248 Test 1

Hospital caused death

Infection; failure to diagnose and treat in time; medication errors

195,000

• Falls; client inherent accidents;
• procedure related accidents; equipment related accidents

Lighting; bathroom hazards; pathogens; obstacles; security; other

• Reduces the incidence of illness and injury
• Prevents extended length of treatment/stay
• Improves or maintains functional status
• Increases client’s well being

• Includes meeting a client’s needs
• Reduces transmissions of pathogens
• Maintains sanitation, reduces pollution

• Developmental level
• Mobility, sensory and cognitive status
• Lifestyle choices
• Risks found in health care settings

• Safety of patient or others
• interruption of therapy

Removed every two hours and assess the area and the need for restraints

• Avoid IV site or proximal to IV site; secure to bed frame (not rails),
• avoid supine position because of aspiration risk, teach patient and family why restraints are needed

• Behavior of patient that caused
• restraints; actions tried prior to restraints being used; time restraints
• applied and type of restraints; patient response to restraints; care provided
• when restraints are on; time discontinued and response; other if needed

• Endocrine disorders
• calcium absorption problems
• change in GI function

• Calcium comes out of bones and can
• cause disuse osteoporosis, patient can also get hypercalcemia.

Loss of appetite which can lead to decreased peristalsis and fecal impaction

• Excess nitrogen is excreted and not
• enough protein is taken in so there is a negative nitrogen balance that can
• lead to weight loss, loss of muscle mass and weakness due to tissue loss

• Assess intake/output, listen to bowel
• sounds, give stool softeners/appetite enhancers as needed.

Upon standing an increase in heart rate of over 15%, a drop of 15mm+ systolic or a drop of 10mm+ diastolic.

Encourage patient to keep moving and drink lots of fluids

• Put patient in TEDS (check legs every shift)
• encourage lots of fluids
• check pressure on legs
• discourage crossing of legs

At least every 15 minutes

At least every 1-2 hours

The Braden scale

Collapse of alveoli caused by pooling of lung secretions in immobile patients. Can result in poor gas exchange. Pooling of secretions can also cause pneumonia.

spirometers, knowledge that pain and pain medications can depress respirations, encouraging patient to "turn, cough, deep breathe" every 1-2 hours

loss of muscle mass and endurance, bone breakages, contractures

urinary stasis causing infections and renal calculi

• moving patient regularly
• monitoring I&O
• looking for bladder distention
• providing good perineal care

• Stage 1: skin is intact but red (unblanchable)
• Stage 2: partial thickness skin loss, will look like abrasion
• Stage 3: full thickness skin loss and can see to fat
• Stage 4: will be able to see fat and bone/muscle/tendon

• rapidly regress to dependency
• loss of muscle strength, weakness, fatigue
• increased risk of falls
• functional decline
• increased risk of pneumonia
• skin breakdown; pressure ulcers
• change in environment causing impaired sleep, depression, confusion

• emotional and behavioral responses (hostility, giddiness, fear, anxiety
• Sensory alterations (sleep/wake)
• Changes in coping (depression, sadness, dejection)

to assist patients with restricted mobility to reduce hazards of immobility

Promotes client’s independence and strength while minimizing workload

Reduces risk of injury to lumbar vertebrae and muscle groups

100 lb at arms length

They are stronger, larger and capable of greater work without injury

Sliding requires less effort than lifting and a pull sheet reduces shearing which can damage a client’s skin

Stabilization and minimization of the trunk

Musculoskeletal

When a microorganism invades the host but does not cause infection

Infectious agentàresevoiràportal of exitàmode of transmissionàportal of entryàhostàinfectious agent

• Nutritional status
• Stress and crowded conditions
• Heredity, age
• Disease processes (diabetes, immune compromised etc)
• Medical therapy (devices, surgery)

• Immune system senescence
• Altered lymphocyte ptoduction
• Nutrition, weight loss, low serum albumin

• Intact skin
• Organ-body system specific
• Inflammatory response

Fever; increased pulse and rr; malaise; nausea; vomiting; anorexia

Increased WBC, increased sedimentation rate and + culture

Redness, heat, swelling, pain, exudate

Medical: practice to reduce microorganisms, clean technique

Surgical: eliminate microorganisms, sterile

Iatrogenic, exogenous (from outside of patient), endogenous (from within

One that is hospital acquired from a diagnostic or theraputic procedure.

A postoperative infection from an organism that was present outside the client

An infection from when the client’s flora becomes altered and overgrowth occurs.

• Items that enter sterile tissue or the vascular system. Must be sterile.
• EG- surgical instruments, catheters, implants

• Items that some in contact with mucus membranes or nonintact skin. Must
• be sterilized. Eg. Respiratory and anesthesia equpt, scopes and tubes

• Items that come into contact with intact skin but not mucous membranes.
• Must be clean. Eg – bedpans, stethoscopes, linens etc.

• Handwashing, gloves, protective eyeware, gowns if needed, cleaning of
• equipment, laundry bagged safely, sharps disposed of safely, private room not
• needed

• Private, negative flow room with HEPA filter and special fit mask (TB, chickenpox,
• measles)

Mask (strep, pneumonia) usually private room

Usually private room, gowns, gloves (VRE, MRSA)

Private room, masks, gowns, gloves etc

• Direct contact with blood or potentially infectious material with an open area of skin, blood or splash in eye, mouth, nose, cuts (can also be blood
• borne pathogens

• Only touched with sterile objects
• Only sterile objects on field
• Above waist and within vision
• Contaminated by air currents, droplets etc
• Contaminated by capillary action
• Water flows down away from hands with handwashing
• 1 inch border
• Only touch edges of containers
• Never reach across field
• Always face towards field
• Avoid draft, currents, sneezes etc

• Social patterns
• Body image
• Health beliefs and motivation
• Personal preferences
• Socioeconomic factors
• Cultural variables

• Cleanliness, prevention of infection
• Circulation stimulation
• Skin conditioning
• Client self image
• Comfort and relaxation
• Maintain ROM and joint function

Bedpan, face/hands, oral

Hands/face, oral, bedpan, linen

• Maintain/promote health of mouth,
• removal of food/plaque/bacteria,
• enhance well being,
• stimulate appetite,
• infection prevention

• Greater need
• Stomatitis (avoid alcohol rinses)
• Position– HOB lowered, head turned
• Tongue blade assess gag reflex – may need suction
• Do not place fingers in mouth