248 Test 1
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. What would you like to do?
What is an
Hospital caused death
What are the three main types of patient errors (60%)?
Infection; failure to diagnose and treat in time; medication errors
How many people died annually from preventable errors?
What are the
four categories of patient safety risks?
- Falls; client inherent accidents;
- procedure related accidents; equipment related accidents
physical hazards to patient safety?
Lighting; bathroom hazards; pathogens; obstacles; security; other
What are four functions of safety in health care settings?
- Reduces the incidence of illness and injury
- Prevents extended length of treatment/stay
- Improves or maintains functional status
- Increases client’s well being
What are three criteria for a safe environment?
- Includes meeting a client’s needs
- Reduces transmissions of pathogens
- Maintains sanitation, reduces pollution
What needs to be assessed in determining patient safety?
- Developmental level
- Mobility, sensory and cognitive status
- Lifestyle choices
- Risks found in health care settings
What are the two reasons to use restraints?
- Safety of patient or others
- interruption of therapy
How often must restraints be removed?
Removed every two hours and assess the area and the need for restraints
What are nursing interventions for restraints?
- Avoid IV site or proximal to IV site; secure to bed frame (not rails),
- avoid supine position because of aspiration risk, teach patient and family why restraints are needed
What needs to be documented when restraints are used?
- Behavior of patient that caused
- restraints; actions tried prior to restraints being used; time restraints
- applied and type of restraints; patient response to restraints; care provided
- when restraints are on; time discontinued and response; other if needed
What are three metabolic results of immobility?
- Endocrine disorders
- calcium absorption problems
- change in GI function
How is calcium affected with immobility?
- Calcium comes out of bones and can
- cause disuse osteoporosis, patient can also get hypercalcemia.
What happens to GI function when patient is immobile?
Loss of appetite which can lead to decreased peristalsis and fecal impaction
What happens to nitrogen balance when patient is immobile?
- Excess nitrogen is excreted and not
- enough protein is taken in so there is a negative nitrogen balance that can
- lead to weight loss, loss of muscle mass and weakness due to tissue loss
What metabolic functions does a nurse need to monitor when patient is immobile?
- Assess intake/output, listen to bowel
- sounds, give stool softeners/appetite enhancers as needed.
What is the definition of orthostatic hypertension?
Upon standing an increase in heart rate of over 15%, a drop of 15mm+ systolic or a drop of 10mm+ diastolic.
What must a nurse do to prevent orthostatic hypertension?
Encourage patient to keep moving and drink lots of fluids
What are nursing interventions to prevent thrombi?
- Put patient in TEDS (check legs every shift)
- encourage lots of fluids
- check pressure on legs
- discourage crossing of legs
If an immobile patient is sitting in a chair, how often should he/she be repositioned?
At least every 15 minutes
How often should immobile patients be repositioned?
At least every 1-2 hours
What scale is used to assess skin breakdown?
The Braden scale
What is atelectasis?
Collapse of alveoli caused by pooling of lung secretions in immobile patients. Can result in poor gas exchange. Pooling of secretions can also cause pneumonia.
What are nursing interventions to prevent respiratory complications in immobile patients?
spirometers, knowledge that pain and pain medications can depress respirations, encouraging patient to "turn, cough, deep breathe" every 1-2 hours
What are musculoskeletal complications from immobility?
loss of muscle mass and endurance, bone breakages, contractures
What are urinary complications of immobility?
urinary stasis causing infections and renal calculi
What should the nurse be doing to prevent urinary complications?
- moving patient regularly
- monitoring I&O
- looking for bladder distention
- providing good perineal care
What are the 4 stages of pressure ulcers?
- Stage 1: skin is intact but red (unblanchable)
- Stage 2: partial thickness skin loss, will look like abrasion
- Stage 3: full thickness skin loss and can see to fat
- Stage 4: will be able to see fat and bone/muscle/tendon
What are hazards of immobility in older adults?
- rapidly regress to dependency
- loss of muscle strength, weakness, fatigue
- increased risk of falls
- functional decline
- increased risk of pneumonia
- skin breakdown; pressure ulcers
- change in environment causing impaired sleep, depression, confusion
What are the psychosocial responses to immobility?
- emotional and behavioral responses (hostility, giddiness, fear, anxiety
- Sensory alterations (sleep/wake)
- Changes in coping (depression, sadness, dejection)
What is the purpose of ROM exercises?
to assist patients with restricted mobility to reduce hazards of immobility
Why should the patient be encouraged to assist in moving them?
Promotes client’s independence and strength while minimizing workload
Why should twisting be avoided when moving client?
Reduces risk of injury to lumbar vertebrae and muscle groups
held at waist height close to the body is equal to …
100 lb at arms length
Why should arm and leg muscles be used instead of back?
They are stronger, larger and capable of greater work without injury
Why is a pull sheet used?
Sliding requires less effort than lifting and a pull sheet reduces shearing which can damage a client’s skin
Why should abdominal and gluteal muscles be “set” before lifting?
Stabilization and minimization of the trunk
What is the most common injury to nurses
What is colonization?
When a microorganism invades the host but does not cause infection
What is the chain of infection?
Infectious agentàresevoiràportal of exitàmode of transmissionàportal of entryàhostàinfectious agent
What are risk factors for infection?
- Nutritional status
- Stress and crowded conditions
- Heredity, age
- Disease processes (diabetes, immune compromised etc)
- Medical therapy (devices, surgery)
Why do older adults have higher risk for infection?
- Immune system senescence
- Altered lymphocyte ptoduction
- Nutrition, weight loss, low serum albumin
What are normal defenses against infection?
- Intact skin
- Organ-body system specific
- Inflammatory response
What are systemic signs of infection?
Fever; increased pulse and rr; malaise; nausea; vomiting; anorexia
What are lab results that indicate infection?
Increased WBC, increased sedimentation rate and + culture
What are local signs of infection?
Redness, heat, swelling, pain, exudate
What is the difference between medical and surgical asepsis?
Medical: practice to reduce microorganisms, clean technique
Surgical: eliminate microorganisms, sterile
What are the three types of hospital acquired infections?
Iatrogenic, exogenous (from outside of patient), endogenous (from within
What is an iatrogenic infection?
One that is hospital acquired from a diagnostic or theraputic procedure.
What is an exogenous infection?
A postoperative infection from an organism that was present outside the client
What is an endogenous infection?
An infection from when the client’s flora becomes altered and overgrowth occurs.
What are critical items?
- Items that enter sterile tissue or the vascular system. Must be sterile.
- EG- surgical instruments, catheters, implants
What are semicritical items?
- Items that some in contact with mucus membranes or nonintact skin. Must
- be sterilized. Eg. Respiratory and anesthesia equpt, scopes and tubes
What are noncritical items?
- Items that come into contact with intact skin but not mucous membranes.
- Must be clean. Eg – bedpans, stethoscopes, linens etc.
What is tier one of standard precautions for all bodily fluids?
- Handwashing, gloves, protective eyeware, gowns if needed, cleaning of
- equipment, laundry bagged safely, sharps disposed of safely, private room not
What is tier 2 of SP for airborne?
- Private, negative flow room with HEPA filter and special fit mask (TB, chickenpox,
What is tier 2 of SP for droplet?
Mask (strep, pneumonia) usually private room
What is tier 2 of SP for contact?
Usually private room, gowns, gloves (VRE, MRSA)
What is tier 2 of SP for protective?
Private room, masks, gowns, gloves etc
What is occupational exposure to infection?
- Direct contact with blood or potentially infectious material with an open area of skin, blood or splash in eye, mouth, nose, cuts (can also be blood
- borne pathogens
How do you maintain a sterile field?
- Only touched with sterile objects
- Only sterile objects on field
- Above waist and within vision
- Contaminated by air currents, droplets etc
- Contaminated by capillary action
- Water flows down away from hands with handwashing
- 1 inch border
- Only touch edges of containers
- Never reach across field
- Always face towards field
- Avoid draft, currents, sneezes etc
What are factors influencing hygiene?
- Social patterns
- Body image
- Health beliefs and motivation
- Personal preferences
- Socioeconomic factors
- Cultural variables
What are goals of hygiene?
- Cleanliness, prevention of infection
- Circulation stimulation
- Skin conditioning
- Client self image
- Comfort and relaxation
- Maintain ROM and joint function
What is usually done during early am care?
Bedpan, face/hands, oral
What is usually done during afternoon care?
Hands/face, oral, bedpan, linen
Why is oral care performed?
- Maintain/promote health of mouth,
- removal of food/plaque/bacteria,
- enhance well being,
- stimulate appetite,
- infection prevention
What needs to be considered when providing oral care to an unconscious patient?
- Greater need
- Stomatitis (avoid alcohol rinses)
- Position– HOB lowered, head turned
- Tongue blade assess gag reflex – may need suction
- Do not place fingers in mouth
What would you like to do?
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