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68C Exam 10
Basic Nursing
| Question | Answer |
|---|---|
| Infancy | 30 days to 1 year. |
| Toddler | 1 to 3 years |
| Preschool | 3 to 5 years |
| School age | 3 to 5 years |
| Adolescence | 13 to 19 years |
| Middle adulthood | 40 to 65 years |
| Late adulthood | 65 years and over |
| Growth | progressive anatomic and physiologic increase in size. |
| Development | increase in function or the gradual process of change and differentiation. |
| Moves from simple to complex and is a life-long process | Development |
| Affectors of development | Experiences, Genes, Family, The world in which one lives |
| Personality | a unique combination of characteristics that result in the individuals’ recurrent pattern of behavior. |
| Developmental theory | Understanding what affects growth and development helps the nurse predict behaviors and responses at each stage of the life cycle. |
| Life Expectancy | the average number of years a person will probably live, currently about 77 years. |
| Females outlive males by about? | 6 years |
| Individuals with an income over $25,000 live? | 3-7 years longer than those with an income of $10,000 |
| Infant mortality rate | refers to the number of deaths before the end of the first year of life. |
| Cephalocaudal | growth and development that proceeds from head to foot |
| Proximodistal | growth and development that proceeds from center to the outside. |
| The Id | (the unconscious mind) is present at birth and generates impulses that seek pleasure and gratification. |
| It is the basic drive for survival and pleasure, not changed with experience, goal is to reduce tension, increase pleasure and minimize discomfort | The Id |
| Ego | The ego is the reality factor Stands for reason and good sense |
| Helps us perceive conditions accurately, Decides how and when to act, Is in contact with the external reality | Ego |
| Super-Ego | Learns to delays immediate gratification for socially appropriate reasons |
| It recognizes good and bad it is also known as the moral guide or conscience, Develops from the ego, Strives for perfection and morality Censor over thoughts and activity, Self observation and the formation of ideas | Super-Ego |
| Who stated, "a strong super-ego serves to inhibit the biological instincts of the id, while a weak super-ego gives in to the id's urgings." | Sigmund Freud |
| Infancy Developmental Task | Basic trust vs. mistrust |
| Infancy Developmental Task Outcomes | Learn to trust or mistrust significant others to meet basic needs for food, sucking, warmth, cleanliness and physical contact. |
| Toddler Developmental Task | Autonomy vs. shame & doubt |
| Toddler Developmental Task Outcomes | Children learn to be self-sufficient or to doubt their own abilities |
| Young adulthood Developmental Task | Intimacy vs. isolation |
| Young adulthood Developmental Task Outcomes | Seek companionship & love or become isolated |
| Middle Adulthood Developmental Task | Generativity vs. stagnation |
| Middle Adulthood Developmental Task Outcomes | Productive, performing meaningful work & raising a family or stagnant & inactive |
| Late Adulthood Developmental Task | Ego integrity vs. despair |
| Late Adulthood Developmental Task Outcomes | Try to make sense out of lives, either seeing life as meaningful & whole or despairing at goals not reached & questions unanswered |
| Preschool Developmental Task | Initiative vs. guilt |
| Preschool Developmental Task Outcomes | Desire to undertake adult-like activity & may test limits |
| School Age Developmental Task | Industry vs. inferiority |
| School Age Developmental Task Outcomes | Eager to learn to be competent & productive or feel inferior and unable to perform |
| Adolescence Developmental Task | Identity vs. role confusion |
| Adolescence Developmental Task Outcomes | “Who am I?” Establish sexual, ethnic & career identities or are confused about future roles |
| Psychoscial Theorist (Nurse's Theorist) | Erikson |
| Erikson identifies intimacy as a developmental task of adulthood. If this task is not accomplished, the outcome will be? | Isolation. |
| Piaget's Cognitive Development Stage 1 | Sensorimotor Stage Birth to 2 years |
| Piaget's Cognitive Development Stage 2 | Preoperational stage 2 to 7 years |
| Piaget's Cognitive Development Stage 3 | Concrete Operational Stage 7 to 11 years |
| Piaget's Cognitive Development Stage 4 | Formal Operational Stage Adolescence and Adulthood |
| Sensorimotor Stage Birth to 2 years | In this intelligence is gained and demonstrated through senses and motor activity |
| Effects of intelligence as it is gained and demonstrated through senses and motor activity | Knowledge of the world is limited (but developing) because it’s based on physical interactions / experiences. Acquires object permanence at about 7 months of age(memory).Understands cause and effect. I.e. crying when hungry & differences in time of day. |
| Concrete Operational Stage 7 to 11 years, Elementary and Early Adolescence | characterized by 7 types of conservation: Number, Length, Liquid, Mass, Weight, Area, Volume |
| Effects of the Concrete Operational Stage | Egocentric thought diminishes. Realistic understanding of the world. Focus is on the present not the future |
| Preoperational stage 2 to 7 years | Egocentric thinking predominates. Attributes life to inanimate objects.Understands one bit of information at a time without see ingabstract relations hips. Language use develops. Uses pretend play. Begins to use logic to understand rules |
| Formal Operational Stage Adolescence and Adulthood | Intelligence is demonstrated through the logical use of symbols related to abstract concepts. |
| Effects as intelligence is demonstrated through the logical use of symbols related to abstract concepts in the formal operational stage | Early in the period there is a return to egocentric thought. Can think in hypothetical terms. Future oriented. Understands scientific basis of theories.Develops a moral sense of what is right and wrong`. |
| When the nurse notes that the 5-year-old has an imaginary friend with whom he converses frequently, the nurse recognizes this is a characteristic of Piaget’s stage of? | Nurse Recognizes Preoperational development traits |
| Nuclear Family | Consist of a Married man and woman. With or without children. Live in independent household |
| Extended Family | Consist of nuclear plus additional family members, Live in same household, Share responsibilities, Basic family group in many societies |
| Single Parent Family | Can be a style of choice or Divorce, death, separation, abandonment. Increasingly more common |
| Blended (Reconstituted) Family | Also called a stepfamily, Results from remarriage, Divorce, Death. Can provide a lot of stressors. Conflicting loyalties. Can be fearful of love and trust. Intensify if children go back and forth between two households |
| Social Contract Family and Cohabitation | Unmarried couples living together. Share roles and responsibilities. |
| Adoptive Family | Family with adopted children. Infertile couples. Millions every year |
| Foster Family | Natural parents unable to care for children. Foster care is usually temporary. |
| The nurse discovers in her intake assessment of a 5-year-old child that he lives with his biological parents and his siblings. The nurse categorizes this family type as? | Nuclear family. |
| Role of the Family | Protection, Nurturance, Education, Sustenance, Socialization. |
| Usually unconditional affection, acceptance, and companionship, The family is the first socialization agent for children society’s expectations and limitations | Role of the Family |
| Patriarchal Family Patterns | Male assumes the dominant role, Assumes the work role, Make most decisions |
| Matriarchal Family Patterns | Woman assume the dominate role, Assumes the work role, Make most decisions |
| Democratic Family Patterns | Adults function s equals, Make joint decisions, Respectful interactions, Favors compromise, negotiations, and growth |
| Rapid growth 4 to 6 months and weight doubles. Triple birth weight by 1 year. Length increases by about 50% by 1 year. Teething begins at 6 months of age. | Infancy Growth |
| all higher than adult norms | Infancy pulse and respiration rates |
| widely variable depending on activity and state of health | Infancy Temperature |
| lower than adult norms. | Infancy Blood Pressure |
| At 2 months the apical pulse is? | about 120 bpm |
| At 12 months the respiratory rate is? | about 30 |
| At 12 months BP is about? | 90/60 |
| An Infant will normally sit up and crawl at? | 7 months |
| An Infant will Creep at? | 9 months |
| An Infant stands and walks between? | 8-15 months |
| Infancy Language development. | Babbles at about 3 months, Varies from child to child |
| Infancy Nutrition | Human breast milk and commercial formula meet nutritional needs. Breast milk is best. Feed when Hungry |
| Breast Milk or Formula is fed to sn infant exclusively for? | 4-6 months |
| Whole milk prohibited for | the first year of life. |
| Foods to Avoid certain foods in first 6 months of life | citrus fruits, egg whites and wheat flours |
| Introduce one food at a time to infants and allow? | several days between new foods. |
| Infancy Safety | Never leave infant alone while feeding. Avoid round, hard foods, which may cause choking, in older infants. At higher risk of dehydration during warmer weather, febrile conditions, and prolonged gastrointestinal illness. |
| Newborns and infants- 18 out of 24 hours; usually short nap like periods. End of first year- sleep 12 hours at night with one nap during day. | Infancy Sleep |
| Infancy Play | Important for learning. Sensorimotor- use of senses and motor abilities. Play is solitary. |
| The nurse instructs the family of a newborn 7-lb. baby that the anticipated weight at 1 year of age would be? | Nurse explains that baby should 21lbs because they are expected to triple birth weight by 12 months. |
| The mother of a 5-month-old child is concerned because the child cannot sit by himself? The nurse explains that sitting alone is not expected until the baby is? | The nurse explains that sitting alone is not expected until the baby is 7 months. |
| Toddler Speaks in? | one or two word phrases |
| Toddler Vocabulary is how many words by age 2 ½ | 450 |
| Toddler Vocabulary is how many words by age 3 | 900 |
| Toddler Growth | Slower, Upright stance. Top-heavy at beginning more proportionate at end of period. |
| What happens to the Baby Pot Belly during toddlerhood? | Exaggerated lumbar lordosis and abdominal protrusion Potbelly disappears as abdominal muscles strengthen by age 3. |
| Toddler dental milestones | All 20 primary teeth erupt by age 2. |
| 90-120 bpm | Toddler pulse ranges |
| 80-100/64 | Toddler Blood Pressure |
| 98-99 degrees | Toddler Temperature Range |
| 20-30 breaths/min | Toddler Respirations |
| Toddler motor skills at 2 | Walking steadily and climbing stairs |
| Toddler motor skills at 3 | Hopping, Running, Pulling and hold-on-tight |
| When a Toddler developed pincer grasp it gains the ability? | to pick up objects with the thumb and forefinger |
| Scribbling | Toddler fine motor skills at 2 |
| Copying a circle | Toddler fine motor skills at 3 |
| Toddler Toilet Training | Begins at about 18-24 months, Bowel control first; then bladder control, Cannot be hurried |
| Toddler Introduction of new foods | Gradual introduction, Bite-sized, finger foods and smaller portions. |
| Toddler Serving Size | 1 tablespoon of each solid food for each year of age |
| Toddler amount of Sleep needed | 12 hours at night plus a daytime nap |
| Promote Toddler sleep by? | Limiting stimulation before sleep time. Quiet activities before sleep. Favorite bed toy. Bedtime ritual. |
| Toddler Safety | 90% accidents occur at home; preventable. |
| Preschooler Growth | Slow and steady. Gains less than 5 lbs per year. Growth about 2 to 21/2 inches per year. Look taller and thinner. Body slimmer, stronger and less top-heavy. |
| Preschooler Motor skills | Gait steadier, Finer motor skills more difficult; encourage development |
| Preschooler Vision | Farsighted. 20/20 achieved by age 5 |
| Preschooler Pulse Rate | 70-110 bpm |
| Preschooler Respirations | 23 breaths per minute |
| Preschooler Blood Pressure | 110/60 |
| Preschooler Temperature | 97-99 degrees Fahrenheit |
| Preschooler Nutrition | High protein need for growth. Dietary likes and dislikes variable; supplementary vitamins may be recommended |
| Preschooler Play | Cooperative- share, take turns and interact. Pretend play- cooking, shopping and driving. Dramatic play- try out social roles, express fears and fantasies and learn to cooperate. Imaginary friends may appear. |
| Preschooler Safety | Teach full name, address and telephone number. Teach how to use phone in emergency. |
| Autocratic Family Patterns | Relationships are unequal. Parents control children. Ridged rules and expectations. Least open to outside influence |
| 11-12 hours at night; may resist daytime nap. | Preschooler Sleep |
| As the child begins to develop language skills, the nurse is aware that a rule of thumb for the number of words in a sentence is that it | 1 word for each year of life. |
| When teaching a young mother that breast milk or formula is the only food an infant needs until? | A nurse feels confident saying, 4-6 months. |
| School Age Growth is? | Is the same for both boys and girls, is Gradual and subtle Most obvious growth in long bones and development of facial bones. May experience "growing pains". Posture straighter; routinely screen for scoliosis.Muscle mass and strength gradually increase. |
| School Age Height increases? | about 2 inches per year |
| School Age Weight increases? | about 4.5-6.5lbs per year |
| Loss of primary teeth begins at about? | age 6; about 4 permanent teeth erupt each year. |
| 55-90 bpm | School Age Pulse |
| 22-24 breaths per minute | School Age Respirations |
| 110/65 | School Age Blood Pressure |
| When the mother asks the nurse about introducing solid foods into the child’s diet, the nurse’s best advice is to introduce solid food | one at a time several days apart. |
| School Age Dietary habits and food preferences established. | Cultural influences. Family habits. Peer pressure. |
| To maintain ideal weight during school age development it is important to? | Increase physical activity and a Proper diet. |
| School Age Sleep | Fatigue, irritability, inattention and poor learning may be related to inadequate sleep. |
| School Age Play | Adequate exercise to enhance muscle development, coordination, balance and strength |
| School Age self Image | Privacy and personal space important. |
| School Age Safety | Accidents still leading cause of death- impulsiveness, poor judgment, curiosity and incomplete control over muscle coordination. |
| During a patient education a young family is told that a child must have adequate physiological, neuromuscular, and psychological maturity in order to master toilet training, usually around the age of? | 18-24 months the Nurse Counsels |
| Adolescence Growth Begins? | Begins at puberty- maturation of the reproductive system. Is the second major growth period in the life span. Primary and secondary sexual development. Menarche in females. Sperm production in males. |
| Adolescence Safety | Often not very coordinated at increased risk for injury. Accidents are the major cause for injury |
| Body shapes are sex differentiated. Other physical changes: males develop more muscle tissue and females develop more body fat. | Adolescence Growth |
| Adlolescent Vital Signs | Same as an adult |
| Adolescence Nutrition | increased caloric need related to rate of growth and increased basal metabolic rate |
| Adolescence Sleep | increased sleep need to restore energy. |
| Adolescence Play | Organized sports, Work with others, Meet challenges, Set personal goals |
| A 14-year-old male patient has undergone a leg amputation. The nurse makes the focus of the nursing care plan to support the patient’s? | body image |
| Early Adulthood Optimal level of functioning | Strength, energy and endurance at peak. Body functions fully developed. |
| Toddler Speech | String together 1 word for each year of life |
| Early Adulthood Physical appearance influenced by? | heredity, environment and general state of wellness. |
| Females reach maximum height by? | 16 to 17 years. |
| Males reach maximum height by? | 18 to 20 years. |
| Early Adulthood Nutrition | Fewer calories than adolescents. Needs based on age, gender, size, physical activity, metabolism and stress. |
| Early Adulthood Rest and Sleep? | 7 to 9 hours restorative sleep |
| Early Adulthood Physical health | annual physical and dental exams |
| Early Adulthood Safety | injuries related to work, vehicle and sports accidents and violence. |
| As the nurse does a physical assessment on a 25-year-old , the nurse has the expectation that during this time the patient is experiencing? | Normally the pateint should be at optimal level of functioning. |
| Middle Adulthood Bone Mass | decreases: Women lose calcium from bone tissue after menopause. Men lose calcium at a more gradual rate. |
| Middle Adulthood Height | Slight changes in height related to compression of the spinal vertebrae & hardening of collagen fibers. |
| Middle Adulthood Muscle | Decreased muscle fibers leads to reduction of muscle mass. |
| Middle Adulthood Body Shape | contour changes related to redistribution of body weight. |
| Middle Adulthood Presbyopia. | farsightedness |
| Middle Adulthood Presbycusis. | Hearing Loss |
| Middle Adulthood Skin changes | Decreased elastic fibers & slight loss of subcutaneous tissue leading to looser, more wrinkled appearance. |
| Middle Adulthood Hair | may change-graying. Hair growth and distribution may change-scalp hair thinner. |
| Middle Adulthood Dental | Higher incidence of periodontal disease. |
| Middle Adulthood Hormonal changes | Female menopause / Male andropause |
| Middle Adulthood Nutrition | Fewer calories needed due to slowing down. Positive lifestyle and regular exercise to maintain joints and bones |
| Middle Adulthood Examinations | Follow American Cancer Society guidelines. Physical and dental examinations: Regular examinations recommended, Cancer screenings recommended |
| Late Adulthood Aging | individualized. Gradual reduction in number and change in composition of aging cells |
| Late Adulthood BMI | Slow increase in body weight until 45 to 50 years; then gradual decline. |
| Late Adulthood Adipose Tissue | Females- over the chest, waist, hips and thighs. Males- waist, chest and lower abdomen. |
| A middle-aged (age 40-65) male is concerned about some hearing loss he is experiencing. The nurse recognizes that this might be due to a sensory change of this age group known as | presbycusis. |
| Late Adulthood height | shrinks after 50 year old |
| Late Adulthood Kyphosis | may increase resulting in a barrel-chest appearance. |
| Late Adulthood Nutrition | Adequate nutrition for health maintenance and quality of life. Foods higher in quality and lower in quantity to meet basic nutrient needs. Adequate fluid intake also crucial. |
| Late Adulthood Common threats to adequate diet. | Poor oral health. Lack of appetite. Food intolerances. Constipation. Psychosocial. Economic. Loneliness. Inability to shop for and prepare meals. |
| Late Adulthood Sleep | More rest needed but less sleep. Accidents may occur when awakening at night. Affected by; Medications. Alcohol. Caffeine. Stress. Environmental noise and temperature |
| The nurse reminds an older adult patient that the task for the older adult is to achieve ego integrity. Failure to achieve this task results in? | sense of despair |
| In assessing the home for fall risks and increased safety for an 85-year-old, the home health nurse suggests that? | excess furniture be removed. |
| Charting Routine care | Chief complaint; subjective and objective findings; diagnosis; treatment plan; response to treatment. |
| Charting Condition change | Condition changes with corresponding actions. Professionals have an obligation to recognize condition change and take action. Can only illustrate this through documentation. |
| What is the first item requested in a claim? | Medical chart |
| Medical Records | The witness that never dies and never lies |
| bad charting | Leading reason malpractice case is settled |
| The chart can be defined as? | The primary communication tool; essential for good patient care. |
| Components of Charting: Who | Hospital policies should govern who can document. E.g., who can document on progress notes. |
| Components of Charting: What | Care and treatment, Changes in condition, Intervention, Response to intervention Coordinated team plan |
| Components of Charting: When | Close to event notes are best, What is your personal custom and practice?Time of events (synopsis v. timed log) |
| Components of Charting: Where | Chart in designated sections |
| Components of Charting: Risk Reduction | Never share your PIN, Never log on to allow charting, Always log off, Be careful at the bedside |
| Components of Charting: Factual, Objective Notations | What you hear, see, feel, and smell. Avoid “appears to be…” (unless you really don’t know), Avoid “inadvertently” and “unfortunately.” Use quotes when you can. |
| Components of Charting: Utilization and Financial Record | What resources were used. Who saw patient. Level of care: Services used: equipment, time (e.g. OR, ER). Procedures and medications, If questioned, this is the audit tool that will be judged. |
| May be the basis for a fraud claim. | Components of Charting: Utilization and Financial Record |
| Components of Charting: Being Specific | (Example Fall) Do not state: “Patient fell out of bed.” State: “Crash heard, patient found at foot of bed with laceration …” |
| (Example Wound) Don’t say: “Wound improved.” State it in objective terms: size, drainage, odor. | Components of Charting: Being Specific |
| Components of Charting: Timely Notes | Timing and dating your notes is vital |
| Components of Charting: Electronic Monitors | Document All; Times are on the print outs. Does it correspond to your charted times? Who is responsible for setting the clocks (preventive maintenance)? |
| Components of Charting: Tampering Forms | Squeezing in a little clarification. Crossing out incorrectly. Obliterating information. Spoliation of evidence: What were you trying to hide? It MUST have been bad. |
| altering the record in any way not just the willful act to destroy record | Components of Charting: Tampering |
| Components of Charting: Blank Lines | You cannot control subsequent providers. Your actions are based on what you knew at the time. If someone asks you to leave a blank, don’t. Show them how to make a late entry. Draw lines through empty spaces. |
| Components of Charting: Legibility | If you are uncertain about a notation and you act anyway, it is inexcusable. Good handwriting. The most common reason for drug errors is illegible or questionable handwriting. |
| Use approved abbreviations | Components of Charting: Legibility |
| Components of Charting: Accuracy | If it is documented, it is assumed to be accurate. Identify whether the care was given by yourself or someone else. Grammar and cleanliness are worthwhile: messy notes give an appearance of messy care. Never document ahead. |
| Correct mistakes: Use a line, note initials, and note “error.”, Spoliation of evidence by obliterating information. Don’t sound tentative. State what you mean. Use real sentences. READ YOUR NOTE | Components of Charting: Accuracy |
| Components of Charting: Irrelevant and Inappropriate Charting | Do not include irrelevant info:. The chart is not the proper forum for complaints: (Criticism of another practitioner, Number of times this has occurred to you before.) |
| Components of Charting: Non-Compliance | Document By: Using quotes when possible to show tnon-compliant behavior, what instruction you gave patient that was not followed. Avoid labeling patient. Seems that you did not like patient. whom you informed about the non-compliance. Incidences of not fo |
| Components of Charting: Discharge Documentation | Illustrates education provided to patient. Provide cautions for symptoms warranting further or urgent care. Provide specific instructions on when to next seek routine care. |
| Maintain a copy of all forms given to patient. Have patient sign discharge instructions. | Components of Charting: Discharge Documentation |
| Discharge is a high-risk event | Instructions given the patient intervenes on their own behalf. Change in condition, need to follow instructions, need to follow-up, need to understand warning signs. Illustrates status at discharge and readiness. Needed regardless of setting. |
| three types of legal aspects of privileged provider's orders. | Written, Telephone, Verbal |
| nine types of patient care orders. | 1)Single orders. 2)Recurrent orders. 3)Standing orders (protocol)4)Routine orders. 5)STAT orders. 6)PRN orders. 7)Telephone orders. 8)Verbal orders. 9)Nursing Orders. (NIOs) |
| use of DA Forms 4677 | Documents Procedure Orders |
| use of DA Forms 4678 | Documents Medication Orders |
| two types of RN Only Order | Telephone & Verbal Orders |
| Legalities of verbal and Telephone orders | Accepted by, and transcribed onto DA-4256 by RN only. must be countersigned within 24 hours by MD |
| Which orders may be called into court | All orders can be subpoenaed |
| Do not's when transcribing orders | Erase/Correction fluid. Skip lines. Write between lines. Leave blank line above signature. Chart for someone else. |
| DA Form 4256 | Dr’s Order |
| Military Outpatient Electronic Charting Systems | (AHLTA) Armed Forces Health Longitudinal Technology Application |
| (CHCS) Composite Health Care System, ESSENTRIS, MEDITECH, (AHLTA) Armed Forces Health Longitudinal Technology Application | Electronic Charting systems |
| Single orders | Order given by the physicain to do one time, usually written |
| Recurrent orders | Order that is done at a certian frequency |
| Standing orders | Standard operating procedure, protocol |
| Routine Orders | must be specified may be pre-printed (e.g. Pre-Op orders), Pre-standing orders |
| STAT Orders | Immediately needs done, takes priority over everything else. |
| PRN Orders | As Needed Orders |
| Telephone Orders | Legal Order communicated over telephone, must be written down in chart. RN Only |
| Verbal orders | Emergency and Stat orders only. Must be charted, LPN has to refer to LPN |
| Nursing Orders. (NIOs) | Nurse Initiated Order. Something a nurse within their Scope of Practice can administer to add to provider order care. |
| Legalities of written orders | Accurate, complete, and legible. Must contain date/time and signature of MD. Must be acknowledged by RN |
| How Many Copies of DA Form 4256 are there? | 3 Copies, White, Pink, and Yellow |
| Purpose od Transcribing Order | Organization of similar tasks. Ease of use. Documentation time |
| Process of Transcribing Orders | Patient’s complete Name & Rank. SSN w/Status code. Service Component. DOB. Hospital location (i.e. Ward). Room and bed number. Determine if orders are complete and accurate. Read all orders and initiate STAT orders first. |
| Transcribing Medicationn orders | Confirm orders are complete by verifying; Medication name. Dose. Route. Frequency. |
| Transcribing PRN meds | must have indication stated |
| Before transcribing, what must the LPN do if the orders are unclear? | Seek Clarity; Review provider’s progress notes for specific information. Collaborate with charge nurse for information. Contact provider directly to clarify order as necessary. |
| two numbers preceeding social security number | Status code number |
| What must you do after performing each entry of a privledged provider's order? | Date, time, initial (may “Bracket” groups of orders). |
| Military Nursing Note | SF 510 |
| Which copy of the transcribed orders does the LPN send the pharmacy? | The Pink Copy. is sent to ensure all medications are appropriately surveyed for interactions |
| After reviewing orders who must the LPN must inform about the patients care? | All Care Providers included in orders must be notified |
| If orders for Labs are required what must the LPN do? | Prepare specific documentation for therapeutic modalities or procedures ordered. |
| Transcription to Discontinue or change medications, treatments, and/or procedures per DOs. | Initiate appropriate column and annotate “D/C’d” w/date, time & initials, then draw line through remaining “Date Completed” or “Date Dispensed” blocks. |
| Military Admitting Electronic Charting systems | ESSENTRIS |
| Who can transcribe a Doctor's note? | RN, LPN, Order's Clerk |
| Defined as the use of words and behaviors to construct, send, and interpret messages. Both verbal and nonverbal communication is used to convey varied messages. | Communication |
| a person who has a thought, idea, or emotion to convey to another person. | Sender |
| the thought, idea, or emotion one person sends to another person. | Message |
| how the message is transmitted may be auditory, visual, or kinesthetic | Channel |
| Channel Auditory (verbal) | hearing and/or listening. |
| Channel Visual (nonverbal) | sight, reading, observation and/or perception. |
| Channel Kinesthetic (tactile or nonverbal) | procedural touch and/or caring touch |
| a person who receives the message | Receiver |
| Receiver Physiological: | process of hearing, seeing, and the reception of the touch stimulus. |
| Receiver Psychological | process may enhance or impede the receiving of the message. |
| Receiver unintended | someone who overhears a statement or conversation. |
| Feedback | a response from the receiver that enables the sender to verify that the message sent was the message received. |
| Aspects of Communication | Influences: both sender and receiver are influenced by their education, culture, emotions, and perceptions and by the situation within which they find themselves |
| Process of Communication | Communication may be one-way or two-way, depending on the roles of the persons in the interaction. |
| highly structured, with the sender being in control and expecting and getting very little response from the receiver. | One-way communication |
| requires both the sender and the receiver participate equally in the interaction. | Two-way communication |
| Use of spoken or written words or symbols. Misunderstanding/misinterpretation of the intended message occurs even if receiver understands the language and symbols being used. | Verbal Communication |
| Verbal Communication | Spoken words can have very different meanings, or connotations, for the sender and the receiver. |
| a word reflects the individual's perception or interpretation of a given word. | Connotative meaning |
| Denotative meaning | refers to the commonly accepted definition of a particular word. |
| is commonplace language or terminology unique to persons in a particular work setting, such as a hospital, or type of work, such as nursing | Jargon |
| Transmission of messages without the use of words. Body language is another name for nonverbal communication. | Nonverbal Communication |
| Nonverbal Communication | very powerful, and if the nonverbal cues are not consistent or congruent with the verbal message, it will most likely be the nonverbal message that is received. This incongruence is frequently the cause of misinterpretation and misunderstanding |
| What are the two forms of therapeutic communication? | Verbal & Nonverbal |
| Style of Communication: Assertive | interaction that takes into account the feelings and needs of the patient, yet honors the nurse's rights as an individual. (Most effective style of communication.) |
| Style of Communication: Aggressive | interacting with another in an overpowering and forceful manner to meet one's own needs at the expense of others. |
| Style of Communication: Unassertive | interaction sacrifices the nurse's legitimate personal rights to meet the needs of the patient at the expense of feeling resentful. |
| Promotes the formation of a positive nurse-patient relationship and actively involves the patient in all areas of the nursing process. | Therapeutic Communication |
| blocks the development of a trusting and therapeutic relationship. | Non-therapeutic Communication |
| Nonverbal Communication Listening | Most effective method. Most difficult skill to acquire. Conveys interest and caring toward the patient. |
| Active Listening: | Full attention to patient. Allows feedback. |
| Passive Listening: | Attends nonverbally through eye contact and nodding. Verbally through encouraging phrases: "Uh huh" and "I see“. Passive listening should be avoided. |
| Maintaining extremely effective therapeutic commo technique, yet underused Allows time to organize thoughts and plan response. Convey respect, understanding, caring and support. Often used in conjunction with touch. Observe patient's nonverbal responses. | Silence Nonverbal Communication |
| Brief verbal comments, such as "Yes, go on". Conveys interest and desire to hear more. Involves nonverbal cues, such as: eye contact and nodding. | Minimal encouragement Nonverbal Communication |
| Can convey warmth, caring, comfort, support and understanding. Consider patient's cultural and personal feelings about being touched. | Touch Nonverbal Communication |
| Acceptance of what the patient is communicating. Non-judgmental; encourages honesty and openness. Minimal verbal interaction. | Convey acceptance Nonverbal Communication |
| Focused on particular answer. "Yes", "no" or short answer response. Provides a specific answer to a specific question. Does not foster open communication, which may provide other useful information. | Closed questioning Verbal Communication |
| Doesn't seek specific answer. Patient can elaborate. Useful to assess feelings. Doesn't influence response | Open-ended questioning Verbal Communication |
| Process of the nurse repeating the main points of what the pt said. Conveys to the patient that you heard what was said. Encourages pt to provide additional information. | Restating Verbal Communication |
| Restating what the patient said in the nurse’s own words to verify that the interpretation was correct. | Paraphrasing Verbal Communication |
| Asking for more information or elaboration. Verification of the accuracy of the message. Useful if message is difficult to understand. | Clarifying Verbal Communication |
| Specific info needed to accurately understand the pt’s message. Pt gives important info, however the message may be too vague to be useful. Nurse seeks further info to focus on specific data, thus providing safe nursing interventions for the Pt. | Focusing Verbal Communication |
| Therapeutic technique that assists the pt to “reflect” their inner feelings and thoughts. Pt’s ideas and thoughts are important and have worth. Empowers the pt to verbalize a solution (Position of control., Promotes self-estee). | Reflecting Verbal Communication |
| Nurse takes note of what they observed during interactions. Useful in validating the accuracy of observations. Helps when verbal message doesn’t match nonverbal message . Provides feedback to validate the intended message was the one received. | Stating Observations Verbal Communication |
| Aphasic | Non Responsive to communication |
| Much of the communicating that the nurse does is offer information. Pt feedback is essential in determining whether the information has been understood. | Offering Information Verbal Communication |
| Examples of Offering Information | Preoperative teaching. Diabetes education. Discharge instructions. |
| Review of the main points. Useful in pt teaching sessions. Sense of closure to the session. | Summarizing Verbal Communication |
| Where and how the nurse sits or stands conveys a message. Most therapeutic posture and position is for the nurse to assume the same position and level as the patient. | Posturing and Positioning Factors Affecting Communication |
| Comfort zone: necessary distance between two or more individuals that must be maintained to guard against personal threat or intimidation. | Space and Territoriality Factors Affecting Communication |
| 0 - 18 inches. Nursing interventions provided to the patient. Must be approached in a professional manner with gentleness and tact. | In imate zone Space and Territoriality |
| 18 inches to 4 feet. Less intimidating to patient. Sitting and talking to patient. | Personal zone Space and Territoriality |
| 4 - 12 feet. Speaking to a small group. | Social zone Space and Territoriality |
| 12 feet or more. Public speaking | Public zone Space and Territoriality |
| Surroundings can alter the effectiveness of the interaction. Provide a calm, relaxed atmosphere. Provide for patient privacy. | Environment Factors Affecting Communication |
| Trusting relationship. Without trust, interaction will not progress past the superficial social interaction. Trust built with confidence and competence. | Level of Trust Factors Affecting Communication |
| Obtain an interpreter. Have a translation dictionary available. Gestures, pictures and acting out may be helpful if the patient has some understanding of the language. | Language Barriers Factors Affecting Communication |
| Significant component of a patient's psychosocial well-being. Seek specific information regarding cultural practices and beliefs. | Culture Factors Affecting Communication |
| Influenced by cultural or societal beliefs and attitudes. Significant age difference may create a barrier to communication. Male and female patterns of communication related to cultural, familial, and lifestyle patterns. | Age and Gender Factors Affecting Communication |
| Can create a barrier for effective communication between the nurse and the patient. Should address prior to proceeding with any other interaction with the patient. | Pain: Physiologic Factors Affecting Communication |
| Hinder effective communication. Patient lacks the ability to receive, process, and send information, communication will not occur. Factors that may affect communication are: (CVA) stroke, sedatives, dementia, and developmental delays. | Altered Cognition: Physiologic Factors Affecting Communication |
| Get the patient's attention. Face the patient. Speak slowly and articulate clearly. Don't shout. | Impaired Hearing: Physiologic Factors Affecting Communication |
| Keep information simple, basic and concrete. Let patient direct the conversation. Be supportive through words and presence. | Stress: Physiologic Factors Affecting Communication |
| Silent presence. Listen and assist through therapeutic touch, warm and caring behaviors, and open-ended statements. | Grieving: Physiologic Factors Affecting Communication |
| Using falsely comforting phrases. May promise something that won't happen or is unrealistic | False Reassurance: Barrier to Communication |
| False Reassurance | Nurse may promise something that will not occur or is unrealistic. |
| Telling the patient what to do. Doesn't allow patient to make decision. | Giving Advice: Barrier to Communication |
| Takes decision making away from the patient; inhibits spontaneity; impairs decision making; creates doubt | Giving advice |
| Jump to conclusions. May be perceived as accusatory or argumentative. | False Assumptions: Barrier to Communication |
| False Assumptions | Can easily lead to the wrong conclusion; may be viewed as accusatory or argumentative. |
| Imposes nurse's own attitudes, values, beliefs and moral standards regarding right and wrong. | Value Judgments: Barrier to Communication |
| Value Judgments | Can lead the patient to doubt his or her own values; may create feelings of guilt and resentment; may cause friction between the pt and the nurse. |
| Stereotyped or superficial comments that don't focus on what patient is feeling or saying. Tends to belittle the individual's feelings and minimize the importance of the message. | Cliché: Barrier to Communication |
| Cliché | Tends to belittle the indicidual’s feeling and minimize the importance of the message; communicates the message that the nurse is not taking the patient’s concerns seriously. |
| Negative response to criticism. Implies that patient doesn't have right to opinion. | Defensiveness: Barrier to Communication |
| Defensiveness | Implies that the patient has no right to an opinion; patient’s concerns are often ignored or minimized because nurse is focusing on defense of self or others |
| May be perceived as accusatory. Patient may think the nurse knows the answer and is testing the patient. | Asking for explanations: Barrier to Communication |
| Asking for explanations | Frequently viewed by the pt as accusatory; pt may thing the nurse knows the answer and is testing the patient; can cause resentment, insecurity and mistrust. |
| Inappropriately focusing on something other than patient's concern. Rude and important information may not be shared. | Changing the subject: Barrier to Communication |
| Changing the subject | Rude and shows lack of empathy; blocks further communication and pt may not feel comfortable expressing feelings; thoughts are interupted and important information may not be shared. |
| “it will be okay” is what type of communication block? | example of False Reassurance |
| Assess patient's ability to use a particular alternative method of communication. i.e. Communication board, signal system, Lip reading. Sign Language. Paper and pencil/magic slate. Computer assisted communication. Clock face communicator. | Ventilator-Dependent: Special Circumstances of Communication |
| Communication board | Board to help a pt. with physical or psychological barriers to communication. Includes; Alphabet. Commonly used phrases. Pictures, or a combination of the three |
| Signal system | Eye blink (one for yes and two for no). Requires patience. |
| deficient or absent language function resulting from ischemic insult to the brain, such as stroke, brain trauma, or anoxia. | Aphasia: Special Circumstances of Communication |
| patient cannot send the desired message. | Expressive aphasia: Special Circumstances of Communication |
| patient cannot recognize or interpret the message being received. | Receptive aphasia: Special Circumstances of Communication |
| impairment of speech. | Dysphasia: Special Circumstances of Communication |
| dysfunction of the muscles used for speech. Speech is difficult, slow and hard to understand. | Dysarthria: Special Circumstances of Communication |
| Actions to communicate with an Aphasic Patient | Listen to the patient and wait for them to communicate. Do not shout or speak loudly (hearing loss is not the problem). Give patient time to understand, be calm and patient. Do not pressure or tire the patient. Avoid patronizing. |
| Assume the patient can understand what is heard. Ensure quiet and relaxed environment. Speak on adult level. Talk to the patient. | Actions to communicate with an Aphasic Patient |
| If the patient has problems receptive aphasia? | Use simple, short questions and facial gestures to give additional clues. Decrease environmental distractions when attempting to communicate. Speak slowly and divide tasks into small steps. |
| If the patient has expressive aphasia? | Ask questions that require simple one/two word or yes/no answers or blinking of the eyes. Use pantomime. Offer pictures or a communication board so the patient can point |
| Assessment | a systemic, dynamic process by which the nurse, collects and analyzes data about the client. |
| Data clustering | process of putting data together to identify areas of the patient's problems. |
| Diagnose | to identify the type and cause of a health condition |
| Etiology | study of all factors that may be involved in the development of a disease; cause of a disease. |
| Evaluation | a determination made about the extent to which the established outcomes have been achieved in a nursing care plan. |
| Goal | a broad statement that describe the intended or desired change in the patient's condition or behavior. |
| Implementation | the phase of the nursing process that included ongoing activities of data collection, prioritization, and performance of nursing intervention and documentation |
| Medical Diagnosis | identification of a disease or condition by a scientific evaluation. |
| NANDA | North American Nursing Diagnosis Association. |
| Nursing Diagnosis | a clinical judgement about individual, family, or community responses to actual or potential health problems/life processes. |
| Nursing Intervention | activities that promote the achievement of the desired patient outcome. |
| Nursing Process | organizational framework for the practice of nursing. Provides a systematic method by which nurses plan and provide care for patients. |
| Objective data | observable and measurable signs which can be recorded. |
| Planning | the phase where the nurse establishes priorities of care, selects and converts nursing interventions into nursing orders, and communicates the plan of care. This is the process of deciding what must be done for the patient. |
| Subjective data | verbal statements provided by the patient. |
| Assessment. Diagnosis. Planning. Implementation. Evaluation. | Components of the Nursing Process |
| Elements of the assessment phase of the nursing process? | Interview & Physical Examination |
| establish a database concerning a patient's physical, psychosocial, and emotional health in order to identify actual and/or potential health problems. | Purpose os an Assessment |
| Collected from patient interview and physical examination | Primary Sources of Data |
| family members, significant others, health care team, medical records, diagnostic procedures, and nursing literature. | Secondary Sources of Data |
| secondary data. | When a patient is admitted and is unable to provide data during assessment, information provided by the family is classified as? |
| provides baseline patient information. Physical examination of all body systems. Review of cognitive, psychosocial, emotional, cultural and spiritual components. Appropriate for stable patients. | Comprehensive (Complete) Assessment |
| concentration of attention on the part of the body where signs and symptoms are localized or most active in order to determine their significance. Appropriate for critically ill, disoriented, or unable to respond patients. | Focused Assessment |
| systematic follow-up is required when problems are identified during a comprehensive or focused assessment. | Ongoing Assessment |
| The two primary methods used to collect data are? | interview and physical examination. |
| The LPN/LVN assist the RN with the Nursing Diagnosis by? | observing and collecting data. |
| A clinical judgment by the physician that identifies or determines a specific disease, condition, or pathological state. | Medical Diagnosis |
| Diagnoses that a patient receives | both a medical and a nursing diagnosis |
| Identifies conditions the physician is licensed and qualified to treat vs. Identifies situations the nurse is licensed and qualified to treat | Medical vs. Nursing Assessments |
| Medical vs. Nursing Assessments | Focus on the illness, injury or disease process vs. Focus on patient’s response to actual or potential health problems or life processes |
| Changes as the client’s response and/or the health problems changes Vs. Remains constant until a cure is effected | Nursing Vs. Medical Assessment |
| Nursing Vs. Medical Assessment Examples | Example: Disturbed body image Vs. Example: Amputation |
| Nursing diagnosis title/label | Cluster subjective and objective cues. Analyze cues. Select label from NANDA approved list. |
| Nursing diagnosis Contributing/etiologic/related factors | Causes/potential causes of problem. Signs and symptoms. Are written as the "related to". |
| Nursing diagnosis Defining characteristics | Evidence of diagnosis. Manifestation of diagnosis. Are written as the "manifested by“ or “as evidenced by”. |
| Construction of a Nursing Diagnosis | Nursing Diagnosis = Problem + Etiology (Cause) + Signs/Symptoms |
| a condition that is currently present. | Actual: Nursing Diagnosis |
| more vulnerable to develop the problem than others in the same or similar situation. | Risk: Nursing Diagnosis |
| when a problem is considered feasible. | Possible: Nursing Diagnosis |
| when a cluster of actual or risk nursing diagnoses are predicted. | Syndrome: Nursing Diagnosis |
| in transition from a specific level of wellness to a higher level of wellness. | Wellness: Nursing Diagnosis |
| Constipation related to decreased fluid intake manifested by abdominal distention, no bowel movement for 5 days, and straining at stool. | Example of ACTUAL Nursing Diagnosis |
| Example of ACTUAL Nursing Diagnosis | Impaired skin integrity related to prolonged pressure on bony prominence as evidence by Stage II pressure ulcer over coccyx, 3 cm in diameter. |
| Risk for impaired skin integrity related to prolonged immobility. | Example of RISK Nursing Diagnosis |
| Example of RISK Nursing Diagnosis | Risk for impaired skin integrity related to physical immobility as evidence by inability to turn self from side to side in bed. |
| Example of POSSIBLE Nursing Diagnosis | Possible constipation related to the effects of anesthesia on gastrointestinal smooth muscle. |
| Example of SYNDROME Nursing Diagnosis | Rape-trauma syndrome |
| Problem + Etiology + Signs and Symptoms = Nursing Diagnosis. | Question: What is the "equation" for writing a nursing diagnosis? |
| Example of WELLNESS Nursing Diagnosis | Readiness for enhanced nutrition. |
| Readiness for enhanced family coping. | Example of SYNDROME Nursing Diagnosis |
| Three Phasses of Planning the Nursing Process | Initial, Ongoing, and Discharge Planning |
| Nursing Process Initial planning | a preliminary plan of care by the nurse who performs the admission assessment. |
| Nursing Process Ongoing planning | continuous updating of the patient's plan of care. |
| Nursing Process Discharge planning | anticipation for the discharge needs |
| Nursing Process planning priorities of care | Making decision about which diagnoses are the most important and therefore require attention first. |
| Most common method to selecting priorities is to consider Maslow's hierarchy of needs. | Nursing Process planning priorities of care |
| Nursing Process planning Outcome statement | describes measurable, observable behavior that the patient should demonstrate after nursing interventions |
| Nursing Process planning Focus | Hone in on what the patient should do |
| Nursing Process planning Patient Inclusiveness | should be involved in the development of his/her plan of care. |
| Nursing Process planning Short term | achievable within 7 - 10 days or before discharge |
| Nursing Process planning Long term | may take many weeks or months to achieve. |
| Nursing Process planning Characteristics of patient-centered goal/desired outcome | Patient is the subject of statement. Measurable verb. Patient/patient problem specific. Realistic for patient/patient problem. Includes time frame for completion/reevaluation. |
| Example: Nursing Diagnosis Vs. Goal/Outcome | Impaired skin integrity r/t prolonged immobility m/b 2 inch diameter ulcer on coccyx. vs. Patient will have intact skin within 3 weeks. |
| The establishment of priorities of care during the planning phase of the nursing process often uses the framework of? | Maslow’s hierarchy of needs |
| an action performed by the nurse that helps the patient achieve the results specified by the goals and expected outcomes. Individualized and stated in specific terms. | Nursing intervention |
| nursing actions that are initiated by the nurse and do not require privileged provider's orders to be implemented, the nurse can implement them. | Independent Nursing Intervention |
| actions that are implemented in a collaborative by the nurse in conjunction with other health care professionals. | Independent Nursing Intervention |
| actions that require an order from the physician | Dependent Nursing Intervention |
| When a nurse is selecting interventions to assist the patient to meet the needs demonstrated? the nurse is in the nursing process phase of? | The nurse is in the nursing process phase of planning |
| Converts nursing interventions into more specific instructional statements. | Nursing Orders |
| Nursing Orders must contain? | Date. Signature. Subject. Action verb. Qualifying details. |
| Nursing orders, as opposed to physician’s orders, prescribe activities which? | may be done independently by the nurse. |
| The primary purpose of nursing orders is to? | provide direction for all caregivers |
| NAMBLA | North American Man Boy Lover Association |
| What is the focus of a nursing diagnosis? | Focus on client’s response to actual or potential health problems or life processes. |
| Nursing Process Implementation Phases | Ongoing activities of data collection. Prioritization. Performance of nursing interventions. Documentation. |
| Nursing Process Documenttion | vital component of the implementation phase |
| A legal record of what occurred while the patient was hospitalized. | Nursing Process Documenttion |
| A determination made about the extent to which the established outcomes have been achieved. | Nursing Process Evaluation |
| Nursing Process Evaluation Steps | 1) Reviews established outcomes. 2) Reassesses the patient. 3)Compares the actual outcome with the desired outcome. |
| Nursing Process Evaluation Revising | Inactivate resolved problems. Add new problems. Revise interventions. Evaluate progress toward outcomes. |
| Nursing Process Evaluation is a continuous process | look for better or more efficient interventions to help patient achieve expected outcomes. |
| Expected outcomes met. Problem resolved. Nursing diagnosis no longer appropriate. | Nursing Process Evaluation Resolving |
| The patient with a urinary tract infection is being assessed using a critical pathway. When a projected outcome is not met by a predetermined date, it is determined that a/an? | variance exists. |
| Why is it important to communicate the nursing plan | Because the nursing staff is constantly changing, written guidelines are needed to promote continuity of patient care. |
| Communicating Plan of Care increses patient trust by? | Creating continuity which increases patient trust in the nursing staff and promotes outcome achievement |
| The role of the LPN/LVN in the nursing process may vary from state to state and with different institutions. | Role of the Licensed Practical Nurse in the Nursing Process |
| Role of the Licensed Practical Nurse in the Nursing Process | LPN/LVN is often responsible for providing direct bedside nursing care. |
| When is a problem considered resolved? | When the expected outcomes have been met. |
| Client education includes | Maintenance and promotion of health and illness prevention, Restoration of health, Coping with impaired functioning |
| Teaching | An interactive process that promotes learning |
| Learning | The purposeful acquisition of knowledge, skills, behaviors, and attitudes |
| When teaching a young child, it is appropriate to? | use play equipment in the teaching process. |
| Role of the Nurse in Teaching and Learning | Teach information the client and family needs to make informed decisions regarding their care. Determine what clients need to know. Identify when clients are ready to learn. |
| learning objective | describes what the learner will be able to accomplish after instruction is given. |
| Domains of Learning: Cognitive | Includes all intellectual behaviors and requires thinking |
| Domains of Learning: Affective | Deals with expression of feelings and acceptance of attitudes, opinions, or values |
| Domains of Learning: Psychomotor | Involves acquiring skills that require integration of mental and muscular activity |
| Basic Learning Principles: Motivation to learn | Addresses the client’s desire or willingness to learn |
| Basic Learning Principles: Ability to learn | Depends on physical and cognitive abilities, developmental level, physical wellness, thought processes |
| Basic Learning Principles: Learning environment | Allows a person to attend to instruction |
| An appropriate teaching plan requires? | collaboration with other health care professionals? |
| Nursing Vs. Teaching Process | The nursing process requires assessment of all data. Vs. The teaching process focuses on the client’s learning needs and ability to learn. |
| Purpose of Client Education | To help indtividuals, families, or communities achieve optimal levels of health |
| Most common Nursing Diagnosis when evaluating for a patient teaching plan | Knowledge Deficit |
| Who requires patient teaching? | the Joint Commission |
| Return demonstration for skills taught. | Patient shows you they can perform the skill taught. |
| Have client repeat teaching in own words. | Patient should paraphrase the lesson to demonstrate cognition and understanding. |
| Common Hazards in the Healthcare Environment | Falls, Burns, Smoking, Fire, Poisoning, Biohazards, Choking, Electrocution |
| Incase of fire (RACE) | Rescue, Alarm, Contain, Extinguish/Evacuate |
| What is the most common cause of injury to elderly patients in the health care setting? | Falling during transfers |
| Risks for Falls | Age, Recent history of falls, Mental status, Visual acuity, Physical strength, Bowel/bladder urgency |
| Nursing Diagnoses: Fall Risk | Risk for falls r/t, Impaired transfer ability r/t, Impaired walking r/t, Impaired physical mobility r/t, Risk for injury r/t |
| The nurse manager clarifies that “safe hospital environment” implies that in the hospital setting people shall be free from? | any injury. |
| What are some indications that a patient may be a risk for falls? | Difficulty getting out of bed/chair, use of walking aide, weak gait |
| Safety Precautions | Assess for fall risk, Orient patient to environment, Bedside table within reach, Call bell within reach, Assist with ambulation |
| Patients at higher risk for falls | Elderly, Patients who are weak/ have an unsteady gait, Disoriented patients. Patients who receive medications that may affect their ability to ambulate |
| Keep environment clutter/litter free, Side rails up x2, Bed in lowest & locked position, Slippers/shoes with skid resistant soles Clean up spills promptly, Adequate light, including night, Use handrails, Non-skid tape in tubs/showers; shower chairs | Safety Precautions |
| In order to decrease risk for falls, the nurse holds frequent in-services to assure the staff has competent skills for? | transferring. |
| Nursing Intervention Classification (NIC) | Linked with NANDA nursing diagnoses. Each has a unique # to facilitate computerization. Standardize commo across healthcare facilities. Encourage enhanced commo between nurses about nursing interventions. Provides measures to improve patient care |
| Environmental Management: Safety | Nursing precautions implemented to prevent falls |
| What types of medication may increase a patient’s risk for falls? | narcotics, sedatives, anti-hypertensives |
| Educate about risks of Falls, Burns, Tripping, Smoking/fire | Patient Teaching - Elderly |
| Educate about risks of Medication effects | Patient Teaching - Adults and older children |
| Educate about risks of Poisoning, Choking, Electrical shock, Burns, Fire, Drowning, Falls | Patient Teaching - Young Children |
| Drowning is the leading cause of unintentional injury-related death among? | children ages 1-4 |
| How much water does it take to drown? | Any amount of water that covers the mouth & nose. |
| Safety Reminder Devices (SRD) | any of the numerous devices used to immobilize a patient or part of the patient’s body, such as arms or hands |
| Indications for an SRD | Safeguard the continuity of treatment |
| Use of SRD's on an elderly patient | Prevents them from wandering, Reduces risk of falling , Restricts the aggressive patient’s movements |
| Legal Implications of Restraints | Restraining devices used only as necessary and as a last resort to protect the patient or others, Applied by licensed, qualified personnel, Follow local policy |
| Physical & mental abuse prohibited, Cannot be used as a punishment, Must have written order by physician | Legal Implications of Restraints |
| Who can apply protective devices? | Licensed, qualified personnel only. |
| Restraint-Free Environment | Orient patient, Encourage visitors to stay with patient, Confused pts near nurses’ station, Visual & auditory stimuli, Remove bothersome treatments as soon as possible |
| Relaxation techniques, Ambulation & exercise, Maintain toileting routines, Consult PT/OT, Evaluate side effects of medications, Assess response to care | Restraint-Free Environment |
| What is the best method to use to maintain a restraint-free environment? | Family members can stay with the patient and act as “sitters.” |
| Place gauze padding around extremity, Tie ends to bed frame, Palpate pulses below device to ensure circulation is not occluded. | Application of Protective Devices - Wrist and Ankle (extremity) |
| Place device over elbow, Check pulse below extremity | Application of Protective Devices - Elbow |
| Apply device over patient gown, Tie strap to frame of the bed or behind wheelchair, Vest is secure with room for a fist to fit between the vest and the patient. | Application of Protective Devices - Vest |
| Prior to applying a safety reminder device (SRD), the nurse must? | get a physician’s order. |
| General Safety Measures | Monitor skin integrity, Check circulation frequently, Allow periods of release, Monitor respiratory status |
| Prevent from wrapping device around neck, Change position , Change soiled or wet devices, Adjust as needed, Use quick release knots | General Safety Measures |
| What type of knot is used to secure protective devices? | Quick release knot |
| Fall Risk- Medications | Cause decreased mental acuity, Cause orthostatic hypotension, Cause diarrhea/polyuria, Alter blood glucose |
| Fall Risk- Gait/Balance | Difficulty getting out of bed/chair, Use of walking aids, Weaker than usual gait, Vertigo |
| An Ounce of Prevention is worth | A pound of cure |
| Safety and dignity check | Has to be done every 15-20 minutes when patient is in restraints. |
| Release from restraints and asses ROM. | Has to be done every 2 hours when patient is in restraints. |
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