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35 Cards in this Set

  • Front
  • Back
Protective Devices and purposes
All restraint have to have a physician's order
1. protect resident
2. protect others
3. during treatment
Physical Restraints
1. Quick, handy, manual methods - physical or mechanical devices
2. Are attached to or next to the resident's body
3. Cannot be easily removed by the resident
4. restrict freedom of movement or access to one's body
5. Consent from resident/family (informed consent)
6. lesser restrictive devices
Chemical Restraints (psychoactive drug)
1. restraints are for protecting residents not staff convenience
2. Require doctors orders
3. The Least restricted methods should be used
4. Used only when other methods have failed
5. require the consent of the resident or the resident or the resident's legal guardian (informed consent)
6. basic needs must be met by the nursing team
7. resident may be more confused after use
Safety Measures For Using Restraints
1. Observe the resident q. 30 m in
2. Breathing restrictions
3. Fractures
4. Bruising
5. Check for constriction: impairs circulation
6. release q. 2 hrs
General Principles
Before you begin working with the resident you must do the following: knock, pause, name (yours, theirs), pull curtains, wash hands, and explain
ASEPSIS
Without infection
Communicable Disease
a disease caused by pathogens that are easily spread
Infection Precautions
practice that limits the spread of pathogens
Medical Asepsis
the techniques and practices used to prevent the spread of pathogens from one person to another
Microorganism
a small living plant or animal that cannot be seen without the aid of a microscope
Pathogens
a disease producing microogranisms
sterile
the absence of all microorganisms
Isolation
to a separate, by using gown, gloves, masks, different room, thus preventing contamination
Nosocomial infection
infection acquired by residents after they have been admitted to a long term care facility
Chain of Infection
Process that occurs to cause infection
1. source
2. reservoir
3. portal of exit
4. method of transmission
5. portal of entry
6. susceptible host
Methods by Which Microorganisms Can Be Spread
1. food
2 water
3. eating and drinking utensils
4. personal hygiene
5. animals
6. dressings
7. insects
8. contact
9. airborne
10 droplet
Hand Washing
The most important prevention measure
1. before and after contact with residents
2. before handling food trays
3. after handling the resident's equipment
4. before and after eating
5. after using the restroom
6. after smoking
Sterile, Clean, and Dirty Concept
1. Sterile - no microorganisms
2. Clean - no pathogens
3. Dirty - all microorganisms
Signs and Symptoms of Infection
redness
swelling
heat
drainage
discoloration
smell
fever
fatigue/weakness
diarrhea
vomiting
pain
puss
loss of appetite
Standard Precautions
Developed in 1999, used by the CDC in 1987. Developed to prevent the spread of AIDS, Hepatitis, and all other infection. Standard Precautions are used for ALL residents. Blood-borne pathogens are present in the blood and all bodily fluids
Bloodborne Pathogen Standard
intended to protect workers from exposure to bloodborne pathogens, developed by OSHA (occupational and Health Administration)
List the Different Body Fluids
sweat
blood
saliva/mucus
urine
feces
vaginal discharge
puss/drainage
tears
sperm
breast milk
emesis
menstruation
Protective Measures (Personal Protective Equipment)
1. wearing gloves and removal of gloves
2. Donning and removal of a gown
3. Donning and removal of a mask
Handling of infectious waste
1. nursing
2. housekeeping
3. laundry
Admission
Official entry of a person into a facility or nursing unit
Discharge
Official departure of a resident from a facility
Transfer
Moving a resident from one room, nursing unit, or to another facility/home, etc.
Admission
1. introduction of self
2. orientation to the room and roommate
3. organized the belonging and labeling
4. fill out the clothing list
Clothing and Valuables
1. label
2. storing of valuables
3. documentation
4. description of the valuables
DIscharge
1. help dress and pack resident
2. transport with wheel chair
3. check off the clothing list
4. valuables
incontinent
involuntary release of body functions
Incontinent Pad
a pad tp prevent soiling of the bed
General Rules (in making a bed)
1. use good body mechanics
2. Follow medical asepsis
3. wash hands
4. bring linen, in order of use
5. never shake linen
6. hold linens away from your uniform
7. Extra linen in the residents room is considered contaminated
8. Never put dirty linen on the floor or on top of clean linen
9. Bottom linens should be pulled tight, this prevents skin tears
10. Change their linen of incontinent residents promptly
11. Make one side of the bed first, and then go to the other side, this saves time
Comfort
1. temperature and ventilation
2. odors
3. noise
4. Lighting
General Rules (of Resident Unit)
1. over bed table within reach
2. personal belongings with in easy reach
3. signal light within reach
4. provide tissue paper, toilet paper
5. meet the needs of residents who cannot use the call system
6. adjusting lighting, temperature, and ventilation for comfort
7. explain the cause of strange noises
8. call housekeeping to deodorize the room if necessary