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NUR 102 review


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Identify safety restraints
Chemical—medications -anxiolytics, sedatives,------Physical—vest, electronic bed, chair alarm devices
documentation processes for safety and security
Documentation should be accurate, factual, complete, current, and organized
Explain the relationship between vital sign measures
Vital sign measurements provides objective data used to assess clients health conditions and the need for interventions
Explain the process for measuring pain
Verbal report using the intensity scale, Measure pain on scale from 0-10 (0=no pain and 10= worst pain), Faces pain scale used to determine intensity (happy face=no pain, crying face=worst pain)
What is transferring
Moving a dependent client with restricted mobility to a position that achieves optimal independence
standard precautions
Tier 1—hands washed, gloves worn, masks, gowns, equipment properly cleaned, discard sharp instruments---Tier 2—airborne precautions (mask), droplet precautions (mask), contact-gloves worn
Identify the nurse's role in disaster management.
Follow SOP (standards of procedure) protecting clients from immediate injury, setting priorities in case of fire using RACE mnemonics
Identify equipment used for measuring respiration
Stethoscope (acoustic)
measures that ensure a secure environment
Reduction of Physical hazards, Reduction of pathogens, Sanitation maintained, Pollution is controlled, Threat of attack prevented
Explain the process for measuring blood pressure
Apply cuff to left arm 1-2 inches above elbow, Palpate over the brachial pulse site and inflate cuff to 30mmHg above where the clients post disappears, Place stethoscope over brachial artery and deflate cuff to 2-3mmHg per second while watching the manometer and listening to the sounds heard through the stethoscope
Identify types of Asepsis
Medical (clean) Surgical (sterile)
Explain body mechanics
Coordinated efforts of the musculoskeletal and nervous system to maintain balance, posture, and body alignment, while lifting, bending, moving, and performing ADL's.
Explain the process for measuring respiration
Count pulse, count respirations while holding wrist, note rate, rhythm, quality and character, observe full cycle of respiration, rates below 12 but further than 20 require greater assessment, if regular respirations count respirations and multiply by 2, irregular—count for 1 full minute
consequences of infection
Localized—client may experience symptoms (such as pain and tenderness at the wound site) Systemic—affects whole body and can be fatal
Principles of body mechanics
Wide base of support to increases stability, Low center of gravity increases stability, and facing direction of movement to prevent abnormal twisting of the spine
Identify safety risk factors
Oxygen, nutrition, temperature, humidity, transmission of pathogens reduced, reduction of physical hazards, sanitation is maintained, pollution is controlled, and threat of attacks is prevented
Explain medical and surgical aseptic procedures, including isolation
Medical—hand hygiene, alcohol, clean dressing procedures-----Surgical—surgical trauma or burns; isolate self from sterile field so that contamination does not occur
Explain the importance of risk management
Nurse attempts to identify potential hazards and to eliminate them before harm occurs
Identify techniques for measuring pain
Verbal and nonverbal, Characteristics of pain—onset (when it starts), duration, location, quality, intensity, variations, Factors affecting pain—culture, developmental stage, gender , anxiety, previous experience, Pain scale—numerical (0-10), verbal (descriptive), visual analog (faces pain rating scale)
OSHA guidelines
Precautions observed to prevent contact with infectious materials, controlled working environment, accessible hand-washing facilities, hand hygiene, no food kept where blood products are stored
Trochanter Rolls
helps to prevent external rotation of legs when patients are in supine postion
inflammatory process
Protective reaction that neutralizes pathogens and repairs body cells, Normal flora, Body systems defenses, Inflammation, Vascular and cellular response, Inflammatory exudates, Tissue repair, GAS (general adaptation syndrome)
Identify issues related to risk management
Identify possible risks, analyze the risk, act to reduce the risk, evaluate steps taken, accurately document findings, and report changes in client's conditions
maintaing optimal body positioning
What is positioning
When patients are moved to maintain correct body alignment and reduce the effects of immobilization
What is ambulation
chain of infection
Infectious agent, resevior, portal of exit, mode of transmission, portal of entry, susceptible host
What are environmental hazards
Carbon monoxide, food poisoning, temperature, and humidity
What are environmental factors
Environmental factors include home, school, hospital, community center, long-term care facility
Explain the process of using safety restraints
Nurse is responsible for assessment of clients safety needs, know agency policy and procedure, part of plan of care (Care plan), physicians order (required), type of restraint, location to be placed, timeframe, behavior for use of restraint, ongoing assessment performed by nurse.
Explain the process for measuring pulse (central and peripheral)
Feel over bony area, do not use thumb, use 2-3 fingers, do not squeeze, count 30 seconds if regular times 2, note rate, rhythm and quality irregular—count for 1 full minute or take apical pulse for 1 minute
Identify equipment used for measuring temperature
Rectal(rounded tip), Oral (elongated tip), Tempanic, Digital with red probe(rectal) blue (oral)
coordination and balance while walking, the ability to carry out ADL's, and the ability to participate in an exercise program
used for patients who suffered from spinal cord, neck, and back injuire. It helps to keep the spinal cord in straight alignment and to prevent other injuires from occuring
provides support and shape to body contours--helps to immobilize extremities and maintain specific body alignment
Identify equipment used for measuring pulse (central and peripheral)
Use 2-3 fingers and a watch to keep time
Identify equipment used for measuring blood pressure
Doppler (ultrasound stethoscope), Electronic BP device, Sphygmomanometer and stethoscope (aneroid & mercury)
Explain risk factors associated with body mechanics
Musculoskeletal injuries, muscle strain, and excessive use of muscle energy
Explain the process for assessing temperature
leave in place 2-3 minutes
What is safety?
Freedom from psychological and physical injury
Side rails
designed to increase patient's ability to move and turn in bed ex. Rolling from side to side or sitting up
Explain guidelines and risk factors for using safety restraints
Assess need for restraint, assess behavior, review agency policy, inspect area where restraint to be placed, approach client in calm manner, provide privacy, apply appropriate size restraints.
Explain the process of reporting breaches in safety and security
Ethics community, chain of command, incident reports, risk management tool, HIPPA

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