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Using the senses of sight, hearing, touch, and smell to collect information
Observation
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That which is desired in or by the person as a result of nursing care
Goal
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Describes a health problem that can be treated by nursing measures; a step in the nursing process
Nursing diagnosis
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Things a person tells you about that you cannot observe through your senses
Subjective data
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The identification of a disease or condition by a doctor
Medical diagnosis
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Objective (signs)
What you see
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Subjective (symptoms)
Cannot be seen. Patient verbalizes and feels it.
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The 5 steps of the nursing process
- 1. Assessment
- 2. Nursing diagnosis
- 3. Planning
- 4. Implementation
- 5. Evaluation
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Assessment
Collecting information about the person. The nurse takes health history about current and past health problems.
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Nursing diagnosis
Describes a health problem that can be treated by nursing measures.
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Planning
Setting priorities and goals. Priorities relate to what is most important. Goal is that which is desired for a or by a person as a result of nursing care.
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Implementation
The step of performing or carrying our nursing interventions (nursing measures or nursing actions).
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Evaluation
Step involves measuring if the goals in the planning steps were met.
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List the rules to follow for verbal communication:
- Face the person, look directly at the person.
- Position yourself at the person’s eye level. Sit or squat by the person as needed.
- Control the loudness and tone of your voice.
- Speak clearly, slowly, and distinctly.
- Do not use slang or vulgar words.
- Repeat information as needed.
- Ask 1 questions at a time. Wait for an answer.
- Do not shout, whisper, or mumble.
- Be kind, courteous, and friendly.
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List nine communication barriers.
- Unfamiliar language.
- Cultural differences.
- Changing the subject.
- Giving your opinion.
- Talking a lot when others silent.
- Failure to listen.
- Pat answers.
- Illness and disability.
- Age.
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List five causes of inappropriate sexual behaviors.
- Disease.
- Confusion
- Dementia.
- Drug side effects.
- Done on purpose.
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A left side-lying position in which the upper leg is sharply flexed so that it is not on the lower leg and the lower arm is behind the person.
Sims’ position
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Lying on the abdomen with the head turned to one side
Prone position
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A semi-sitting position; the head of the bed is raised between 45 and 60 degrees
Fowler’s position
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Using the body in an efficient and careful way
Body mechanics
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The way the head, trunk, arms, and legs are aligned with one another; posture
Body alignment
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The area on which an object rests
Base of support
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Keep your body in good alignment with a ____ base of support.
wide
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Keep objects ____ to your body when you lift, move, or carry them.
close
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____ your work area. This prevents unnecessary ____.
Face, twisting
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____, _____, or ____ heavy objects whenever you can rather than lifting them.
Push, slide, or pull
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Bend your _____ and ____ to lift heavy objects from the floor.
hips and knees
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The goal of ergonomics is to
Help reduce stress on the worker’s body.
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Early signs and symptoms of work-related musculoskeletal disorders include:
- Pain.
- Limited joint movement.
- Soft tissue swelling.
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Contractures can develop from staying in one position too long.
Moving, turning, and repositioning help prevent contractures.
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Why are beds raised to move persons in bed?
The reduces bending and reaching
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You must perform tasks safely. The _____ and ________ tell you how many staff members are needed to complete a task.
The care plan and nurse’s directions
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_______ is the rubbing of one surface against another.
Friction
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Moving the person up in bed is best done with at least two staff members. Perform this procedure alone only if:
- The person is small in size.
- The person can follow directions.
- The person can assist with much or some of the moving.
- The person uses a trapeze.
- The person can push against the mattress with or her feet.
- The nurse says it is safe to do so.
- You are comfortable doing so.
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List three methods used to move persons to the side of the bed.
- Moving the person in segments.
- Moving the person with a drawsheet.
- Use a mechanical lift.
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A mechanical lift or the assist device method is used to move the following persons in bed:
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Logrolling is
Turing the person as a unit, in alignment, with 1 motion.
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Before you begin, what information do you need from the nurse and the care plan?
- Areas of weakness.
- The person’s functional status.
- The amount of help the person needs.
- If you need a co-worker to help you.
- If the bed is raised or in a low position, safe, and comfortable for the person.
- How long the person needs to sit on the side of the bed.
- What exercises are to be done while dangling.
- If the person will walk or transfer to a chair after dangling.
- What observations to report and record.
- When to report observations. k. What patient or resident concerns to report at once.
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______ is to turn one’s body from a set standing position.
Pivot
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A lateral transfer is
When a person moves between 2 horizontal surfaces.
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______ the breaks when transferring to or from the wheelchair.
Lock
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_______ is a common fear for persons in mechanical lifts.
Falling
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To promote mental comfort when transferring a person, you should:
- Explain what you are going to do and how the person can help.
- Screen and cover the person to protect the right to privacy.
- Keep the person in good alignment.
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Friction-reducing devices that protect the skin from friction and shearing during lateral transfers include:
- Lift sheet, turning sheet or drawsheet.
- Turning pad.
- Large re-usable waterproof underpad.
- Slide sheet.
- Lateral transfer device with a slide board.
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Mechanical lifts are used for persons _______ and/or _______.
Too heavy for staff and/or for a person who cannot assist with transfer.
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Stand-assist lifts are used for persons who require some help with transfers and can:
- Bear some weight.
- Follow directions.
- Sit up the side of the be with or without assistance.
- Bend the hips, knees, and ankle.
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Full-sling mechanical lifts are used for persons who:
- Cannot assist with transfers.
- Are partially able or unable to bear weight.
- Are heavy.
- Have physical limits preventing others types of transfers.
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Why is it important for the person to wear non-skid footwear for transfers?
This footwear protects the person from falls, and prevents slipping and sliding.
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MDS
Electronic program that shows potential problems with patients
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Communication Methods
- Listening
- Paraphrasing
- Direct Questions
- Open ended questions
- Clarifying
- Focusing
- Silence
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Maslow's Hierarchy of needs (bottom to top)
- Physical needs
- Safety and Security needs
- Love and belonging needs
- Self-esteem needs
- Self actualization needs
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What are the 4 factors that causes work related injuries?
Force, repeating action, awkward postures, heavy lifting.
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