Restraints
A drug or medication when it is used as a restriction to manage a patient's behavior or restrict the patient's freedom of movement.
chemical restraint
Who can identify patient and blood prior to transfusion?
Two licensed nurses.
What are the weight bearing classifications of orthopedic patients?
WBAT, NWB, PWB, TTWB/TDWB
How do you measure for an NG tube?
measuring from the tip of the nose to the earlobe, down to the xiphoid process, and then midway to the umbilicus.
What is the diet ordered for a patient on suicide precautions?
Suicide Precautions or finger foods only
how often should patients with violent or self- destructive behavior in restraints be assessed and monitored?
15 minutes
Who can initiate blood?
RN
The patient is to use this on the "strong" side or uninvolved side to help shift weight away from the affected side.
What is a cane
How do you measure using a Broselow Tape?
from the head to the heel
Who is screened for risk of suicide and/or self-injury?
All patients
What are restraint/seclusion reduction interventions?
Pain management, exercise, prayer
What IV fluid is used to prime the blood administration set?
NSS
This is placed around the patient’s waist, with the buckle facing front. Adjust it to fit snugly around the patient’s waist.
What is a Gait Belt?
What is the glucometer.
How do you clean it/disinfect?
The patient on suicide precautions must wear
Hospital attire
What is the duration of a non-violent or non-self destructive restraint order?
One calendar day
How long does the nurse stay at the bedside to observe for reaction at the beginning of a blood transfusion?
15 minutes
How often do we do postop vital signs?
Perform these every 15 minutes x 4, then every 30 minutes x2, every hour x4,
How do you use an Incentive Spirometer?
Instruct the patient to exhale normally, insert the mouthpiece, close the lips tightly around the mouthpiece, and inhale slow and deep (like sucking through a straw). If possible, have the patient hold inhalation for 5 seconds.
The maximum distance the patient should be away from the nursing staff member
3 feet
Name the components of the patient assessment that will occur while a patient is in restraints?
Skin integrity, Respiratory and circulatory status, vital signs, nutrition and hydration needs, range of motion, hygiene and elimination, signs of injury related to the use of the restraint, readiness for less restrictive alternative, temporary removal, or discontinuation.
What is the maximum amount of time blood can hang/infuse?
4 hours
When is rehabilitation started on THR, TKR?
Started on the day of surgery for THR, TKR.
What is the strap free device which locks the Foley catheter in place, stabilizes the catheter and eliminates any chance of a sudden pull?
statlock
When do environmental safety checks have to be completed?
Upon arrival to the unit and at every hand off communication.