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Eye Charts - 🧠 ANSWER ✔✔1. Snellen
- Stand 20 ft away
2. Rosenbaum
- Stand 14 inches away
SAFTEY IS BIG ON THIS ATI!
,Factors that affect the patient's ability to protect themselves - 🧠 ANSWER
✔✔- Age
- Mobility
- Cognitive and sensory awareness
- Emotional state
- Ability to communicate
- Lifestyle
- Safety Awareness
Fall Risk - 🧠 ANSWER ✔✔- Decreased visual acuity
- Generalized weakness
- Urinary frequency
- Gait and balance problems (Cerebral palsy, MS, Parkinsons)
- Cognitive dysfunction
- Medication side effects
Seizure precautions - 🧠 ANSWER ✔✔- Have oxygen, suction, oral airway
at bedside
,- Padded side rails
- Saline locked IV for immediate access (High risk patients)
- Rapid intervention to maintain airway patency.
- Clutter free environment
- Make sure everyone (family too) knows that if pt. has a seizure, to not put
anything in their mouth during seizure. *Only thing that would go in mouth
during seizure is airway for status epilepticus.
- During seizure do not restrain pt. Lower pt. to floor or bed and protect pt.
head. Remove nearby furniture. Put patient on side with head flexed
slightly forward if possible and loosen his clothing.
How would you help prevent falls for a patient with orthostatic hypotension?
- 🧠 ANSWER ✔✔- Avoid getting up to quickly
- Sit on the side of the bed for a few seconds prior to standing
- Stand at the side of the bed a few seconds prior to walking
Seclusion and Restraints - 🧠 ANSWER ✔✔- When everything else fails
(orientation to environment, family member, sitter, diversional activities,
electronic devices) is when you use restraints.
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, - Provider must prescribe after seeing the patient face to face
Provider prescription for restraints must include what? - 🧠 ANSWER ✔✔-
Reason for restraints
- Type of restraints
- Location of restraints
- How long to use restraints
- Type of behavior that warrants restraints
- *Prescription only last 4 hours for an adult. Providers may renew these
prescriptions with a maximum of 24 consecutive hours.*
Restraints in an emergency situation - 🧠 ANSWER ✔✔- When there is an
immediate risk to the patient or others, nurses may place restraints on
patient.
- The nurse must then obtain a prescription from the provider ASAP,
usually within 1 hour.