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Nur 352 Exam 2
Describe nurse responsibilities for patient safety - ANS>-Use risk assessment tools
- Encourage clients to speak up
- Create a culture of checks and balances
- Communicate risk factors and plans of care to patients, family, and other staff
- Use protocols for responding to dangerous situations
- Adopt quality care priorities
- Know the facility's disaster plan
- Use current evidence to promote a culture of safety
- Identify and document incidents and responses according to facility's policy
- Know the location of safety data sheets and hazardous chemicals in the environment
- Use equipment only after adequate instruction and safety inspection
- Correct delegation When is it okay to delegate? - ANS>-patient is stable
- task is within worker's job description
- you're able to teach and supervise
- and you've planned how to monitor
When is it not okay to delegate? - ANS>-thinking, complex assessment, and judgment are required
- there is an unpredictable outcome
- increased risk of harm
- creativity and problem solving are required What are the steps of delegation? - ANS>(1) assess and plan, (2) communicate, (3) ensure surveillance and supervision, (4) evaluate and give feedback What are the 5 rights of delegation? - ANS>task, situation, worker, direction & communication, and teaching, supervision, & evaluation What is a sentinel event? - ANS>A critical unexpected adverse event that caused severe physical harm to a patient including death and dismemberment, permanent injury, or severe, temporary injury What is another name for a serious reportable event (SRE)? - ANS>"Never event" Examples of an SRE - ANS>-surgery on wrong body part
- infant discharged to wrong person
- foreign object left in patients after surgery
- provide cognitive/physical activities for client
- non-skid footwear
- lock wheels of bed
- clutter free environment
- adequate lighting
- call light/belongings in reach
- fall prevention education
- restraints Describe risk factors for any population involving fall risks (physical, cognitive, environmental, etc.) - ANS>Physical disorders: stroke, amputation, recent surgery, MS, visual impairment, chronic pain, malnutrition, weakness, unsteady gait Cognitive: sleep disorders, impulsiveness, disorientation, depression Environmental: room clutter, poor lighting, slippery floors Other: certain medications with strong correlation with falls (antidepressants, antihypertensives, opioids), staffing levels on unit, bathroom frequency
Describe physical restraints - ANS>appropriate only for a short term situation or procedure, uses physical strength to restrain (ex. swaddle wrap for insertion of IV in pediatric client) Describe mechanical restraints - ANS>physical device applied such as straps, mittens, jackets, vests, belts, fabric around wrist or ankles typically tied to bed frame using quick release knot Describe chemical restraints - ANS>administration of medications to reduce client movement/behavior (ex. benzos) Describe barrier restraints - ANS>limit movement within a setting (ex. bed enclosures, concave mattresses, lapboards, cribs for pediatrics) Describe seclusion - ANS>environmental restraint involving placement of client alone in a securely locked room without their consent, typically used for clients who are very combative and pose a risk to other clients and staff When is it appropriate to obtain an order for restraints? - ANS>-client must be exhibiting unnecessary or unwanted movement that is considered unsafe
- attempting to remove needed medical items
- aggressive or combative
- danger to self or others
Describe safety concerns for infants/toddlers - ANS>burn injuries related to hot liquids or steam, accidental poisonings/choking, drowning, properly fitting car seats (rear-facing) Describe safety concerns for school aged children - ANS>vehicle safety (sit in backseat), safe participation in sports (helmets, eye protection, etc.), water safety, Internet safety (bullying), firearm safety (not toys), stranger danger Describe safety concerns for adolescents - ANS>risks involving fire, water, sports, firearms, vehicles, bullying, intimate-partner violence, substance abuse, speeding, unprotected sex, suicide, nutrition Describe safety concerns for adults under 65y/o - ANS>stress, poorly developed coping strategies, alcohol consumption, mental disorders, obesity, workplace accidents/violence Describe safety concerns for older adults over 65y/o - ANS>chronic illnesses, less physical activity, impaired mobility, cognitive/sensory deficits, FALLS, frailty Describe home safety risks for an older adult (bathroom, bedroom, kitchen, general) - ANS>Bathroom: slipping in shower/tub/tile, toilets too low to ground, step in showers/tubs, use of non-electric razors, water temperature too hot, toxic cleaning supplies, accidental
electrocution in the event client's wet hand or body part comes into contact with outlet Bedroom: bed is too high and client could roll out of bed, no use of mat/bed/motion alarm for clients who have mobility/cognitive issues, no use of hospital beds for clients with mobility difficulty Kitchen: commonly used items out of reach, step stools without rubber grippers to prevent sliding, stoves without automatic shut off mechanisms, toxic cleaning supplies, accidental burns from knocking/pulling over pot handles on the stove, accidental electrocution in the event client's wet hand or body part comes into contact with outlet General: dim lights, rounded traditional door knobs, animals and animal food/water bowls (tripping hazard), swivel/chairs with wheels, loose rugs, unsecured electrical cords, multicolored painted walls, medications not organized into pill dispenser, lack of use of chair lift, lack of handrails, uneven flooring, no emergency numbers in phone or nearby What are Standards of Compliance? - ANS>former National Safety Goals (NSG) that have been routinely adopted by healthcare professional and are now retired, but still must be continually met (medical error prevention, verification of qualifications and competency of health care staff procedures, rights and education of clients, infection control, management of medications, emergency preparedness)
Joint Commission Patient Safety Goals: Use alarms safely - ANS>-Clinical safety alarms both warn of potentially serious event that is occurring and if the machine is malfunctioning
- Alarm fatigue Joint Commission Patient Safety Goals: Prevent HAIs - ANS>-Commonly found with: central line-associated bloodstream infection, catheter- associated urinary tract infection, surgical-site infection, and ventilator- associated pneumonia
- Multidrug-resistant organisms are big concern with HAI Joint Commission Patient Safety Goals: Reduce risk of patient harm resulting in falls - ANS>-Education on fall risks (age, clutter, poor eyesight, etc.)
- Education on using call button for help Joint Commission Patient Safety Goals: Prevent healthcare associated decubitus ulcers - ANS>-Education on frequent ambulation
- Rotation of immobile clients every two hours Joint Commission Patient Safety Goals: The organization identifies safety risks inherent to its patient population - ANS>Nursing assessments and considerations to specific populations
Describe some basic fire safety guidelines - ANS>-Installation of fire alarms and CO detectors
- Fire extinguishers nearby and on every floor
- Clear exit pathway (2 exits)
- Practice escape plan
- Ensure electrical outlets are not overcrowded (one appliance per outlet)
- Flammable items at minimum 3 ft away from space heaters and away from children
- Teach stop, drop, and roll and not to play near/touch space heaters Describe some fire safety guidelines for clients on oxygen - ANS>no smoking signs posted outside and inside house, never smoke whole medical oxygen is in home, do not wear oxygen while cooking, do not use oil-based lotions, lipsticks, or aerosol sprays What is R.A.C.E.? - ANS>Rescue, alarm, contain, extinguish What is P.A.S.S.? - ANS>Pull, Aim, Squeeze, Sweep What 3 elements do fires need to burn? - ANS>oxygen, a combustible material, and heat to raise the material's temperature to the ignition temperature
Describe seizure safety measures - ANS>Pre Seizure: ensure suction and oxygen equipment is set up at bedside, check baseline vital signs, establish two IV sites, nsure side rails are padded and that restrictive clothing/jewelry is removed During seizure: call for immediate assistance, assume client to side-lying position, protect head from injury, remove dangerous objects around client, do not hold client down, determine if seizure activity was or was not bilateral, determine eye activity, administer medication per provider prescription, monitor ABCs, assess vitals and skin, assess bowel or bladder incontinence, obtain blood glucose if needed, and provide verbal reassurance help is on the way Post Seizure: obtain lab toxicology screen if prescribed, blood drug level of anticonvulsant if prescribed, assess gag reflex, assess swallowing, and explain to client what occurred and provide reassurance that client is safe What are ALL of the rights of medication administration? - ANS>-Right client: two identifiers
- Right medication: confirm name and form of medication
- Right dose: check medication against order
- Right route: confirm route
- Right time: confirm time drug is to be given and last time drug was administered
- Right documentation: document time the drug was given
Additional rights:
- Right to refuse
- Right assessment: confirm medication is appropriate for client's condition
- Right education: provide adequate education addressing what medication the client is taking, expected benefits, and side effects
- Right response/evaluation: observe client response to drug What are the 3 checks of administration? - ANS>-Checking medication against MAR or medication information device upon removal of drug from dispensing device
- Checking drug upon preparation
- Checking the drug just prior to administration What are some prevention strategies for medication errors? - ANS>- Only take verbal or telephone orders when absolutely necessary
- ensure order is complete and correct by reading back to provider (rights)
- second nurse check for high alert medications
- use resources when working with unfamiliar medications
- label medications
- administer medications for one patient at a time
- avoid administering medication you did not prepare
extremity can be slightly cooler if it is immobilized in a cast or if a client has a circulation problem to an extremity Unexpected: hyper/hypothermia Describe expected vs unexpected findings for skin integrity - ANS>Expected: skin should be smooth and intact Unexpected: primary vs. secondary lesions, ABCDE assessment, infestation Describe expected vs unexpected findings for skin moisture/texture/turgor - ANS>Expected: wrinkling, acne, scars from trauma/procedures, should rise easily when pinched and return rapidly to flat position when released but this can be delayed in older clients due to decreased skin elasticity Unexpected: profound dryness, rough, flaking, velvet texture, diaphoresis, tenting, edema Describe expected vs unexpected findings for hair/nails - ANS>Expected: hair evenly distributed, quantity, and good hygiene; nails are symmetrical, smooth, slightly curved/flat, color similar to client's skin tone, not pale, and quick capillary refill <2sec
Unexpected: hair loss (alopecia); nails broken/missing, clubbing (spongy to touch, spoon-like), delayed capillary refill, loosely attached, pale(anemia)/brown(melanoma)/blue(cyanosis) color, linear depressions (Raynauds), not smooth What is the difference between primary vs secondary lesions? - ANS>Primary lesions are the direct result of an underlying condition Secondary lesions are the result of primary lesions What is edema? Causes? Manifestations? Measurement scales? - ANS>accumulation of fluid in interstitial spaces, most commonly found in lower extremities, sacrum increased risk for pressure injury skin will appear shiny and tight pitting vs. non-pitting (1+ = trace(rapid response), 2+ = mild (10-15sec response), 3+ = moderate (prolonged), 4+ = severe (prolonged)) if edema is bilateral the cause is a central problem like heart failure, if it is unilateral or localized the cause is likely not central; edema could mask signs of jaundice or cyanosis
- clients being pulled up or across the bed linens resulting in a friction injury
- edema can predispose client due to greater fluid pooling What are some prevention strategies for wounds? - ANS>-inspect skin of at-risk clients daily for signs of breakdown
- reposition clients who have decreased mobility every 2 hrs
- elevate head of bed no more than 30 degrees to prevent a shearing injury which occurs when the client slides downward in a bed or chair
- remove sources of excessive moisture due to incontinence or drainage or diaphoresis
- provide dietary supplements as indicated to improve nutritional status
- never rub a reddened area (stage I pressure injury)
- use a lift device instead of dragging across bed How do we assess/measure gait and balance? - ANS>Assessment: Presence of limping, shuffling, or ataxia (lack of coordination) Measurement: unsteady vs steady gait; balanced vs unbalanced vs has coordinated control Describe ROM/strength for TMJ - ANS>-jaw side to side is lateral motion
- jaw forward is protrusion
- chin to chest is flexion
- normal position is extension
- head back is hyperextension
- neck to side with ear closer to shoulder is lateral flexion
- turn head side to side is rotation
- to test strength repeat ROM but against pressure of hand Describe ROM/strength for shoulders - ANS>-arms forward and overhead is flexion
- arms at side elbows extended is extension
- arms behind them with palms up is hyperextension
- arms at side with elbows extended making wide arc ending above head with palms together is abduction
- bring arms back down from abduction to midline of body is adduction
- rotate palms away from body and behind back then place hand at lumbar level is internal rotation
- with elbows bent bring arms up and around until hands are behind head is external rotation
- to test strength repeat ROM but against pressure of hand Describe ROM/strength for elbows - ANS>-bend elbows is flexion
- straighten elbows is extension
- rotate hands placing the palms up is supination and the palms down are pronation
