Review of Topics Exam 3.docx

**BSQS Review of Topics Exam 3** - Bringing the bed to height appropriate working level can prevent a back injury. Although other options are part of the occupied bed skill, they are not directed at preventing back strain. \| - Older adults have drier, thinner skin and less subcutaneou...

**BSQS Review of Topics Exam 3** - Bringing the bed to height appropriate working level can prevent a back injury. Although other options are part of the occupied bed skill, they are not directed at preventing back strain. \| - Older adults have drier, thinner skin and less subcutaneous fat. Therefore, warm, not hot, water is needed, and chilling should be avoided. The older adult should use less soap (to decrease dryness), and the use of oils in the water can be hazardous. Older adults should be patted, not rubbed, dry, and moisturizer should be applied to skin that is still damp. \| - With aging, fat replaces muscle cells, which leads to loss of strength and stamina. There is also loss of collagen fibers makes the skin more fragile and slower to heal. - Placing the wheelchair and other assistive devices on the patient's stronger side aids in transfer. Keeping the beds wheels locked at all times will also prevent falls in patient with ambulation impairments. - The Braden Scale is used to predict pressure sore risk. The Glasgow scale is used to assess LOC; Korotkoff refers to sounds heard during a blood pressure measurement; Kussmaul refers to respirations. - Stage 4 is full-thickness skin loss with extensive tissue necrosis or damage to muscle, bone, or supporting structures. An area of intact skin that is deep pink-red or mottled skin that does not blanch with fingertip pressure is a Stage 1 pressure injury. Stage 2 involves partial-thickness skin loss with exposed dermis; stage 3 is full-thickness skin loss that may extend to the fascia, with subcutaneous tissue damaged or necrotic. Eschar must be removed to accurately stage an ulcer, because the nurse cannot know how deep the ulcer is. Patients with darkly pigmented skin will show a purple coloration under natural light in the beginning stages of a pressure ulcer instead of a reddened area. - Keeping the patients in a sitting position in their bed puts extra pressure on their coccyx and bottom due to gravity. Pressure Sore - Symptoms of Pressure Ulcers Symptoms of pressure ulcers The parts of the bod... \| Pressure ulcer, Pressure ulcer staging, Wound care nursing  - Diaphoresis (sweating) is the body's normal response to rid itself of heat. Drinking fluids to replace those lost prevents dehydration. - The dermis, or corium, is the inner, thinner layer of skin made of dense connective tissue that contains blood vessels, nerves, and glands. The epidermis is the outer, thicker layer that does tissue. The subcutaneous tissue contains fat and bigger blood vessels that will provide nutrients and oxygen to the dermis. - Protective devices are appropriate for sudden changes in mental status or behavior that could result in client harm or to properly continue medical treatments, such as protection of an IV site. - A **sentinel event** is an occurrence that causes a client\'s death or serious injury. The other situations are not sentinel events. - Moving the patient with partial immobility (strokes, etc) to a supine position provides safety for the patient while keeping the rails up. - The main cause of noise is people. Encourage the staff to limit conversations in the hallway and speak in lowered voices is always helpful to help patients to sleep. - Grab bars in the tub and at the toilet help the patients with joint impairment to bathe and toilet safely. Using well-lit areas during the day and night lights at night is helpful to avoid falls. Daytime napping may cause restlessness at night. - Extra blankets and bed socks will reduce the sense of cold. A person with diabetes or impaired circulation is more easily burned than a person in good health. - Placing patients with risks for falls close to the nurses' station is the best measure to allow the nurse to check on the patient frequently. The nurse needs to get an order for a vest protective device. - Local and federal laws prohibit the use of physical and chemical restraints except those authorized by a health care provider. Health care workers are encouraged to find other alternatives such as asking a family member to supervise the patient before resorting to the use of protective devices, thus having a family member or friend sitting with the client is always a good strategy. - Protective devices may not be used without an order or to punish or discipline a patient. Talking to the patient is an excellent strategy to determine the cause of the problem. Medications may also cause mood alterations. Stay with the patient who is confused or unsteady. Second action would be to determine if there is family members that might be able to stay with the patient. - A safety data sheet (SDS), formerly known as material safety data sheet (MSDS), should be available for each biohazard substance stored or used on the nursing unit. These sheets, often available electronically on the unit, are consulted for recommended methods of storage, labeling, handling spills, and disposal. Everyone must comply with these guidelines. - These bed and chair alarms along with cardiac and oxygen sensor alarms are among the alarms specified in the 2019 National Patient Safety Goal of improving the safety of medical alarms. All medical equipment alarms need to be closely monitored and checked for functionality and volume at the start of the shift and frequently throughout the shift. Steps need to be taken to prevent the catastrophic outcomes of alarm fatigue. Alarm fatigue occurs when nurses become desensitized to patient care alarms and then miss or delay response to an alarm. These absent or delayed responses have resulted in adverse patient outcomes, so responding promptly to alarm beeps will prevent this situation. - The acronym PASS can be used to correctly use a fire extinguisher: Pull the pin, Aim at the base of the fire, Squeeze the trigger, and Sweep side to side. - A very low humidity will dry respiratory passages. In patients with respiratory conditions, vaporizers or humidifiers may be ordered for a patient with a respiratory condition to moisten the respiratory passages. Small table fans may help some persons to breathe more easily. - To transfer a patient from the bed to a wheelchair, after locking the wheels of the wheelchair, the nurse should seat the patient on the side of the bed with the feet touching the floor. To transfer **a patient who can stand** can safely be assisted to pivot and transfer with the use of a transfer belt. This benefits the patient (active exercise) and is safe for both the nurse and the patient. - The prone position is an excellent position to take pressure off the sacral area, so it is an ideal position for patients that are semiconscious and/or beadbound. Raising the head and the knees of the patient interferes with venous return from the legs and puts a great deal of pressure on the sacrum. Use of a wheelchair for a semiconscious patient is not effective. - **A waist high bed height is a comfortable and safe working** height for the nurse, and also prevents staff back injuries. Before repositioning patients **this is the first thing to do**. The head is not raised in a side lying position; it is in a Fowler's or semi-Fowler's position. - The use of high-top sneakers (or a footboard) prevents footdrop and maintains dorsiflexion for physically immobile client in bed in the supine position. - A patient who has been immobilized for any length of time may feel dizzy or experience a drop in blood pressure when sitting or standing for the first time. Therefore, the nurse must assess the patient carefully to determine whether transfer to a chair, ambulation, or return to bed is indicated, by assessing the client's response to the changed position, looking for orthostatic hypotension, nausea, or dizziness before proceeding. - When a patient is pulled up in bed without being lifted first, shearing force is applied on the bony prominences and tissues of the back, which predisposes the patient to a pressure ulcer. - Passive range of motion (ROM) exercises, although not part of care given to all patients, does prevent contractures in persons who are bedfast and improves joint mobility. ROM does not guarantee the prevention of pressure ulcers but helps in the improved circulation of the limbs. - A patient who is threatening to fall needs to be lowered to the floor to avoid injury from a fall by stepping behind the client, grasping them around the waist or chest, and slide them down their leg gently to the floor. - For patients with unsteady gait, the nurse puts his hand from the bottom at the rear, so he can pull up if the patient starts to fall and not lose the grip on the gait belt. The nurse should slide one hand from the bottom under the gait belt at the middle of the client's back. The gait belt should be tight enough to secure the patient, but loose enough for the passage of the nurse's hand. - Fixing feet and placing one foot in front of the other and facing the direction of the movement and then turning their upper body to move the client up in bed with a rocking movement will ease the work of moving a patient up in bed. Good body mechanics will help to prevent low back injuries and less effort from the nurse when mobilizing a patient. Pulling requires less effort than pushing in this scenario. Twisting should be avoided; nurses should use leg muscles rather than back muscles to pick up objects from the floor. Work should be close to the body to reduce effort and strain. - Fowler's position is arranged by elevating the head of the bed 60 to 90 degrees. **Semi-Fowler's or mid-Fowler's position is an elevation of 30 to 60 degrees**, and low Fowler's is an elevation of 15 to 30 degrees. Unless contraindicated, the knees can be raised 10 to 15 degrees in these positions. - Before the insertion of the nasogastric tube, the nurse places the patient in a sitting or High Fowler's position to reduce the risk of pulmonary aspiration if the patient begins to vomit. A pillow may be placed behind the head and shoulders to promote the client's ability to swallow during the procedure. - A cane would benefit a person by giving them extra stability when walking. Poor lighting is a risk factor because it could cause someone to stumble over items on the floor or cause an imbalance by bumping into unseen furniture. Muscle weakness and slower reflexes are also risk factors for falls in the elderly. ***Positions for patient examination:*** Prone: To examine spine and dorsal part of the body. Supine: To examine abdomen and ventral part of the body. Fowler's: For patients with shortness of breath and some procedures (Eg.NG Tube insertion) Lithotomy: Gynecological examination, rectal examination. Sim's: Rectal examination, enemas. Knee-chest: Rectal and gynecological (reposition of the fetus) - A patient with increased weight and inability to move requires **at least two people to move them up in bed.** A lift sheet enables the patient to be moved, p**lacing the patient on her back** to decrease gravitational pull, and **using a lift sheet**. This will make the move easier. A mechanical lift is used to transfer a patient, not to move her up in bed. - The skin (and intact mucous membrane) is the first line of defense against invasion by pathogens, and any cut or abrasion can be an entry site. Scar formation, nerve damage, and fluid/electrolyte disturbance are likely only when there is a large or deep wound. - Older adults have decreased sweat and sebaceous gland activity and do not need a full bath or shower daily. Their skin is thinner, and it becomes drier and itchy with overly frequent bathing. Because of their unsteadiness, it is not safe to have older adults shower alone and they should always do it with assistance. - Different cultures have different views of hygiene practices, such as use of deodorant, shaving, or daily bathing. The nurse need to understand that the patient's hygienic practices might be different from theirs. - Dentures should be removed and cleaned before they are stored in a labeled container at bedtime. Hot water should never be used. Dentures may be cleaned in the patient's mouth, but they need to be removed to clean the patient's palate and gums, as well as the undersides of the dentures. - After a trauma to the head, the patient with blood tangling the hair must have it untangled by using alcohol or water on small sections of hair and holding the hair between the scalp and the area the nurse is brushing or combing. Trying to shampoo before removing some of the tangles makes the situation worse. **Medication Calculation:** - - - - **To the whole \#:** Answer with the number before the point. **To the nearest tenth:** Answer with the first number after the point. **To the nearest hundredth:** Answer with the second number after the point. **If the number behind is =+ 5**, then you add 1 to the number that is before. **If the number behind is - 5**, then the number that is before remains the same. - **Ratio and Proportion: See Calculation Review for Exam \# 2.** - *Between milligrams and milliliters.* - *Using percentages.* - *Using fractions.*