Unit 2 - Week 1
is freedom from injury
- Cognitive and Sensory awareness
- Emotional State
- Ability to communicate
- Lifestyle and Safety Awareness
Factors that affect the client's ability to protect himself from injury
is a sudden surge of electrical activity in the brain.
It can occur at any time due to epilepsy, fever, or a variety of medical problems.
are due to electrical surges in one part of the brain, and generalized seizures that involve the entire brain.
- R - rescue
- A - alarm
- C - contain/confine
- E - extinguish
Follow the RACE sequence when it comes to Fire Safety.
What does RACE abbv stands for?
- P - pull the pin
- A - aim at the base of the fire
- S - squeeze the handle
- S - sweep the extinguisher from side to side, covering the area of the fire
Follow the PASS sequence when it comes to using fire estinguisher
What does PASS abbv stands for?
- Class A - for combustibles such as paper, wood, upholstery, rags, and other types of trash fires.
- Class B - for flammable liquids and gas fires.
- Class C - for electrical fires.
Classes of fire stinguisher
devices, materials, and equipment that physically prevent individuals from moving freely, such as walking, standing, lying, transferring, or sitting.
drugs used to restrict the freedom or movement of a patient or in some cases to sedate the patient.
- sensitive nursing care
alternatives to restraints require:
- Rescue clients who are in immediate danger
- Activate the fire alarm
- Confine the fire
- Extinguish the fire
Fire Safety: Priority Nursing Action
if an electrical equipment is not maintained in good working order, and it is not grounded.
- Musculoskeletal changes
- Nervous System changes
- Sensory changes
- Genitourinary changes
Phsysiological Changes in Older Clients That Increase the Risk of Accidents
- Reason for safety device
- Method of use for safety device
- Date and time of application of safety device
- Duration of use of safety device and client's response
- Release from safety device with periodic exercise and circulatory, neurovascular, and skin assessment
- Assessment of continued need for safety device
- Evaluation of client's response
Documentation Points with Use of a Safety Device (Restraint)
- Use available safety equipment
- Keep the weight to be lifted as close to the body as possible
- Bend at the knees
- Tighten abdominal muscles ad truck the pelvis
- Maintain the trunk erect and knees bent so that multiple muscle groups work together in a coordinated manner.
Steps to prevent Injury to the Health Care Worker when moving a client.
- is spread mainly by hand-to-hand contact in a health care setting.
- Clients taking multiple antibiotics for a prolonged period are most at risk.
- known as Health Care-associated infections.
- also known as hospital-acquired infections.
disasters that occurs within the health care facility
disasters occurs in the community, and victims are brought to health care facility for care
- is transmitted by direct contact with bacteria and spores.
- spores are dormant encapsulated bacteria that become active when they enter a live host
- usually treated with antibiotics
- transmission (skin, gastrointestinal, inhalation)
- mobility and balance
- knowledge about safety hazards
- sensory and cognitive awareness
- communication skills
- home and work environment
- community in which the client lives
- lifestyle choices
Risk factors for client Injury
physical, cognitive, and sensory changes
changes in the musculoskeletal and neurological systems
impaired visions/or hearing
frequesnt trips to the bathroom at night because of nocturia and incontinence
Risk factors for fall in older adults
The mnemonic we should use when an event where client's clothing or skin is on fire.
A: Airway/Cervical Spine
- most important step in performing the primary survey.
- if patient airway is not established, subsequent steps of the primary survey are futile
- protect cervical spine if head of neck trauma is suspected.
- after achieving a patient airway, assess for the presence and effectiveness of breathing.
- after ensuring adequate ventilation, assess circulation
- perform a quick assessment to determine the client's level of consciousness
- perform a quick assessment to determine the client's exposure to adverse elements such as heat or cold.
guides the primary survey and emergency care.
- Fractures and splinting
- Heat Stroke
The primary surveys to complete before performing first aid.
What are the 5 Ps when assessing fractures and splinting?
- R - rest
- I - ice
- C - compress
- E - elevate
RICE principles used for sprains
- CardioPulmonary Resuscitation
is a combination of basic interventions designed to sustain oxygen and circulation to vital organs until more advanced interventions can be initiated to correct the root cause of the cardiac arrest.
is the ability to receive and interpret sensory impressions through sight (visual), hearing (auditory), touch (tactile), smell (olfactory), taste (gustatory), and movement or position (kinesthetic)
it affects consciousness, arousal, awareness, memory, affect, judgment, awareness of reality, and language.
- is a change in reception and/or perception.
- it can affect any of the senses.
- if it develops gradually, the body often compensates for the deficit.
- is reduced sensory input from the internal or external environment.
- it can result from illness, trauma, or isolation.
- can be cognitive (decreased ability to lean, disorientation), affective (restlessness, anxiousness), or perceptual (decreased coordination, decreased color perception)
- is excessive, sustained, and unmanageable multisensory stimulation.
- similar to those sensory deprivation and include racing thoughts, anxiousness, and restlessness.
age-related loss of the eye's ability to focus on close objects due to decreased elasticity of the lense.
Opacity of the lens, which blocks the entry of light rays into the eye
structural damage within the eye resulting from elevated pressure within the eye leading to blindness
noninflammatory changes in the eye's blood vessels leading to blindess
loss of central vision from deterioration of the center of the retina
allows visualization of the back part of the eyeball (fundus(, including the retina, optic dis, macula, and blood vessels.
Visual acuity tests
Snellen adn Rosenbaum eye charts
Measures intraocular pressure (expected range 10 to 21 mm Hg), which is elevated with glaucoma, especially angle-closure glaucoma
allows visualization of the iridocorneal angle or anterior chamber of the eyes
Slit lamp examination
allows visualization of the anterior portion of the eye, such as the cornea anterior chamber, and lens.
Conductive hearing loss
is an alteration in the middle ear that blocks sound waves before they reach the cochlea of the inner ear
Sensorineural hearing loss
is an alteration in the inner ear, auditory nerve, or hearing center of the brain
Mixed hearing loss
is a combination of conductive and sensorineural hearing loss
a diagnostic procedure that identifies whether hearing loss is sensorineural and/or conductive
a diagnostic procedure that measures the mobility of the tympanic membrane and middle ear structures relative to sound to diagnose disorders of the middle ear.
a diagnostic procedure that allows visualization of the external auditory canal, the tympanic membrane (TM), and malleus bone visible through the TM.
is a surgical reconstruction of the middle ear structure
is an eardrum repair
- diabetic retinopathy
- mascular degeneration
- brain tumor
- wax accumulation
- tympanic membrane perforation
- ear infections
Conductive hearing loss:
- Exposure to loud noises
- ototoxic medications
- acoustic neuroma
Sensorineural hearing loss:
- sit and face the client
- avoid covering your mouth while speaking
- encourage the use of hearing devices
- speak slowly and clearly
- do not shout
- Try lowering vocal pitch before increasing volume
- Use brief sentences with simple words
- Write down what clients do not understand
- Minimize background noise
- Ask for a sign language interpreter if necessary
Interventions for clients who have hearing loss
- Call clients by name before approaching to avoid startling
- identify yourself
- stay within clients visual field if they have a partial loss
-Give specific information about the location of items or areas of the building
-Explain interventions before touching clients
- Before leaving, inform client of your departure
- Carefully appraise clients clothing, and suggest changes if soiled or torn
- Make a radio, television, CD Player, or digital audio player available
- Describe the arrangement of the food on the tray before leaving the room
Interventions for clients who have vision loss
- Greet clients and call them by name
- make sure only one person speaks at a time
- speak clearly and slowly using short sentences and simple words
- do not shout
-pause between statements to allow time for clients to understand
-check for comprehension
-tell clients when you do not understand them
- ask questions that require simple answers
- reinforce verbal with nonverbal communication
- allow plenty of time for clients to respond
- use methods speech therapists implement, such as a picture chart, to improve communication
- acknowledge any frustration in communicating
Interventions for clients who have aphasia
- Call clients by name and identify yourself
- maintain eye contact at eye level
- use brief, simple sentences
- ask only one question at a time
- allow plenty of time for clients to respond
- give directions one step at a time
- avoid lengthy conversations
- provide for adequate sleep and pain management
Interventions for clients who are disoriented
is a science that focuses on the factors or qualities in an object's design or use that contribute to comfort, safety, efficiency, and ease of use.
- is the use of muscles to maintain balance, posture, and body alignment when performing a physical task.
- it is used when providing care to clients by lifting, bending, and assisting clients with the activities of daily living.
keeps the center of gravity stable, which promotes comfort and reduces strain on the muscles.