Safe Care
Terms
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- Hip Precautions Don'ts
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Do not:
-Flex hip more than 90° in relation to trunk
-Sit low in chair lean forward while sitting or getting up
-Squat
-Bend knees while reclining in bed
-Lean forward with legs straight out or bent
-Roll knees or toes in while lying
-Turn knees and/or toes inward towards body
-Allow knee to be turned inwards toward the midline even if toes are pointed while sitting or standing
-Adduct hip
-Cross legs
-Roll onto or lie on surgical side - Bath
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-Assess need for hygiene, level of independence and comfort needs
-Plan for type of bath required r/t medical and surgical diagnosis and ability to care for self
-Intervention do bath and AM care
-Evaluation: Is my patient clean, was comfort provided, was the level of care provided appropriate? - Performing the procedure and afterwards
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-Perform procedure and monitor patient response
-Finish the procedure
-Raise the side rail
-Lower bed and check patient response
-Replace call light and check for safety before leaving
-Leave the environment clean and safe
-Wash Hands
-Look back into the room, is everything where it is supposed to be?
-Document immediately if you can - Procedure for entering the room
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-Knock on door
-Identify the patient
-Introduce yourself to patient
-Explain procedure/getting permission
-Gather all equipment
-Provide privacy
-Move bed and patient into appropriate position
-Lower the side rail nearest you
-Organize set-up and assess patient - Urinary elimination
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-Micturation
-Respond to urge (nurse answer call light)
-Use sound of running water - Maintenance of hygiene
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-Promote circulation and comfort
-Remove excessive debris and secretions
-Maintain skin integrity - Intake and output
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-Should be equal (what goes in must come out)
-Intake is anything that is liquid at room temperature e.g. ice cream
-Output is any urine stool or drainage - Restraints
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-Reassessed time limit:
-Adults: every 4 hours
-Children 9 -17: every 2 hours
-Children under 9: every 1 hour
-The order can be renewed for up to 24h
-Visual checks: every 15min
-Assess: every 2 hours and allow fluids, nutrition, toileting, provide ROM and skin integrity checks - Factors that influence individual hygiene practices
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-Culture
-Religion
-Environment
-Developmental level
-Health and energy level
-Personal Preferences - Bowel elimination
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-Defecation
-Privacy and timing are essential
-Fluids, exercise, and diet are influential - Average daily output of an adult
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-Urine: 1500cc
-Feces: 200cc
-Insensible losses:
--Lungs/skin: 800cc
--Sweat: 100cc - Hip precaution dos
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Do:
-Have pillows between knees while lying on side, keep knee pointed straight ahead
-Keep knee and toes pointing to ceiling when lying on back and keep large pillow between knees
-Sit in as high a chair as comfortable (one wiht armrests)
-Use a raised toilet seat - Identifying dirty to clean
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Dirtiest: toilets, sinks, body-fluids
Dirty: Floor, desks, phones, charts
Clean: Washed hands
Cleaner: linen
Cleanest: sterile material - Basics Standards for Safe Nursing Care
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-Demonstrates Accountability and Professional Behavior
-Practices Principles of Asepsis
-Provides Physical Safety
-Provides Psychological Safety
-Organizes Care
-Documents and Communicates Care - Universal precautions
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-Hand washing
-Gloves
-Protective clothing, eyewear, masks
-Proper placement of patients
-Proper disposal of wastes and linen
-Needle disposal
-Masks when giving CPR
-Treat all patients and body fluids as though they were
Contaminated - Body Mechanics
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-Maintain balance: use strongest and longest muscles to provide a wide base of support
-Reduce energy requirements by the use of body structure for support and movement
-Prevent injury by never twisting your back - Medical asepsis
- a clean technique for procedures that reduces the number and transfer of pathogens
- Maslow's Hierarchy of Needs
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-Self-actualization
-Esteem
-Belonging
-Safety
-Physiological - AM Care
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-Help patient to use restroom
-Brush hair
-Brush teeth or rinse with soft sponge/stick or mouth wash
-Get patient dressed (or ready for breakfast)
-Wash face and hands
-Shave
-Apply makeup - Surgical asepsis
- is a sterile procedure that establishes and maintains an environment free of microorganisms
- Selecting a restraint
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-It restricts the client as little as possible
-It does not interfere w/client's treatment or health
-It is readily changeable
-It is safe for the particular client
-It is the least obvious to others - Kinds of restraints
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-Jacket restraint
-Belt restraint
-The mitt or hand restraint
-Limb restraint
-Elbow restraint
-Mummy restraint - Client's that are at high risk for decubiti
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-Bedridden
-Incontinent
-Decreased mental status
-Excessive body heat
-Elderly
-Unconscious - Decubiti Stages
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-Stage 1: redness
-Stage 2: partial thickness skin loss (abrasion, blister, or shallow crater)
-Stage 3: full thickness skin loss involving damage of subcutaneous tissue (ulcer like a deep crater)
-Stage 4: full thickness skin loss, dameage to muscle, bone, or supporting structures such as tendon or joint - Measures to prevent decubiti
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-Keeping skin clean and dry
-Changing position in bed q2h
-Good nutrition
-Recognizing need for movement before there is any redness - Abduct
- Moving limbs away from midline of body
- Adduct
- Moving limbs towards midline of body
- Dorsiflex
- Movement that flexes or bends the hand back towards the body or the foot towards the leg
- Eversion
- Movement that turns the sole of the foot outward
- Extend
- The return movement of flexion, the joint angle is increased
- Flexion
- Bending of the joint so that the angle of the joint diminishes
- Hyperextension
- Further extension or straightening of a joint
- Invert
- Movement that turns the sole of the foot inwards
- Opposition
- Touching of the thumb to the top of each finger of the same hand
- Plantar flex
- Movement that flexes or bends the foot in the direction of the sole
- Suppinate
- Turning upward