Fundamentals of Nursing, Chapter 27, set 2, Temple College

nursing history
This includes data about a person’s level of Wellness to determine if any underlying conditions exist that pose threats to safety. Ex., lower body muscle strength


Federal Emergency Management agency

Range of motion

– Through the patient’s eyes,
– nursing history,
– Healthcare environment which includes risk for Falls, risk for medical errors, disasters,
– patients home environment.

Nursing process
Assessment, diagnosis, planning, implementation, evaluation

Critical thinking model for the nursing process
Knowledge, experience, standard, attitudes – kesa

What is your knowledge? What is your experience?
What are the standards?
What attitude should you have?

excessive outward curvature of the spine, causing hunching of the back.

A standard approach to communication -situation, background, assessment, recommendation – this helps to obtain and organize information.

90 million
# Americans have low health literacy

Type a – used for ordinary combustibles.
Type b – used for flammable
Type c – used for electrical equipment

Extinguisher Process
P – pull pin
A – aim at base of fire
S – squeeze handles
S – sweep from side to side

Fire – know phone number for reporting fires, know evacuation and drill, know locations of extinguishers, turn off Oxy,
R – rescue and remove
A – activate the alarm
C – confine fire, shut doors
E – extinguish fire

Poison control number

Safety expected outcomes
– A Safe physical environment
– a patient whose expectations have been met
– a patient who is knowledgeable about safety factors and precautions
– a patient free of injury

Safe environment
An environment that basic needs are met, physical hazards are reduced, transmission of pathogens is reduced, sanitation is maintained, pollution is controlled.

Medical asepsis
Includes hand hygiene and environmental cleanliness, reduces the transfer of organisms. Aseptic practice, can teach to patients.

Fall Risk
Poor Vision, cognitive dysfunction, impaired gait or balance and difficulty walking, difficulty getting in and out of bed, orthostatic hypotension, urinary frequency or receiving diuretics, weakness from disease process or therapy, current medication.

Safety risks in health care agency
Chemical used, medical errors, Falls, accidents

National patient safety goals
Identify patients correctly, improve staff communication, use medicines safely, use alarms safely, prevent infection, prevent mistakes in surgery.

Required in health care. Provides detailed information about the chemical, health hazards from post, first aid guidelines, and precautions for Safe Handling and use. They give information on the steps to take in case material is released or spilled.

Is often a bright light, smell, or taste.

Hyper excitation and disorderly discharge of neurons in the brain leading to a sudden, Violent, involuntary series of muscle contractions that is paroxysmal and episodic, causing loss of consciousness, falling, tonicity, and clonicity.

Rigidity of muscles

Jerking of muscles

Status epilepticus
A medical emergency that requires intensive monitoring and treatment. Prolonged or repeated seizures indicate this.

Seizure precautions
These Encompass all nursing interventions to protect a patient from traumatic injury, position for adequate ventilation and drainage of oral secretions, and provide privacy and support following a seizure.

Tonic clonic seizure
Insert a bite block or oral Airway in advance if you recognize the possibility of this type of seizure.

5 Ps
Pain, potty, position, possessions, and plan of care – hourly rounding and checking these help prevent falls and call light response

Fall prevention
– Fall risk assessment tool
– hospital bed with side rails, low bed
– call light, intercom system
– gait belt
– wheelchair, walker, non skid footwear
– bed alarm pad, wedge cushion

– symptoms at time of fall
– previous fall
– location of fall
– activity at time of fall
– time at fall
– trauma After Fall

Fall inducing meds
Sedatives, hypnotics, tranquilizers, analgesics, diuretics

Timed get up and go
Tug for fall assessment,

Circulation, movement, sensation – check restraints for

Types of restraints
Chemical, elbow, mitt, 4 point, extremity, physical, belt

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nutrition study of food, how it affects the body and influences health and how the body metabolizes food for energy -adequate nutriton is essential to wellness and poor nutrition leads to disease nutrients -building blocks for cells and tissues -supply …

Nursing diagnostic process assessment of patients health status——->validate data with other sources————>are additional data needed?————>no—————>interpret and analyze meaning of data————–>data clustering (group signs and symptoms, classify and organize)————->look for defining characteristics and related factors———->identify patients needs———->formulate nursing dignoses and collaborative …

Nursing Process a way of thinking and acting based on scientific method Nursing Process a tool for identifying patients problems or potential problems and an organized method for meeting patients needs WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY …

. One purpose of using standard formal nursing diagnoses in practice is to a. Form a language that can be encoded only by nurses. b. Distinguish the nurse’s role from the physician’s role. c. Allow for the communication of patient …

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