Nursing 101 Unit 2 Exam Outline PDF

Alanis Leite Nursing 101 September 30, 2024 Unit 2 Exam Mechanical/Thermal ○ Patient Safety Significance Help the patient on a better outcome in the helping process by...

Alanis Leite Nursing 101 September 30, 2024 Unit 2 Exam Mechanical/Thermal ○ Patient Safety Significance Help the patient on a better outcome in the helping process by assessing and maintaining a safe environment, knowing where all the things are in case of an emergency (i.e. fire) Know the reason why meds are given an assess the patient before administering Environment Safety Free of clutter rooms, hallways, walkways Emergency alarms on doorway No debris Cleanliness and free of debris I.V. poles are free of the move and be unplugged for bathroom use Socket & plugs are being used safe (free of clutter) Locate fire alarm and extinguishers Make sure call bell is within reach Meds ○ Pre & Post assessment  Nurse Promotion of Patient safety Be eyes and ears ○ Don’t turn a blind eye Patient spilled a drink, pick it up ○ Infection control guidelines PPE, Handwashing, etc ○ Safety and Security ○ Security emergency hotline memorized ○ Plan Language Emergency Alerts Facility Alert Fire Evacuations Security Alert Missing Person Active Shooter Medical Alert Mass Casualty Medical Emergency Factors that affect the person's ability to protect themselves Lifestyle ○ Diet, exercise, substance abuse, sleep patterns etc. Interventions:  Educate, promote physical exercise, rehab, support groups, health screenings etc Mobility ○ Fall risk, skin breakdowns (PUs), breakages Interventions: Assistive devices, fall prevention, safe environment, exercise Sensory-Perception Alterations ○ Impaired senses (vision, hearing, touching, taste) (not able to perceive dangers) Interventions: Assess & adaptations, adequate lighting, assistive devices, clear simple communications Cognitive Awareness ○ Dementia, Alzhiemers, confusion (affect judgment and ability to recognize threats leading to unsafe behaviors) Interventions: Structured environments, provide clear instructions, memory aids, & assessments Communications ○ Language Barriers & impairment Interventions:  Assess communication abilities, adaptation methods, ensure patient understanding Environmental Factors ○ Poor lighting, pollution, clutter, unsafe equipment Interventions: Education on safe home environment, environment assessment, recommendations for modifications Asepsis Medical Asepsis - Clean Technique ○ Standard Precaution, handwashing, transmission-based precaution Surgical Asepsis - Sterile Technique ○ Only Sterile object can touch other sterile object Side Rails Pros ○ Help Turn Patient and Repositioning ○ Provide a hand to hold for getting into or out of bed ○ Give the patient a sense of comfort and security ○ Reduce the risk of the patient falling out of the bed during transportation ○ Easy access to bed Cons  ○ Suffocation ○ Strangulation ○ Injury ○ Death ○ Falls ○ Fall Risk Preventing Hospital Injuries Roles of the nurse ○ Comprehensive assessment on admission ○ Risk Assessment Previous safety Concerns: Previous injuries Previous Falls Home Hazard Issues and Concerns Common Characteristics of fall risk Pt ○ History of Falls ○ Gait Disturbance (Balance Issues) ○ Dizziness ○ Visual Impairment ○ Medication List ○ Incontinence Issues ○ Frequency Issues Nurse Interventions  ○ Side rails up ○ Educating the patient, family, and other healthcare workers of safety measures in place ○ Restraints ○ Fall alert Patient Injury: The Nurse is responsible ○ Assessing ○ Treating the problem ○ Find physician, also family ○ Stabilizing the patient ○ Notifying and completing injury report ○ Revise and change plan of care Incident Report ○ Document How the patient was found Vital Signs How did they treat the patient? Status of patient post accident Purpose of the document An investigative tool to figure out Who? What? When? Why? How?, and how are we  going to change so this won’t happen again. Also helps in lawsuits ○ Fire Safety Common Causes of fires in Hospitals Malfunction of electrical equipment Damage wires Patient or Employee smoking Unsafe discarding of cigarettes War combustion of anesthetic gasses Common Cause of Death in Fires Smoke inhalation RACE R-escue ○ Evacuate the person who is in imminent danger A-larm ○ Pull alarm (call operator, dial 911, fire alarms) C-ontain ○ Contain fire/smoke (close doors) E-xtinguish ○ Extinguish or end the fire (responsibility) PASS How to use the fire extinguisher P-ull  A-im ○ The nozzle S-queeze ○ The handle S-weep ○ From side to side ○ Developmental Considerations Fetus abnormal Growth and Development Neonate infection, falls, suffocation Infant car seat, drowning, crib compliant with railing; SIDS; burns, injury from toys, inhaling FB Toddlers injury such as cuts or burns, drowning, suffocation, inhalation FB, window lock School Age/Adolescence make sure chemical secure; pot handles; sharp objects; drowning, substance use, bullying, sport injuries Young adult MVC, drugs/alcohol, drowning, workplace injury, domestic violence, stress  Elderly safety home hazards, vision or hearing loss, less reflexes, falls, abuse, MVA ○ Restraints Physical Restraints Devices that could be material or piece of equipment that are attached to the patient or adjacent to the patient and prevent the body part from moving freely to a position of the patient choice with expectation of devices used for positioning supports necessary treatment Alternative Restraints Staff and environment involvement ○ 1 to 1 - sitters, cameras Behavior Management Structured Activities ○ I.e. set schedule Contradiction of restraints Restraints are conducted when its convenience of the staff or trying to discipline patient Before applying restraints The physician would like to know if any alternatives have been used. Emergency Protocol  If patient is a threat to themselves and others Disruption of treatment ○ I.e pulling tubes Creating physical damage No need a physician/start with least restrictive ○ MUST BE NOTIFIED IMMEDIATELY Reassessing and re-order Reassess every 24 hours by physician Documentation has to be done every 2 hours Skin integrity check Different types of restraints Belt restraints- typically used when sitting up in chair; be sure that pt cannot slip thru/under belt; known to cause strangulation if not used properly; allows for extremity and upper body mobility but does prevent rising Jacket/vest- can be used in bed or chair; allows extremities to be free but prevents rising by minimizing upper body mobility Mitt- looks like an oversized thumbless mitten; prevents fine motor grasping; typically used with patients who like to pull things out..IVs, feeding tubes, trachs, dressing, getting/scratching at wounds but still allows for upper extremity movement  Wrist/Ankle- be sure you are able to put 2 fingers under restraint; prevents any upper/lower extremity movement; used on patients who are hitting, kicking, attempting to get OOB ○ Gait Belt ○ Hot & Cold Therapies Physiologic Effects Heat (vasodilation) - works as a sedative ○ Dilates peripheral blood vessels (increases blood flow, and provides extra oxygen to the tissue that need it most) ○ Reduces blood viscosity (thins the blood and makes it less sticky) (ability of the blood to flow through the blood vessels) ○ Increases capillary permeability( may result in edema) ○ Increases inflammation & promotes healing ○ Sedative effect and muscle relaxation ○ Increase tissue metabolism Reduces muscle tension Helps relieve pain ○ ONLY FOR 20-30 MIN FOR HEAT THERAPY Cold (vasoconstriction) - works as a local anesthetic, loss of sensation such as pain ○ Constrict peripheral blood vessels (Reduce blood flow to tissue)  ○ Decreases the release of pain producing histamine ○ Reduce formation of edema, and decrease inflammation Alter tissue sensitivity - Numbness ○ reduce oxygen supply ○ Decreases capillary permeability which means impair circulation deprive cells from oxygen can cause tissue damage or death ○ ONLY 15-20 MIN FOR COLD THERAPY Rebound Phenomena After the treatment length is passed it does the opposite effect: ○ Heat Increase cardiac output Diaphoresis Increased pulse rate Decreased blood pressure Vasoconstriction ○ Cold Increased blood pressure Shivering Tissue injury Vasodilation Contradictions  Heat ○ Open wounds ○ Hemorrhage ○ Presence of edema ○ Inflamed areas ○ Localized malignant tumor ○ Testes ○ Abdomen of pregnant woman ○ Over area of a metallic implant Cold ○ Open wounds ○ When peripheral circulation is impaired ○ Hypersensitivity to cold Guideline to Thermal Therapies Tolerance Contradiction Explanation Assessment Discomfort Revisit Remove Examine Different types thermal Therapies  Heat ○ Dry Hot water bags water temperature 105°-109° do not exceed 125°; fill one- half to two thirds full or to fill mark; expel air; plug bag; cover with towel, apply to affected are for 30-45 minutes; Assess skin at frequent interval and check leaks Electric heating pads turn on and warm up pad before placement, use power with switch that cannot be turned up beyond safe temp; chi over with towel, nothing heavy; place pad anterior or lateral to affected area, never under the patient, avoid moist area; do not use pins to secure; assess skin… Aquathermia pads follow instruction; fill unit ⅔ full or to fill mark with distilled water only; temp 105° preset; attach pad tubing to unit; warm pad before use, apply 20-30 min, secure in place with gauze or tape; assess skin…  Hot packs - follow instruction; cover with washcloth; assess skin every 5-10 min, check for leaks ○ Moist Warm moist compress moist cloth with warm water, place on area, cover with impervious wrap to hold moisture, cold quickly so needs to be changed often, assess skin… Sitz bath Follow instruction, warm soak of perineum/ rectal area, used in treatment of hemorrhoids, anal fissures and postpartum, reduce inflammation and pain, water temp 93-99° Warm soaks immersion of body part in warm water, promote circulation, temp 105-109° for 15-20 min Cold ○ Dry Ice bags  fill ⅔ full with crushed ice, expel air, close cap, cover bag with towel, 30 min on so 1 hour off then 30 min on, assess skin…check for leaks Cold packs follow instructions, assess skin every 5-10 min; check for leaks Hypothermia blanket used for body temp regulation Glove Ice Pack postpartum patients Elderly Patient Considerations Lifespan Sensory Losses Decrease response in reflexes Reduce Kidney Function Health Assessment