Exam1
Concept of Safety
Definition of Safety: An individual is considered safe if they are alert, oriented, and mobile.
Types of Falls
Accidental Falls:
Definition: Falls that occur due to trips or other preventable causes.
Anticipated Falls:
Definition: Falls resulting from underlying conditions that predispose the individual to fall.
Unanticipated Falls:
Definition: Falls that are unpredictable or occur suddenly due to unforeseen situations.
Reporting Types of Falls
Witnessed: Reported by the patient or an observer.
Found on Floor: Documenting injuries when a patient is found on the floor.
Medicare and Medicaid Billing
Accidental Falls: Covered under personal liability or lawyer claims.
Anticipated Falls: Paid by organizations based on liability.
Unanticipated Falls: Covered under personal insurance policies.
Preventable Falls: Organizational dues are applicable for these falls, as no reimbursement is available otherwise.
Fall Risk Screening
Key Questions:
Have you fallen in the last year? If so, how severe was the fall?
Do you feel unsteady when standing or walking?
Are you afraid of falling?
Additional Considerations:
If an individual has fallen more than twice in the past two years, it indicates a pattern.
Assess ability to regain standing if a fall occurs.
Explore prior loss of consciousness during falls.
Band Colors and Their Meanings in Healthcare
Yellow: Indicates fall risk.
Purple: Designates a Do Not Resuscitate (DNR) status.
Green: Signifies a latex allergy.
Red: Alerts to a general allergy, typically to certain drugs.
Pink: Indicates a restricted extremity (e.g., limb removals or dialysis).
Risks in Healthcare
Medication Errors: Common and critical errors include administering drugs incorrectly (wrong route, drug, frequency).
Procedure Related Risks: Include using the wrong tools or limbs for procedures.
Equipment Related Risks: Outdated or broken equipment pose safety hazards.
Chemical Exposure: Often occurs from cleaning products or hazardous materials.
The Joint Commission (TJC) Forms
Ambulatory Healthcare National Patient Safety Goals: Focus on identifying and prioritizing common patient safety issues.
Patients’ Rights: Know your care and its purpose.
Serious Reportable Events: Events in healthcare that are deemed preventable with nursing interventions.
Environmental Safety Issues
Environmental hazards include smoking in patient rooms, especially near oxygen supplies.
Home safety issues: improper use of cooking equipment, heaters, and electrical cords.
Prevention tools: functioning fire extinguishers and smoke detectors.
Fire Safety Procedures
Rescue, Alarm, Confine, Extinguish: Basic response strategies for fire emergencies.
Fire Extinguisher Use:
Pull the pin.
Aim at the base of the fire.
Squeeze the handle.
Sweep the nozzle side to side.
Restraints in Healthcare
Physical Restraints: Devices or methods to immobilize or restrict body movement. Requires physician orders within 24 hours.
Chemical Restraints: Medical sedatives used to manage behaviors, not allowed on a PRN basis.
Types of Restraints:
Bed restraints over two rails are categorized as restraints.
Alternatives: Personal protections, hiding lines, managing pain, engaging patients in activities.
Oxygen Needs in Healthcare
Patient education is essential before discharge:
No smoking near oxygen tanks; oxygen can accumulate in hair and clothing.
Suggest using carbon monoxide monitors and proper signage.
Encourage use of lubricants (water-based) and humidity management.
Seizure Risks
Emergency protocol during seizure:
Avoid calling for rapid response or code blue.
Monitor the start time of seizure, call for assistance, and position the patient safely on their side.
Clear the environment around the patient for safety.
Family Education During Seizures
Importance of not leaving the patient alone during a seizure.
Ensure patients wear medical identification.
Workplace Safety Issues
Workplace Violence: Includes verbal abuse escalating to physical assault.
Increased occurrence of physical assaults targeting healthcare workers.
Impact of Violence: Leads to frustration, anger, fear, stress, irritability, and compassion fatigue. May result in physical injuries and psychological trauma.
Risk factors: Family violence, overcrowding, wait times, workplace isolation, and inadequate security.
Recognizing Potential Violence Signs
Signs include mumbling, ignoring, and pacing; observe cognitive impairments or situational fears.
De-escalation Techniques in Healthcare
Approaches include non-judgmental attitudes, maintaining respect for feelings and personal space.
Vital Signs Concept
Perfusion - Key vital sign measurements exemplifying health.
Normal Vital Signs in Adults
Temperature Range: 96.8°F – 99°F
Oral/Tympanic: 98.6°F
Rectal: 99.5°F
Axillary: 97.7°F
Pulse: 60-100 BPM, must be strong and regular.
SpO2: Greater than or equal to 95% (may drop to 92% in children).
Respirations: 12-20 breaths/min, categorized as deep and regular.
Blood Pressure:
Systolic: Above 120
Diastolic: Below 80
Pulse Pressure (PP): 30-50 mm Hg.
Measuring Vital Signs
Understand and record each patient’s normal ranges, history, and prescriptions.
Consider OTC drugs which may influence vital signs.
Minimize environmental factors that could alter measurements.
Establish baseline vital signs before administering specific medications.
Importance of Vital Signs Monitoring
Record vital signs during admission, examinations, surgical procedures, transfusions, and following any changes in patient conditions.
Communicate findings to both the patient and their family to explain significance.
Temperature Regulation
The human body produces heat through mechanisms such as shivering and metabolism.
Factors influencing temperature: age, puberty, exercise, hormone levels, sleep cycles.
Peak temperature is typically at 4 PM and lows at 6 AM.
An elevated temperature is identified as above 100.4°F.
Rectal readings are deemed the most accurate as they reflect core body temperature.
Temperature Measurement Methods
Techniques include rectal, oral, ear, temporal, and axillary readings.
Always document the site of measurement due to differing outcomes.
Inconsistencies in Temperature Readings
If a reading seems incorrect, recheck at a different site, and assess patient symptoms (e.g., flushing, sweating).
Consider potential influences such as recent food or drink intake, smoking, or oral infections affecting accuracy.
Hyperthermia Management
Individuals post-surgery or with trauma may enter a hypermetabolic state causing elevated temperatures due to healing processes.
Key Interventions:
Administer fluids (oral preferred; IV if not possible).
Monitor lab results, particularly blood and wound cultures.
Regular monitoring: ideally every morning or 2-3 times daily, varying by condition.
Contact healthcare providers for non-normal temperature ranges for potential antibiotic treatment.
Avoid antibiotic treatments for viral infections as they can lead to further issues (e.g., yeast infections in women).
Use non-pharmaceutical interventions (e.g., cooling packs, sponge baths).
Maintain patient comfort through hygiene and bedding changes.
Heart Rate Monitoring
Awareness of normal pulse rates for age-group; athletes may possess lower rates.
Auscultation reveals the heartbeat, noting any irregularities (e.g., s3 or s4 sounds).
Doppler devices can aid in assessing weak pulses.
Conditions such as hemorrhage may initially elevate heart rate before causing compensatory drops.
Tachycardia Management
Focus on severely low blood/fluid volume scenarios stemming from hemorrhaging.
Approach:
Administer fluids (oral/IV) while avoiding caffeine/sugar.
Adjust care for high heart rates to mitigate overload on heart function.
Fluid restriction and diuretics may be necessary.
Responses to Emotional Causes of Tachycardia
Alleviate anxiety through breathing techniques and calming interventions.
Monitor and supply supplemental oxygen, starting with lower flow rates (approximately 2L, especially excluding COPD).
Monitor electrolytes and conduct EKG assessments as needed.
Bradycardia Care Strategies
Administer prescribed IV fluids and support oxygen therapy as necessary.
Continuous monitoring through EKG is essential.
Regularly check vital signs, focusing on pulse rates.
Assess electrolyte levels for trends, making changes as necessary.
Be ready to prepare the patient for potential pacemaker insertion if conditions do not stabilize.
Respiratory Evaluation
Maintain knowledge of acceptable respiratory rates for different age groups.
Assess effort during respiration; abnormalities in sounds should be evaluated.
Adults breathe primarily through the chest, while infants use abdominal movements.
Pay attention to effects of medications (e.g., opioids may depress breathing).
Dyspnea Management Steps
Essential Protocols:
Raise the head of the bed to reduce respiratory effort.
Monitor oxygen saturation and respirations frequently (every 30 min to an hour).
Reorient and support disoriented patients.
Change patient position to alleviate lung fluid accumulation every 2 hours.
Implement suctioning for secretion management.
Teach pursed-lip breathing techniques to patients for comfort.
Oxygen Saturation Monitoring
Definition: Measures the amount of oxygen carried by hemoglobin.
Measurement locations include finger, ear, nose, toe, and mouth.
Standard target: 95%-100% for general patients, while specific demographics (like COPD patients) may present lower averages.
Managing Abnormal Oxygen Saturation Readings
If problems arise in obtaining a reading, immediate retakes should be conducted following proper patient stabilization techniques.
Supplemental modalities may include oxygen therapy, respiratory therapy referrals, or breathing treatments as indicated.
Blood Pressure Monitoring
The mean arterial pressure above 60 mm Hg is adequate for brain perfusion.
Confirm doubts of blood pressure readings with manual assessments.
Hypertension diagnosis requires two readings on different days, recorded at various times.
Management for Hypertension
Inquire about symptoms: headaches, blurred vision, facial flushing.
Interventions include dietary modifications (lower sodium intake), stress management, limited alcohol, cessation of smoking, increased physical activity, and weight management.
Hypotension Causes and Management
Hypotension may result from ineffective blood pumping by the heart, manifesting signs like cool clammy skin, faintness, or decreased urine output.
Immediate response should involve:
IV fluid administration.
Blood transfusions if applicable.
Administer oxygen and position patients supinely.
Orthostatic Hypotension Definition
Defined as a drop in blood pressure during positional changes (e.g., laying to standing).
Manifestations include dizziness and fainting spells, often associated with dehydration or anemia.
Interventions for Orthostatic Hypotension
Respond to symptoms by assisting patients back to a lying position, advocating careful transitions, promoting hydration, and advising sodium intake to support blood volume.
Therapeutic Communication Skills
Concepts: Verbal and non-verbal methods, ISBAR communication model.
General Communication Principles
Both subjective and objective data should be documented; discrepancies between observed behavior and verbal reports may occur.
Non-verbal cues to watch for: appearance, posture, expression, eye contact, gestures, and vocal tones.
Attributes of Professional Communication
Essential components include professional demeanor, appearance, behavior, and grooming standards.
Build rapport through warmth, clarity, integrity, and team collaboration.
Efficiently address all forms of patient communication with appropriate professionalism.
Therapeutic Communication Techniques
Techniques include:
Sharing observations, empathy, hope, humor, and feelings.
Appropriate uses of touch and silence to foster a comfortable environment.
Clarification, focusing, and validation of patient concerns.
Non-therapeutic communication examples: irrelevant personal questions, subjective beliefs, changing subjects mid-conversation, offering false reassurance, or argumentative behavior.
Interprofessional Communication
Key aspects include sharing sufficient, clear, and contextual information.
Utilize the ISBAR communication framework:
Identify: Name, location, patient details.
Situation: Reason for communication.
Background: Relevant patient history and treatment.
Assessment: Clear reasons for concern.
Recommendation: Suggestions for care going forward.
Special Considerations in Communication
Adapt communication for adults with hearing loss (use of aids, face-to-face contact).
Be cognizant of varying patient abilities that may impact communication clarity.
Active Listening Skills
Recommended practices for effective listening:
Face the patient at an angle to promote comfort.
Avoid crossing arms/legs to indicate openness.
Maintain a relaxed demeanor to help patients feel at ease.
Maintain eye contact to establish involvement and attention.
Use physical touch judiciously to convey empathy or understanding.
Trust your instincts in interaction as you gain experience and confidence in the healthcare setting.