FINAL EXAM MDC 1, MDC 1 FINAL Q & A
PERFECTLY SOLVED!!
1. Fall Prevention
a. In Homes:
i. Remove items that could cause the client to trip(throw rugs and loose carpets)
ii. Place electrical cords and extension cords against a wall behind furniture
iii. Monitor gait and balance, and provide aids as needed
iv. Make sure that steps and sidewalks are in good repair
Place grab bars near the toilet and in the tub or shower and install a stool riser
Fall Prevention
In Hospitals
i. Fall bracelets and yellow socks
ii. Bed alarm
iii. Remove clutter
iv. Keep items within reach(call light, personal items)
v. Gait Belts
vi. "Call, don't fall"
1. Orient them to the call light and educate them to use call light to get help rather than
getting up without assistance. Nurses should respond to call light in a timely manner
vii. Put them in room close to nurses station
viii. Have good lighting (especially at night)
ix. BEDS:
1. Put in low position
2. Lock wheels
3. Use side rails appropriately
1. Home Safety
a. Preschoolers and School Age Children
i. Firearms
1. Keep firearms unloaded, locked up, and out of reach
2. Teach to never touch a gun or stay at a friend's house where a gun is accessible
3. Store bullets in a different locations from guns
1. Home Safety
a. Preschoolers and School Age Children
i. Poison
1. Teach child about the hazards of alcohol, cigarettes, and prescription, non-
prescription, and illicit drugs
2. Keep potentially dangerous substances out of reach
Have the poison control hotline number available
1. Home Safety
a. Preschoolers and School Age Children
i. Motor Vehicles
1. Use booster seats for children who are less than 4ft 9in tall and weigh less than
40lbs(usually 4 to 8 years old)
2. If the care has a passenger air bag, place children under 12 yrs in the back seat
,3. Use seatbelts properly after booster seats are no longer necessary
4. Use protective equipment when participating in sports, riding a bike, or riding as
passenger on a bike
5. Supervise and teach safe use of equipment
6. Teach the child to play in safe areas and never run after a ball or toy that goes into a
road
7. Teach child safety rules of the road.
a. Look both ways before crossing road
a. Fire Safety
i. Elements of Home Safety Plan
1. Where the exit plan in
2. Oxygen safety measures
3. Fire extinguishers and everyone knows there location
Smoke detectors need batteries checked every 6 mos
1. Center of Gravity
a. should be close to the base of support (below the umbilicus at the top of the pelvis)
b. spread feet, wide base of support
c. hold objects close to you
Bathing
a. Bathe clients to cleanse the body, stimulate circulation, provide relaxation, and
enhance healing.
b. Bathing clients is often delegated to the assistive personnel. However, the nurse is
responsible for data collection and client care
c. Bathe clients whose health problems have exhausted them or limited their mobility.
i. Give a complete bath to clients who can tolerate it and who hygiene needs warrant it
ii. Allow rest periods for clients who become tired during bathing
iii. Partial baths are useful when clients cannot tolerate a complete bath, need particular,
cleansing of odorous or uncomfortable areas, or can perform part of the bath
independently.
iv. Therapeutic baths are used to promote comfort and provide treatment (soothing itchy
skin)
Bed Bath:
i. Ensure privacy
ii. Start with face then arms and chest, then go to legs and feet, and then finally
perineal.
iii. Encourage patient to participate:
1. Wash their face and perineal area
2. usually set up the washcloth for them and allow them to do what they can and help
with what they can't allowing them the independence they still have. "we'll work
together"
3. Brush their own teeth
Foot Care
a. Prevents skin breakdown, pain, and infection
b. Is extremely important for clients with diabetes mellitus and a qualified professional
must perform it.
c. Scrub between toes
, d. Don't clip nails but file if needed.
e. Check for sores, signs of cyanosis, and skin breakdown
1. Pain Assessment
a.P:provoking/relieving; what makes it worse and better
b. Q: quality; how the pain feels: throbbing, aching, burning
c. R: radiate; does the pain radiate anywhere else
d. S: severity; on a scale of 1 to 10 how much does it hurt
T: timing; onset, duration, and frequency
1. Pain Medication Administration
a. Asses before giving pain meds:
i. PQRST
ii. Possible drug interactions, allergies
iii. Correct orders
iv. Correct dosage and medications
1. Pain Medication Administration (PT.2)
a. Analgesics are the mainstay for relieving pain. The three classes of analgesics are
non-opioids, opioids and adjuvants
i. Concerns when taking Opioids:
1. Lower BP and HR
a. Orthostatic hypotension (fall risk)
2. Constipation
3. Urinary retention
4. Respiratory depression
a. S&S
i. Bradypnea, RR less than 8 per min, and are shallow
Low O2 saturation
Pain Medication Administration (PT.3)
a. Before giving more pain medications reassess vitals (look at quality of respirations)
and another pain assessment
Pain Medication Administration (PT.4)
a. After giving medication:
i. Reevaluate pain level in:
1. IV: 30 min
2. Oral: 1 hour
ii. Check vitals
b. The parenteral route is best for immediate, short-term relief of acute pain
The oral route is better for chronic, non-fluctuating pain
1. Culture
a. Is what people in a group have in common and it changes over time.
a. Can be adopted by assimilation
b. Effect on healthcare:
i. What treatments they accept
ii. How they view healthcare
iii. How they view illness/disease/health/pain
iv. How often or when they access health care
v. Death rituals
PERFECTLY SOLVED!!
1. Fall Prevention
a. In Homes:
i. Remove items that could cause the client to trip(throw rugs and loose carpets)
ii. Place electrical cords and extension cords against a wall behind furniture
iii. Monitor gait and balance, and provide aids as needed
iv. Make sure that steps and sidewalks are in good repair
Place grab bars near the toilet and in the tub or shower and install a stool riser
Fall Prevention
In Hospitals
i. Fall bracelets and yellow socks
ii. Bed alarm
iii. Remove clutter
iv. Keep items within reach(call light, personal items)
v. Gait Belts
vi. "Call, don't fall"
1. Orient them to the call light and educate them to use call light to get help rather than
getting up without assistance. Nurses should respond to call light in a timely manner
vii. Put them in room close to nurses station
viii. Have good lighting (especially at night)
ix. BEDS:
1. Put in low position
2. Lock wheels
3. Use side rails appropriately
1. Home Safety
a. Preschoolers and School Age Children
i. Firearms
1. Keep firearms unloaded, locked up, and out of reach
2. Teach to never touch a gun or stay at a friend's house where a gun is accessible
3. Store bullets in a different locations from guns
1. Home Safety
a. Preschoolers and School Age Children
i. Poison
1. Teach child about the hazards of alcohol, cigarettes, and prescription, non-
prescription, and illicit drugs
2. Keep potentially dangerous substances out of reach
Have the poison control hotline number available
1. Home Safety
a. Preschoolers and School Age Children
i. Motor Vehicles
1. Use booster seats for children who are less than 4ft 9in tall and weigh less than
40lbs(usually 4 to 8 years old)
2. If the care has a passenger air bag, place children under 12 yrs in the back seat
,3. Use seatbelts properly after booster seats are no longer necessary
4. Use protective equipment when participating in sports, riding a bike, or riding as
passenger on a bike
5. Supervise and teach safe use of equipment
6. Teach the child to play in safe areas and never run after a ball or toy that goes into a
road
7. Teach child safety rules of the road.
a. Look both ways before crossing road
a. Fire Safety
i. Elements of Home Safety Plan
1. Where the exit plan in
2. Oxygen safety measures
3. Fire extinguishers and everyone knows there location
Smoke detectors need batteries checked every 6 mos
1. Center of Gravity
a. should be close to the base of support (below the umbilicus at the top of the pelvis)
b. spread feet, wide base of support
c. hold objects close to you
Bathing
a. Bathe clients to cleanse the body, stimulate circulation, provide relaxation, and
enhance healing.
b. Bathing clients is often delegated to the assistive personnel. However, the nurse is
responsible for data collection and client care
c. Bathe clients whose health problems have exhausted them or limited their mobility.
i. Give a complete bath to clients who can tolerate it and who hygiene needs warrant it
ii. Allow rest periods for clients who become tired during bathing
iii. Partial baths are useful when clients cannot tolerate a complete bath, need particular,
cleansing of odorous or uncomfortable areas, or can perform part of the bath
independently.
iv. Therapeutic baths are used to promote comfort and provide treatment (soothing itchy
skin)
Bed Bath:
i. Ensure privacy
ii. Start with face then arms and chest, then go to legs and feet, and then finally
perineal.
iii. Encourage patient to participate:
1. Wash their face and perineal area
2. usually set up the washcloth for them and allow them to do what they can and help
with what they can't allowing them the independence they still have. "we'll work
together"
3. Brush their own teeth
Foot Care
a. Prevents skin breakdown, pain, and infection
b. Is extremely important for clients with diabetes mellitus and a qualified professional
must perform it.
c. Scrub between toes
, d. Don't clip nails but file if needed.
e. Check for sores, signs of cyanosis, and skin breakdown
1. Pain Assessment
a.P:provoking/relieving; what makes it worse and better
b. Q: quality; how the pain feels: throbbing, aching, burning
c. R: radiate; does the pain radiate anywhere else
d. S: severity; on a scale of 1 to 10 how much does it hurt
T: timing; onset, duration, and frequency
1. Pain Medication Administration
a. Asses before giving pain meds:
i. PQRST
ii. Possible drug interactions, allergies
iii. Correct orders
iv. Correct dosage and medications
1. Pain Medication Administration (PT.2)
a. Analgesics are the mainstay for relieving pain. The three classes of analgesics are
non-opioids, opioids and adjuvants
i. Concerns when taking Opioids:
1. Lower BP and HR
a. Orthostatic hypotension (fall risk)
2. Constipation
3. Urinary retention
4. Respiratory depression
a. S&S
i. Bradypnea, RR less than 8 per min, and are shallow
Low O2 saturation
Pain Medication Administration (PT.3)
a. Before giving more pain medications reassess vitals (look at quality of respirations)
and another pain assessment
Pain Medication Administration (PT.4)
a. After giving medication:
i. Reevaluate pain level in:
1. IV: 30 min
2. Oral: 1 hour
ii. Check vitals
b. The parenteral route is best for immediate, short-term relief of acute pain
The oral route is better for chronic, non-fluctuating pain
1. Culture
a. Is what people in a group have in common and it changes over time.
a. Can be adopted by assimilation
b. Effect on healthcare:
i. What treatments they accept
ii. How they view healthcare
iii. How they view illness/disease/health/pain
iv. How often or when they access health care
v. Death rituals
