Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
42 Cards in this Set
- Front
- Back
|
3 common fall risk tools |
Morse fall scale Get up and go Hendrick II |
|
|
Morse Fall Scale |
0-24 low risk for falls 25-50 moderate risk for falls > 50 high risk for falls |
|
|
When should fall risk precautions be implemented? |
Moderate-high risk categories |
|
|
Nursing interventions to prevent falls |
Orientation and call light |
|
|
3 types of restraints |
Physical Chemical Seclusion |
|
|
Restraint orders |
NEED order within 12 hours after application for medical restraint Renew every 24 hours Remove/reassess restraint Q2h to check circulation, skin breakdown, discontinue when able |
|
|
OSHAwh |
Occupational safety health administration Regulates workplace safety Microbial regulations, blood borne pathogens, physical, and environmental |
|
|
When to complete incident report |
Anytime there is a breach in safety Employee injuries also reported |
|
|
What is a “never” event |
**** preventable Adverse events resulted in death or extreme harm |
|
|
Sentinel event |
Patient safety event reaches the patient and results in death, permanent harm, or interventions needed to sustain life |
|
|
RACE |
Rescue Alarm Contain Extinguish |
|
|
6 links in chain of infection |
Infections agent Portals of exit Modes of transmission Portals of entry Susceptible host |
|
|
1st line of defense against infection |
Intact skin Normal skin flora protect against harmful bacteria |
|
|
2nd line of defense against infection |
Leucocytes (WBC) and inflammatory response |
|
|
SIRS |
Systemic Inflammatory Response Syndrome Happens before sepsis Treat SIRS before it turns into sepsis |
|
|
Signs of SIRS |
Temp above 38 or below 36 HR > 90 Resp rate > 20 or PaCO2 < 32 WBC > 12x10 or < 4x10 |
|
|
Purpose of skin |
Protection Thermal regulation Sensation Metabolism of vitamin D Communication |
|
|
Friction |
When 2 surfaces rub together and cause abrasion |
|
|
Shear |
When tissue layers move over each other causing blood vessels to stretch as they pass through subq tissue |
|
|
Pressure |
Low intensity pressure for long periods or high intensity pressure for short periods of time can cause pressure injuries ESP. At risk patients |
|
|
Stage 1 pressure injury |
Non blanchable erythema Can be reversed |
|
|
Stage 2 pressure injury |
Partial thickness loss of skin, exposed dermis |
|
|
Stage 3 pressure injury |
Full thickness loss into subq tissue, visible fat |
|
|
Stage 4 |
Full thickness loss, exposed bone, tendon, muscle |
|
|
Phases of wound healing |
Hemostasis Inflammatory Proliferation Remodeling/maturation |
|
|
Hemostasis |
Stop bleeding |
|
|
Inflammatory |
3 days Histamine leads to redness, swelling, and serous exudate |
|
|
Proliferation |
Epithelialization occurs |
|
|
Remodeling/maturationwhat |
Final stage 3 weeks post injury can take up to 2 years! Collagen continues to reorganize and gain strength |
|
|
Unstageable |
Would based covered by slough or eschar, can’t see what’s underneath to determine stage |
|
|
Slough |
Soft, yellow, or white tissue |
|
|
Serosanguinous |
Clear w/ blood streaks |
|
|
Sanguineous |
Bright red, thicker than serous |
|
|
MONA |
Heart attack intervention Morphine, oxygen, nitroglycerin, asprin |
|
|
Autonomy |
Person’s ability to act on his or her own values and interests |
|
|
Beneficence |
Act of charity/kindness Doing good to others including moral obligation |
|
|
Nonmaleficence |
Do no harm |
|
|
Veracity |
Truth or facts |
|
|
Fidelity |
Faithfulness |
|
|
Steps to resolve ethical dilemma |
Identify problem Generate alternatives Decide course of action Implement |
|
|
Braden scale and categories |
Risk for skin breakdown Sensory, moisture, activity, mobility, nutrition, friction 15-18 mild 13-14 moderate 10-12 high < 9 severe |
|
|
Normal ranges for ABG readings |
HCO3 22-26 meq/L PH 7.35-7.45 CO2 35-45 mmHg |
