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Terms in this set (77)

- fall-risk assessment for each client at admission and at regular intervals. instruct a client who has orthostatic hypotension to avoid getting up too quickly, to sit on the side of the bed for a few seconds prior to standing, and to stand at the side of the bed for a few seconds prior to walking.
● Be sure the client knows how to use the call light (by giving a return demonstration), that it is in reach, and to encourage its use.
● Respond to call lights in a timely manner.
● Use fall-risk alerts (color-coded wristbands).
● Provide regular toileting and orientation of clients who have cognitive impairment.
● Provide adequate lighting.
● Orient clients to the setting to make sure they know how to use all assistive devices (grab bars) and can locate necessary items.
● Place clients at risk for falls near the nurses' station.
● Provide hourly rounding.
● Make sure' bedside tables, overbed tables, and frequent-use items (telephone, water, facial tissues) are within reach.
● Keep the bed in the low position and lock the brakes. ● For clients who are sedated, unconscious, or otherwise compromised, keep the side rails up.
● Avoid the use of full side rails for clients who get out of bed or attempt to get out of bed without assistance. ● Provide nonskid footwear and nonskid bath mats for use in tubs and showers.
● Use gait belts and additional safety equipment when moving clients.
● Keep the floor clean, dry, and free from clutter with a clear path to the bathroom (no scatter rugs, cords, or furniture)
Keep assistive devices nearby after validation of safe use (eyeglasses, walkers, transfer devices).
● Educate the client and family about safety risks and the plan of care. Clients and family who are aware of risks are more likely to call for assistance.
● Lock the wheels on beds, wheelchairs, and carts to prevent them from rolling during transfers or stops.
● Use electronic safety monitoring devices (chair or bed sensors) for clients at risk for getting up without assistance to alert staff of independent ambulation.
● Report and document all incidents. This provides valuable information that can help prevent similar incidents.
Administered through metered-dose inhalers (MDI) or dry-powder inhalers (DPI) MDI CLIENT EDUCATION ● Remove the cap from the inhaler's mouthpiece. ● Shake the inhaler vigorously five or six times. ● Hold the inhaler with the mouthpiece at the bottom. ● Hold the inhaler with your thumb near the mouthpiece and your index and middle fingers at the top. ● Hold the inhaler about 2 to 4 cm (1 to 2 in) away from the front of your mouth or close your mouth around the mouthpiece of the inhaler with the opening pointing toward the back of your throat. ● Take a deep breath, and then exhale. ● Tilt your head back slightly, press the inhaler, and, at the same time, begin a slow, deep inhalation breath. Continue to breathe slowly and deeply for 3 to 5 seconds to facilitate delivery to the air passages. ● Hold your breath for 10 seconds to allow the medication to deposit in your airways. ● Take the inhaler out of your mouth and slowly exhale through pursed lips. ● Resume normal breathing. ● A spacer keeps the medication in the device longer, thereby increasing the amount of medication the device delivers to the lungs and decreasing the amount of medication in the oropharynx. ● For clients who use a spacer ◯ Remove the covers from the mouthpieces of the inhaler and of the spacer. ◯ Insert the MDI into the end of the spacer. ◯ Shake the inhaler five or six times. ◯ Exhale completely, and then close your mouth around the spacer's mouthpiece. Continue as with an MDI.