NUR 120 Exam 3 (All Correct)

Factors that affect patient safety correct answers Developmental characteristics - very young and elderly need more safety planning Lifestyle - past and current environments Mobility - the more mobility the bigger the risk Sensory perception - altered vision, hearing, smell, etc. Knowledge - lack of safety awareness, nurse needs to teach pt appropriately Ability to communicate Health state - are they on sedating meds? Weak? Consider general health state Psychosocial state - stress and depression increase risk Fall risk - history of falls is a warning sign What patients are at risk for injury? correct answers sedated - altered mental status - use of ambulatory aids - elderly - history of falls Nursing diagnoses related to safety correct answers Risk for injury - Risk for falls - Risk for poisoning - will verbalize safe storage of meds - Ineffective protection - will be free of complications of immobility - Risk for suffocation - airway patent; wife verbalizes position for airway maintenance - Risk for suicide - verbalizes plans for future activities and desire to participate - Risk for trauma - no bruises, skin tears, cuts - Risk for disuse syndrome (R/T restraints) - uses all extremities during hygiene and meals - Impaired home maintenance - home environ free of safety hazards Teaching fall prevention to family of hospitalized patient correct answers Orient to surroundings, low bed with locked brakes, keep ambulation devices in easy reach, skid proof footwear, ID furniture with wheels and tell them these are not to be used as support, tell them purpose or use of equipment or tubing Low/Moderate/High risk for falls correct answers low - hourly rounding to check for needs and provide with safety education Moderate and high risk - yellow star on door frame, yellow armband, can have any of the following: 3 side rails up, low bed, call light in reach, mats in use, reorient to environment, BSC Define restraint correct answers Physical - Any manual method, device, or material that immobilizes or reduces patient's ability to move their extremities Chemical - Medication that restricts a patient's freedom of movement that's not a standard treatment for their condition/s.