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