under lower legs reduces external rotation of hips, prevents foot drop Supine position: 1. Rolled towel under lumbar area supports lumbar spine 2. Pillow under head, neck & upper shoulders prevents flexion contractures of cervical vertebrae 3. Pillow under heels prevents pressure sores 4. Footboard maintains dorsiflexion of feet and prevents foot drop 5.Rolls or sandbags along legs prevents external rotation of hips 6.Hand rolls reduces extension of fingers and abduction of thumb Positioning client for comfort The image you’ve shared is demonstrating the Sims’ position, a specific patient positioning technique often used in healthcare settings. Sims’ Position: The patient lies on their side, with one leg (the lower one) straight and the other leg (the upper one) bent at the knee and hip. The patient’s lower arm is positioned behind the body, while the upper arm is flexed and in front, often with a pillow for support. Purpose of Sims’ Position:  Comfort: It’s often used to promote comfort, especially in patients who are resting or sleeping. Medical procedures: It’s commonly used during certain exams or treatments, like administering enemas or rectal examinations. Postural drainage: It helps in draining secretions from the mouth or lungs. This position helps keep the airway open and provides access to the rectal area, which can be useful for both patient care and comfort. Positioning client for comfort Lateral Side Lying: Removes pressure from bony prominences on back and buttocks Pillow under head & neck reduces lateral neck flexion & reduces strain on sternocleidomastoid muscle Shoulder flexed forward prevents weight directly on shoulder joint Pillow under upper arm decreases internal rotation & adduction of shoulder Pillow under semi flexed upper leg prevents pressure on bony prominences Positioning client for comfort Trendelenburg position – not used any more in hypovolemic shock Head-down used more for to facilitate medical interventions Positioning Devices his image shows a variety of positioning devices used in healthcare settings to assist with patient comfort, safety, and alignment during medical care. Here’s an explanation of each device shown: 1.Foot Elevator (top-left): This device is typically used to elevate a patient’s heel, preventing pressure sores and keeping the foot in the correct anatomical position. It’s useful for patients who are bedridden for long periods. 2.Trochanter Roll (top-right): This positioning device helps maintain the correct alignment of the lower extremities. It’s commonly used to prevent external rotation of the hips in patients who are immobile. 3.Positioning Pillow/Wedge (middle-left): This pillow or wedge helps position a patient in a side-lying or semi-prone position, offering support to reduce pressure on certain areas of the body. 4.Hand Roll (middle-center): The small device being held is a hand roll, designed to prevent contractures and maintain the functional positioning of a patient’s hand. It is often used for individuals with limited mobility in their hands or after strokes. 5.Bed Rail (bottom-right): Bed rails are safety devices used to prevent patients from falling out of bed. They can also assist with mobility, helping patients reposition themselves or get in and out of bed. These devices are commonly used in various healthcare settings, especially for patients who are bedridden or need help maintaining proper body alignment and preventing complications like pressure ulcers or contractures. Apply Thromboembolitic Hose (TEDs) This image is explaining how to apply Thromboembolic Deterrent Stockings (TEDs), also known as anti-embolism stockings, which are commonly used to prevent blood clots, especially in patients who are bedridden or post-surgery. Here’s a breakdown of the key elements in the image: 1.Sizing Guidelines: The chart provides a sizing guide for knee-length TED stockings based on measurements of the leg. Step 1: Measure the circumference of the calf at its widest point to determine the size. Step 2: Measure the distance from the bend of the knee to the base of the heel to determine the correct length. 2.Available Sizes: The chart lists different sizes and codes based on the measurements taken. Sizes include: X-Large Regular Large Regular  Medium Regular Small Regular Each size comes with options for both Regular and Long lengths to accommodate different leg lengths. 3.Anti-Embolism Stockings Purpose: These stockings are designed to improve blood circulation in the legs and prevent the formation of blood clots (deep vein thrombosis or DVT), particularly in individuals who are immobile for extended periods. They are often used post-surgery or during hospitalization when patients are confined to bed and at a higher risk of blood clot formation. 4.Measuring Accuracy: Ensuring accurate measurements of calf circumference and leg length is critical to ensure proper fit and effectiveness of the stockings. In summary, the image provides guidance on how to select and apply TED stockings properly to help prevent blood clots, ensuring both correct size and length based on the patient’s measurements. Apply Thromboembolitic Hose (TEDs) To apply Thromboembolic Deterrent Stockings (TEDs) properly, follow these steps: 1. Measure the Leg for Correct Sizing Calf Circumference: Measure the largest part of the calf to determine the correct width of the stocking. Leg Length: Measure the distance from the base of the heel to the bend of the knee to select the appropriate length. 2. Prepare the Stockings Turn the stocking inside out down to the heel. This makes it easier to slide over the foot. Ensure there are no wrinkles in the stocking as this can cause discomfort and pressure points. 3. Position the Patient  Have the patient lie down with their leg elevated for a few minutes if possible. This reduces swelling in the leg before applying the stocking. 4. Apply the Stocking Step 1: Slide the stocking over the foot, ensuring the heel is in the correct position in the heel pocket of the stocking. Step 2: Gently pull the stocking up the leg. Smooth it as you go to avoid any wrinkles. Step 3: Continue pulling the stocking up until it reaches the knee (for knee-high TEDs). Ensure that the stocking is smooth and even with no bunching or folds. 5. Check the Fit The stocking should fit snugly but not tightly enough to cause pain or discomfort. Ensure that the toes are not restricted or turning blue, which could indicate that the stockings are too tight. 6. Reapply and Check Regularly TED stockings should be removed periodically (e.g., once a day) to inspect the skin and allow for circulation. Reapply the stockings daily or as directed, ensuring proper fit each time. Following these steps helps ensure TED stockings are applied effectively to prevent blood clots while maintaining patient comfort. Apply Sequential Compression Device This image shows Sequential Compression Devices (SCDs) applied to a patient’s legs. Here’s how you can explain what they are and how they are used: Sequential Compression Device (SCD): SCDs are used to help prevent deep vein thrombosis (DVT), which are blood clots that can form in the legs, especially in patients who are immobile or bedridden for extended periods. These devices consist of inflatable sleeves that wrap around the legs and are connected to a pump that intermittently inflates and deflates them. How SCDs Work: The sleeves inflate in a sequential pattern, starting at the lower leg and moving upward. This mimics the natural muscle contractions that occur during walking, which helps to improve blood flow back to the heart and reduce the risk of blood clots. How to Apply Sequential Compression Devices: 1.Prepare the Device: Ensure the device is set up and properly connected to the compression pump. Verify that the machine is working and set to the correct compression cycle. 2.Position the Sleeves:  Wrap the SCD sleeves around the patient’s legs, making sure they are snug but not too tight. Position the sleeves so the inflatable bladders cover the lower legs properly. 3.Connect the Tubes: Attach the tubing from the sleeves to the pump unit, ensuring that the connections are secure. 4.Turn On the Device: Turn on the machine, and it will begin inflating the sleeves in a sequential pattern. Observe to make sure the sleeves inflate and deflate as expected. Monitoring: Regularly check that the sleeves are applied correctly and that the patient is comfortable. Inspect the skin under the sleeves for any signs of irritation, and make sure the sleeves are not too tight to ensure proper circulation. Sequential compression devices are vital in post-operative care and for patients at risk of DVT due to prolonged immobility. They assist in promoting circulation and preventing the formation of dangerous blood clots. Assisting with Ambulation Gait Belts Walk slowly Client sets the pace Walk on the client's weaker side Hold the handrail, if available, with client’s strong arm Assisting with Ambulation Indication = Some imbalance or weakness Must be able to: Weight bear on at least one foot Use of hands & arms Proper Use: Standing straight with elbows slightly flexed Provide instructions for use & then evaluate Assisting with Ambulation Canes Indication: Weakness or paralysis on one side Safe Use: Hold on unaffected side Height- elbow slightly bent when walking Three-point and four-point canes 6-10 inches to the outside of the foot Check rubber tip Crutches This image provides instructions for using crutches with different walking patterns or gaits. The diagram illustrates three types of gait patterns: three-point gait, two-point gait, and four-point gait, which are used depending on the patient’s level of weight-bearing ability and mobility needs. Here’s an explanation of each: 1. Three-Point Gait (for non-weight-bearing or limited weight-bearing on one leg) Step 1: Both crutches and the affected leg (the leg that is injured or weak) move forward together. Step 2: The unaffected leg (strong leg) then advances forward. This gait is often used by patients who are unable to bear weight on one leg, allowing them to move forward without putting pressure on the injured leg. 2. Two-Point Gait (for partial weight-bearing) Step 1: Move the right crutch and left foot forward together. Step 2: Move the left crutch and right foot forward together. This gait provides more stability and is used when the patient can put some weight on both legs. It mimics normal walking but with the support of crutches. 3. Four-Point Gait (for full weight-bearing or balanced support) Step 1: Move the right crutch forward. Step 2: Move the left foot forward. Step 3: Move the left crutch forward. Step 4: Move the right foot forward.  This gait is slower but provides maximum support and stability because three points of contact (both crutches and one foot) are always on the ground. It is ideal for patients who need balanced support but can bear weight on both legs. Tripod Position Before starting with any gait, the patient stands in the tripod position, where both crutches are positioned a few inches in front and slightly to the sides of the feet, providing stability. These gait patterns help patients with various levels of mobility regain their ability to walk while providing the necessary support to prevent further injury. Transfers Bed to Chair 1. One nurse - patient who can assist 2. Explain procedure first 3. Chair beside bed with back same plane as HOB 4. Consider transfer belt 5. Use good body alignment Stand Aid Lift Assessment prior to using: 1. cognition 2. predictability 3. trunk contro Mechanical Lifts 1. Ceiling models 2. Floor models Health Education Across the Lifespan Lifespan Considerations 1. Body mechanics and transfer techniques apply to all clients 2. Infants require a different approach Newborn Sleep - Wake States This image explains the different sleep and wake states of a newborn. These states describe how a newborn’s behavior and activity levels change depending on whether they are asleep, drowsy, or awake. Here’s a breakdown of the different states: Sleep States: 1.Deep Sleep/Quiet Sleep: Description: The newborn is in a deep sleep. Characteristics: No rapid eye movement (REM), no body movements except for occasional startles or jerky movements. Breathing is regular. Significance: This is the most restful and restorative stage of sleep, where the body is fully relaxed. 2.Light Sleep/Active Sleep: Description: The newborn is in a lighter sleep stage. Characteristics: REM is present, some low levels of body activity, and breathing tends to be irregular. The baby may move more in this stage. Significance: Light sleep is important for brain development, and the baby may wake more easily from this stage. Transitional State: 3.Drowsiness: Description: The newborn is between sleeping and waking. Characteristics: The baby may have eye-opening or fluttering, with delayed responses to sensory input. Significance: This is a transitional state as the baby either falls asleep or wakes up. It may take time for the baby to fully engage in either sleep or wakefulness. Awake States: 4.Alert State: Description: The newborn is fully awake and alert. Characteristics: The baby shows a bright look, focuses on the environment, and pays attention to sensory input. Significance: This is the best time for interacting with the newborn because they are fully aware and able to process stimuli. 5.Active State: Description: The newborn is awake and active. Characteristics: Increased motor activity (such as moving arms and legs), some fussiness or brief periods of frustration. Significance: In this state, the baby may be overstimulated or preparing to cry if needs are not met. 6.Crying State: Description: The newborn is crying and upset. Characteristics: High motor activity, intense crying, and difficulty calming down. Significance: This state indicates that the baby needs something—like food, comfort, or a diaper change. Conclusion: Understanding these sleep-wake states is important for caregivers to respond appropriately to the newborn’s needs and provide the right type of interaction at the right time. For example, the alert state is ideal for feeding and bonding, while active or crying states may require soothing or addressing the baby’s discomfort. Sudden Unexpected Infant Death (SIUD) Unexplained death of child under age 1 suffocation Recommendations/Interventions: Back to sleep promotes inhalation of oxygen and exhalation of carbon dioxide Prevents inhaling pockets of previously exhaled air Do not sleep with your baby Remove all objects from sleeping area Early Lifespan Considerations Infants: flexed, and with growth/strength, develops anteroposterior curves of adult spine (for sitting/standing) Toddlers: protruding abdomen, sway back = imbalance; with growth, foot eversion improves Adolescence: significant growth period; uneven spurts (WEEK 5) Class 5: Tuesday, Oct 8 - Restraints, Seizure Precautions, Fall Prevention & Management 1. Discuss the legal, ethical, nursing & medical issues involved in the use of restraints: Describe the least-restraint approach. Identify alternatives to restraints. Describe & give examples of physical, environmental & chemical restraints Identify four objectives for the use of restraints. 2. Identify potential complications of physical restraints. 3. Identify nursing responsibilities regarding the use of restraints, including assessment, documentation & support for client & family. 4. Discuss seizure precautions to ensure client safety. 5. Understand how to use a fall risk assessment tool to improve client safety. Client Safety and Use of Restraints This image discusses client safety and the use of restraints in a healthcare setting, which is an important part of managing patients who may be at risk of harming themselves or others. Here’s an explanation of the elements in the image: Types of Restraints: 1.Soft Limb Restraints (left and center images): These are padded restraints designed to immobilize a patient’s limbs (arms or legs) to prevent them from pulling out medical devices (like IVs) or harming themselves. They are typically used for patients who may be confused, agitated, or at risk of falling or injuring themselves. The design of soft limb restraints ensures comfort and prevents injury while restricting movement. The padded nature of the restraints helps minimize pressure or skin damage. 2.Posey Belt Restraint (center image): This restraint wraps around the patient’s wrist or ankle and is tied to the bed or chair, keeping the patient safely restrained. The goal is to ensure that the patient cannot move in ways that would cause harm, such as getting out of bed unsafely. 3.Crib or Bed Restraint (right image): This image shows a bed with high rails, which can be used for patient restraint, particularly for children or infants. These beds are used to ensure the safety of patients who are at risk of falling or climbing out of bed, especially in pediatric or specialized care settings. The rails are often locked in place, providing a safe enclosure without the need for physical restraints on the body. Importance of Restraint Use: Restraints should only be used when absolutely necessary and as a last resort after trying other safety measures. They are applied to prevent harm to the patient or others, but their use must follow strict medical guidelines to ensure the patient’s rights and dignity are respected. Restraints should always be checked regularly to prevent injury, ensure proper circulation, and ensure they are still necessary. Patient Safety Considerations: While restraints are used to protect patients, they must be applied in a way that avoids physical harm, promotes comfort, and ensures the patient’s safety at all times. Proper documentation, regular reassessment, and minimizing restraint use are crucial in adhering to ethical and legal standards in healthcare. What are Restraints? Any method, physical or mechanical device, materials or equipment attached or adjacent to the patient’s body which restricts a person’s movement, physical activity, or normal access to their body. Types: 1. Physical 2. Chemical 3. Environmental 1. Physical Restraints: Definition: These are any devices, materials, or equipment attached to or near the patient’s body that restricts their movement. Examples: Limb restraints (e.g., wrist or ankle restraints) to prevent the patient from pulling out tubes or IV lines. Bed rails that prevent patients from getting out of bed unsafely. Vests or belts that keep a patient in a chair or bed. Purpose: Physical restraints are used to prevent falls, stop patients from injuring themselves, or protect medical equipment (like IVs or catheters) from being tampered with. Consideration: Physical restraints must be used carefully to avoid injury or emotional distress. Healthcare providers must check regularly for proper circulation and skin integrity. 2. Chemical Restraints: Definition: These involve using medications to control a patient’s behavior or restrict their movement. These medications are not part of the treatment for the patient’s underlying condition but are used to manage agitation, aggression, or confusion. Examples: Sedatives (e.g., benzodiazepines like lorazepam) to calm the patient or make them less responsive. Antipsychotics (e.g., haloperidol) to manage aggressive or psychotic behavior. Purpose: Chemical restraints are used when a patient’s behavior becomes dangerous or unmanageable, posing a risk to themselves or others. Consideration: Chemical restraints should be used with caution, as they can have side effects such as drowsiness, confusion, or a decline in cognitive function. Their use should be regularly monitored, and alternatives should always be explored. 3. Environmental Restraints: Definition: These involve modifying the patient’s surroundings to limit their freedom of movement or prevent access to certain areas. Examples: Locked units or rooms to prevent patients from wandering unsafely (e.g., in dementia care). Seclusion rooms in psychiatric settings, where a patient is placed in a room that they cannot leave on their own.  High-sided or enclosed beds that prevent patients from getting out of bed without assistance. Purpose: Environmental restraints are typically used in patients who may wander, exhibit harmful behavior, or are at risk of injury due to their environment. Consideration: While these are less invasive than physical or chemical restraints, they can still limit a patient’s freedom. Their use must follow ethical guidelines, and patients should not feel imprisoned or isolated unnecessarily. General Considerations for All Types of Restraints: Ethical and Legal Guidelines: Restraints should only be used as a last resort, when all other methods of ensuring safety (such as de-escalation techniques or constant supervision) have failed. Ongoing Monitoring: Patients under any form of restraint must be monitored regularly to ensure their safety, comfort, and well-being. Minimization: Healthcare professionals must use the least restrictive option possible and only for as long as necessary. Each type of restraint requires careful consideration, assessment, and documentation to ensure that the patient’s rights, dignity, and safety are maintained. Purpose for Restraints Two types of reasons for using restraints: Behavioural Restraint 1. Almost exclusively in ER Used for the control of aggressive/violent behavior or behavior that is dangerous to self or others (hitting, falling). 2.Medical/Surgical Restraint Most common on units Used for care management for a patient who is exhibiting behavior that is interfering with treatment (e.g. pulling on IV, Foley, life support equipment, or dressings). Physical Restraints Reduce the risk of client injury (doesn’t prevent falls) 1. Prevent the interruption of therapy, such as traction, IV infusion, NG tube feeding, Foley catheterization 2. Prevent the confused or combative client from removing life- support equipment 3.Reduce the risk of injury to others by the client This image shows different types of physical restraints along with their indications and accompanying images. Here’s an explanation of each type: 1. Mitten Restraints: Indications: These are used for patients who scratch themselves or are prone to pulling out tubes such as IV lines, feeding tubes, or catheters.  Image: The image shows a mitten restraint being used on a patient’s hand. It prevents the patient from using their fingers to manipulate medical equipment or cause self-injury. The mitten allows movement of the hand but restricts fine motor control, reducing the ability to grab or pull. 2. Lap or Belt Restraint: Indications: These are applied to patients at risk of sliding or falling from a chair or wheelchair. Image: The image shows a patient sitting in a chair with a belt wrapped around the waist. This restraint keeps the patient securely in place, preventing them from slipping out of the chair or attempting to stand unsafely without assistance. 3. Bed Rail or Side Rail: Indications: Bed rails are used for patients at risk of falling out of bed, especially those who may be confused, restless, or have mobility issues. Image: The image shows a bed with raised side rails. The rails create a physical barrier that helps to prevent the patient from accidentally rolling out of bed, providing added safety during rest. Summary: Mitten Restraints: Prevent fine hand movements to stop the patient from removing medical devices or causing injury. Lap or Belt Restraints: Secure the patient in a seated position to prevent falls from chairs. Bed Rails: Provide a barrier in bed to prevent falls or rolling off. These restraints are used to protect patient safety in specific circumstances where there is a risk of self-harm, falls, or disruption of medical treatment. It’s important that they are used ethically and in accordance with healthcare guidelines to minimize patient distress while ensuring safety. This image provides explanations for additional types of physical restraints used in healthcare settings, particularly for preventing patients from harming themselves or others. Here’s a detailed explanation of the types shown: 4. Wrist Restraints: Indications: Used for patients at risk of pulling out tubes, such as IV lines or catheters. Also used for patients who may hit others, especially in situations where they may become agitated or violent. Image: The image shows a wrist restraint secured to the patient’s wrist and attached to a fixed point, such as a bed or chair, to restrict movement of the arm and prevent harmful behaviors. 5. Elbow Restraints: Indications: Specifically used for patients at risk of pulling out tubes, particularly in pediatric care where younger children may not understand the importance of keeping medical devices in place. Image: The image shows a child with an elbow restraint, which prevents them from bending their arms. This limits their ability to reach their face or body to pull at tubes or medical equipment, while still allowing some movement of the arm. 6. Mummy Restraints: Indications: Used to restrict the movement of limbs in small children, especially during medical procedures. Image: The illustration shows the process of wrapping a child in a “mummy” restraint, where the child’s body and limbs are wrapped in a blanket or cloth to immobilize them. This is often done for infants or very young children during procedures like IV placement or wound care to prevent movement and ensure the procedure is performed safely. Summary: Wrist Restraints: Secure the wrists to prevent harmful actions like hitting or pulling at medical equipment. Elbow Restraints: Prevent bending of the elbows, especially useful in children, to keep them from disturbing medical devices. Mummy Restraints: Used for young children to fully immobilize them during medical procedures for safety. Chairs, Beds he image of the chairs and beds in this context likely relates to environmental restraints—a type of restraint that limits a patient’s movement by modifying their environment. Here’s how these devices relate to restraint use: 1. Reclining Medical Chair (Left Image): Restraint Use: This chair can be used as a form of restraint when it includes additional features like belts, trays, or locked wheels. These features can restrict a patient’s ability to stand up or move freely without assistance. Why It’s Considered a Restraint: The tray table can serve as a restraint if it prevents the patient from getting up or moving out of the chair. If the wheels are locked and the chair is reclined to a position that prevents the patient from standing up independently, it can act as a restraint, especially for patients who are prone to falling or wandering. Purpose: It’s typically used for patients with mobility issues or those at risk of falling who need to be restricted to the chair for their own safety. It can also be used to limit dangerous behavior, like trying to get up unsafely. 2. Hospital Bed (Right Image): Restraint Use: The side rails on the bed serve as a type of restraint, as they prevent the patient from getting out of bed without assistance. Why It’s Considered a Restraint: If the rails are raised to keep a patient in bed, it can act as a restraint by restricting the patient’s ability to get out of bed on their own. The adjustable features of the bed, like lowering the bed close to the floor or tilting it into a reclining position, can also act as environmental restraints by reducing the patient’s ability to move freely or leave the bed without help. Purpose: Beds with side rails are typically used for patients at risk of falling or those who are confused and may try to get up unsafely. The restraint limits movement to protect the patient from injury. How It Relates to Restraints: Environmental Restraints: Both the chair and the bed can act as environmental restraints, which modify the patient’s environment to restrict movement. These are typically less invasive than physical or chemical restraints but still limit the patient’s ability to move freely. Purpose of Restraint: The use of these items as restraints is to ensure patient safety by preventing falls, stopping unsafe behavior, or keeping the patient in a position that allows for proper medical care and monitoring. In conclusion, both the chair and the bed are forms of environmental restraints used to keep patients safe by limiting their ability to move in ways that could cause harm. ASSESSING THE PATIENT IS THE FIRST STEP Goal in restraint use is to find the safest, least restrictive way to care for the patient. Discover the Cause of the Problem If the patient wanders, try to figure out what he or she is seeking. If the patient is unsteady, look for underlying problems, such as poor shoes, side effects of medications, or bad eyesight. Learn About the Patient’s Interests A confused or agitated patient may be happier if allowed to follow familiar routines. Give the Patient a Say Discuss problems openly with the patient.. If possible, ask the patient how he/she would solve the problem. Involve Family Members They can provide information about the patient’s habits. They can take part in his or her daily activities. Document a Care Plan 1. Alternative Interventions 2. Alternative means of meeting the patients needs should be attempted first: 3. Move patient closer to nurses' station 4. Keep patient door open 5. Bed in low position 6. Call bell within reach 7. Reorient patient to environment 8. Conceal IV site & tubing with Stretch Netting 9. Decrease noise/minimize stimulation 10. Bed/Exit alarms with sensor pads (Posey Sitter II) 11. Encourage family involvement 12. lternative Interventions cont’d 13. Wrap Around Belt may be applied as long as it is 14. documented patient can “demonstrate” self release with 15. Velcro. 16. Exit Alarms with sensor pads for beds or chairs 17. Bed Alarms if available on beds. Use Restraints as a Last Resort Use Restraints only when: You have exhausted all alternative interventions Vital treatments depend on their use There is a clear and present danger IF RESTRAINTS MUST BE USED 1. Protect the patient’s rights and dignity 2. Choose the least restrictive method 3. Document each occurrence of restraint use 4. Properly trained / authorized staff may apply & remove restraints 5. Choose the correct restraint size - if too small, restraints may cause increased agitation and if too large, the patient can slide down in the restraint which could lead to asphyxiation. Physician’s Order Criteria for Restraints Physician must be informed and a face-to-face assessment with counter signed orders within ONE hour. Order must include: 1. Start and stop time 2. Date 3. Reason for restraint 4. Type of restraint to be used 5. Signature of Physician 6. Maximum duration 4 hours ages adults 18 and older 7. 2 hours ages 9-17 years old 8. 1 hour 0–8-year-old The physician must make a face-to-face re-evaluation and orders renewed every 8 hours for Adults and older every 4 hours for Children 17 and younger Nursing Procedure 1. Check the physician order. 2. Identify the patients. 3. Explain the procedure to the patients and family 4. Allow the patient to ask Q’s and encourage them toparticipate in the procedure as much as possible. 5. Ensure patients privacy. 6. Wash and dry hands. 7. Arrange the articles near the patient's bed side. 8. Make sure that the restraints are correct size for the patients build and weight. 9. Obtain adequate assistance to manually restrain the patient. Nursing Responsibilities Monitor a patient in restraint Q 15 mins for: signs of injury, circulation and rage of motion, comfort and readiness for discontinuation of restraint. Must communicates with the client and family. Apply the least restrictive to most restrictive devices. 1. 4 Side Rails up 2. Roll Belt 3. Mittens 4. 1- or 2-point soft restraint 5. 4-point soft restraint Arrange the client under restraint in a place for easy, close and regular observation.  Particular attention to their safety, comfort and dignity, privacy and physical and mental conditions. Review the restraint regularly or according to institutional policies. Consider the earliest possible discontinuation of restraint. Document Q2h the use of restraint for record and inspection purposes. Offer liquid, nutrition and bathroom Q2h. Hazards of Restraints Immobilizes a client, or client’s extremity, restricts freedom of movement or normal access to a person’s body Risk of tangling, pressure ulcers, constipation, pneumonia, urinary & fecal incontinence, urinary retention, contracture, nerve damage, circulatory impairment and asphyxia Emotionally humiliating, fear, anger, loss of self-esteem Problems with Long-term Use of Restraints Self Esteem Cause of incontinence Immobility Pressure ulcers Infections Falls Serious injuries Untimely death Law Least-restraint approach is recommended to ensure highest quality care Ensures alternatives have been attempted, and the restraint selected addresses a client need in the least restrictive way Thorough assessment is done by nursing and MD, consent may be required from family See story of David’s Mittens (Box 38.12 - p. 891) Seizures A seizure is one of many neurologic conditions characterized by abnormal electrical brain activity. Epilepsy is a chronic seizure disorder with recurrent and/or random seizure activity (Devinsky, et al., 2015). Types of Seizures - Many people with epilepsy have more than one type of seizure. Seizures are generally classified into twocategories: Generalized seizures I. Focal seizures SIGNS This image describes the signs of seizure activity in two distinct phases: pre-ictal (before the seizure) and post-ictal (after the seizure). Here’s an explanation of each phase and the associated signs: 1. Pre-ictal Phase (Aura) Aura: This is a warning sign that occurs before the actual seizure starts. It may manifest as a simple or complex partial seizure. Signs: Abnormal sensations: The person may experience unusual smells, tastes, or other sensations. Vertigo: A sensation of dizziness or spinning. Nausea: Feeling of sickness or discomfort in the stomach. Anxiety: The person may feel anxious or unsettled. Déjà vu: A feeling of familiarity with a situation, as though it has happened before. Visual and auditory phenomena: The person may experience visual distortions, see flashing lights, or hear strange sounds. Purpose of Aura: For some individuals, the aura acts as a signal that a seizure is imminent, giving them time to prepare or seek safety. 2. Post-ictal Phase (After the Seizure) Signs: Confusion: After a seizure, the person may be disoriented and confused. Lethargy: The person often feels very tired and sluggish. Upset or embarrassed: Emotional reactions may follow, as the person may not remember what happened or feel self-conscious. Memory loss: The person may not recall the seizure or experience other short-term memory loss. Abnormal or combative behavior: Some individuals may exhibit aggressive or unusual behavior immediately after the seizure. Postictal coughing: A cough that occurs during the recovery phase. Spitting and hypersalivation: Increased saliva production may lead to drooling or spitting. Nose-wiping: The person may reflexively wipe their nose after a seizure. Psychosis and mania: In rare cases, individuals may experience psychotic or manic symptoms following a seizure. Summary: The pre-ictal phase involves the aura, a warning that the seizure is about to happen, with signs like sensory changes, vertigo, or déjà vu. The post-ictal phase refers to the recovery period after the seizure, where confusion, fatigue, and various physical or behavioral changes can occur. Understanding these signs can help caregivers and medical professionals respond appropriately before and after a seizure, ensuring the safety and well-being of the patient. COMPLICATIONS This image outlines the complications associated with seizures. Seizures can have significant consequences beyond the immediate event, and this diagram explains several of the key risks: 1. Aspiration Pneumonia: Explanation: During a seizure, there is a risk of breathing in food, liquids, or saliva into the lungs, which can lead to aspiration pneumonia. This occurs when foreign materials enter the lungs, causing infection and inflammation. Complication: Aspiration can result in serious respiratory issues, including difficulty breathing and lung infections that may require medical intervention. 2. Injury from Falls, Bumps, or Self-Inflicted Bites: Explanation: A person experiencing a seizure may be at risk of falling, hitting their head, or biting their tongue or lips during the episode. Complication: Injuries from seizures can range from minor bruises to more severe trauma, such as head injuries or broken bones, especially if the person is in a hazardous environment when the seizure occurs. 3. Permanent Brain Damage: Explanation: Severe seizures, particularly those that are prolonged or frequent, can result in permanent brain damage, including stroke or other neurological injuries. Complication: This can lead to long-term cognitive impairments, memory loss, or changes in behavior. In extreme cases, it can be life-threatening if critical areas of the brain are affected. 4. Medication Side Effects: Explanation: Anti-seizure medications, while essential for controlling seizures, can have side effects, including drowsiness, dizziness, and, in some cases, drug toxicity if doses are too high. Complication: These side effects may affect daily functioning and quality of life, and patients may require regular monitoring to adjust medications and minimize adverse effects. 5. Long-term Medication Side Effects (Osteoporosis): Explanation: Long-term use of certain anti-seizure medications, particularly those that affect bone metabolism, can lead to osteoporosis (a condition where bones become weak and brittle). Complication: This increases the risk of bone fractures and other skeletal issues, particularly in older adults or those who have been on medication for many years. Summary: The complications of seizures can range from immediate physical injury (such as falls or aspiration pneumonia) to long-term health impacts (such as brain damage or osteoporosis). Additionally, managing seizures with medication can come with side effects that must be carefully monitored. It’s crucial for healthcare providers to weigh the benefits of seizure control against the potential risks and side effects, and to ensure that safety measures are in place to protect patients during and after seizures. 1. Seizure Precautions 2. Consider: padded side rails, head board 3. Safety equipment accessible: oral airways, suction 4. equipment & disposable gloves 5. During seizure: position client, clear surrounding area, 6. provide privacy, loosen tight clothing, do not put 7. anything in client’s mouth, stay with client (observing 8. behaviours & timing event) 9. Following seizure: explain what happened to client, 10. answer questions, recovery position, comfort, call bell 11. within reach, quiet, non-stimulating environment Client Injury & Falls Factors contributing to falls: 1. age 2. previous falls 3. gait disturbance 4. balance 5. mobility problems 6. medications 7. postural hypotension 8. sensory impairment 9. urinary & bladder dysfunction 10. certain medical diagnose Falls: most reported incident of client injury Assessing Fall Risk Hendrich II Fall Risk Model: 7 Categories Confusion or disorientation: acute or chronic earn same score (interview, patterns of behaviour) Depression: history or diagnosis, observed signs or client’s expression Altered elimination Dizziness or vertigo: client’s expression or observed Gender - Male Medications: anti-epileptics & benzodiazepines Get-Up-and-Go test (scoring mobility) The Hendrich II Fall Risk Model is a tool used to assess a patient’s risk of falling in healthcare settings. It assigns points based on different risk factors, and a total score of 5 or more indicates that a patient is at high risk of falling. Risk Factors and Points: 1.Confusion/Disorientation: If the patient is confused or disoriented, they get 4 points. 2.Depression: If the patient shows signs of depression, they get 2 points. 3.Altered Elimination: If the patient has problems controlling urination or bowel movements, they get 1 point. 4.Dizziness/Vertigo: If the patient experiences dizziness or vertigo, they get 1 point. 5.Gender (Male): If the patient is male, they get 1 point. 6.Medications: If the patient is taking certain medications like anticonvulsants (for seizures) or benzodiazepines (for anxiety), they get 1 point. 7.Get-up-and-go” Test: This test checks how easily a patient can rise from a chair: 0 points: Able to rise in one smooth movement. 1 point: Pushes up successfully in one attempt. 3 points: Needs multiple attempts but can rise eventually. 4 points: Unable to rise without assistance. Scoring: Add up the points from all the relevant risk factors. If the total is 5 or more, the patient is considered at high risk of falling, and extra precautions may be needed to keep them safe. This tool helps healthcare professionals quickly assess and identify patients who might need additional fall prevention measures. Assessing Fall Risk Morse Fall Scale: 6 Categories 1.History of Falls this hospital stay and past 3 months 2.Secondary diagnosis 3.Ambulatory aid 4.IV or IV access or other equipment i.e. Foley catheter or monitoring equipment 5.Gait weak vs. impaired Mental Status The Morse Fall Scale (MFS) is a tool used to assess a patient’s risk of falling in healthcare settings. It looks at different risk factors and assigns points. The higher the total score, the higher the risk of the patient falling. Here’s a simple breakdown of the key points: How the Morse Fall Scale Works: 1.History of falling (25 points if the patient has fallen recently). If the patient has fallen within the last 3 months, they get 25 points. No recent falls, 0 points. 2.Secondary diagnosis (15 points if the patient has more than one medical issue). If the patient has more than one diagnosis, they get 15 points. If not, they get 0 points. 3.Use of ambulatory aid (0, 15, or 30 points depending on the device used). 0 points if the patient doesn’t use any walking aid. 15 points if they use a cane, crutch, or walker. 30 points if they rely on furniture or can’t walk without help. 4.IV/Heparin lock (20 points if the patient has an IV or similar equipment). If the patient has an IV or similar device, they get 20 points. If not, they get 0 points. 5.Gait (walking style) (0, 10, or 20 points based on the patient’s movement). 0 points if they walk normally. 10 points if they have a weak gait (e.g., shuffle or are unsteady). 20 points if they have an impaired gait (e.g., difficulty rising or severe unsteadiness). 6.Mental status (15 points if the patient is forgetful about their limitations). 0 points if the patient understands their own limits and abilities. 15 points if they are forgetful and overestimate their abilities. Scoring: Add up all the points from the categories above. Total score determines fall risk: 0-24: Low risk (Good basic nursing care). 25-50: Moderate risk (Standard fall prevention needed). 51 and above: High risk (High-risk fall prevention needed). Summary: The MFS helps healthcare professionals quickly identify patients who are at risk of falling and implement appropriate interventions to keep them safe. A higher score means a higher risk of falls, and different actions are taken depending on the score. Fall Prevention Activities 1. Manage underlying health conditions 2. osteoporosis, delirium, infections 3. Exercise programs 4. Strategies to promote continence 5. Ensure use of aids (glasses, walkers) 6. Monitor medications, reduce polypharmacy 7. Bed-exit alarm 8. Appropriate footwear 9. Minimize environment clutter 10. Minimizing effects of orthostatic hypotension