Exam 1 Study Guide PDF

Safety 1.​ What is the purpose of the Joint Commision National Patient Safety Goals? Provide an example of one and explain how it contributes to patient safety. TJC created the NPSGs to reduce the risk of harm to self and others in all healthcare settings. Some of the NPSGs for...

Safety 1.​ What is the purpose of the Joint Commision National Patient Safety Goals? Provide an example of one and explain how it contributes to patient safety. TJC created the NPSGs to reduce the risk of harm to self and others in all healthcare settings. Some of the NPSGs for 2021 include: -​ Improve accuracy of patient identification -​ Improve effectiveness of communication among caregivers -​ Reduce risk for health care-associated infections 2.​ How do each of the following contribute to a culture of safety? The culture of safety consists of team work/empowerment, communication, transparency, and accountability. a.​ Reporting errors that could reach the patient. Transparency b.​ Reporting errors that don’t reach the patient. Accountability c.​ Holding yourself accountable. Accountability d.​ Using ISBARR to communicate with other healthcare providers. Communication 3. What is a Sentinel Event? What are some examples? Sentinel events are a patient safety incident that causes harm, injury, or death. Some examples of sentinel events include: -​ Patient on suicide watch commits suicide -​ An infant is discharged to the wrong family -​ Performing surgery on the wrong patient, or wrong body part 4. What are some common risk factors for falling? -​ Environment -​ Age -​ Mental status -​ Medications -​ The need to use the washroom -​ The patient has a past history of falling 5. After performing the Morse Fall Scale on a client, they are confirmed to be a high fall risk. What interventions are you implementing as a nurse? As their nurse, you can bring the patient closer to you, place them on a bed alarm, use 2-3 bed rails (never 4 because it would be considered a restraint), place their belongings and call light within reach, keep the bed at the lowest position, and identify the patient as a fall risk. 6. When is it appropriate to place a patient in restraints? Restraints are used by the nurse with the intent of preventing injury or harm to themself, others, or therapy disruption. Restraints increase the risk of fall-related injuries! There are different types of restraints: physical, mechanical device, and chemical. 7. As a nurse, what can you do to avoid using restraints? Only use restraints as your last resort! To avoid using restraints, you can try distracting the patient, placing them with a sitter, communicating, and putting them near the nurses station. 8. Deborah, has soft wrist restraints ordered and applied correctly. She remains agitated towards the staff. What are your responsibilities and assessments while the restraints are in place? -​ To assess Deborah’s skin integrity and provide skin care per protocol, usually every 2 hours. -​ Offer food and fluid to Deborah  -​ Provide hygiene and elimination needs -​ Monitor her vital signs -​ Offer range of motion exercises to Deborah 9. You as the nurse can delegate tasks like applying restraints. What must you do after the nursing assistive personnel (NAP) applies the restraints? After they’ve placed the restraints, I have to ensure two fingers fit underneath the restraint, make sure they’re not tied to the bed rails, and the correct size restraints are placed on the patient. Mobility 1.​ How can the nurse practice good body mechanics? -​ Lift with your legs not your back -​ Squat to lift -​ Have a wide base of support -​ Raise the bed to your waist level when working with a patient -​ Use assistive devices -​ Ask for help from others 2.​ What is the difference between active, passive, and full ROM? Active ROM - The patient can move their limbs Passive ROM - The nurse moves the patient's limbs Full ROM - The patient can move all of their limbs without any support 3.​ Provide examples of patient illnesses and injuries that would benefit from passive ROM exercises? A patient that has suffered from a head injury that immobilizes them would benefit from passive ROM exercises. A patient who undergoes knee replacement surgery may be prescribed a passive motion machine that continuously flexes and extends the patient’s knee while lying in bed. 4.​ Describe how immobility affects the following systems. List some interventions that might be helpful to prevent those problems. A.​ Musculoskeletal - Immobility can cause joint stiffness, and contractures. ROM exercises are an intervention. B.​ Lungs - Immobility can cause decreased lung expansion, and increased risk of pneumonia (lung infection). Deep breathing exercises and semi-fowler's positioning are interventions. C.​ Heart and Blood Vessels - Immobility can increase the risk of blood clots (thrombosis), orthostatic hypotension, and decreased cardiac output. Frequent position changes, placing SCDs on their legs, and leg exercises are examples of interventions. D.​ Skin - Immobility can cause skin breakdown and pressure ulcers. To prevent skin breakdown make sure to maintain proper hygiene, keeping the skin clean and dry. Frequent repositioning, movement, and cushions can help with pressure ulcers. E.​ Gastrointestinal - Immobility can cause constipation, weight loss and decreased appetite. To prevent this, you can give stool softeners, encourage high-fiber diet and hydration, and monitor food intake and weight. F.​ Urinary - Immobility can cause incontinence, resulting in placing a catheter and increased risks of UTIs. To prevent this, encourage plenty of fluids, monitor urine output, and ensure proper perineal hygiene. G.​ Psychological - Immobility can lead to depression, social isolation, and anxiety. To help with this, you can promote cognitive stimulation, encourage social interaction, and provide emotional support. 5. What are specific interventions for preventing pressure ulcers? To prevent pressure ulcers, you should assess (look for early stages of pressure ulcers) and reposition the patient every 2 hours, if immobile. Use proper padding under the patient's bony prominences. 6. What assistive devices can the nurse use to safely ambulate with clients in the hall? -​ Gait belt -​ Crutches -​ Cane -​ Walker 7. Oh no! You did everything right but your client says they feel like they’re about to pass out while ambulating! What are you going to do? If a patient begins to feel dizzy while ambulating or transferring, assist them to sit on a chair or on the floor to avoid a fall. Make sure to protect their head as much as possible! If the patient begins to fall, do not try to stop the fall or catch the patient. Try to control their fall by lowering them to the floor. Vital Signs 1.​ Where can you measure a surface temperature? Where can you measure a core temperature? Surface temperatures can be taken on your forehead (temporal artery), in your ear (tympanic), armpit (axillary), and orally. Surface temperatures are lower than your core temperature. For an axillary temperature, add 1 degree for a more accurate reading. The rectal temperature measures your core temperature. 2.​ How is heat exchanged in each of these processes? Give an example for each. A.​ Radiation → The heat loss from one surface to another without direct contact. B.​ Convection → The loss of heat from cool air flowing over a warm body. C.​ Evaporation → The conversion of a liquid to a vapor, such as when perspiration (sweat) evaporates. D.​ Conduction → The transfer of heat from a warm object (the patient) to a cooler object (the cooling blanket) during direct contact. 3. The nursing assistive personnel (NAP) calls to report a BP of 170/100 on a client. They have consistently had an average BP of 120/70 for the last 3 days. As the nurse, what would you do? 170/100 can indicate hypertension. As a nurse, I would reassess the patient's vitals. Then I would ask the patient if they’re experiencing any pain, stress, or just got done exercising. If the patient’s blood pressure remains as high as before, I would contact their PCP. 4. What are some reasons a client might experience hypoxemia? The patient might have COPD or a heart disease. Hypoxemia is caused from a lack of oxygen being supplied to the body’s tissue. 5. What signs and symptoms can you expect from someone with an oxygen saturation of 88% who reports dyspnea? What nursing interventions can you perform? Signs and symptoms of low oxygen saturation (hypoxemia) include: blue skin (cyanosis), lack of consciousness, restlessness, apprehension (feeling of impending doom), confusion, dizziness, or fatigue. As a nurse, I will put them in a fowler’s position, tell them to take deep breaths, and put them on supplemental oxygen. 6. What signs and symptoms can you expect from a hypotensive patient with a BP of 102/58? Some signs and symptoms of hypotension (low blood pressure) include: cold to the touch, clammy skin, fast and shallow breathing, weak and rapid pulse, and confusion. 7. When would you want to obtain an apical pulse over a peripheral pulse? An apical pulse (over the apex of the heart) is more accurate than a peripheral pulse (wrist, neck, or groin). You would want to obtain an apical pulse over a peripheral pulse when the patient’s pulse is abnormal.