Term
| What are Seizures? And what is a common risk for those patints? |
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Definition
Interruption of normal brain function due to abnormal electrical activity in the neurons.
May be partial (focal) or general (involving the whole brain).
Spasms or convulsions with grand-mal seizures and loss of consciousness = at risk for injury |
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Term
| An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? |
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Definition
| Provide a bedside commode. |
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Term
| A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure? |
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Definition
| Use a bed exit safety monitoring device |
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Term
| Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting? |
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Definition
| Place the bed in the lowest position |
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Term
| What are some seizure precautions? |
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Definition
Pad the bed by securing blankets, linens around the head, foot, and side rails of the bed
Put oral suction equipment in place and test to ensure that it is functional
Children who have frequent seizures should wear helmets for protection
UAP should be familiar with establishing and implementing seizure precautions and assist during a seizure
Care during a seizure is the nurses responsibility due to importance of assessment and potential need for intervention |
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Term
| What should you do if a seizue occurs? |
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Definition
Remain with the client,Assist client to floor if not in bed. Turn client to lateral position if possible
Move items in environment for client safety
Do not insert anything into mouth
Time the seizure duration
Observe progression of seizure
Apply oxygen,Suction oral airwary
Administer anticonvulsants as ordered
Assist client to comfortable position
Document the event in the client record using forms or checklists supplemented by narrative notes when appropriate |
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Term
| What other things would you educate the patient and family on? |
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Definition
Should wear a medical identification tag. Safety precautions if seizures are not well-controlled include restriction or direct supervision by others for certain activities:
Tub bathing
Swimming
Cooking
Using electrical equipment or machinery
Driving |
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Term
What organization helps with goal such as:Improve the accuracy of patient identification. Improve the effectiveness of communication among caregivers. Improve the safety of using medications. Reduce the risk of health care–associated infections
Accurately and completely reconcile medications across the continuum of care. Reduce the risk of residential harm resulting from falls
Prevent health care-associated pressure ulcers. The hospital identifies safety risks inherent in its patient population |
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Definition
| National Patient Safety Goals (NPSGs) |
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Term
| Being a student in the Pierce College Nursing Program means what with regards to the NPSGs? |
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Definition
Learning and using:
Braden Scale for pressure ulcer risk
Fall Risk Assessment
Site Evaluations |
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Term
| Infants and older adults are prone to falling? True or False? |
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Definition
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Term
Falls are not a leading cause of injury in the older adults?
True or False? |
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Definition
| False One third of older adults who fall are admitted to hospitals and nursing homes. Contributing factors: Poor vision, weak muscle tone, medications (diuretics, sedatives, analgesics), arthritis/mobility issues |
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Term
| What is the most frequently reported hospitalization adverse event? |
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Definition
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Term
Most falls occur in the home?
True or False? |
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Definition
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Term
| The “get up and go” test will prevent your patient from falling? True or False? |
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Definition
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Term
| What are ways as nurses can we help with prevention of falls? |
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Definition
Orient clients to surroundings and explain call system.Assess the client’s ability to ambulate and transfer.Provide walking aids and assistance as required. Closely supervise the clients at risk for falls, especially at night
Encourage the client to use the call bell to request assistance and ensure that the bell is within easy reach
Place bedside tables and overbed tables near the bed or chair so that clients do not overreach
Always keep hospital beds in the low position and wheels locked when not providing care so that clients can move in or out of bed easily, encourage grab bars and railing use and nonskid bath mats and non skid footwear. |
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Term
| How do you use Bed or Chair Exit Safety Monitoring Devices? |
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Definition
Apply the leg band or sensor pad
Place the client’s leg in a straight horizontal position
Sensor is usually placed under the buttocks area
Set the time delay
Connect the sensor pad to the control unit. Instruct to client to call nurse when getting up
May delegate if UAP is trained in application and monitoring
Documentation-
The type of alarm used
Where it was placed
Its effectiveness
All additional safety precautions and interventions discussed and employed |
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Term
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Definition
| Protective devices used to limit the physical activity of the client or part of the body |
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Term
| List Two reasons for restraining |
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Definition
Avoid and/or prevent purposeful or accidental harm to the resident/client
To do what is required to provide medically necessary treatment that could not be provided through any other means |
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Term
| What is another reason a nurse might use restraints? |
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Definition
| May also be used to prevent client harming others |
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Term
| List two types of restraints. |
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Definition
Physical restraint-
Any manual or physical or mechanical device, material, or equipment attached to client’s body
Chemical restraint-
Medications used to control socially disruptive behavior |
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Term
| What are the legal implications of restraints? |
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Definition
Restraints restrict the individual’s freedom
U.S. Centers for Medicare and Medicaid Services standards-
Acute medical and surgical care standard
Directly support medical healing
Client interfere with a physical treatment or devices (e.g. IV line, respirator, dressing)
Behavior management standard
Protect the client from injury to self or others because of emotional or behavioral disorders
The behavior may be violent or aggressive |
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Term
| How many hours before obtaining a physician's written order for restraints legally? |
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Definition
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Term
| How long is a order for restraints good for and what must the order state? |
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Definition
Orders renewed daily
Order must state the reason and time period
PRN order prohibited
In all cases, restraints used only after every possible means of ensuring safety unsuccessful and documented
Nurses must document need for the restraint made clear both to client and family |
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Term
| Who can apply the restraints? |
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Definition
Nurse may apply restraints but the physician or other licensed independent practitioner must see the client within 1 hour for evaluation
Written restraint order for an adult, following evaluation, valid for only 4 hours. |
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Term
| Must a patient in restraints be monitored> |
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Definition
| Yes. Must be continual visual and audio monitoring if client restrained and secluded |
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Term
| What are the alternatives to restraints? |
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Definition
Assign nurses in pairs
Place unstable clients in an area that is constantly or closely supervised
Prepare clients before a move to limit relocation shock
Stay with a client using a bedside commode or bathroom if confused, sedated or has a gait disturbance or a high risk score for falling
Monitor all the client’s medication and if possible lower or eliminate dosages of sedatives or psychotropics
Position beds in lowest position |
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Term
| What are some other alternatives to restraints? |
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Definition
Replace full-length side rails with half- or three-quarter length rails
Use rocking chairs to help confused clients expend some energy
Wedge pillows or pads against the sides of wheelchairs
Place a removable lap tray on a wheelchair
Try a warm beverage, soft lights, a back rub or a walk
Use “environmental restraints”
Place a picture or other personal item on the door to the client’s room
Try to determine the causes of the client’s sundowner syndrome
Establish ongoing assessment |
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Term
| What are some things to consider when selecting a restraint? |
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Definition
It restricts the client’s movement as little as possible
It is safe for the particular client
It does not interfere with the client’s treatment or health problem
It is readily changeable
It is as discreet as possible |
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Term
| What things would you document regarding restraint in the client's chart? |
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Definition
The time the restraints were removed and skin care given
Explanation given to the client and significant others
The client’s behavior
All other interventions implemented in an attempt to avoid the use of restraints and their outcomes
The time the primary care provider was notified
The type of restraint applied
The client’s response to the restraint |
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Term
| Application of ordered restraints and their temporary removal for skin monitoring and care may be delegated to UAP who have been trained. True or False? |
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Definition
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