West Coast University: NURS 100 Funds Midterm Study Guide Review 2,100% CORRECT
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Course
NURS 100
Institution
NURS 100
West Coast University: NURS 100Funds Midterm Study Guide Review 2
Funds Lecture Midterm Study Guide
Fall Prevention
- Complete a fallrisk assessment for each patient conducted on admission and routinely until patients discharge.
o Many health care organizations are implementing hourly round...
west coast university nurs 100funds midterm study guide review 2
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West Coast University: NURS 100Funds Midterm Study Guide
Review 2
Funds Lecture Midterm Study Guide
Fall Prevention
- Complete a fallrisk assessment for each patient conducted on
admission and routinely until patients discharge.
o Many health care organizations are implementing hourly rounding.
- Apply yellowcolored wristband to patients to communicate that patient is at
risk of falling.
- Be sure patient knows how to use call light and that it is in reach
- Provide regular toileting and orientation of clients who have cognitive
impairments
- Placement of a fall pad on the floor alongside the bed
- Use of bed safety alarms and motion detectors
- Provide adequate lighting
- Be sure patients knows how to use all assistive devices
o Canes, crutches, or walker
o Remember to check condition of aids
- Place patients at risk for falling near nurses’ station
- Keep important/ frequently used items within reach
- Remove excess furniture and equipment
- Make sure patients wear rubbersoled shoes, slippers, or socks
- Keep bed at lowest positions and lock wheels of bed and wheelchair
- Keep side rails up for patients who are unconscious or sedated
- Use gait belts when moving patient
- Keep floor clean, dry, and free of clutter
- Educate patient and family of safety risks
- Chair/bed sensors for patients at risk for getting up without assistance
- Report and document all incidents
Fecal Occult Blood Testing
- Measures microscopic amounts of blood in feces
- Diagnostic screening tool for colon cancer
- Test must be repeated 3 times from 3 different stools, while patients
refrains from ingesting foods (raw veggies, red meat, poultry, fish) and
medications (Vit. C, aspirin, NSAIDS)
,Black stool indications:
- Iron ingestion
- Upper GI bleeding or injury
, Sleep Disorders
Insomnia
- Chronic difficulty sleeping (chronic)
- May be caused by stressful situations (acute)
- Signals underlying physical or psychological disorder
- Associated with poor sleep hygiene
Sleep Apnea: lack of airflow through nose and mouth for periods of 10 seconds or
longer during sleep
- Central Sleep Apnea: CNS dysfunction – brain fails to trigger breathing during
sleep
- Obstructive Sleep Apnea: structures in throat and mouth relax during
sleep and occlude upper airway low oxy sat levels
- Patients frequently experience excessive daytime sleepiness and fatigue
- Rarely achieve deep sleep
Narcolepsy: person falls asleep uncontrollably at inappropriate times
- Excessive daytime sleepiness is the most common complaint
- REM occurs within 15 minutes of falling asleep
- Brief daytime naps no longer than 20 minutes help reduce sleepiness
- Regular exercise and healthy sleeping habits also
help Nursing diagnosis for sleep disorders:
- Anxiety
- Ineffective breathing pattern
- Acute confusion
- Ineffective coping
- Insomnia
- Fatigue
- Disturbed sleep pattern
- obstruction
- Sleep deprivation
- Readiness for enhanced sleep
Vital Signs – Normal ranges
- Blood Pressure: 120/80 mmHg
- Pulse: 60100 beats per minute
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