Patient Safety
What is the difference between direct and indirect care?
Direct care is face-to-face while indirect does not involve any patient interaction
What are some things we should educate our fall risk patients when there going home?
Cords/wires, pets, lighting, rugs, uneven floors, fire alarms, appliances, door locks
What is the correct way of donning and doffing?
gown, mask, shield/eyewear, gloves- donning
gloves, shield/eyewear, gown, mask-doffing
What is the difference between isometric and isotonic movements? Give examples for each
In isometric, the muscle contracts/tightens without any movement. Like pressing on the mattress with your thigh for ten seconds and then completely relaxing without joint movement.
While isotonic is when the tone or tension within a muscle remains the same as the length of a muscle changes. Muscle contracts with movement. Like palm strecth, dorsiflexion, and plantarflexion.
What are the rights of medication?
Right patient
right medication
right drug
right route
right time
right documentation
right indication
How do we write a diagnostic statement?
1. A diagnostic label.
2. Related factors
3. Major defining characteristics
What are some examples of fall risk in the healthcare setting?
Patient slips or trips over IV tubing or slips on water, medications, footwear (slippers), bed not in a low position
What is the correct PPE for airborne?
N95, negative pressure room, gown, mask, eyewear and gloves.
What patients would be at risk for harm when doing exercises?
Cardiac patients- may cause strain on the heart
COPD-may increase exertion/bronchospasm
Parkinsons disease- may cause tremors/fall risk
How do we administer eye drops?
Clean eyelids from inner to outer canthus, pull eyelid down to create the conjunctiva sac, avoid touching the tip, and apply gentle nasolacrimal occlusion for 30-60 seconds. Wait 5 minutes between drops, ointments are always last
SMART GOALS
S-specific
m-measurable
a-attainable
r-realistic
t-timed
If a patient is on restraints, how often must we reassess the use of restraints?
Every 24 hours.
what are HAIs? How do we prevent them?
Healthcare-acquired infections
By meticulous hand hygiene practices, the use of chlorexidine washes for bathing and personal hygiene care, advanced in the ICU infection prevention, and the creation of evidence-based bundles help prevent these infections.
How do we give oral care for a patient who is unconscious?
Have two nurses provide the care, turn the patients head foward and place bed in the semi-fowler position. One nurse does the actual cleaning and the other nurse removes secretion with suction. Use a oral airway or a padded tongue blade to hold the mouth open.
What are the gauge sizes for intradermal, intramuscular, subcutaneous?
For intradermal: 25-27g 3/8-5/8
For subcutaneous 25-31g 3/8-5/8
For intramuscular: 21-25g 1-1.5
What are interdependent interventions?
Interventions in nursing that involve collaborative actions between nurses and other healthcare professionals that provide care.
How often do we check on patients with restraints, and how often do we release them?
We check on them every 15 minutes, and we release them every two hours.
If i see that the tapes on sterile items have not changed color, what does this indicate?
That the item is not sterile
What do we consider before bathing patients?
Their culture, physical condition and mobility, skin condition and breakdown, cognitive status and ability to perform self-care. medica devices and equipment
Which insulin do we roll?
For inhalers do we shake MDI or DPI?
We roll the NPH insulin (cloudy)
We shake the MDI
How do you measure evaluation?
examine the results
compare outcomes
interpret findings
revise plan
document findings
How do we assess if someone is at high risk for falls?
Fall history, medication review, mobility assessment, LOC, assess a patients gait and posture
Only sterile objects can touch sterile
Objects remain above waist level
Never turn your back on sterile field
Outer 1inch/2.5 cm of any sterile field is contaminated
Avoid moisture on field
If you doubt its sterility
What are some complications that arise from immobility?
Orthostatic hypotension, pressure ulcers, constipation, urinary incontinence, pneumonia, increased blood clots.
What are the three MAR checks?
first check: reading the label when obtaining the medication order and physicians order. before getting the meds
second check: before opening or preparing the medication, compare the label with the MAR
third check: Before administering the medication to the pt at bedside, ensure the correct drug is given