Exam (elaborations)
NURS 2528 - Practice Lab 1 (TEST 1)
- Module
- MSF Basic Rider Course Test
- Institution
- MSF Basic Rider Course Test
NURS 2528 - Practice Lab 1 (TEST 1)
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NURS 2528 - Practice Lab 1 (TEST 1)4 moments of hand hygiene - ANS-1. Before initial patient/patient environment contact
2. Before aseptic procedure
3. After body fluid exposure risk
4. After patient/patient environment contact
4 types of bone - ANS-long, short, flat, irregular
active ROM - ANS--the resident assist with the movement
-normal day to day movement
-can be achieved by opposing muscles that contract + relax; joint movement
-improve muscle mass, tone, strength
alchohol based rub - ANS--kills organism in seconds
-preferred method of HH if not visibly soiled
alignment - ANS-posture
ambulate to chair - ANS-- 3 times daily
- especially at mealtime
- shift weight "cheek to cheek" q15m or q1h if dependant
assess (principles of ROM) - ANS-before and during
assessing risk for falls - ANS-- sit and stand test
- get up and go test
-a simple way to assess muscle balance and strength
authority to use restraints - ANS--doctors order
-must have patients permission
-emergency: harmful to others
-patient is able to refuse
base of support - ANS-area beneath of person
basic aseptic principles - ANS-- clean to dirty (head to toe)
- distal to proximal
- front to back
,bed bath - ANS--Only if patient is unable
-Always promote independence
-Ensure privacy
-Assess pain & need BR prior
-Gather all equipment
-Organization is critical!
-Do as much as possible at once!
bed bath : protective behaviors - ANS-- Moisturizers - use sparingly
- Powder - Avoid use
bed bath tips - ANS-- Fold washcloth as a mitt
- Wash, Rinse, Pat dry
- Soak hands and feet if possible
- Special attention to skin folds
bed bath: procedure - ANS-- Wash Eyes First: No soap, inner to outer canthus,
separate part of cloth
- Front: Face, Neck, Arms, Chest, Abdomen, Legs, Perineum
- Back: Back, Buttocks, Anal area
bed making - ANS--PPE
-bring what you need
-carry soiled linens away from you
-if linen falls, discard
-don't place dirty linens on the floor
bed making guidelines - ANS--change prn or scheduled
-work head- toe
-check personal belongings
-work together
-if alone make one side before other
bedside basics: environmental space - ANS-brakes,call bell, clutter,bed height, side rails
etc
bedside basics: physical environment - ANS-intimate space - personal space - social
space - public space
, bedside table - ANS--clients personal space
-don't work around things
-don't touch without permission
bedside tables - ANS--used to store personal care items
-don't work around things
-don't touch things without permission
behavioural fall risk factors - ANS--previous falls
-fear of falling
-medications
-alcohol
-lack of exercise/sleep
body mechanics - ANS-efficient use of the body as a machine
braden skin interventions: high risk - ANS--continue moderate risk interventions,
supplement turning with shifts in weight
• Very High Risk
braden skin interventions: mildly at risk - ANS--turning schedule
-maximum remobilization
-heel protection
-management of moisture and nutrition, pressure reduction support
braden skin interventions: moderate risk - ANS--continue mild risk interventions
-turn patient between 15-30 degrees
-elevate head of bed up to 30 degrees for short periods only
braden skin interventions: very high risk - ANS--continue high risk interventions, air
mattress may be indicated, must have a turning schedule
bradens skin assessment - ANS-• Sensory Perception
• Moisture
• Activity
• Mobility
• Nutrition
• Friction and Shear
break the chain of infection: infectious agent - ANS-disinfect, sterilize
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