Exam 2 Foundation

What should the nurse assess before transferring or moving a patient?

Patient’s strength,

mobility,

balance,

ability to follow directions,

weight-bearing ability, and

how much assistance they can provide.

What equipment can be used for safe patient handling/transfers?

Gait belts,

stand-assist/repositioning aids,

friction-reducing sheets,

lateral-assist devices,

transfer chairs, and

powered/full-body lifts.

The patient’s ability to help determines which device is appropriate.

Why are friction-reducing devices used?

To make repositioning/transfers easier and decrease friction, shearing, and injury to the patient and nurse.

What is the purpose of a gait belt?

Provides a secure grip to support a patient during transfers or ambulation and helps prevent falls.

How should a cane be used?

Hold it on the unaffected/strong side. If the right leg is weak, hold the cane in the left hand. Stand upright and do not lean over the cane.

What is the proper height for a cane?

With the cane about 4 inches from the foot, the handle should reach the crease on the inside of the wrist.

What should you know about crutch fit and use?

Crutches should be about 2 finger widths below the armpit, elbows slightly bent, and body weight should be supported through the arms/hands—not the armpits.

What are the key principles of safe body mechanics?

Maintain proper alignment/posture, have a stable base of support, keep the load close to the body, use the legs when lifting, avoid twisting, and use assistive devices when needed.

What increases a nurse’s risk for back/musculoskeletal injury?

Manual lifting/transfers without assistive devices, uncoordinated lifts, repetitive lifting/repositioning, fatigue, prolonged standing, and moving confused/uncooperative patients.

What is Fowler’s/High Fowler’s position used for?

Upright position that improves cardiac and respiratory function and is optimal for eating.

What is Semi-Fowler’s position?

Head of bed moderately elevated; promotes breathing while providing more rest than High Fowler’s.

What is supine/dorsal recumbent position?

Lying on the back; commonly used for general examination.

What is prone position?

Lying on the abdomen; can promote postural drainage.

What is a lateral/side-lying position?

Lying on the side; helps relieve pressure from the back and can aid positioning/drainage.

What is left lateral recumbent position?

Patient lies on the left side, often used when side-lying positioning is needed.

What is Trendelenburg position?

Head lower than the feet; may increase venous return in hypotensive patients. Use only when appropriate/not contraindicated.

What are the major complications of immobility?

Cardiovascular →
Respiratory →
Musculoskeletal →
GI →
Urinary →
Skin →
Psychosocial →

Cardiovascular → ↓ cardiac output/blood flow
Respiratory → ↓ lung capacity, ↑ respiratory infection risk
Musculoskeletal → muscle atrophy + bone loss
GI → ↓ motility/digestion
Urinary → retention + ↑ UTI risk
Skin → pressure injuries
Psychosocial → depression, anxiety, isolation

What nursing interventions help prevent complications of immobility?

Reposition regularly,

encourage progressive mobility/exercise,

ROM exercises,

protect skin,

encourage fluids/nutrition as appropriate, and

use safe transfer/assistive devices.

Why is progressive mobility important?

Gradually increases activity and prevents complications of prolonged immobility without overexerting the patient.

Why is mobility especially important for older adults and post-stroke patients?

They are at increased risk for weakness, falls, loss of independence, and complications from immobility; activity should increase gradually and safely.

What are the major benefits of regular exercise?

Improves strength, flexibility, coordination, circulation, breathing, GI motility, bone health, sleep, energy, and overall well-being.

What is the main nursing goal related to safety?

Keep the patient safe and prevent injury in the hospital, home, and community. Nurses assess risks, intervene, educate, and reevaluate.

What should nurses assess for fall risk?

Previous falls,

unsteadiness,

fear of falling,

mobility/balance,

medications,

assistive devices,

environment, and

support system.

What are basic fall-prevention interventions?

Remove hazards, keep needed items within reach, provide appropriate assistive devices, ensure safe footwear, assist with ambulation, and modify the environment according to the patient’s risk.

Why are older adults at increased risk for falls?

Changes in balance, vision, hearing, heat/cold perception, medications/polypharmacy, and other age-related changes.

What safety teaching is important for a patient with diabetic neuropathy?

Protect areas with decreased sensation,

inspect feet/skin regularly,

use proper footwear,

remove fall hazards, and

avoid injuries from heat or sharp objects.

What poisoning prevention is important for toddlers/preschoolers?

Lock medications and cleaning products away/out of reach; childproof the environment.

What other major safety risks exist for toddlers/preschoolers?

Choking/foreign bodies, burns, poisoning, asphyxiation, and abuse.

What basic firearm safety teaching should patients receive?

Store firearms securely and prevent unauthorized access, especially by children.

What is especially important when providing prenatal safety teaching?

Identify environmental/behavioral hazards and teach ways to protect both the pregnant patient and developing fetus.

When should restraints be used?

Last resort when necessary to protect the patient or others after less restrictive alternatives have failed.

What should be tried before restraints?

Identify/correct the cause of behavior and try alternatives such as education, a 1:1 sitter, or bed/chair alarms.

What type of restraint should be used if restraints are necessary?

The least restrictive restraint that maintains safety.

What order is required for restraints?

Provider order; in an emergency, restraints may be applied first but an order must be obtained ASAP. Orders are renewed every 24 hours and are never PRN.

What 7 must be documented when restraints are applied?

Date/time, type, reason, alternatives attempted and outcomes, provider/family notification, patient response, and ongoing assessments.

What should be assessed frequently for a restrained patient?

Safety, skin/circulation, ROM, toileting, food/fluid needs, and response to the restraint. The slides emphasize frequent assessment, including approximately hourly assessment.

When is a safety event/incident report completed?

Immediately after an accident/event that compromises patient safety.

What 3 goes in an incident report?

Objective circumstances of what happened, patient assessment/response, and treatment/actions taken.

Is an incident report part of the medical record?

NO. It is not part of the patient chart and should not be mentioned in the medical record.

What does RACE mean during a fire?

R = Rescue anyone in immediate danger
A = Activate alarm/fire code
C = Confine fire by closing doors/windows
E = Evacuate to a safe area

What does PASS mean for a fire extinguisher?

P = Pull pin
A = Aim at base of fire
S = Squeeze lever
S = Sweep side to side

What is the nurse’s responsibility when child abuse is suspected?

Healthcare professionals are mandated reporters—report suspected abuse to the appropriate authority.

What should the nurse do if elder abuse or neglect is suspected?

Assess, objectively document findings, and report suspected abuse/neglect according to policy/law.

What home-safety teaching is especially important for older adults?

Remove fall hazards, ensure adequate lighting, maintain working smoke detectors, manage medications safely, use needed glasses/hearing aids/assistive devices, and modify the environment as needed.

What are the characteristics of effective nursing documentation?

Complete, accurate, concise, factual, organized, timely, legally prudent, confidential, and consistent with professional/agency standards.

What should NEVER be charted?

: Opinions, assumptions, blame, vague information, or anything you did not actually observe/do.

What does SOAP stand for?

S = Subjective
O = Objective
A = Assessment
P = Plan

What does PIE stand for?

P = Problem
I = Intervention
E = Evaluation

What is special about PIE charting?

It incorporates the care plan into the progress notes rather than using a separate care plan.

What is narrative documentation?

Chronological written description of patient condition, nursing care, and response.

What is charting by exception?

Only abnormal or significant findings/exceptions from established standards are documented.

What are flow sheets/graphic records used for?

Quickly record frequently assessed information such as vital signs, intake/output, assessments, or other repeated data.

What patient information is confidential?

All patient information—written, spoken, or electronic—including identity/contact information, diagnosis/health problems, treatments, and past health information.

What are examples of confidentiality breaches?

Leaving a computer logged in, discussing patients where others can hear, displaying information publicly, throwing patient information in regular trash, sending information through unsecured systems, or sharing with unauthorized people.

If a nurse walks away from a computer without logging off, is that a confidentiality breach?

Yes.

Can patients change/rewrite information already documented in their medical record?

No. They may obtain/review the record and request updates, but cannot simply revise existing documentation.

What does ISBARR stand for?

I = Identity/Introduction
S = Situation
B = Background
A = Assessment
R = Recommendation
R = Read back/response

Why is ISBARR used?

Provides a structured, concise way to communicate important patient information during handoffs or when reporting changes to another healthcare provider.

What 7 information belongs in a change-of-shift report?

Patient identification, diagnosis/providers, current health status, current/new orders, abnormal events during shift, unfinished orders/tasks, patient/family concerns, and transfers/discharges.

1. Patient identification	Who is the patient? Name, room number, age.
2. Diagnosis/providers	Why is the patient in the hospital? Who is their doctor?
3. Current health status	How is the patient doing right now? Stable? In pain?
4. Current/new orders	Did the doctor order new medications, tests, or treatments?
5. Abnormal events	Did anything unusual happen during your shift? For example, the patient fell or developed a fever.
6. Unfinished tasks	What still needs to be done? For example, medication or blood work.
7. Patient/family concerns and transfers/discharges

Where is medication administration documented?

MAR (Medication Administration Record).

Where are vital signs commonly documented?

Vital-sign/graphic flow sheet or the appropriate electronic assessment flowsheet.

Where should the patient’s response to an intervention be documented?

Progress/nursing notes or appropriate flowsheet as part of the evaluation of care.

What information should be recorded during a phone/provider report?

Date/time, what was communicated, current patient findings, and the provider’s response/orders.

What should a nurse do when receiving a verbal order?

Record the order, label it as verbal order, read it back to verify accuracy, document date/time and provider name, and follow agency policy. Verbal orders should generally be limited to urgent situations.

What is a Stage 1 pressure injury?

Intact skin with nonblanchable redness/erythema.

What is a Stage 2 pressure injury?

Partial-thickness skin loss with exposed dermis.

What is a Stage 3 pressure injury?

Full-thickness skin loss without involvement/exposure of underlying fascia.

What is a Stage 4 pressure injury?

Full-thickness skin and tissue loss with deeper structures involved/exposed.

What is an unstageable pressure injury?

Full-thickness skin/tissue loss where the true depth cannot be determined because it is obscured.

What is a deep tissue pressure injury?

Persistent nonblanchable deep red, maroon, or purple discoloration.

What is friction?

Rubbing of skin against another surface, causing superficial skin damage.

What is shearing?

Skin remains in place while deeper tissues move, damaging blood vessels/tissue; can happen when a patient slides down in bed.

What factors increase pressure injury risk?

Immobility, aging/thin skin, poor nutrition, moisture/incontinence, chronic illness, altered consciousness, neurologic injury, and inability to relieve pressure.

Why does moisture increase skin breakdown?

Prolonged moisture softens/macerates the skin, making it easier to damage.

What is serous drainage?

Clear/watery drainage.

What is sanguineous drainage?

bright red bloody drainage

What is serosanguineous drainage?

Thin, watery pink/red mixture of serum and blood.

What is purulent drainage?

Thick drainage/pus associated with infection.

What should be assessed/documented about a wound?

Appearance, location/size, depth, wound edges, undermining/tunneling/sinus tract, surrounding skin, drainage type/amount, and signs of infection.

What factors can delay wound healing?

Poor circulation/oxygenation, poor nutrition, older age, chronic illness, immunosuppression, corticosteroids/steroids, radiation therapy, and poor adherence to treatment.

What nutrition helps promote wound healing?

Adequate fluids and nutrition, especially protein and vitamin C.

What is dehiscence?

Partial or complete separation of wound layers because the wound has not healed sufficiently.

What is evisceration?

Wound completely separates and internal abdominal organs protrude through the incision

Is evisceration an emergency?

YES — medical emergency.

What should the nurse do for evisceration?

Stay with patient → cover organs/wound with sterile gauze moistened with sterile 0.9% normal saline → notify provider → keep patient NPO for possible surgery.

What is a Penrose drain?

Open drainage system that allows fluid to drain onto/into a dressing.

What are Jackson-Pratt (JP) and Hemovac drains?

Closed drainage systems that use suction to collect wound drainage

What should the nurse monitor with wound drains?

Drainage amount/type/color, insertion site, patency/function of drain, and signs of infection.

What technique is used for ordered sterile wound care?

Sterile technique with hand hygiene and prevention of contamination.

How should a wound generally be cleaned?

Use new gauze with each wipe and clean from top to bottom and/or center outward, using 0.9% normal saline as directed.

What signs suggest wound infection?

Increased redness/erythema, warmth, pain, abnormal/purulent drainage, odor, swelling, or fever.

What are the major purposes of a wound dressing?

Control/prevent infection, absorb drainage, maintain moisture balance, protect wound and surrounding skin, prevent further injury, and promote healing.

What should patients be taught for home wound care?

Proper hand hygiene, dressing/wound-care technique, keeping wound protected, nutrition/hydration, preventing pressure, and reporting infection signs such as increased redness, pain, drainage, odor, or fever.

What intervention helps prevent pressure injury and promote healing in an immobile patient?

Reposition about every 2 hours as appropriate, relieve pressure over bony prominences, and support nutrition/hydration.