Unit 2 - Week 1

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1. ATI Fundamentals For Nursing Chapter 12 - Client and Safety 2. ATI Fundamentals For Nursing Chapter 13 - Home Safety 3. ATI Fundamentals For Nursing Chapter 14 - Sensory Perception 3. Lewis Medical Surgical Nursing Chapter 5 - Chronic Illness & Older Adults (Page 74 per guide) .
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1

Safety

is freedom from injury

2
  1. Age
  2. Mobility
  3. Cognitive and Sensory awareness
  4. Emotional State
  5. Ability to communicate
  6. Lifestyle and Safety Awareness

Factors that affect the client's ability to protect himself from injury

3

Seizure

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.

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Partial Seizure

are due to electrical surges in one part of the brain, and generalized seizures that involve the entire brain.

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  • 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?

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  • 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?

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  • 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

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Physical Restraint

devices, materials, and equipment that physically prevent individuals from moving freely, such as walking, standing, lying, transferring, or sitting.

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Chemical Restraint

drugs used to restrict the freedom or movement of a patient or in some cases to sedate the patient.

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  • vigilant
  • creative
  • sensitive nursing care

alternatives to restraints require:

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  1. Rescue clients who are in immediate danger
  2. Activate the fire alarm
  3. Confine the fire
  4. Extinguish the fire

Fire Safety: Priority Nursing Action

12

Physical Hazzard

if an electrical equipment is not maintained in good working order, and it is not grounded.

13
  • Musculoskeletal changes
  • Nervous System changes
  • Sensory changes
  • Genitourinary changes

Phsysiological Changes in Older Clients That Increase the Risk of Accidents

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  • 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)

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  • 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.

16

Clostridium difficile

  • 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.
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Nosocomial

  • known as Health Care-associated infections.
  • also known as hospital-acquired infections.
18

Internal disasters

disasters that occurs within the health care facility

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external disasters

disasters occurs in the community, and victims are brought to health care facility for care

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anthrax

  • 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)
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  • age
  • 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

22

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

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Stop-Drop-and-Roll

The mnemonic we should use when an event where client's clothing or skin is on fire.

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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.

B: Breathing

  • after achieving a patient airway, assess for the presence and effectiveness of breathing.

C: Circulation

  • after ensuring adequate ventilation, assess circulation

D: Disability

  • perform a quick assessment to determine the client's level of consciousness

E: Exposure

  • perform a quick assessment to determine the client's exposure to adverse elements such as heat or cold.

ABCDE Principle

guides the primary survey and emergency care.

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  • Bleeding
  • Fractures and splinting
  • Sprains
  • Heat Stroke

The primary surveys to complete before performing first aid.

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  1. Pain
  2. Pulse
  3. Pallor
  4. Paresthesia
  5. Paralysis

What are the 5 Ps when assessing fractures and splinting?

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  • R - rest
  • I - ice
  • C - compress
  • E - elevate

RICE principles used for sprains

28

CPR

  • 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.

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Sensory perception

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)

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Sensory Input

it affects consciousness, arousal, awareness, memory, affect, judgment, awareness of reality, and language.

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Sensory deficit

  • 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.
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Sensory deprivation

  • 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)
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Sensory overload

  • is excessive, sustained, and unmanageable multisensory stimulation.
  • similar to those sensory deprivation and include racing thoughts, anxiousness, and restlessness.
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Prespyopia

age-related loss of the eye's ability to focus on close objects due to decreased elasticity of the lense.

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Cataracts

Opacity of the lens, which blocks the entry of light rays into the eye

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Glaucoma

structural damage within the eye resulting from elevated pressure within the eye leading to blindness

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Diabetic retinopathy

noninflammatory changes in the eye's blood vessels leading to blindess

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Mascular degeneration

loss of central vision from deterioration of the center of the retina

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Ophthalmoscopy

allows visualization of the back part of the eyeball (fundus(, including the retina, optic dis, macula, and blood vessels.

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Visual acuity tests

Snellen adn Rosenbaum eye charts

41

Tonometry

Measures intraocular pressure (expected range 10 to 21 mm Hg), which is elevated with glaucoma, especially angle-closure glaucoma

42

Gonioscopy

allows visualization of the iridocorneal angle or anterior chamber of the eyes

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Slit lamp examination

allows visualization of the anterior portion of the eye, such as the cornea anterior chamber, and lens.

44

Conductive hearing loss

is an alteration in the middle ear that blocks sound waves before they reach the cochlea of the inner ear

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Sensorineural hearing loss

is an alteration in the inner ear, auditory nerve, or hearing center of the brain

46

Mixed hearing loss

is a combination of conductive and sensorineural hearing loss

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Audiogram

a diagnostic procedure that identifies whether hearing loss is sensorineural and/or conductive

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Tympanogram

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.

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Otoscopy

a diagnostic procedure that allows visualization of the external auditory canal, the tympanic membrane (TM), and malleus bone visible through the TM.

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Tympanoplasty

is a surgical reconstruction of the middle ear structure

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Myringoplasty

is an eardrum repair

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  • Presbyopia
  • cataracts
  • glaucoma
  • diabetic retinopathy
  • mascular degeneration
  • infection
  • inflammation
  • injury
  • brain tumor

Vision loss

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  • Obstruction
  • wax accumulation
  • tympanic membrane perforation
  • ear infections
  • otosclerosis

Conductive hearing loss:

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  • Exposure to loud noises
  • ototoxic medications
  • aging
  • acoustic neuroma

Sensorineural hearing loss:

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- 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

56

- Call clients by name before approaching to avoid startling them
- 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

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- 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

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- 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

59

Ergonomics

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.

60

Body mechanics

  • 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.
61

Body alignment

keeps the center of gravity stable, which promotes comfort and reduces strain on the muscles.