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68C Exam 10

Basic Nursing

QuestionAnswer
Infancy 30 days to 1 year.
Toddler 1 to 3 years
Preschool 3 to 5 years
School age 3 to 5 years
Adolescence 13 to 19 years
Middle adulthood 40 to 65 years
Late adulthood 65 years and over
Growth progressive anatomic and physiologic increase in size.
Development increase in function or the gradual process of change and differentiation.
Moves from simple to complex and is a life-long process Development
Affectors of development Experiences, Genes, Family, The world in which one lives
Personality a unique combination of characteristics that result in the individuals’ recurrent pattern of behavior.
Developmental theory Understanding what affects growth and development helps the nurse predict behaviors and responses at each stage of the life cycle.
Life Expectancy the average number of years a person will probably live, currently about 77 years.
Females outlive males by about? 6 years
Individuals with an income over $25,000 live? 3-7 years longer than those with an income of $10,000
Infant mortality rate refers to the number of deaths before the end of the first year of life.
Cephalocaudal growth and development that proceeds from head to foot
Proximodistal growth and development that proceeds from center to the outside.
The Id (the unconscious mind) is present at birth and generates impulses that seek pleasure and gratification.
It is the basic drive for survival and pleasure, not changed with experience, goal is to reduce tension, increase pleasure and minimize discomfort The Id
Ego The ego is the reality factor Stands for reason and good sense
Helps us perceive conditions accurately, Decides how and when to act, Is in contact with the external reality Ego
Super-Ego Learns to delays immediate gratification for socially appropriate reasons
It recognizes good and bad it is also known as the moral guide or conscience, Develops from the ego, Strives for perfection and morality Censor over thoughts and activity, Self observation and the formation of ideas Super-Ego
Who stated, "a strong super-ego serves to inhibit the biological instincts of the id, while a weak super-ego gives in to the id's urgings." Sigmund Freud
Infancy Developmental Task Basic trust vs. mistrust
Infancy Developmental Task Outcomes Learn to trust or mistrust significant others to meet basic needs for food, sucking, warmth, cleanliness and physical contact.
Toddler Developmental Task Autonomy vs. shame & doubt
Toddler Developmental Task Outcomes Children learn to be self-sufficient or to doubt their own abilities
Young adulthood Developmental Task Intimacy vs. isolation
Young adulthood Developmental Task Outcomes Seek companionship & love or become isolated
Middle Adulthood Developmental Task Generativity vs. stagnation
Middle Adulthood Developmental Task Outcomes Productive, performing meaningful work & raising a family or stagnant & inactive
Late Adulthood Developmental Task Ego integrity vs. despair
Late Adulthood Developmental Task Outcomes Try to make sense out of lives, either seeing life as meaningful & whole or despairing at goals not reached & questions unanswered
Preschool Developmental Task Initiative vs. guilt
Preschool Developmental Task Outcomes Desire to undertake adult-like activity & may test limits
School Age Developmental Task Industry vs. inferiority
School Age Developmental Task Outcomes Eager to learn to be competent & productive or feel inferior and unable to perform
Adolescence Developmental Task Identity vs. role confusion
Adolescence Developmental Task Outcomes “Who am I?” Establish sexual, ethnic & career identities or are confused about future roles
Psychoscial Theorist (Nurse's Theorist) Erikson
Erikson identifies intimacy as a developmental task of adulthood. If this task is not accomplished, the outcome will be? Isolation.
Piaget's Cognitive Development Stage 1 Sensorimotor Stage Birth to 2 years
Piaget's Cognitive Development Stage 2 Preoperational stage 2 to 7 years
Piaget's Cognitive Development Stage 3 Concrete Operational Stage 7 to 11 years
Piaget's Cognitive Development Stage 4 Formal Operational Stage Adolescence and Adulthood
Sensorimotor Stage Birth to 2 years In this intelligence is gained and demonstrated through senses and motor activity
Effects of intelligence as it is gained and demonstrated through senses and motor activity Knowledge of the world is limited (but developing) because it’s based on physical interactions / experiences. Acquires object permanence at about 7 months of age(memory).Understands cause and effect. I.e. crying when hungry & differences in time of day.
Concrete Operational Stage 7 to 11 years, Elementary and Early Adolescence characterized by 7 types of conservation: Number, Length, Liquid, Mass, Weight, Area, Volume
Effects of the Concrete Operational Stage Egocentric thought diminishes. Realistic understanding of the world. Focus is on the present not the future
Preoperational stage 2 to 7 years Egocentric thinking predominates. Attributes life to inanimate objects.Understands one bit of information at a time without see ingabstract relations hips. Language use develops. Uses pretend play. Begins to use logic to understand rules
Formal Operational Stage Adolescence and Adulthood Intelligence is demonstrated through the logical use of symbols related to abstract concepts.
Effects as intelligence is demonstrated through the logical use of symbols related to abstract concepts in the formal operational stage Early in the period there is a return to egocentric thought. Can think in hypothetical terms. Future oriented. Understands scientific basis of theories.Develops a moral sense of what is right and wrong`.
When the nurse notes that the 5-year-old has an imaginary friend with whom he converses frequently, the nurse recognizes this is a characteristic of Piaget’s stage of? Nurse Recognizes Preoperational development traits
Nuclear Family Consist of a Married man and woman. With or without children. Live in independent household
Extended Family Consist of nuclear plus additional family members, Live in same household, Share responsibilities, Basic family group in many societies
Single Parent Family Can be a style of choice or Divorce, death, separation, abandonment. Increasingly more common
Blended (Reconstituted) Family Also called a stepfamily, Results from remarriage, Divorce, Death. Can provide a lot of stressors. Conflicting loyalties. Can be fearful of love and trust. Intensify if children go back and forth between two households
Social Contract Family and Cohabitation Unmarried couples living together. Share roles and responsibilities.
Adoptive Family Family with adopted children. Infertile couples. Millions every year
Foster Family Natural parents unable to care for children. Foster care is usually temporary.
The nurse discovers in her intake assessment of a 5-year-old child that he lives with his biological parents and his siblings. The nurse categorizes this family type as? Nuclear family.
Role of the Family Protection, Nurturance, Education, Sustenance, Socialization.
Usually unconditional affection, acceptance, and companionship, The family is the first socialization agent for children society’s expectations and limitations Role of the Family
Patriarchal Family Patterns Male assumes the dominant role, Assumes the work role, Make most decisions
Matriarchal Family Patterns Woman assume the dominate role, Assumes the work role, Make most decisions
Democratic Family Patterns Adults function s equals, Make joint decisions, Respectful interactions, Favors compromise, negotiations, and growth
Rapid growth 4 to 6 months and weight doubles. Triple birth weight by 1 year. Length increases by about 50% by 1 year. Teething begins at 6 months of age. Infancy Growth
all higher than adult norms Infancy pulse and respiration rates
widely variable depending on activity and state of health Infancy Temperature
lower than adult norms. Infancy Blood Pressure
At 2 months the apical pulse is? about 120 bpm
At 12 months the respiratory rate is? about 30
At 12 months BP is about? 90/60
An Infant will normally sit up and crawl at? 7 months
An Infant will Creep at? 9 months
An Infant stands and walks between? 8-15 months
Infancy Language development. Babbles at about 3 months, Varies from child to child
Infancy Nutrition Human breast milk and commercial formula meet nutritional needs. Breast milk is best. Feed when Hungry
Breast Milk or Formula is fed to sn infant exclusively for? 4-6 months
Whole milk prohibited for the first year of life.
Foods to Avoid certain foods in first 6 months of life citrus fruits, egg whites and wheat flours
Introduce one food at a time to infants and allow? several days between new foods.
Infancy Safety Never leave infant alone while feeding. Avoid round, hard foods, which may cause choking, in older infants. At higher risk of dehydration during warmer weather, febrile conditions, and prolonged gastrointestinal illness.
Newborns and infants- 18 out of 24 hours; usually short nap like periods. End of first year- sleep 12 hours at night with one nap during day. Infancy Sleep
Infancy Play Important for learning. Sensorimotor- use of senses and motor abilities. Play is solitary.
The nurse instructs the family of a newborn 7-lb. baby that the anticipated weight at 1 year of age would be? Nurse explains that baby should 21lbs because they are expected to triple birth weight by 12 months.
The mother of a 5-month-old child is concerned because the child cannot sit by himself? The nurse explains that sitting alone is not expected until the baby is? The nurse explains that sitting alone is not expected until the baby is 7 months.
Toddler Speaks in? one or two word phrases
Toddler Vocabulary is how many words by age 2 ½ 450
Toddler Vocabulary is how many words by age 3 900
Toddler Growth Slower, Upright stance. Top-heavy at beginning more proportionate at end of period.
What happens to the Baby Pot Belly during toddlerhood? Exaggerated lumbar lordosis and abdominal protrusion Potbelly disappears as abdominal muscles strengthen by age 3.
Toddler dental milestones All 20 primary teeth erupt by age 2.
90-120 bpm Toddler pulse ranges
80-100/64 Toddler Blood Pressure
98-99 degrees Toddler Temperature Range
20-30 breaths/min Toddler Respirations
Toddler motor skills at 2 Walking steadily and climbing stairs
Toddler motor skills at 3 Hopping, Running, Pulling and hold-on-tight
When a Toddler developed pincer grasp it gains the ability? to pick up objects with the thumb and forefinger
Scribbling Toddler fine motor skills at 2
Copying a circle Toddler fine motor skills at 3
Toddler Toilet Training Begins at about 18-24 months, Bowel control first; then bladder control, Cannot be hurried
Toddler Introduction of new foods Gradual introduction, Bite-sized, finger foods and smaller portions.
Toddler Serving Size 1 tablespoon of each solid food for each year of age
Toddler amount of Sleep needed 12 hours at night plus a daytime nap
Promote Toddler sleep by? Limiting stimulation before sleep time. Quiet activities before sleep. Favorite bed toy. Bedtime ritual.
Toddler Safety 90% accidents occur at home; preventable.
Preschooler Growth Slow and steady. Gains less than 5 lbs per year. Growth about 2 to 21/2 inches per year. Look taller and thinner. Body slimmer, stronger and less top-heavy.
Preschooler Motor skills Gait steadier, Finer motor skills more difficult; encourage development
Preschooler Vision Farsighted. 20/20 achieved by age 5
Preschooler Pulse Rate 70-110 bpm
Preschooler Respirations 23 breaths per minute
Preschooler Blood Pressure 110/60
Preschooler Temperature 97-99 degrees Fahrenheit
Preschooler Nutrition High protein need for growth. Dietary likes and dislikes variable; supplementary vitamins may be recommended
Preschooler Play Cooperative- share, take turns and interact. Pretend play- cooking, shopping and driving. Dramatic play- try out social roles, express fears and fantasies and learn to cooperate. Imaginary friends may appear.
Preschooler Safety Teach full name, address and telephone number. Teach how to use phone in emergency.
Autocratic Family Patterns Relationships are unequal. Parents control children. Ridged rules and expectations. Least open to outside influence
11-12 hours at night; may resist daytime nap. Preschooler Sleep
As the child begins to develop language skills, the nurse is aware that a rule of thumb for the number of words in a sentence is that it 1 word for each year of life.
When teaching a young mother that breast milk or formula is the only food an infant needs until? A nurse feels confident saying, 4-6 months.
School Age Growth is? Is the same for both boys and girls, is Gradual and subtle Most obvious growth in long bones and development of facial bones. May experience "growing pains". Posture straighter; routinely screen for scoliosis.Muscle mass and strength gradually increase.
School Age Height increases? about 2 inches per year
School Age Weight increases? about 4.5-6.5lbs per year
Loss of primary teeth begins at about? age 6; about 4 permanent teeth erupt each year.
55-90 bpm School Age Pulse
22-24 breaths per minute School Age Respirations
110/65 School Age Blood Pressure
When the mother asks the nurse about introducing solid foods into the child’s diet, the nurse’s best advice is to introduce solid food one at a time several days apart.
School Age Dietary habits and food preferences established. Cultural influences. Family habits. Peer pressure.
To maintain ideal weight during school age development it is important to? Increase physical activity and a Proper diet.
School Age Sleep Fatigue, irritability, inattention and poor learning may be related to inadequate sleep.
School Age Play Adequate exercise to enhance muscle development, coordination, balance and strength
School Age self Image Privacy and personal space important.
School Age Safety Accidents still leading cause of death- impulsiveness, poor judgment, curiosity and incomplete control over muscle coordination.
During a patient education a young family is told that a child must have adequate physiological, neuromuscular, and psychological maturity in order to master toilet training, usually around the age of? 18-24 months the Nurse Counsels
Adolescence Growth Begins? Begins at puberty- maturation of the reproductive system. Is the second major growth period in the life span. Primary and secondary sexual development. Menarche in females. Sperm production in males.
Adolescence Safety Often not very coordinated at increased risk for injury. Accidents are the major cause for injury
Body shapes are sex differentiated. Other physical changes: males develop more muscle tissue and females develop more body fat. Adolescence Growth
Adlolescent Vital Signs Same as an adult
Adolescence Nutrition increased caloric need related to rate of growth and increased basal metabolic rate
Adolescence Sleep increased sleep need to restore energy.
Adolescence Play Organized sports, Work with others, Meet challenges, Set personal goals
A 14-year-old male patient has undergone a leg amputation. The nurse makes the focus of the nursing care plan to support the patient’s? body image
Early Adulthood Optimal level of functioning Strength, energy and endurance at peak. Body functions fully developed.
Toddler Speech String together 1 word for each year of life
Early Adulthood Physical appearance influenced by? heredity, environment and general state of wellness.
Females reach maximum height by? 16 to 17 years.
Males reach maximum height by? 18 to 20 years.
Early Adulthood Nutrition Fewer calories than adolescents. Needs based on age, gender, size, physical activity, metabolism and stress.
Early Adulthood Rest and Sleep? 7 to 9 hours restorative sleep
Early Adulthood Physical health annual physical and dental exams
Early Adulthood Safety injuries related to work, vehicle and sports accidents and violence.
As the nurse does a physical assessment on a 25-year-old , the nurse has the expectation that during this time the patient is experiencing? Normally the pateint should be at optimal level of functioning.
Middle Adulthood Bone Mass decreases: Women lose calcium from bone tissue after menopause. Men lose calcium at a more gradual rate.
Middle Adulthood Height Slight changes in height related to compression of the spinal vertebrae & hardening of collagen fibers.
Middle Adulthood Muscle Decreased muscle fibers leads to reduction of muscle mass.
Middle Adulthood Body Shape contour changes related to redistribution of body weight.
Middle Adulthood Presbyopia. farsightedness
Middle Adulthood Presbycusis. Hearing Loss
Middle Adulthood Skin changes Decreased elastic fibers & slight loss of subcutaneous tissue leading to looser, more wrinkled appearance.
Middle Adulthood Hair may change-graying. Hair growth and distribution may change-scalp hair thinner.
Middle Adulthood Dental Higher incidence of periodontal disease.
Middle Adulthood Hormonal changes Female menopause / Male andropause
Middle Adulthood Nutrition Fewer calories needed due to slowing down. Positive lifestyle and regular exercise to maintain joints and bones
Middle Adulthood Examinations Follow American Cancer Society guidelines. Physical and dental examinations: Regular examinations recommended, Cancer screenings recommended
Late Adulthood Aging individualized. Gradual reduction in number and change in composition of aging cells
Late Adulthood BMI Slow increase in body weight until 45 to 50 years; then gradual decline.
Late Adulthood Adipose Tissue Females- over the chest, waist, hips and thighs. Males- waist, chest and lower abdomen.
A middle-aged (age 40-65) male is concerned about some hearing loss he is experiencing. The nurse recognizes that this might be due to a sensory change of this age group known as presbycusis.
Late Adulthood height shrinks after 50 year old
Late Adulthood Kyphosis may increase resulting in a barrel-chest appearance.
Late Adulthood Nutrition Adequate nutrition for health maintenance and quality of life. Foods higher in quality and lower in quantity to meet basic nutrient needs. Adequate fluid intake also crucial.
Late Adulthood Common threats to adequate diet. Poor oral health. Lack of appetite. Food intolerances. Constipation. Psychosocial. Economic. Loneliness. Inability to shop for and prepare meals.
Late Adulthood Sleep More rest needed but less sleep. Accidents may occur when awakening at night. Affected by; Medications. Alcohol. Caffeine. Stress. Environmental noise and temperature
The nurse reminds an older adult patient that the task for the older adult is to achieve ego integrity. Failure to achieve this task results in? sense of despair
In assessing the home for fall risks and increased safety for an 85-year-old, the home health nurse suggests that? excess furniture be removed.
Charting Routine care Chief complaint; subjective and objective findings; diagnosis; treatment plan; response to treatment.
Charting Condition change Condition changes with corresponding actions. Professionals have an obligation to recognize condition change and take action. Can only illustrate this through documentation.
What is the first item requested in a claim? Medical chart
Medical Records The witness that never dies and never lies
bad charting Leading reason malpractice case is settled
The chart can be defined as? The primary communication tool; essential for good patient care.
Components of Charting: Who Hospital policies should govern who can document. E.g., who can document on progress notes.
Components of Charting: What Care and treatment, Changes in condition, Intervention, Response to intervention Coordinated team plan
Components of Charting: When Close to event notes are best, What is your personal custom and practice?Time of events (synopsis v. timed log)
Components of Charting: Where Chart in designated sections
Components of Charting: Risk Reduction Never share your PIN, Never log on to allow charting, Always log off, Be careful at the bedside
Components of Charting: Factual, Objective Notations What you hear, see, feel, and smell. Avoid “appears to be…” (unless you really don’t know), Avoid “inadvertently” and “unfortunately.” Use quotes when you can.
Components of Charting: Utilization and Financial Record What resources were used. Who saw patient. Level of care: Services used: equipment, time (e.g. OR, ER). Procedures and medications, If questioned, this is the audit tool that will be judged.
May be the basis for a fraud claim. Components of Charting: Utilization and Financial Record
Components of Charting: Being Specific (Example Fall) Do not state: “Patient fell out of bed.” State: “Crash heard, patient found at foot of bed with laceration …”
(Example Wound) Don’t say: “Wound improved.” State it in objective terms: size, drainage, odor. Components of Charting: Being Specific
Components of Charting: Timely Notes Timing and dating your notes is vital
Components of Charting: Electronic Monitors Document All; Times are on the print outs. Does it correspond to your charted times? Who is responsible for setting the clocks (preventive maintenance)?
Components of Charting: Tampering Forms Squeezing in a little clarification. Crossing out incorrectly. Obliterating information. Spoliation of evidence: What were you trying to hide? It MUST have been bad.
altering the record in any way not just the willful act to destroy record Components of Charting: Tampering
Components of Charting: Blank Lines You cannot control subsequent providers. Your actions are based on what you knew at the time. If someone asks you to leave a blank, don’t. Show them how to make a late entry. Draw lines through empty spaces.
Components of Charting: Legibility If you are uncertain about a notation and you act anyway, it is inexcusable. Good handwriting. The most common reason for drug errors is illegible or questionable handwriting.
Use approved abbreviations Components of Charting: Legibility
Components of Charting: Accuracy If it is documented, it is assumed to be accurate. Identify whether the care was given by yourself or someone else. Grammar and cleanliness are worthwhile: messy notes give an appearance of messy care. Never document ahead.
Correct mistakes: Use a line, note initials, and note “error.”, Spoliation of evidence by obliterating information. Don’t sound tentative. State what you mean. Use real sentences. READ YOUR NOTE Components of Charting: Accuracy
Components of Charting: Irrelevant and Inappropriate Charting Do not include irrelevant info:. The chart is not the proper forum for complaints: (Criticism of another practitioner, Number of times this has occurred to you before.)
Components of Charting: Non-Compliance Document By: Using quotes when possible to show tnon-compliant behavior, what instruction you gave patient that was not followed. Avoid labeling patient. Seems that you did not like patient. whom you informed about the non-compliance. Incidences of not fo
Components of Charting: Discharge Documentation Illustrates education provided to patient. Provide cautions for symptoms warranting further or urgent care. Provide specific instructions on when to next seek routine care.
Maintain a copy of all forms given to patient. Have patient sign discharge instructions. Components of Charting: Discharge Documentation
Discharge is a high-risk event Instructions given the patient intervenes on their own behalf. Change in condition, need to follow instructions, need to follow-up, need to understand warning signs. Illustrates status at discharge and readiness. Needed regardless of setting.
three types of legal aspects of privileged provider's orders. Written, Telephone, Verbal
nine types of patient care orders. 1)Single orders. 2)Recurrent orders. 3)Standing orders (protocol)4)Routine orders. 5)STAT orders. 6)PRN orders. 7)Telephone orders. 8)Verbal orders. 9)Nursing Orders. (NIOs)
use of DA Forms 4677 Documents Procedure Orders
use of DA Forms 4678 Documents Medication Orders
two types of RN Only Order Telephone & Verbal Orders
Legalities of verbal and Telephone orders Accepted by, and transcribed onto DA-4256 by RN only. must be countersigned within 24 hours by MD
Which orders may be called into court All orders can be subpoenaed
Do not's when transcribing orders Erase/Correction fluid. Skip lines. Write between lines. Leave blank line above signature. Chart for someone else.
DA Form 4256 Dr’s Order
Military Outpatient Electronic Charting Systems (AHLTA) Armed Forces Health Longitudinal Technology Application
(CHCS) Composite Health Care System, ESSENTRIS, MEDITECH, (AHLTA) Armed Forces Health Longitudinal Technology Application Electronic Charting systems
Single orders Order given by the physicain to do one time, usually written
Recurrent orders Order that is done at a certian frequency
Standing orders Standard operating procedure, protocol
Routine Orders must be specified may be pre-printed (e.g. Pre-Op orders), Pre-standing orders
STAT Orders Immediately needs done, takes priority over everything else.
PRN Orders As Needed Orders
Telephone Orders Legal Order communicated over telephone, must be written down in chart. RN Only
Verbal orders Emergency and Stat orders only. Must be charted, LPN has to refer to LPN
Nursing Orders. (NIOs) Nurse Initiated Order. Something a nurse within their Scope of Practice can administer to add to provider order care.
Legalities of written orders Accurate, complete, and legible. Must contain date/time and signature of MD. Must be acknowledged by RN
How Many Copies of DA Form 4256 are there? 3 Copies, White, Pink, and Yellow
Purpose od Transcribing Order Organization of similar tasks. Ease of use. Documentation time
Process of Transcribing Orders Patient’s complete Name & Rank. SSN w/Status code. Service Component. DOB. Hospital location (i.e. Ward). Room and bed number. Determine if orders are complete and accurate. Read all orders and initiate STAT orders first.
Transcribing Medicationn orders Confirm orders are complete by verifying; Medication name. Dose. Route. Frequency.
Transcribing PRN meds must have indication stated
Before transcribing, what must the LPN do if the orders are unclear? Seek Clarity; Review provider’s progress notes for specific information. Collaborate with charge nurse for information. Contact provider directly to clarify order as necessary.
two numbers preceeding social security number Status code number
What must you do after performing each entry of a privledged provider's order? Date, time, initial (may “Bracket” groups of orders).
Military Nursing Note SF 510
Which copy of the transcribed orders does the LPN send the pharmacy? The Pink Copy. is sent to ensure all medications are appropriately surveyed for interactions
After reviewing orders who must the LPN must inform about the patients care? All Care Providers included in orders must be notified
If orders for Labs are required what must the LPN do? Prepare specific documentation for therapeutic modalities or procedures ordered.
Transcription to Discontinue or change medications, treatments, and/or procedures per DOs. Initiate appropriate column and annotate “D/C’d” w/date, time & initials, then draw line through remaining “Date Completed” or “Date Dispensed” blocks.
Military Admitting Electronic Charting systems ESSENTRIS
Who can transcribe a Doctor's note? RN, LPN, Order's Clerk
Defined as the use of words and behaviors to construct, send, and interpret messages. Both verbal and nonverbal communication is used to convey varied messages. Communication
a person who has a thought, idea, or emotion to convey to another person. Sender
the thought, idea, or emotion one person sends to another person. Message
how the message is transmitted may be auditory, visual, or kinesthetic Channel
Channel Auditory (verbal) hearing and/or listening.
Channel Visual (nonverbal) sight, reading, observation and/or perception.
Channel Kinesthetic (tactile or nonverbal) procedural touch and/or caring touch
a person who receives the message Receiver
Receiver Physiological: process of hearing, seeing, and the reception of the touch stimulus.
Receiver Psychological process may enhance or impede the receiving of the message.
Receiver unintended someone who overhears a statement or conversation.
Feedback a response from the receiver that enables the sender to verify that the message sent was the message received.
Aspects of Communication Influences: both sender and receiver are influenced by their education, culture, emotions, and perceptions and by the situation within which they find themselves
Process of Communication Communication may be one-way or two-way, depending on the roles of the persons in the interaction.
highly structured, with the sender being in control and expecting and getting very little response from the receiver. One-way communication
requires both the sender and the receiver participate equally in the interaction. Two-way communication
Use of spoken or written words or symbols. Misunderstanding/misinterpretation of the intended message occurs even if receiver understands the language and symbols being used. Verbal Communication
Verbal Communication Spoken words can have very different meanings, or connotations, for the sender and the receiver.
a word reflects the individual's perception or interpretation of a given word. Connotative meaning
Denotative meaning refers to the commonly accepted definition of a particular word.
is commonplace language or terminology unique to persons in a particular work setting, such as a hospital, or type of work, such as nursing Jargon
Transmission of messages without the use of words. Body language is another name for nonverbal communication. Nonverbal Communication
Nonverbal Communication very powerful, and if the nonverbal cues are not consistent or congruent with the verbal message, it will most likely be the nonverbal message that is received. This incongruence is frequently the cause of misinterpretation and misunderstanding
What are the two forms of therapeutic communication? Verbal & Nonverbal
Style of Communication: Assertive interaction that takes into account the feelings and needs of the patient, yet honors the nurse's rights as an individual. (Most effective style of communication.)
Style of Communication: Aggressive interacting with another in an overpowering and forceful manner to meet one's own needs at the expense of others.
Style of Communication: Unassertive interaction sacrifices the nurse's legitimate personal rights to meet the needs of the patient at the expense of feeling resentful.
Promotes the formation of a positive nurse-patient relationship and actively involves the patient in all areas of the nursing process. Therapeutic Communication
blocks the development of a trusting and therapeutic relationship. Non-therapeutic Communication
Nonverbal Communication Listening Most effective method. Most difficult skill to acquire. Conveys interest and caring toward the patient.
Active Listening: Full attention to patient. Allows feedback.
Passive Listening: Attends nonverbally through eye contact and nodding. Verbally through encouraging phrases: "Uh huh" and "I see“. Passive listening should be avoided.
Maintaining extremely effective therapeutic commo technique, yet underused Allows time to organize thoughts and plan response. Convey respect, understanding, caring and support. Often used in conjunction with touch. Observe patient's nonverbal responses. Silence Nonverbal Communication
Brief verbal comments, such as "Yes, go on". Conveys interest and desire to hear more. Involves nonverbal cues, such as: eye contact and nodding. Minimal encouragement Nonverbal Communication
Can convey warmth, caring, comfort, support and understanding. Consider patient's cultural and personal feelings about being touched. Touch Nonverbal Communication
Acceptance of what the patient is communicating. Non-judgmental; encourages honesty and openness. Minimal verbal interaction. Convey acceptance Nonverbal Communication
Focused on particular answer. "Yes", "no" or short answer response. Provides a specific answer to a specific question. Does not foster open communication, which may provide other useful information. Closed questioning Verbal Communication
Doesn't seek specific answer. Patient can elaborate. Useful to assess feelings. Doesn't influence response Open-ended questioning Verbal Communication
Process of the nurse repeating the main points of what the pt said. Conveys to the patient that you heard what was said. Encourages pt to provide additional information. Restating Verbal Communication
Restating what the patient said in the nurse’s own words to verify that the interpretation was correct. Paraphrasing Verbal Communication
Asking for more information or elaboration. Verification of the accuracy of the message. Useful if message is difficult to understand. Clarifying Verbal Communication
Specific info needed to accurately understand the pt’s message. Pt gives important info, however the message may be too vague to be useful. Nurse seeks further info to focus on specific data, thus providing safe nursing interventions for the Pt. Focusing Verbal Communication
Therapeutic technique that assists the pt to “reflect” their inner feelings and thoughts. Pt’s ideas and thoughts are important and have worth. Empowers the pt to verbalize a solution (Position of control., Promotes self-estee). Reflecting Verbal Communication
Nurse takes note of what they observed during interactions. Useful in validating the accuracy of observations. Helps when verbal message doesn’t match nonverbal message . Provides feedback to validate the intended message was the one received. Stating Observations Verbal Communication
Aphasic Non Responsive to communication
Much of the communicating that the nurse does is offer information. Pt feedback is essential in determining whether the information has been understood. Offering Information Verbal Communication
Examples of Offering Information Preoperative teaching. Diabetes education. Discharge instructions.
Review of the main points. Useful in pt teaching sessions. Sense of closure to the session. Summarizing Verbal Communication
Where and how the nurse sits or stands conveys a message. Most therapeutic posture and position is for the nurse to assume the same position and level as the patient. Posturing and Positioning Factors Affecting Communication
Comfort zone: necessary distance between two or more individuals that must be maintained to guard against personal threat or intimidation. Space and Territoriality Factors Affecting Communication
0 - 18 inches. Nursing interventions provided to the patient. Must be approached in a professional manner with gentleness and tact. In imate zone Space and Territoriality
18 inches to 4 feet. Less intimidating to patient. Sitting and talking to patient. Personal zone Space and Territoriality
4 - 12 feet. Speaking to a small group. Social zone Space and Territoriality
12 feet or more. Public speaking Public zone Space and Territoriality
Surroundings can alter the effectiveness of the interaction. Provide a calm, relaxed atmosphere. Provide for patient privacy. Environment Factors Affecting Communication
Trusting relationship. Without trust, interaction will not progress past the superficial social interaction. Trust built with confidence and competence. Level of Trust Factors Affecting Communication
Obtain an interpreter. Have a translation dictionary available. Gestures, pictures and acting out may be helpful if the patient has some understanding of the language. Language Barriers Factors Affecting Communication
Significant component of a patient's psychosocial well-being. Seek specific information regarding cultural practices and beliefs. Culture Factors Affecting Communication
Influenced by cultural or societal beliefs and attitudes. Significant age difference may create a barrier to communication. Male and female patterns of communication related to cultural, familial, and lifestyle patterns. Age and Gender Factors Affecting Communication
Can create a barrier for effective communication between the nurse and the patient. Should address prior to proceeding with any other interaction with the patient. Pain: Physiologic Factors Affecting Communication
Hinder effective communication. Patient lacks the ability to receive, process, and send information, communication will not occur. Factors that may affect communication are: (CVA) stroke, sedatives, dementia, and developmental delays. Altered Cognition: Physiologic Factors Affecting Communication
Get the patient's attention. Face the patient. Speak slowly and articulate clearly. Don't shout. Impaired Hearing: Physiologic Factors Affecting Communication
Keep information simple, basic and concrete. Let patient direct the conversation. Be supportive through words and presence. Stress: Physiologic Factors Affecting Communication
Silent presence. Listen and assist through therapeutic touch, warm and caring behaviors, and open-ended statements. Grieving: Physiologic Factors Affecting Communication
Using falsely comforting phrases. May promise something that won't happen or is unrealistic False Reassurance: Barrier to Communication
False Reassurance Nurse may promise something that will not occur or is unrealistic.
Telling the patient what to do. Doesn't allow patient to make decision. Giving Advice: Barrier to Communication
Takes decision making away from the patient; inhibits spontaneity; impairs decision making; creates doubt Giving advice
Jump to conclusions. May be perceived as accusatory or argumentative. False Assumptions: Barrier to Communication
False Assumptions Can easily lead to the wrong conclusion; may be viewed as accusatory or argumentative.
Imposes nurse's own attitudes, values, beliefs and moral standards regarding right and wrong. Value Judgments: Barrier to Communication
Value Judgments Can lead the patient to doubt his or her own values; may create feelings of guilt and resentment; may cause friction between the pt and the nurse.
Stereotyped or superficial comments that don't focus on what patient is feeling or saying. Tends to belittle the individual's feelings and minimize the importance of the message. Cliché: Barrier to Communication
Cliché Tends to belittle the indicidual’s feeling and minimize the importance of the message; communicates the message that the nurse is not taking the patient’s concerns seriously.
Negative response to criticism. Implies that patient doesn't have right to opinion. Defensiveness: Barrier to Communication
Defensiveness Implies that the patient has no right to an opinion; patient’s concerns are often ignored or minimized because nurse is focusing on defense of self or others
May be perceived as accusatory. Patient may think the nurse knows the answer and is testing the patient. Asking for explanations: Barrier to Communication
Asking for explanations Frequently viewed by the pt as accusatory; pt may thing the nurse knows the answer and is testing the patient; can cause resentment, insecurity and mistrust.
Inappropriately focusing on something other than patient's concern. Rude and important information may not be shared. Changing the subject: Barrier to Communication
Changing the subject Rude and shows lack of empathy; blocks further communication and pt may not feel comfortable expressing feelings; thoughts are interupted and important information may not be shared.
“it will be okay” is what type of communication block? example of False Reassurance
Assess patient's ability to use a particular alternative method of communication. i.e. Communication board, signal system, Lip reading. Sign Language. Paper and pencil/magic slate. Computer assisted communication. Clock face communicator. Ventilator-Dependent: Special Circumstances of Communication
Communication board Board to help a pt. with physical or psychological barriers to communication. Includes; Alphabet. Commonly used phrases. Pictures, or a combination of the three
Signal system Eye blink (one for yes and two for no). Requires patience.
deficient or absent language function resulting from ischemic insult to the brain, such as stroke, brain trauma, or anoxia. Aphasia: Special Circumstances of Communication
patient cannot send the desired message. Expressive aphasia: Special Circumstances of Communication
patient cannot recognize or interpret the message being received. Receptive aphasia: Special Circumstances of Communication
impairment of speech. Dysphasia: Special Circumstances of Communication
dysfunction of the muscles used for speech. Speech is difficult, slow and hard to understand. Dysarthria: Special Circumstances of Communication
Actions to communicate with an Aphasic Patient Listen to the patient and wait for them to communicate. Do not shout or speak loudly (hearing loss is not the problem). Give patient time to understand, be calm and patient. Do not pressure or tire the patient. Avoid patronizing.
Assume the patient can understand what is heard. Ensure quiet and relaxed environment. Speak on adult level. Talk to the patient. Actions to communicate with an Aphasic Patient
If the patient has problems receptive aphasia? Use simple, short questions and facial gestures to give additional clues. Decrease environmental distractions when attempting to communicate. Speak slowly and divide tasks into small steps.
If the patient has expressive aphasia? Ask questions that require simple one/two word or yes/no answers or blinking of the eyes. Use pantomime. Offer pictures or a communication board so the patient can point
Assessment a systemic, dynamic process by which the nurse, collects and analyzes data about the client.
Data clustering process of putting data together to identify areas of the patient's problems.
Diagnose to identify the type and cause of a health condition
Etiology study of all factors that may be involved in the development of a disease; cause of a disease.
Evaluation a determination made about the extent to which the established outcomes have been achieved in a nursing care plan.
Goal a broad statement that describe the intended or desired change in the patient's condition or behavior.
Implementation the phase of the nursing process that included ongoing activities of data collection, prioritization, and performance of nursing intervention and documentation
Medical Diagnosis identification of a disease or condition by a scientific evaluation.
NANDA North American Nursing Diagnosis Association.
Nursing Diagnosis a clinical judgement about individual, family, or community responses to actual or potential health problems/life processes.
Nursing Intervention activities that promote the achievement of the desired patient outcome.
Nursing Process organizational framework for the practice of nursing. Provides a systematic method by which nurses plan and provide care for patients.
Objective data observable and measurable signs which can be recorded.
Planning the phase where the nurse establishes priorities of care, selects and converts nursing interventions into nursing orders, and communicates the plan of care. This is the process of deciding what must be done for the patient.
Subjective data verbal statements provided by the patient.
Assessment. Diagnosis. Planning. Implementation. Evaluation. Components of the Nursing Process
Elements of the assessment phase of the nursing process? Interview & Physical Examination
establish a database concerning a patient's physical, psychosocial, and emotional health in order to identify actual and/or potential health problems. Purpose os an Assessment
Collected from patient interview and physical examination Primary Sources of Data
family members, significant others, health care team, medical records, diagnostic procedures, and nursing literature. Secondary Sources of Data
secondary data. When a patient is admitted and is unable to provide data during assessment, information provided by the family is classified as?
provides baseline patient information. Physical examination of all body systems. Review of cognitive, psychosocial, emotional, cultural and spiritual components. Appropriate for stable patients. Comprehensive (Complete) Assessment
concentration of attention on the part of the body where signs and symptoms are localized or most active in order to determine their significance. Appropriate for critically ill, disoriented, or unable to respond patients. Focused Assessment
systematic follow-up is required when problems are identified during a comprehensive or focused assessment. Ongoing Assessment
The two primary methods used to collect data are? interview and physical examination.
The LPN/LVN assist the RN with the Nursing Diagnosis by? observing and collecting data.
A clinical judgment by the physician that identifies or determines a specific disease, condition, or pathological state. Medical Diagnosis
Diagnoses that a patient receives both a medical and a nursing diagnosis
Identifies conditions the physician is licensed and qualified to treat vs. Identifies situations the nurse is licensed and qualified to treat Medical vs. Nursing Assessments
Medical vs. Nursing Assessments Focus on the illness, injury or disease process vs. Focus on patient’s response to actual or potential health problems or life processes
Changes as the client’s response and/or the health problems changes Vs. Remains constant until a cure is effected Nursing Vs. Medical Assessment
Nursing Vs. Medical Assessment Examples Example: Disturbed body image Vs. Example: Amputation
Nursing diagnosis title/label Cluster subjective and objective cues. Analyze cues. Select label from NANDA approved list.
Nursing diagnosis Contributing/etiologic/related factors Causes/potential causes of problem. Signs and symptoms. Are written as the "related to".
Nursing diagnosis Defining characteristics Evidence of diagnosis. Manifestation of diagnosis. Are written as the "manifested by“ or “as evidenced by”.
Construction of a Nursing Diagnosis Nursing Diagnosis = Problem + Etiology (Cause) + Signs/Symptoms
a condition that is currently present. Actual: Nursing Diagnosis
more vulnerable to develop the problem than others in the same or similar situation. Risk: Nursing Diagnosis
when a problem is considered feasible. Possible: Nursing Diagnosis
when a cluster of actual or risk nursing diagnoses are predicted. Syndrome: Nursing Diagnosis
in transition from a specific level of wellness to a higher level of wellness. Wellness: Nursing Diagnosis
Constipation related to decreased fluid intake manifested by abdominal distention, no bowel movement for 5 days, and straining at stool. Example of ACTUAL Nursing Diagnosis
Example of ACTUAL Nursing Diagnosis Impaired skin integrity related to prolonged pressure on bony prominence as evidence by Stage II pressure ulcer over coccyx, 3 cm in diameter.
Risk for impaired skin integrity related to prolonged immobility. Example of RISK Nursing Diagnosis
Example of RISK Nursing Diagnosis Risk for impaired skin integrity related to physical immobility as evidence by inability to turn self from side to side in bed.
Example of POSSIBLE Nursing Diagnosis Possible constipation related to the effects of anesthesia on gastrointestinal smooth muscle.
Example of SYNDROME Nursing Diagnosis Rape-trauma syndrome
Problem + Etiology + Signs and Symptoms = Nursing Diagnosis. Question: What is the "equation" for writing a nursing diagnosis?
Example of WELLNESS Nursing Diagnosis Readiness for enhanced nutrition.
Readiness for enhanced family coping. Example of SYNDROME Nursing Diagnosis
Three Phasses of Planning the Nursing Process Initial, Ongoing, and Discharge Planning
Nursing Process Initial planning a preliminary plan of care by the nurse who performs the admission assessment.
Nursing Process Ongoing planning continuous updating of the patient's plan of care.
Nursing Process Discharge planning anticipation for the discharge needs
Nursing Process planning priorities of care Making decision about which diagnoses are the most important and therefore require attention first.
Most common method to selecting priorities is to consider Maslow's hierarchy of needs. Nursing Process planning priorities of care
Nursing Process planning Outcome statement describes measurable, observable behavior that the patient should demonstrate after nursing interventions
Nursing Process planning Focus Hone in on what the patient should do
Nursing Process planning Patient Inclusiveness should be involved in the development of his/her plan of care.
Nursing Process planning Short term achievable within 7 - 10 days or before discharge
Nursing Process planning Long term may take many weeks or months to achieve.
Nursing Process planning Characteristics of patient-centered goal/desired outcome Patient is the subject of statement. Measurable verb. Patient/patient problem specific. Realistic for patient/patient problem. Includes time frame for completion/reevaluation.
Example: Nursing Diagnosis Vs. Goal/Outcome Impaired skin integrity r/t prolonged immobility m/b 2 inch diameter ulcer on coccyx. vs. Patient will have intact skin within 3 weeks.
The establishment of priorities of care during the planning phase of the nursing process often uses the framework of? Maslow’s hierarchy of needs
an action performed by the nurse that helps the patient achieve the results specified by the goals and expected outcomes. Individualized and stated in specific terms. Nursing intervention
nursing actions that are initiated by the nurse and do not require privileged provider's orders to be implemented, the nurse can implement them. Independent Nursing Intervention
actions that are implemented in a collaborative by the nurse in conjunction with other health care professionals. Independent Nursing Intervention
actions that require an order from the physician Dependent Nursing Intervention
When a nurse is selecting interventions to assist the patient to meet the needs demonstrated? the nurse is in the nursing process phase of? The nurse is in the nursing process phase of planning
Converts nursing interventions into more specific instructional statements. Nursing Orders
Nursing Orders must contain? Date. Signature. Subject. Action verb. Qualifying details.
Nursing orders, as opposed to physician’s orders, prescribe activities which? may be done independently by the nurse.
The primary purpose of nursing orders is to? provide direction for all caregivers
NAMBLA North American Man Boy Lover Association
What is the focus of a nursing diagnosis? Focus on client’s response to actual or potential health problems or life processes.
Nursing Process Implementation Phases Ongoing activities of data collection. Prioritization. Performance of nursing interventions. Documentation.
Nursing Process Documenttion vital component of the implementation phase
A legal record of what occurred while the patient was hospitalized. Nursing Process Documenttion
A determination made about the extent to which the established outcomes have been achieved. Nursing Process Evaluation
Nursing Process Evaluation Steps 1) Reviews established outcomes. 2) Reassesses the patient. 3)Compares the actual outcome with the desired outcome.
Nursing Process Evaluation Revising Inactivate resolved problems. Add new problems. Revise interventions. Evaluate progress toward outcomes.
Nursing Process Evaluation is a continuous process look for better or more efficient interventions to help patient achieve expected outcomes.
Expected outcomes met. Problem resolved. Nursing diagnosis no longer appropriate. Nursing Process Evaluation Resolving
The patient with a urinary tract infection is being assessed using a critical pathway. When a projected outcome is not met by a predetermined date, it is determined that a/an? variance exists.
Why is it important to communicate the nursing plan Because the nursing staff is constantly changing, written guidelines are needed to promote continuity of patient care.
Communicating Plan of Care increses patient trust by? Creating continuity which increases patient trust in the nursing staff and promotes outcome achievement
The role of the LPN/LVN in the nursing process may vary from state to state and with different institutions. Role of the Licensed Practical Nurse in the Nursing Process
Role of the Licensed Practical Nurse in the Nursing Process LPN/LVN is often responsible for providing direct bedside nursing care.
When is a problem considered resolved? When the expected outcomes have been met.
Client education includes Maintenance and promotion of health and illness prevention, Restoration of health, Coping with impaired functioning
Teaching An interactive process that promotes learning
Learning The purposeful acquisition of knowledge, skills, behaviors, and attitudes
When teaching a young child, it is appropriate to? use play equipment in the teaching process.
Role of the Nurse in Teaching and Learning Teach information the client and family needs to make informed decisions regarding their care. Determine what clients need to know. Identify when clients are ready to learn.
learning objective describes what the learner will be able to accomplish after instruction is given.
Domains of Learning: Cognitive Includes all intellectual behaviors and requires thinking
Domains of Learning: Affective Deals with expression of feelings and acceptance of attitudes, opinions, or values
Domains of Learning: Psychomotor Involves acquiring skills that require integration of mental and muscular activity
Basic Learning Principles: Motivation to learn Addresses the client’s desire or willingness to learn
Basic Learning Principles: Ability to learn Depends on physical and cognitive abilities, developmental level, physical wellness, thought processes
Basic Learning Principles: Learning environment Allows a person to attend to instruction
An appropriate teaching plan requires? collaboration with other health care professionals?
Nursing Vs. Teaching Process The nursing process requires assessment of all data. Vs. The teaching process focuses on the client’s learning needs and ability to learn.
Purpose of Client Education To help indtividuals, families, or communities achieve optimal levels of health
Most common Nursing Diagnosis when evaluating for a patient teaching plan Knowledge Deficit
Who requires patient teaching? the Joint Commission
Return demonstration for skills taught. Patient shows you they can perform the skill taught.
Have client repeat teaching in own words. Patient should paraphrase the lesson to demonstrate cognition and understanding.
Common Hazards in the Healthcare Environment Falls, Burns, Smoking, Fire, Poisoning, Biohazards, Choking, Electrocution
Incase of fire (RACE) Rescue, Alarm, Contain, Extinguish/Evacuate
What is the most common cause of injury to elderly patients in the health care setting? Falling during transfers
Risks for Falls Age, Recent history of falls, Mental status, Visual acuity, Physical strength, Bowel/bladder urgency
Nursing Diagnoses: Fall Risk Risk for falls r/t, Impaired transfer ability r/t, Impaired walking r/t, Impaired physical mobility r/t, Risk for injury r/t
The nurse manager clarifies that “safe hospital environment” implies that in the hospital setting people shall be free from? any injury.
What are some indications that a patient may be a risk for falls? Difficulty getting out of bed/chair, use of walking aide, weak gait
Safety Precautions Assess for fall risk, Orient patient to environment, Bedside table within reach, Call bell within reach, Assist with ambulation
Patients at higher risk for falls Elderly, Patients who are weak/ have an unsteady gait, Disoriented patients. Patients who receive medications that may affect their ability to ambulate
Keep environment clutter/litter free, Side rails up x2, Bed in lowest & locked position, Slippers/shoes with skid resistant soles Clean up spills promptly, Adequate light, including night, Use handrails, Non-skid tape in tubs/showers; shower chairs Safety Precautions
In order to decrease risk for falls, the nurse holds frequent in-services to assure the staff has competent skills for? transferring.
Nursing Intervention Classification (NIC) Linked with NANDA nursing diagnoses. Each has a unique # to facilitate computerization. Standardize commo across healthcare facilities. Encourage enhanced commo between nurses about nursing interventions. Provides measures to improve patient care
Environmental Management: Safety Nursing precautions implemented to prevent falls
What types of medication may increase a patient’s risk for falls? narcotics, sedatives, anti-hypertensives
Educate about risks of Falls, Burns, Tripping, Smoking/fire Patient Teaching - Elderly
Educate about risks of Medication effects Patient Teaching - Adults and older children
Educate about risks of Poisoning, Choking, Electrical shock, Burns, Fire, Drowning, Falls Patient Teaching - Young Children
Drowning is the leading cause of unintentional injury-related death among? children ages 1-4
How much water does it take to drown? Any amount of water that covers the mouth & nose.
Safety Reminder Devices (SRD) any of the numerous devices used to immobilize a patient or part of the patient’s body, such as arms or hands
Indications for an SRD Safeguard the continuity of treatment
Use of SRD's on an elderly patient Prevents them from wandering, Reduces risk of falling , Restricts the aggressive patient’s movements
Legal Implications of Restraints Restraining devices used only as necessary and as a last resort to protect the patient or others, Applied by licensed, qualified personnel, Follow local policy
Physical & mental abuse prohibited, Cannot be used as a punishment, Must have written order by physician Legal Implications of Restraints
Who can apply protective devices? Licensed, qualified personnel only.
Restraint-Free Environment Orient patient, Encourage visitors to stay with patient, Confused pts near nurses’ station, Visual & auditory stimuli, Remove bothersome treatments as soon as possible
Relaxation techniques, Ambulation & exercise, Maintain toileting routines, Consult PT/OT, Evaluate side effects of medications, Assess response to care Restraint-Free Environment
What is the best method to use to maintain a restraint-free environment? Family members can stay with the patient and act as “sitters.”
Place gauze padding around extremity, Tie ends to bed frame, Palpate pulses below device to ensure circulation is not occluded. Application of Protective Devices - Wrist and Ankle (extremity)
Place device over elbow, Check pulse below extremity Application of Protective Devices - Elbow
Apply device over patient gown, Tie strap to frame of the bed or behind wheelchair, Vest is secure with room for a fist to fit between the vest and the patient. Application of Protective Devices - Vest
Prior to applying a safety reminder device (SRD), the nurse must? get a physician’s order.
General Safety Measures Monitor skin integrity, Check circulation frequently, Allow periods of release, Monitor respiratory status
Prevent from wrapping device around neck, Change position , Change soiled or wet devices, Adjust as needed, Use quick release knots General Safety Measures
What type of knot is used to secure protective devices? Quick release knot
Fall Risk- Medications Cause decreased mental acuity, Cause orthostatic hypotension, Cause diarrhea/polyuria, Alter blood glucose
Fall Risk- Gait/Balance Difficulty getting out of bed/chair, Use of walking aids, Weaker than usual gait, Vertigo
An Ounce of Prevention is worth A pound of cure
Safety and dignity check Has to be done every 15-20 minutes when patient is in restraints.
Release from restraints and asses ROM. Has to be done every 2 hours when patient is in restraints.
Created by: 68C14006