precautions / protocols

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created 10 years ago by tracey_brown4238
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updated 10 years ago by tracey_brown4238
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College: Second year
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1

Hip Precautions/Protocols:

No hip flexion past 90

2

Back Precautions/Protocols:

No bending

3

Orthostatic Hypotension Episode:

Call for help!
Client must be reclined quickly.

4

Cardiac/Sternal Precautions/Protocols:

No pushing

5

Orthostatic Hypotension Episode:

Symptoms: dizziness, nausea, and loss of consciousness.

6

Suicide Precautions:

Counting all sharps used during group and/or 1:1 treatment (if appropriate)

.

7

Autonomic Dysreflexia Episode:

Call for help!
Place client in upright position
Remove anything that is restrictive to reduce blood pressure
Bladder should be drained or leg bag tubing checked for obstruction.
Monitor symptoms and blood pressure until the client returns to normal

8

Autonomic Dysreflexia Episode:

Symptoms: immediate pounding headache, anxiety, perspiration, flushing, chills, nasal congestion, paroxysmal hypertension, and bradycardia.

9

Autonomic Dysreflexia Episode:

Medical emergency and life threatening

10

Skin Breakdown, Pressure Sores, or Decubitus Ulcers:

Prevention: Routine skin checks and protecting areas of the body that may experience excessive shearing, heat and moisture. Instruct client in pressure relief techniques. Repositioning of body

11

Suicide Precautions:

No aluminum cans, plastic forks, plastic bags (even trash bags are paper), etc
Listen closely to clients and report any safety issues to nursing

12

CVA

No blood pressures on affected UE

13

Skin Breakdown, Pressure Sores, or Decubitus Ulcers:

Symptoms: Reddened area, blanches when pressed, then reddened area no longer blanches with pressure (necrosis begins). Blister or ulceration appears.

14

Deep Vein Thrombosis:

Symptoms: LE is hot, red, edemas, tender to the touch (hard), appearance (shiny).

15

Suicide Precautions:

If you have a patient with self-injurious behaviors no pencils or markers can be left unattended (swallowing the marker caps has occurred).

16

Suicide Precautions:

Monitor bathroom use while in group as the doors can be looked from the inside and require a special key to unlock from outside

17

Deep Vein Thrombosis:

Stop treatment, notify nursing, and notify the OT. Follow facility protocol in regards to resuming treatment

18

General Transfer and Standing Precautions:

All clients must have some sort of safe and secure foot coverings on prior to standing or transferring

19

Hip precaution/protocol

No twisting operated leg in or out (internal/external rotation)

20

CVA:

Fall precautions

21

Back Precautions/Protocols:

No lifting

22

Suicide Precautions:

Lock sharp cabinets and draws.
15 min checks on all patients by staff whether in group or not.

23

CVA

Be aware of possible safety issues based on

24

Hip precaution/protocol

No crossing legs, ankles or feet

25

General Transfer and Standing Precautions:

Gait belt must be on snuggly and securely. Use the two finger rule

26

Cardiac/Sternal Precautions/Protocols:

No pulling

27

Back Precautions/Protocols:

No twisting
Adhere to ‘log rolling’ technique with bed mobility

28

Orthostatic Hypotension Episode:

Call for help
If in a wheelchair, the wheelchair should should be tipped back with legs elevated.

29

Cardiac/Sternal Precautions/Protocols:

No lifting

30

General Transfer and Standing Precautions:

Make sure beds, b/s chairs, b/s commodes, tub seats or tub benches and wheelchairs are secure and breaks are locked if appropriate