National patient safety goal
requirements to meet each goal are established by the committee
ex: identify patient using 2 identifiers -most common
-full name and DOB
factors contributing to an unsafe patient environment
- everything changes
- unfamiliar setting
- loss of privacy
- age &ability to understand
- impaired mobility
- communication
- pain& discomfort
- delayed assistance
- equipment being used
promoting patient safety
you must constantly monitoring the patient and the surrounding environment
ex: preventing falls
MORSE FALL SCALE
a fall assessment rating scale (rating scale commonly used in acute care setting)
consists of 6 categories:
...
morse scale levels
...
restraint alternatives
not true restraints
-they are less restrictive
ex: monitors: bed alarm, chair alarms, personal alarm, and leg monitor
types of restraints
- vests
- waist
- extremity
- mitt
Race acronym
- rescue- remove patients from immediate danger
- Alarm- sound fire alarm or dial extension
- confine- confine the fire to one room, close the door
- extinguisher- only attempt to extinguish a small fire with a fire extinguisher
full code
everything!
ex: CPR, inhibition, AED, etc.
limited code
when they don't want something
ex: no intubation- no blood transfusion
DNR
DO NOT RESUSITATE
osteoporosis
loss of bone minerals
footdrop
- occurs when toes are allowed to fall toward the foot of the bed
- supine position- ankles should be flexed approximately 90 degree dorsiflexion
preventing musculoskeletal complications
correct Body alignment should be maintained while the patient is supine, Side-lying positions and even when sitting
ROM
range of motion
nursing actions to prevent contractures and osteoporosis
- perform ROM exercises every 8 hours
- assist with ambulation as soon as orders permit
footboard
- board placed at a 90 degree angle to the foot of the bed
- patients feet will be supported in a normal flexed position to prevent foot drop
pneumonia
- inflammation of lung tissue
- causes- bacterial, viral, fungal, aspiration, immobility
hypostatic pneumonia
lung infection occurring from immobility
pulmonary embolus (pe)
a blockage in the pulmonary artery, which supplies blood to the lungs
S/S of pulmonary embolus
- sudden shortness of breath
- sudden chest pain
- cough
- diaphoretic
- tachycardia
- tachypnea
atelectasis
lung collapse
shallow respirations
secretions blocking airways
patients who smoke
PASS acronym
pull-aim-squeeze-sweep
muscle atrophy
- muscle decreases in size, tone, and strength
- ligaments and tendons
supportive devices
foot-boot, gloves, wedges, pillows, (keeping someone on their side)
movement is considered an order
true
ROM exercises
- active- patient performs independently
- passive- you perform ROM for patient
degree for dorsiflex ?
90 degree angle
immobility cardiovascular system
bedrest
50% reduction of blood flow to the legs
(blood flow to the legs is venous return)
medical term for a blood clot
deep vein thrombosis
also known as a DVT
Embolus
clot becomes mobile-dislodges-moves through bloodstream
S/S OF DVT
- swelling
- pain
- redness
- increased warmth
- mayo only have 1 of the s/s
- asses/report/document
prevent DVT formation
- encourage movement of extremities -active or passive ROM exercise -leg excersies
- use devices to prevent pooling of blood in lower extremities
Anti-TED'S and anti-ems stockings
- need order (dependent intervention)
- make sure you can put 2 fingers in between
- checking circulation while they are on
anti-em guidlines
- wrinkles in stocking- can breakdown skin
- neurovascular- checking color of skin, warmth, and edema
- constant wetness against skin can cause breakdown (MAsculation)
- make Sure skin is dry before applying
intermittent sequential compression device (ISCD'S)
AKA- pneumonic air stockings
used for venous return, they are meant only for bed
ISCD purpose
- venous return of blood to the heart
- USE ONLY IN BED- remove for OOB activities
orthostatic hypotension
- decrease in BP when patient changes position
- form lying to sitting
- from sitting to standing