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a device which is worn on the leg and signals when the leg is in a dependent position such as when its over the side rail or on the floor
the reduction and spread of microorganisms
a clients environment includes all of the physical and psychosocial factors that influence or affect their life and survival
the federal agency responsible for the enforcement offederal regulations regarding the manufacture, processing and distribution of food, drugs and cosmetics and to protect consumers from the sale of impure or dangerous substances
Food Poisoning is caused by
ingestion of bacterial toxins produced in food ex) staph and clostridia
Grounded is the
third prong in a plug that carries stray electrical current back to the ground
- is hot dry skin
- rectal temp is above 105*
- exposure to extreme cold
- the bodies core temp falls below 95*
- the process by which resistance to an infectious disease is produced
- can produce active or passive immunity
- a CLEAN technique aimed at the reduction and prevention of the spread of microbes
- ex) handwashing, gloves, cleaning, disinfection
any microorganism capable of producing illness
Personal Protective Equipment
- mask; protection from droplet or airborne precautions
- goggles; to prevent infection from splashing or spraying
- gown; barrier protection and contact precautions, also is fluid resistant
- gloves; non-sterile are worn when touching blood, bodily fluids and contaminated items
any substance that impairs health or destroys life when ingested, inhaled or otherwise absorbed by the body
a harmful chemical or waste material discharged into water, soil or air
a device used to immobilize a client or extremity and that restricts the movement or normal access to a pts body
Standard Precautions apply to...
- blood, all bodily fluids, secretion, excretions, nonintact skin and mucous membranes.
- teir 1- is designed for all pts in any setting regardless of dx or presumed infection
- teir 2- applies with droplet nuclei, droplet and contact precautions
the complete elimination or destruction of all microorganisms
Surgical Asepsis is...
- sterilization or elimination of all microorganisms including pathogens and spores
- an object is considered contaminated if it comes in contact with an object that is not sterile
Characteristics of a safe environment is one in which...
- basic needs are met
- physical hazards are reduced
- sanitation is maintained
- pollution is controlled
- skin integrity is maintained
- nervous system, cell structure andfx are also maintained
Individual risk factors in regards to safety include...
- lifestyle risks; Etoh, drugs and smoking
- impaired mobility; inability to get out of the way of danger
- sensory/ communication deficit; no sensation, blind or deaf
- lack of knowledge of safe practice
Risk factors for older adults include...
- decreased muscle strength, fx, mobility and ROM
- decreased reflexes and ability to respond to multiple stimuli
- decreased perception to hot or cold
- decreased peripheral vision
2 components of a safe environment are
- physical safety from environmental hazards
- biological safety from pathogens
A pts biological safety is maintained when...
- the transmission of pathogens is reduced
- the bodies normal defense mechanisms are supported
- the inflammatory process is working
- the skin and mucous membranes are intact
Standard Precautions are used because...
healthcare workers are continuously at risk for exposure to infectious microorganisms
Handwashing is necessary when...
- hands are visibly soiled
- before and after client contact
- after contact w a source of microorganism ex blood, bodily fluid, mucous membranes, non intact skin or equipment
- before the performance of invasive procedures
- after removing gloves
Common Environmental Hazards include...
- Physical- hand rails, clutter
- Mechanical- defective equipment
- Thermal- fire, heat or cold
- Chemical- poison, meds or carbon monoxide
- Radiation- XR, sun exposure
- Ecological- air, land or water pollution
Ways to establish a restraint free environment include...
- orient clients and families to surroundings and explain procedures
- encourage family and friends to stay or use sitters
- assign a confused or disoriented client to a room near the nurses station
- eliminate bothersome tx as soon as possible
- use relaxation techniques
In home modifications to decrease physical hazards include...
- side rails on beds
- safety bars in toilets and showers
- call bells
- fall risk assessments
Psychological implications of isolation include...
- sense of loneliness that may stem from the disruption of social relationships and limited sensory contact
- feelings of rejection, guilt, undesirability and uncleanliness
Legal issues and documentation guidelines...
- LI-reasons must be clearly stated; must be part of the clients medical tx; all less restrictive interventions must be tried first
- DG- must have an MD order; the type of restraint and reason must be given; they must be re-ordered every 24h
Chain of infection:
- anything in the chain of infection can affect a pts biological safety
- causative agents such as bacteria, fungi, viruses, protozoa and rickettsiae
- break the chain by identifying and treating causative agent; eliminate reservoirs of infection; proper attire; elimination of means of transmission; aseptic technique and to recognize high risk pts
TIER 1- Universal Precautions
- hand are washed b\t clients, after contact with blood, body fluids, secretions, excretions and after contact w equipment or articles that may have become contaminated by them; and immediately after gloves are removed
- gloves are worn when touching blood, body fluids, secretion, excretions, non intact skin, mucous membranes or contaminated items; gloves should be removed and the hands washed between pts
- Masks, eye protection or face shields are worn if client care activities may generate splashes or sprays of blood or bodily fluid
- gowns are worn if the soiling of clothes is likely from blood or bodily fluid, wash hands after gown removal
- client care equipment is properly cleaned and reprocessed; single use items are properly discarded
- contaminated linen is placed in a leakproof bag and is handled as to prevent skin mucous membrane exposure
- all sharps are discarded in a puncture resistant container
TIER 2- Airborne, Droplet & Contact Precautions
- Airborne; droplet nuclei < 5 microns (TB, Varicella) require a private room, negative pressure air flow w at least 6 exchanges/h and a mask or respiratory protection device
- Droplet; droplets > 5 microns (rubella, strep and pneumonia) require a private room and a mask
- Contact; colonization or infection with a multi-drug resistant organism (herpes, scabies) require a private room, gloves and a gown
When a fire occurs, the RN...
- protects the clients from immediate injury (R-escue)
- reports the exact location of the fire (A-ctivate the alarm)
- contain the fire (C-onfine the fire)
- put out the fire if possible (E-xtinguish)
Containment guidelines for a fire include...
- close windows
- shut off O2
- unplug electrical items
- close doors
Prevention of electrical hazards include...
- maintaining good working order of equipment
- grounding electrical equipment
- education of family and pt abt possible hazards
Common nursing dx associated w safety risks include...
- dx-Impaired mobility
- intervention- use of wheelchair/walker
Intervention for a pt who has ingested poison:
- assess ABC's
- terminate exposure (remove visable material from nose and mouth)
- identify the amt/ type of substance ingested
- call poison control
- if instructed, induce vomit vomiting via ipecac and h2o
- if directed, save vomit for lab
- place the pt on their side to prevent aspiration of vomit
- never induce vomiting on an unconscious pt or w harsh chemicals
Your pt is confused as to time and place and thinks his roommate is his father. Should he be restrained?
No, this pt does not meet the requirement for physical restraint, b/c the pt is confused there are other measure that should be taken to ensure the safety of the pt and his roommate such as being put in a room closer to the nurses station, checked on more frequently or asking the roommate to notify you in case of change in the pt.
Is a nurses aide able to apply restraints?
No, the use of restraints requires problems solving and knowledge application unique to professional nursing.
- C- glaucoma, cataracts
- E- impaired mobility
- C-cerumen accumulation
- E- impaired hearing
- C- dizziness, vertigo
- E- increased risk for falls
- C- xerostomia (drymouth)
- E- difficulty w speach & eating, halitosis
- C- peripheral neuropathy
- E- impaired impulses to brain
- C- aphasia, ventilators
- E- frustration, inability to communicate
- Inadequate quality or quantity of stimulation
- E- regression, restlessness and panic
- NI- screening, safety and promotion of meaningful stimulation
- Pt receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore
- E- disorientation and mood swings
- NI- environmental control and adequate sleep
Nursing intervention for fall prevention includes...
- placing call bell, phone and personal belongings within pts reach
- frequent checking in on the pt
- assessing need for side rails for support
- adequate lighting
increased opacity of the lens that causes a clouding over the eye
impaired near vision
Macular Degeneration is...
- a degeneration of the retina that causes a decrease in central vision.
- like a clouded circle in the center of your vision
- a common cause of blindness
a decrease in vision due to and increased pressure on the optic nerve.
age related hearing loss
Peripheral Neuropathy is
numbness and pain in the limbs caused by nerve damage.
Basic procedure for pt identification is to...
- use two identifiers to confirm that you have the right pt.
- never use room number as one, pts tend to wander
Buccal Glands are...
mucous membranes that line the cheeks
Perineal Care is...
cleaning of the patients genital area
a series of massage strokes that use light touch
Biological Weapons are...
deliberate release of viruses or bacteria to cause illness or death in people, plants or animals
Chemical Weapons are...
toxic chemicals that are used to cause damage to people
RN interventions to maintain safe environment and prevent safety hazards...
- basic needs are met
- physical hazards reduced
- pollution is controlled sanitation is maintained
- skin integrity is maintained
- staff safety
- nervous and immune function
- "feeling safe"
Therapeutic RN interventions for a pt experiencing sensory alteration...
- increase or decrease stimulation
- decrease noise level
- group tasks together
- soft lighting
Describe the nursing interventions that promote the current pt safety goals of the joint commission...
- improve accuracy of pt identification
- improve effectiveness of communication among caregivers
- increase safety of medication administration
- reduce the risk of health care associated infections
- accurately and completely reconcile medications across the care continuum
- reduce harms from falls