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37 Cards in this Set

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Hip Precautions Don'ts
Do not:
-Flex hip more than 90° in relation to trunk
-Sit low in chair lean forward while sitting or getting up
-Squat
-Bend knees while reclining in bed
-Lean forward with legs straight out or bent
-Roll knees or toes in while lying
-Turn knees and/or toes inward towards body
-Allow knee to be turned inwards toward the midline even if toes are pointed while sitting or standing
-Adduct hip
-Cross legs
-Roll onto or lie on surgical side
Bath
-Assess need for hygiene, level of independence and comfort needs
-Plan for type of bath required r/t medical and surgical diagnosis and ability to care for self
-Intervention do bath and AM care
-Evaluation: Is my patient clean, was comfort provided, was the level of care provided appropriate?
Performing the procedure and afterwards
-Perform procedure and monitor patient response
-Finish the procedure
-Raise the side rail
-Lower bed and check patient response
-Replace call light and check for safety before leaving
-Leave the environment clean and safe
-Wash Hands
-Look back into the room, is everything where it is supposed to be?
-Document immediately if you can
Procedure for entering the room
-Knock on door
-Identify the patient
-Introduce yourself to patient
-Explain procedure/getting permission
-Gather all equipment
-Provide privacy
-Move bed and patient into appropriate position
-Lower the side rail nearest you
-Organize set-up and assess patient
Urinary elimination
-Micturation
-Respond to urge (nurse answer call light)
-Use sound of running water
Maintenance of hygiene
-Promote circulation and comfort
-Remove excessive debris and secretions
-Maintain skin integrity
Intake and output
-Should be equal (what goes in must come out)
-Intake is anything that is liquid at room temperature e.g. ice cream
-Output is any urine stool or drainage
Restraints
-Reassessed time limit:
-Adults: every 4 hours
-Children 9 -17: every 2 hours
-Children under 9: every 1 hour
-The order can be renewed for up to 24h
-Visual checks: every 15min
-Assess: every 2 hours and allow fluids, nutrition, toileting, provide ROM and skin integrity checks
Factors that influence individual hygiene practices
-Culture
-Religion
-Environment
-Developmental level
-Health and energy level
-Personal Preferences
Bowel elimination
-Defecation
-Privacy and timing are essential
-Fluids, exercise, and diet are influential
Average daily output of an adult
-Urine: 1500cc
-Feces: 200cc
-Insensible losses:
--Lungs/skin: 800cc
--Sweat: 100cc
Hip precaution dos
Do:
-Have pillows between knees while lying on side, keep knee pointed straight ahead
-Keep knee and toes pointing to ceiling when lying on back and keep large pillow between knees
-Sit in as high a chair as comfortable (one wiht armrests)
-Use a raised toilet seat
Identifying dirty to clean
Dirtiest: toilets, sinks, body-fluids
Dirty: Floor, desks, phones, charts
Clean: Washed hands
Cleaner: linen
Cleanest: sterile material
Basics Standards for Safe Nursing Care
-Demonstrates Accountability and Professional Behavior
-Practices Principles of Asepsis
-Provides Physical Safety
-Provides Psychological Safety
-Organizes Care
-Documents and Communicates Care
Universal precautions
-Hand washing
-Gloves
-Protective clothing, eyewear, masks
-Proper placement of patients
-Proper disposal of wastes and linen
-Needle disposal
-Masks when giving CPR

-Treat all patients and body fluids as though they were
Contaminated
Body Mechanics
-Maintain balance: use strongest and longest muscles to provide a wide base of support
-Reduce energy requirements by the use of body structure for support and movement
-Prevent injury by never twisting your back
Medical asepsis
a clean technique for procedures that reduces the number and transfer of pathogens
Maslow's Hierarchy of Needs
-Self-actualization
-Esteem
-Belonging
-Safety
-Physiological
AM Care
-Help patient to use restroom
-Brush hair
-Brush teeth or rinse with soft sponge/stick or mouth wash
-Get patient dressed (or ready for breakfast)
-Wash face and hands
-Shave
-Apply makeup
Surgical asepsis
is a sterile procedure that establishes and maintains an environment free of microorganisms
Selecting a restraint
-It restricts the client as little as possible
-It does not interfere w/client's treatment or health
-It is readily changeable
-It is safe for the particular client
-It is the least obvious to others
Kinds of restraints
-Jacket restraint
-Belt restraint
-The mitt or hand restraint
-Limb restraint
-Elbow restraint
-Mummy restraint
Client's that are at high risk for decubiti
-Bedridden
-Incontinent
-Decreased mental status
-Excessive body heat
-Elderly
-Unconscious
Decubiti Stages
-Stage 1: redness
-Stage 2: partial thickness skin loss (abrasion, blister, or shallow crater)
-Stage 3: full thickness skin loss involving damage of subcutaneous tissue (ulcer like a deep crater)
-Stage 4: full thickness skin loss, dameage to muscle, bone, or supporting structures such as tendon or joint
Measures to prevent decubiti
-Keeping skin clean and dry
-Changing position in bed q2h
-Good nutrition
-Recognizing need for movement before there is any redness
Decubiti Stages
-Stage 1: redness
-Stage 2: partial thickness skin loss (abrasion, blister, or shallow crater)
-Stage 3: full thickness skin loss involving damage of subcutaneous tissue (ulcer like a deep crater)
-Stage 4: full thickness skin loss, dameage to muscle, bone, or supporting structures such as tendon or joint
Abduct
Moving limbs away from midline of body
Adduct
Moving limbs towards midline of body
Dorsiflex
Movement that flexes or bends the hand back towards the body or the foot towards the leg
Eversion
Movement that turns the sole of the foot outward
Extend
The return movement of flexion, the joint angle is increased
Flexion
Bending of the joint so that the angle of the joint diminishes
Hyperextension
Further extension or straightening of a joint
Invert
Movement that turns the sole of the foot inwards
Opposition
Touching of the thumb to the top of each finger of the same hand
Plantar flex
Movement that flexes or bends the foot in the direction of the sole
Suppinate
Turning upward