FUND ATI WEEK 2
Terms in this set (27)
What actions can a nurse do to ensure safety for their clients and the workplace?
Use risk assessment tools to evaluate clients and the environment
Encourage clients to speak up about their care
Communicate risk factors and plan of care to patients, family, and staff
ID and document incidents to help tract patterns and trends
Use equipment you are qualified to use only
Know the location of safety data sheets and hazardous chemicals
Why are older adults at an increased risk of falls?
They have decreased strength, balance, mobility, and endurance.
Focal or partial seizures
Electrical surges in one part of the brain.
Electrical surges that involve the whole brain.
A condition in which seizures recur every few minutes or last more than 30 minutes.
Describe how to handle a patient having a seizure.
Stay with the client and call for help
Maintain an open airway and suction secretions as needed
Not the duration, sequence, and movements
After, determine mental status and gather vital signs. Explain what happened and provide comfort.
Document the seizure (movements, injuries, duration, aura, postictal state) and report to provider
Describe precautions you can take to prepare for a seizure
Ensure rescue equipment is located close to the bed (oxygen, oral airway, suction, and padding)
Ensure rapid intervention
Remove all possibilities for injury during seizures
Assist client with ambulation and transferring to reduce falls
Advise family and caregivers to not put anything in the patients mouth during a seizure and to not restrain the patient. They can help by laying the patient on their size and protecting their head.
Describe the two types of client restraints
Physical (vest, belt, mitt, limb)
Chemical (sedatives or psychotrophic meds)
What are three complications that can arise from the use of restraints?
When is it inappropriate to use restraints or seclusion?
When the client is physically or mentally unstable
When the client cannot handle the decreased stimulation
What are four points to using restraints?
They should not interfere with treatment
They should restrict as little movement as possible
They should fit properly and be discreet
Be easy to remove and change
When should restraints be used?
As a last resort; when less restrictive means failed to prevent the client from harming themselves or others.
Clients are talked to, supervised, given diversional activities, and electronics before restrictive measures are taken.
What are the time limits for restraints?
4 hours on an adult
2 hours between 9-17
1 hour for those <9
Describe the process providers must go through to prescribe restraints.
They must meet face-to-face with the client to determine if it is necessary.
The prescrition should include:
The type of restraints
The location of the restraints
How long to use them
The behavior that warrants the use
While the client is in restraints, what are the nurses responsibilities?
Explaining they are necessary for staff and client safety
Get a signed consent form
Use a quick release knot
2 fingers between the restraints and client
Remove/replace frequently to ensure good circulation, allow full range of motion, and to evaluate the skin
Regularly determine the need to use the restraints
Regularly offer food/water, provide hygiene and elimination care, monitor vitals, offer ROM exercises
How do you document a restraint put on a client?
Behavior with restraints
Condition of skin in restraints
Response to removal
Type and frequency of care
What is the RACE sequence?
Rescue and protect clients
Alarm to others to report the fire
Contain the fire by closing doors, windows, and oxygen
Extinguish the fire if possible with an extinguisher
Describe the three classes of fire extinguishers
Class A: Paper, wood, upholstery, rags, or trash fires
Class B: Flammable liquids or gas
Class C: Electrical fires
What factors that put clients at higher risk for injury?
Mobility and balancce
Age and developmental status
Knowledge of hazards
Home and work environment
How can you avoid aspiration incidents in infants and toddlers?
Keep small objects out of reach
Check toys for sharp or loose parts
No whole hot dog, popcorn, peanuts, or hard candy
Do not feed in supine
No string around neck on pacifier
How can you avoid suffocation in infants and toddlers?
"Back to sleep"
No plastic bags or latex balloons
No toys in crib
Supervision in the bath
Fence in pools and teach swimming as early as possible
Keep bathrooms closed and toilet seats down
CPR and heimlich maneuver
How can you prevent poisoning in infants and toddlers?
Houseplants and cleaning agents out of reach
Remove sources of lead or inspect for chipping
Lock chemicals and medications away
Dispose of old medications
How can you prevent falls in infants and toddlers?
Keep crip/playpin rails up
Supervise when on high surfaces
Screened in windows and gated stairs
Restrain properly and supervise in high chairs, swings, and strollers
Place in low bed when toddler begins climbing
How can you avoid motor vehicle injuries in infants and toddlers?
Rear facing car seat until 2 or max out height and weight limit
Use a car seat with 5 point harness
Federally approved and in the back seat
How can you avoid burns in infants and toddlers?
Test the temp of bath water and formula
Use back burners and keep handles parallel to the wall
Supervise the use of faucets
Matches and lights should be locked away
Cover electrical outlets
Describe the four types of immobility
Temp: After surgery
Sudden onset: Fractured bones
Slow onset: Multiple sclerosis
Describe body mechanics
Coordination between the musculoskeletal and nervous system by using alignment, balance, gravity, and friction.