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84 Cards in this Set
- Front
- Back
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Incident report |
the reporting of certain sentinel events |
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falls |
most common safety problem |
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fall risk assessment |
necessary upon admission or if there is a change in condition |
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gait belts |
prevents fall, walk on side slightly behind, on weaker saide |
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infacts and children safety |
accidents involving children are largely preventable but parents and caregivers need to be aware |
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older adults safety |
unsteadiness in gait, vision changes, vertigo, slow reflexes |
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older adults safety issues |
driving, in hospital, poisioning, loneliness |
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Restraint |
safety reminder devices (SRDs) |
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disadvantages of SRD |
-causes feeling of disorientation, agitation, anxiety and powerlessness -contributes to patient immobility, dehydration, and incontinence -increased skin tears and circulation problems |
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SRDS used |
used only for patient safety, may be used to safeguard (endotube from pulling out), family teaching, to moveable part of bed frame |
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unsafe environment |
latex sensitivity, electrical hazards, radiation |
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workplace safety |
needle sticks are another source of potential injury, use safety devices that avoid the need to recap needles |
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OSHA |
occuational safety and health administration |
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CDC |
centers for disease control and prevention
a federal agency that provides facilities and services for investigation, identification, prevention, and control of disease |
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fire safety |
follow protical |
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Type A Fire extinguisher |
paper |
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Type B Fire extinguisher |
Liquid gases |
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Type C Fire extinguisher |
Electric |
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Type ABC Fire extinguisher |
all types of fire |
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universal carry |
move patient from bed to the floor |
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R.A.C.E |
Rescue, activate, confine, extinguish |
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child poisioning |
major cause of death in children under 5 years of age |
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ipecacin |
-don't keep in the house -need prescription -don't enduce vomitting |
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disaster situation |
an uncontrolled, unexpected, psychologically shocking event
overwhelms the resources |
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external disaster situation |
earthquake, outside of facitlity |
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internal disaster situation |
inside facility |
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priority in disaster situations: |
chest pain, severe bleeding |
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bioterroism |
biologic agents to create fear and threat |
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botulism |
neruotoxin
causes paralysis |
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bioterrorism |
-rapidly increasing incidence of a disease -an unusual increase in the number of people seeking care -an endemic disease rapidly emerging at an uncharacteristic time or in an unusual pattern -lower illness rates among patients who had been indoors compared with ppl who had been outdoors -cluster of pts arriving from a single locale -lrg number of rapidly fatal cases |
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chemical terrorism |
spread by arosol |
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proper body mechanics |
protects lrg muscle groups from injury, provides safety |
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principles of body mechanics |
maintain appropriate body alignment, maintain wide base of support, bend knees and hips, do not bend from waist, use arms and legs bc lrger stronger muscles, slide pt toward you, center load over feet |
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complications immobility |
muscle atrophy, contractures, osteoporosis, pressure ulcer, constipation, pneumonia, pulmonary embolism |
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assistive devices |
pillows, foot boots, trochanter rolls (prevent rolling of hips), sandbags, trapeze bars, hand rolls |
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dorsal |
laying flat on back |
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fowler's |
head of bed is raised 45-60 (dyspnea) |
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sims |
lying on side with knee and thigh drawn toward chest (enema) |
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prone |
lying face down in horizontal position |
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orthopneic |
sitting up in bed at 90 degree angle or sometimes resting in forward tilt while supported by pillow on overbed table |
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lithotomy |
lying supine with hips and knees flexed, thighs abducted and rotated externally (GYN) |
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trendelenburgs |
head low, body and legs are on inclined plane |
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lateral |
on side |
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CSM |
circulation, movement, sensation |
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CSM LPN check |
skin color, temperature, movement, sensation, pulses, capillary refill, and pain |
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ROM |
range of motion
to point of resistance or pain |
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active range of motion |
performed by patient |
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passive range of motion |
performed by caregivers (paralized) |
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extention |
to 180 degrees |
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hyperextention |
over 180 degrees |
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flexion |
bending |
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abduction |
away from body |
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adduction |
towards to body |
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opposition |
touching each finger |
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circumduction |
moving in a circle |
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dorsiflexion |
fulling foot up |
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plantar flexion |
pointing toe |
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CPM |
continuous passive motion machines
machine that flexes and extends joints to passively mobilize them used for total knee replacement |
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precautions when moving patient w/hydralic lift |
have 2 ppl bed wheels locked w/c bed wheels locked lift wheels locked |
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Assessment for Mobility |
-ROM, muscle strength, activity tolerance, gait, posture -observe for fatigue, muscle strength, ROM -assistance needed for tranfers |
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S.H.I.P. |
Supplies Hand washing Identify Privacy |
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external fixation |
devices used to hold bone fragments in normal position (ex. cast, traction, braces, and metal pins) |
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cast |
immobilization device, made out of plaster or fiberglass depending on bone and time needed to heal |
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Assessment with mechanical immobilizations |
capillary refill every 15-30 min for several hours, observe skin, temp, move fingers and toes, pain |
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petal cast |
smooth edges of cast |
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short arm cast |
elbow to palm |
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long leg cast |
upper thigh to base of toe |
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spica cast |
covers trunk and one or both extremities (genitals cut out) entire body |
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Bi-valve |
too much swelling |
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Traction |
1. align and stabilize 2. relive pressure on nerves 3. maintain correct positioning 4. prevent deformities 5. relieve muscle spasms |
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skeletal traction |
applied directly to bone
longer time and heavier weights |
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skin traction |
short use, lighter weights, directly to skin below site of fracture |
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types of skin traction |
1. bucks - temp to provide support and comfort while waiting for treatment. used for hip before surgery, muscle spasms, minor fracutres 2. Russells - like buck except uses sling |
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Nurse interventions for tractions |
pin sites cleaned and monitored, weights stay off floor |
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6 purposes for mechanical immoblization |
1. align and support skeletal injuries 2. end muscle spasm 3. relieves pain 4. maintains functional position till healed 5. allows activities while limited movement of area 6. restricts movement while injuries heal 7. prevents further damage or deformity |
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a client who uses cane, walker or crutches may need this strengthening |
Upper arm strengthening |
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double rows of stationary bars as handrails to gain practice in ambulating is known as..... |
mobility parallel bar |
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key points about canes: |
-right height -handle parallel to hips -15-30 degree elbow flexion -made out of: aluminum or wood -hand held -held on unaffected side |
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key points about walkers |
-most stable -stand within a walker -pick up walker and advance 12 in -take step forward move with walker -start with weaker leg |
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when would you have a client use a 3 point gait |
NWB and amputation, sprain |
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when would you have a client use a 4 point gait |
arthritis, cerebel palsy |
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nursing diagnosis for client using ambulating devices |
fall risk, risk for muscle distrophy, risk for activity intolurance |
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gerontological considerations when ambulating |
limited mobility, shuffling gait, gait belt important safety devise, evaluate home safety, access attitude, teach: rubber tips and hand tips clean and replaces when worn |
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measuring for crutches: Standing Supine |
Standing: shoes, axillary fold to heals and 2 inches: 4-6 inches away from body
Supine: shoes on first, measure 2-4 inches from top of pad and armpit to heals of shoe |
