PCC, final exam 2022/2023 WITH COMPLETE SOLUTIONS

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Assessment: collect data, use evidence-based assessment techniques, document relevant data Diagnosis: compare clinical findings with normal/abnormal variation & developmental events, interpret data... , validate diagnoses, document diagnoses Planning: establish priorities, develop outcomes, set timelines for outcomes, culturally appropriate, realistic and measurable, include a timeline Implementation: in a safe & timely manner, use evidence-based interventions, collaborate w/ colleagues, use community resources, coordinate care delivery, provide health teaching & health promotion, document implementation and any modification Evaluation: progress towards outcomes, conduct criterion-based evaluation, include pt. and significant others, use ongoing assessment to revise diagnoses, outcomes, plan, disseminate results to pt. and family What is the nursing process? falls a major health problem esp 65 or older falls are the leading cause of fatal and nonfatal injuries Numerous factors increase the risk of falls, including a history of falling, being age 65 or older, reduced vision, orthostatic hypotension, lower-extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications. Falls are also a common problem in health care settings Minor to severe injury Underlying disease more susceptible to injury Interventions Close proximity, signage, improved hand-offs, nurse toilet/comfort safety rounds, involving family in care Foreign object retained after surgery Air embolism Blood incompatibility Pressure Ulcer Stage III or IV Falls and trauma Catheter associated UTI Vascular catheter-associated infection Manifestations of poor glycemic control Surgical site infections following: Mediastinitis following coronary artery bypass graft Orthopedic procedures of spine, neck, shoulder, elbow Bariatric surgery for obesity (laparoscopic gastric bypass, gasteroenterastomy, laparoscopic gastric restrictive sleeve) Cardiac implantable medical device DVT, PE following knee or hip replacement Iatrogenic pneumothorax with venous catheterization What are the "never ever" events? Adequate lighting- orient to surroundings Remove obstacles from halls and traffic areas Throw rugs Necessary patient items on bedside table within reach Nonessential items away to decrease clutter No scatter rugs at home or be sure secure with non-skid back Electronic safety alert device if at risk at home and alone Yellow wristbands traditionally mean fall risk Adequate footwear, armbands, surroundings, call light, side rails fall interventions Must be clinically justified Have to have one of the uses for restraints, have to have tried alternatives MD order required- based on face-t0-face assessment Order must be current Must specify duration and circumstances restraint is used State a specific time frame as per facility policy 8 hours adults 2 hours 9-17 1 hour under 9 On-going assessment Bc of complications, must assess for them and release restraints, take off and get person up, see if they still need them Document Behaviors of need Procedure used in restraining Condition of body restrained Evaluation of patient response Removed Periodically and determine need to continue May not be ordered PRN Consent if necessary restraint orders [Show More]

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