Nursing Process
This type of data is obtained from your patient and are verbal descriptions of their health problems. Including feelings, perceptions, and self reports.
Subjective Data
Any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.
Restraints
What are some alternatives to restraints?
What are the legal implications when using restraints?
What risk factors predispose a patient to a pressure injury?
Immobility, impaired sensory perceptions, moisture, alteration in level of consciousness, shear, and friction
This occurs when 2 medications combined have a greater effect than when given separately.
Synergistic Effect
How can the nurse prevent atelectasis postop?
Instruction of incentive spirometry, coughing and deep breathing, Q2 turns, and early ambulation.
Observations and measurements of a patient's health status. Example would be vital signs.
Objective Data
How can a nurse prevent falls in the hospital setting?
Call light within reach, proper patient footwear when ambulating, remove clutter, use of gait belt, use of appropriate assistive device such as a walker, proper fall risk assessment, bed/ chair alarm, fall risk noted to staff, wrist band, close to the nurses station,etc
Stage 3/ Full-Thickness Skin Loss
What are the 6 rights to a med pass?
Right patient
Right dose
Right route
Right time
Right medication
Right documentation
Hypoxia
Third step in the nursing process and involves collaborating with the patient, their family, and the health care team.
Planning
This is a protective vascular reaction that delivers fluid, blood products, and nutrients to an area of injury.
Inflammation
Healthy tissues that is red, moist and composed of new blood vessels, the presence of which indicates progression toward wound healing.
Granulation Tissue
Some medications are readily absorbed after being placed under the tongue to dissolve. This is an example of what type of administration?
Sublingual
Nursing Considerations: Instruct patient not to swallow medication or drink anything until the medication is completely dissolved.
Process of moving gases into and out of the lungs.
Ventillation
This is a preprinted document containing orders for routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identical clinical problems. ( Implementation phase)
Standing order
The most effective basic technique in preventing and controlling the transmission of infection is what?
Hand hygiene
This is when protrusion of visceral organs occurs through a wound opening
Evisceration
Nursing considerations: sterile gauzed soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues. Alerts surgery immediately and make patient NPO
The trough
Example: Vancomycin
The easiest intervention to maintain or improve join mobility for patients and one that can be coordinated with other activities is the use of what?
ROM exercise
What is the difference between passive and active ROM?
This part of the nursing process includes 2 steps: collection of information from a primary source and the interpretation and validation of data.
Assessment
This type of precaution is used for the colonization or infection with multi-drug resistant organisms such as VRE, MRSA, and C-Diff. Includes gloves, gowns, and private room or cohort of patients (depending on agency policy)
Contact Precautions
The most effective way to prevent a pressure injury
Q2 turns
The nurse is unclear about a medication order from the provider. What is the nurse's next step.
Call provider and clarify the order.
Drop of blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure and include symptoms of dizziness, light-headedness, nausea, tachycardia, pallor, or fainting.
Orthostatic hypotension
What would be the nursing interventions associated with this?