NURPM3480PMFinalPMExam
1. Safety/Falls:P M oPMFallsPMcanPMcausePMlife-threateningPMinjuries
o HavenPMfallenPMpreviouslyPMisPManPMimportantPMindicatorPMforPMaPMfuturePMfall
o LookPMinPMroomPMforPMthingsPMthatPMcanPMcontributePMtoPMfallPMrisks.
o AllPMfourPMsidePMrailsPMupPMisPMaPMrestraintPMifPMpatientPMisPMconfused.
o IncludePMfamilyPMmembers,PMsittersPM(usuallyPMnotPMfirstPMresort),PMhourlyPMrounding,PMgaitPMbelts,PMcommunication
FirstPMpriorityPMwhenPMpatientPMfallsPMisPMtoPMASSESSPMpatient
ExercisePMpreventsPMfallPMriskPMbyPMinc.PMbalancePMandPMpreventingPMweakness
StayPMarmPMlengthPMawayPMfromPMpatientPMifPMyouPMhelpedPMthemPMgetPMtoPMthePMbathroomPMC
onsiderPMassistivePMdevices,PMIVPMpole,PMcatheter
UsePMcautionPMwithPMbedsidePMcommodes:PMfallPMrisk
ËHi gh PMfallPMriskPMorPMconfusedPMpt.:PMremainPMbyPMbedsidePMuntilPMtheyPMarePMdonePMusingPMthePMcommode
2. PrimaryP M causesP M ofP M falls:P M confusion,PMdepression,PMenvironment,PMmeds
3. FallPMinterventions:PMfollowPMhospitalPMpolicy,PMlockPMbed,PMbedPMlow,PMcommunicationPM(patientPMeducation),PMtoiletingPM
plan,PMobserve,PMassessPMifPMpatientPMneedsPMbedsidePMcommode.
CallPMlight,PMlightingPMinPMroom,PMexercise,PMassistivePMdevices/nurse,PMDoPMNotPMleavePMpatientPMinPMthePMbathroomPMifPMyouPMtookPMt
mPMthere/armPMlength.
4. Restraints:P M oPMAlwaysPMlastPMresort
ªLeastPMrestrictivePMfirst,PMcanPMincreasePMriskPMforPMfalls,PMskinPMbreakdown,PMinjury,PMaspirationPMcanPMallPMoccurPMwhenPMusingPMrestraint
RNPMassessmentPMonly
ªTurnPMandPMandPMcheckPMskinPMeveryPM2PMhours,PMªDocume
ntation,PMMDPMtoPMevaluatePMwithinPM24PMhoursPMªDetermine
PM typePMofPMrestraintPMforPMpatientPM(hard/soft)PMªEx:PMMitts,PMso
ft,PMPoseyPMvest,PMorPMleather
1
PM/P
M44
, NURPM3480PMFinalPMExa
m
StudyPMonlinePMatPMhttps://quizlet.com/_8c48
sa
SafetyPMinterventionsPMforPMconfusedPMpt.:
ÏRestraintsPM(soft)/allPM4PMbedPMrailsPMup:PMneedPMdoctorPMorder
MustPMinformPMfamilyPMmembersPMifPMrestraintsPMneededPMandPMifPMpt.PMisPMatPMriskPMforPMfalls
5. Hygiene:PMÏInitialPMassessment:PMmustPMassessPMskinPMofPMpt.,PMespeciallyPMifPMincontinent,PMtoPMpreventPMskinPMbreakdownPMandP
Minfection
o MaintainPM privacyPM whenPM cleaning
o ConsiderP M gender/culturalP M ditterences
o DoPMnotPMwashPMoverPMIVPMsites,PMcentralPMlines,PMwounds,PMetc
o PatientsPMshouldPMhavePMbathPMdailyPM(EncouragePMpatientPMtoPMwashPMasPMmuchPMforPMthemselves),PMkeepPMpatientPMwarm,PMkeepP
MwaterPMwarm,PMdoPMnotPMscrubPMskin-couldPMdamagePMskinPMtissue
-Oral/denturePM care;PM cautionPM whenPM consideringPM shaving/nailPM cuttingPM (notPM recommended-bleedingPM risk)
EncouragePMthePMpt.PMtoPMdoPMasPMmuchPMasPMtheyPMcanPMthemselves
6. Activity:P M oPMAssessPMpatientPMPRIORPMtoPMmoving
o NeedPMtoPMconsiderPMifPMyouPMneedPMhelp:PMslidingPMboard,PMwheelchair,PMlift,PMgaitPMbelt
IfPMpt.PMisPMablePMtoPMperformPMallPMADLs,PMthenPMtheyPMarePMusingPMettectivePMROM
ËActive: PMwithPMparticipationPMfromPMpt.
ËPassive: PMw/outPMparticipationPMfromPMpt
o CommunicatePMwithPMpatientPMwhenPMmoving
o SidePMrailsPMshouldPMbePMupPMwhenPMturningPMpatient,PMturnPMpatientPMeveryPM2PMhours
o LockPMallPMdevicesPMbeforePMmovingPMpatient;PMPatientsPMshouldPMnotPMgrabPMwalkerPMuntilPMcompletelyPMinPMupright,PMstandingPMpos
ition,PMifPMnot,PMthisPMcanPMleadPMtoPMfalls.
o PtsPMwithPMcompressionPMstocking,PMtakePMottPMandPMassessPMskinPMatPMleastPMoncePMaPMshift.
2
PM/P
M44
, NURPM3480PMFinalPMExa
m
StudyPMonlinePMatPMhttps://quizlet.com/_8c48
sa
o SCDs:PM increasesPM venousPM return,PM pre-postPM op
o Traction:PMassistsPMwithPMhelpingPMopenPMfracturesPMwithPMsoftPMtissuePMdamage.
7. RiskPM factorsPM forPM infection:PM oPMImmunocompromised:PMsick,PMcancer,PMWBCPMcount,PMetc
o Co-existingPMillness:PMDiabetes
o IncreasedPMentryPMintoPMthePMbody:PMsurgery,PMburns,PMcuts,PMmouth,PMears,PMetc
o Age:PMYoungerPMvsPMolder
-PMOpenPMwounds,PMenvironment,PMproceduresPMthatPMinvolvePMenteringPMthePMbody,PMunsterilePMtechnique
8. SignsP M ofP M Infection:P M oPMRedness
o Swelling
o Warmth
o PurulentPMdrainage
o FoulPModor
o Pain
-diaphoresis
-sepsis
9. SterilePMTechnique:PMoPMAlsoPMcalledPMsurgicalPMasepsisPM(usedPMforPManyPMprocedurePMenteringPMthePMbodyPMviaPMopening
PMofPMskinPMorPMinjection)
o HighPMtempPMpressurizedPMcleaningPMandPMpackagingPMtoPMgetPMridPMofPMallPMinfectiousPMagents
o OnlyPMsterilePMcanPMtouchPMsterile
ªFromPMwaistPMtoPMshoulder
ªSetPMupPMone-inchPMborderPMbeingPMunsterile
o NoPMtalking,PMsneezing,PMbreathingPMonPMsterilePMobjects;PMdon'tPMturnPMbackPMonPMsterilePMobjects
o UsedPMforPManyPMprocedurePMenteringPMthePMskin
3
PM/P
M44
, NURPM3480PMFinalPMExa
m
StudyPM
ªOpenPMwounds onlinePMatPMhttps://quizlet.com/_8c48
PMªInje
sa
ctionsPMªFoleys
10. InfectionPMPrevention:PMoPMTryPMtoPMstopPMatPMeachPMlevelPMofPMthePMchainPMofPMinfection
o LimitPMinfectiousPMagents:PMcleaning,PMusingPMcertainPMwipes,PMvaccines,PMmedications
o SusceptiblePMhost:PMcleanPMwoundsPMandPMkeepPMprotected,PMexaminePMbodyPMofPMopenPMwounds,PMsurgery,PMage,PMburns,PMimmunePM
deficiency
o PortalsPMofPMentry:PMcoverPMopenPMwounds,PMwearPMmask,PMhowPMfoodPMisPMcooked.
o ModePMofPMtransmission:PMDroplet,PMcontact,PMairborne,PMphysical
o PortalsPMofPMexit:PMBlood,PMsecretions,PMexcretions,PMskin
o Reservoirs:PMpeople,PMwater,PMfood,PManimals,PMplants
11. StandardPMprecautions:PMhandPMhygienePMbeforePMandPMafterPMeveryPMpt.PM
contact,PMPPE,PMcorrectPMandPMsafePMdisposalPMofPMsharpsPMandPMlinens
12. ContactP M precautions:P M ÏhandPMhygiene,PMgown,PMgloves
ËDiagnosed PMwithPMmultidrug-resistantPMorganisms:PMex.PMMRSA,PMVRE,PMC.PMDIFF,PMESBL,PMDRAININGPMULCERS
o PrivatePMroomPMifPMpossiblePMorPMwithPMptPMwithPMsamePMdiagnosis
13. DropletP M precautions:P M Ïgown,PMgloves,PMmask,PMgoggles
ËRubella, PMmumps,PMdiphtheria,PMadenovirus,PMBACTERIALPMMENINGITIS,PMINFLUENZA,PMwhoopingPMcough
ËSneeze, PMcough,PMsweating,PMbreathing
o PtPMwearsPMsurgicalPMmaskPMwhenPMtransportedPMoutPMofPMroom
o VisitorsPMmustPMstayPM3PMfeetPMawayPMfromPMpatient
4PM/PM
44
1. Safety/Falls:P M oPMFallsPMcanPMcausePMlife-threateningPMinjuries
o HavenPMfallenPMpreviouslyPMisPManPMimportantPMindicatorPMforPMaPMfuturePMfall
o LookPMinPMroomPMforPMthingsPMthatPMcanPMcontributePMtoPMfallPMrisks.
o AllPMfourPMsidePMrailsPMupPMisPMaPMrestraintPMifPMpatientPMisPMconfused.
o IncludePMfamilyPMmembers,PMsittersPM(usuallyPMnotPMfirstPMresort),PMhourlyPMrounding,PMgaitPMbelts,PMcommunication
FirstPMpriorityPMwhenPMpatientPMfallsPMisPMtoPMASSESSPMpatient
ExercisePMpreventsPMfallPMriskPMbyPMinc.PMbalancePMandPMpreventingPMweakness
StayPMarmPMlengthPMawayPMfromPMpatientPMifPMyouPMhelpedPMthemPMgetPMtoPMthePMbathroomPMC
onsiderPMassistivePMdevices,PMIVPMpole,PMcatheter
UsePMcautionPMwithPMbedsidePMcommodes:PMfallPMrisk
ËHi gh PMfallPMriskPMorPMconfusedPMpt.:PMremainPMbyPMbedsidePMuntilPMtheyPMarePMdonePMusingPMthePMcommode
2. PrimaryP M causesP M ofP M falls:P M confusion,PMdepression,PMenvironment,PMmeds
3. FallPMinterventions:PMfollowPMhospitalPMpolicy,PMlockPMbed,PMbedPMlow,PMcommunicationPM(patientPMeducation),PMtoiletingPM
plan,PMobserve,PMassessPMifPMpatientPMneedsPMbedsidePMcommode.
CallPMlight,PMlightingPMinPMroom,PMexercise,PMassistivePMdevices/nurse,PMDoPMNotPMleavePMpatientPMinPMthePMbathroomPMifPMyouPMtookPMt
mPMthere/armPMlength.
4. Restraints:P M oPMAlwaysPMlastPMresort
ªLeastPMrestrictivePMfirst,PMcanPMincreasePMriskPMforPMfalls,PMskinPMbreakdown,PMinjury,PMaspirationPMcanPMallPMoccurPMwhenPMusingPMrestraint
RNPMassessmentPMonly
ªTurnPMandPMandPMcheckPMskinPMeveryPM2PMhours,PMªDocume
ntation,PMMDPMtoPMevaluatePMwithinPM24PMhoursPMªDetermine
PM typePMofPMrestraintPMforPMpatientPM(hard/soft)PMªEx:PMMitts,PMso
ft,PMPoseyPMvest,PMorPMleather
1
PM/P
M44
, NURPM3480PMFinalPMExa
m
StudyPMonlinePMatPMhttps://quizlet.com/_8c48
sa
SafetyPMinterventionsPMforPMconfusedPMpt.:
ÏRestraintsPM(soft)/allPM4PMbedPMrailsPMup:PMneedPMdoctorPMorder
MustPMinformPMfamilyPMmembersPMifPMrestraintsPMneededPMandPMifPMpt.PMisPMatPMriskPMforPMfalls
5. Hygiene:PMÏInitialPMassessment:PMmustPMassessPMskinPMofPMpt.,PMespeciallyPMifPMincontinent,PMtoPMpreventPMskinPMbreakdownPMandP
Minfection
o MaintainPM privacyPM whenPM cleaning
o ConsiderP M gender/culturalP M ditterences
o DoPMnotPMwashPMoverPMIVPMsites,PMcentralPMlines,PMwounds,PMetc
o PatientsPMshouldPMhavePMbathPMdailyPM(EncouragePMpatientPMtoPMwashPMasPMmuchPMforPMthemselves),PMkeepPMpatientPMwarm,PMkeepP
MwaterPMwarm,PMdoPMnotPMscrubPMskin-couldPMdamagePMskinPMtissue
-Oral/denturePM care;PM cautionPM whenPM consideringPM shaving/nailPM cuttingPM (notPM recommended-bleedingPM risk)
EncouragePMthePMpt.PMtoPMdoPMasPMmuchPMasPMtheyPMcanPMthemselves
6. Activity:P M oPMAssessPMpatientPMPRIORPMtoPMmoving
o NeedPMtoPMconsiderPMifPMyouPMneedPMhelp:PMslidingPMboard,PMwheelchair,PMlift,PMgaitPMbelt
IfPMpt.PMisPMablePMtoPMperformPMallPMADLs,PMthenPMtheyPMarePMusingPMettectivePMROM
ËActive: PMwithPMparticipationPMfromPMpt.
ËPassive: PMw/outPMparticipationPMfromPMpt
o CommunicatePMwithPMpatientPMwhenPMmoving
o SidePMrailsPMshouldPMbePMupPMwhenPMturningPMpatient,PMturnPMpatientPMeveryPM2PMhours
o LockPMallPMdevicesPMbeforePMmovingPMpatient;PMPatientsPMshouldPMnotPMgrabPMwalkerPMuntilPMcompletelyPMinPMupright,PMstandingPMpos
ition,PMifPMnot,PMthisPMcanPMleadPMtoPMfalls.
o PtsPMwithPMcompressionPMstocking,PMtakePMottPMandPMassessPMskinPMatPMleastPMoncePMaPMshift.
2
PM/P
M44
, NURPM3480PMFinalPMExa
m
StudyPMonlinePMatPMhttps://quizlet.com/_8c48
sa
o SCDs:PM increasesPM venousPM return,PM pre-postPM op
o Traction:PMassistsPMwithPMhelpingPMopenPMfracturesPMwithPMsoftPMtissuePMdamage.
7. RiskPM factorsPM forPM infection:PM oPMImmunocompromised:PMsick,PMcancer,PMWBCPMcount,PMetc
o Co-existingPMillness:PMDiabetes
o IncreasedPMentryPMintoPMthePMbody:PMsurgery,PMburns,PMcuts,PMmouth,PMears,PMetc
o Age:PMYoungerPMvsPMolder
-PMOpenPMwounds,PMenvironment,PMproceduresPMthatPMinvolvePMenteringPMthePMbody,PMunsterilePMtechnique
8. SignsP M ofP M Infection:P M oPMRedness
o Swelling
o Warmth
o PurulentPMdrainage
o FoulPModor
o Pain
-diaphoresis
-sepsis
9. SterilePMTechnique:PMoPMAlsoPMcalledPMsurgicalPMasepsisPM(usedPMforPManyPMprocedurePMenteringPMthePMbodyPMviaPMopening
PMofPMskinPMorPMinjection)
o HighPMtempPMpressurizedPMcleaningPMandPMpackagingPMtoPMgetPMridPMofPMallPMinfectiousPMagents
o OnlyPMsterilePMcanPMtouchPMsterile
ªFromPMwaistPMtoPMshoulder
ªSetPMupPMone-inchPMborderPMbeingPMunsterile
o NoPMtalking,PMsneezing,PMbreathingPMonPMsterilePMobjects;PMdon'tPMturnPMbackPMonPMsterilePMobjects
o UsedPMforPManyPMprocedurePMenteringPMthePMskin
3
PM/P
M44
, NURPM3480PMFinalPMExa
m
StudyPM
ªOpenPMwounds onlinePMatPMhttps://quizlet.com/_8c48
PMªInje
sa
ctionsPMªFoleys
10. InfectionPMPrevention:PMoPMTryPMtoPMstopPMatPMeachPMlevelPMofPMthePMchainPMofPMinfection
o LimitPMinfectiousPMagents:PMcleaning,PMusingPMcertainPMwipes,PMvaccines,PMmedications
o SusceptiblePMhost:PMcleanPMwoundsPMandPMkeepPMprotected,PMexaminePMbodyPMofPMopenPMwounds,PMsurgery,PMage,PMburns,PMimmunePM
deficiency
o PortalsPMofPMentry:PMcoverPMopenPMwounds,PMwearPMmask,PMhowPMfoodPMisPMcooked.
o ModePMofPMtransmission:PMDroplet,PMcontact,PMairborne,PMphysical
o PortalsPMofPMexit:PMBlood,PMsecretions,PMexcretions,PMskin
o Reservoirs:PMpeople,PMwater,PMfood,PManimals,PMplants
11. StandardPMprecautions:PMhandPMhygienePMbeforePMandPMafterPMeveryPMpt.PM
contact,PMPPE,PMcorrectPMandPMsafePMdisposalPMofPMsharpsPMandPMlinens
12. ContactP M precautions:P M ÏhandPMhygiene,PMgown,PMgloves
ËDiagnosed PMwithPMmultidrug-resistantPMorganisms:PMex.PMMRSA,PMVRE,PMC.PMDIFF,PMESBL,PMDRAININGPMULCERS
o PrivatePMroomPMifPMpossiblePMorPMwithPMptPMwithPMsamePMdiagnosis
13. DropletP M precautions:P M Ïgown,PMgloves,PMmask,PMgoggles
ËRubella, PMmumps,PMdiphtheria,PMadenovirus,PMBACTERIALPMMENINGITIS,PMINFLUENZA,PMwhoopingPMcough
ËSneeze, PMcough,PMsweating,PMbreathing
o PtPMwearsPMsurgicalPMmaskPMwhenPMtransportedPMoutPMofPMroom
o VisitorsPMmustPMstayPM3PMfeetPMawayPMfromPMpatient
4PM/PM
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