NUR 209 Final Exam Review.

NUR 209 Final Exam Review. Safety (9/5) ⟶ Defines as the state of being free from harm or danger ⟶ Multiple healthcare settings have different safety concerns ⟶ Nurse must assess the patient, their equipment, and the environment and plan to maintain safety ⟶ Perform a risk assessment o Falls o Malnutrition o Bed sores Risk Assessment Screening Tools ⟶ Braden Scale for Bed Sore Risk o 0-23 o 23: Low risk o 9: High risk ⟶ Hendrich II Fall Risk o 5: High risk ⟶ Glasgow Coma Scale: Consciousness o 15: Fully alert ⟶ MMSE: Cognition o 30: Max o 27: Average o 24: No cognition Factors Affecting Safety ⟶ Musculoskeletal: Arthritis ⟶ Neurological & Sensory: Seizures, confusion ⟶ Cardiovascular & Respiratory: Shortness of breath, heart failure, blood pressure ⟶ Immune: Autoimmune disorders or immunocompromised patients ⟶ Integumentary: Open wounds, risk for bed sores Risk Assessment ⟶ Unsteady gait ⟶ Medications o Pain medication o Blood pressure medication ⟶ Blood pressure changes ⟶ Altered mental status o Dementia o Confusion ⟶ Sensory impairment o Sight, smell, taste, touch, hearing ⟶ Prolonged bed rest