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Using the senses of sight, hearing, touch, and smell to collect information
That which is desired in or by the person as a result of nursing care
Describes a health problem that can be treated by nursing measures; a step in the nursing process
Things a person tells you about that you cannot observe through your senses
The identification of a disease or condition by a doctor
What you see
Cannot be seen. Patient verbalizes and feels it.
The 5 steps of the nursing process
- 1. Assessment
- 2. Nursing diagnosis
- 3. Planning
- 4. Implementation
- 5. Evaluation
Collecting information about the person. The nurse takes health history about current and past health problems.
Describes a health problem that can be treated by nursing measures.
Setting priorities and goals. Priorities relate to what is most important. Goal is that which is desired for a or by a person as a result of nursing care.
The step of performing or carrying our nursing interventions (nursing measures or nursing actions).
Step involves measuring if the goals in the planning steps were met.
List the rules to follow for verbal communication:
- Face the person, look directly at the person.
- Position yourself at the person’s eye level. Sit or squat by the person as needed.
- Control the loudness and tone of your voice.
- Speak clearly, slowly, and distinctly.
- Do not use slang or vulgar words.
- Repeat information as needed.
- Ask 1 questions at a time. Wait for an answer.
- Do not shout, whisper, or mumble.
- Be kind, courteous, and friendly.
List nine communication barriers.
- Unfamiliar language.
- Cultural differences.
- Changing the subject.
- Giving your opinion.
- Talking a lot when others silent.
- Failure to listen.
- Pat answers.
- Illness and disability.
List five causes of inappropriate sexual behaviors.
- Drug side effects.
- Done on purpose.
A left side-lying position in which the upper leg is sharply flexed so that it is not on the lower leg and the lower arm is behind the person.
Lying on the abdomen with the head turned to one side
A semi-sitting position; the head of the bed is raised between 45 and 60 degrees
Using the body in an efficient and careful way
The way the head, trunk, arms, and legs are aligned with one another; posture
The area on which an object rests
Base of support
Keep your body in good alignment with a ____ base of support.
Keep objects ____ to your body when you lift, move, or carry them.
____ your work area. This prevents unnecessary ____.
____, _____, or ____ heavy objects whenever you can rather than lifting them.
Push, slide, or pull
Bend your _____ and ____ to lift heavy objects from the floor.
hips and knees
The goal of ergonomics is to
Help reduce stress on the worker’s body.
Early signs and symptoms of work-related musculoskeletal disorders include:
- Limited joint movement.
- Soft tissue swelling.
Contractures can develop from staying in one position too long.
Moving, turning, and repositioning help prevent contractures.
Why are beds raised to move persons in bed?
The reduces bending and reaching
You must perform tasks safely. The _____ and ________ tell you how many staff members are needed to complete a task.
The care plan and nurse’s directions
_______ is the rubbing of one surface against another.
Moving the person up in bed is best done with at least two staff members. Perform this procedure alone only if:
- The person is small in size.
- The person can follow directions.
- The person can assist with much or some of the moving.
- The person uses a trapeze.
- The person can push against the mattress with or her feet.
- The nurse says it is safe to do so.
- You are comfortable doing so.
List three methods used to move persons to the side of the bed.
- Moving the person in segments.
- Moving the person with a drawsheet.
- Use a mechanical lift.
A mechanical lift or the assist device method is used to move the following persons in bed:
Turing the person as a unit, in alignment, with 1 motion.
Before you begin, what information do you need from the nurse and the care plan?
- Areas of weakness.
- The person’s functional status.
- The amount of help the person needs.
- If you need a co-worker to help you.
- If the bed is raised or in a low position, safe, and comfortable for the person.
- How long the person needs to sit on the side of the bed.
- What exercises are to be done while dangling.
- If the person will walk or transfer to a chair after dangling.
- What observations to report and record.
- When to report observations. k. What patient or resident concerns to report at once.
______ is to turn one’s body from a set standing position.
A lateral transfer is
When a person moves between 2 horizontal surfaces.
______ the breaks when transferring to or from the wheelchair.
_______ is a common fear for persons in mechanical lifts.
To promote mental comfort when transferring a person, you should:
- Explain what you are going to do and how the person can help.
- Screen and cover the person to protect the right to privacy.
- Keep the person in good alignment.
Friction-reducing devices that protect the skin from friction and shearing during lateral transfers include:
- Lift sheet, turning sheet or drawsheet.
- Turning pad.
- Large re-usable waterproof underpad.
- Slide sheet.
- Lateral transfer device with a slide board.
Mechanical lifts are used for persons _______ and/or _______.
Too heavy for staff and/or for a person who cannot assist with transfer.
Stand-assist lifts are used for persons who require some help with transfers and can:
- Bear some weight.
- Follow directions.
- Sit up the side of the be with or without assistance.
- Bend the hips, knees, and ankle.
Full-sling mechanical lifts are used for persons who:
- Cannot assist with transfers.
- Are partially able or unable to bear weight.
- Are heavy.
- Have physical limits preventing others types of transfers.
Why is it important for the person to wear non-skid footwear for transfers?
This footwear protects the person from falls, and prevents slipping and sliding.
Electronic program that shows potential problems with patients
- Direct Questions
- Open ended questions
Maslow's Hierarchy of needs (bottom to top)
- Physical needs
- Safety and Security needs
- Love and belonging needs
- Self-esteem needs
- Self actualization needs
What are the 4 factors that causes work related injuries?
Force, repeating action, awkward postures, heavy lifting.