NUR 209 Final Exam Review.

NUR 209 Final Exam Review.
Final Exam Review

Safety (9/5)
⟶ Defines as the state of being free from harm or danger
⟶ Multiple healthcare settings have different safety concerns
⟶ Nurse must assess the patient, their equipment, and the environment and plan to maintain
safety
⟶ Perform a risk assessment
o Falls
o Malnutrition
o Bed sores

Risk Assessment Screening Tools
⟶ Braden Scale for Bed Sore Risk
o 0-23
o 23: Low risk
o <9: High risk
⟶ Hendrich II Fall Risk
o >5: High risk
⟶ Glasgow Coma Scale: Consciousness
o 15: Fully alert
⟶ MMSE: Cognition
o 30: Max
o 27: Average
o <24: No cognition

Factors Affecting Safety
⟶ Musculoskeletal: Arthritis
⟶ Neurological & Sensory: Seizures, confusion
⟶ Cardiovascular & Respiratory: Shortness of breath, heart failure, blood pressure
⟶ Immune: Autoimmune disorders or immunocompromised patients
⟶ Integumentary: Open wounds, risk for bed sores

Risk Assessment
⟶ Unsteady gait
⟶ Medications
o Pain medication
o Blood pressure medication
⟶ Blood pressure changes
⟶ Altered mental status
o Dementia
o Confusion
⟶ Sensory impairment
o Sight, smell, taste, touch, hearing
⟶ Prolonged bed rest

, o Leads to depression, atrophy, contractures, bed sores, respiratory impairment
⟶ Incontinence/lack of toileting schedule
⟶ Environment
o Hospital
Factors Affecting Safety
⟶ Environmental
o Workplace
▪ HAI’s
o Other
▪ Fire
▪ Pollution
▪ Radiation
▪ Terrorism
⟶ Equipment
o Call bell
o Oxygen
o IV
o Monitors
o Urinary catheters
o Tubes

Mechanisms for Quality & Safety Improvement
1. Mistake-proofing
2. Checklists
3. Redundancy
4. Communication

Tools for Quality & Safety Improvement
⟶ TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety
⟶ SBAR (Change in status)
o Situation
o Background
o Assessment
o Recommendation
⟶ IPASS the BATON (Change in shift)
o Identify self
o Patient identification
o Assessment
o Situation
o Safety
o Background
o Action
o Timing
o Ownership
o Next steps

, ⟶ Huddles (Pre-conference)
⟶ Debriefing (Post-conference or post-event)

Alternative to Restraints
⟶ Education
⟶ Comfort measures
⟶ Toileting schedule
⟶ Re-orienting
⟶ Pain Relief
⟶ Relaxation techniques
⟶ Decreased sensory overload
⟶ Activity/Exercise
⟶ Sleep hygiene
⟶ One-to-one

*Restraints need to be re-ordered every 24 hours
*Non-violent restraints to have a face-to-face assessment every 24 hours and violent restraints
need to have a face-to-face assessment every 4 hours

Infection Control (9/5)
⟶ Sepsis: Infection in tissue
⟶ Septicemia: Infection in blood
⟶ Infection disease: Transmissible

Chain of Infection
⟶ Infectious agent
o Bacteria
o Fungi
o Virus
o Parasite
o Prion
⟶ Source
o Humans
o Animals
o Inanimate objects
⟶ Portal of exit
o Sputum
o Blood
o Stool
o Emesis
⟶ Mode of transmission
o Contact
o Droplet
o Airborne
⟶ Portal of entry

, o Mucous membranes
o Nonintact skin
o GI tract
o GU tract
o Respiratory tract
⟶ Susceptible host
o Immunocompromised patients
o Elderly patients
o Chronically ill patients
o Trauma patients
o Surgical patients

Isolation Systems
⟶ Standard precautions
⟶ Transmission based precautions (negative pressure)
o Airborne (Measles, TB)
o Droplet (Flu)
o Contact (MRSA, C. diff)
⟶ Protective isolation (positive pressure)
o Immunosuppressed patients

Communication: Nurse-Patient Relationship (9/12)
Types of Communication
⟶ Written
⟶ Verbal
⟶ Non-verbal
⟶ Metacommunication

Communication Relationships
⟶ Congruent
⟶ Incongruent

Communication Process
⟶ Sender
⟶ Encoding
⟶ Decoding
⟶ Receiver
⟶ Feedback

Nurse-Patient Relationship
⟶ Phases
o Orientation
o Working
o Termination
⟶ Contract setting