* Assess patient’s pain level and administers appropriate pain relief measures. * Maintains patient’s safety(airway, circulation, prevention of injury) * Administer medication, fluid and blood component therapy, if prescribed. * Assess patient’s readiness for transfer to in hospital unit or for discharge home based on institutional policy. 2. Identify priority nursing care to prevent potential complications following this type of surgery.
The nurse knows that this particular type of fracture can cause damage to the nerve pathways, cranial nerves, or vital centers. Jeff's vital signs and neurologic status will be monitored frequently. 1. Which assessment technique allows the nurse to assess for Battle's sign? A) Assess Jeff's pupillary response to light.
The nurse must be very observant and watch for signs of pain. According to Herr, pain assessment in unresponsive patients should be achieved by direct observation using the Pain Assessment in Advanced Dementia Scale (PAINAD) or the Pain Assessment for Seniors with Limited Ability to Communicate (PASCLAC) scale (2010). Each of these scales provides a pain score based on observations of the patient, such as body language, facial expression, breathing, and activity
The nurse knows that this particular type of fracture can cause damage to the nerve pathways, cranial nerves, or vital centers. Jeff's vital signs and neurologic status will be monitored frequently. 1. Which assessment technique allows the nurse to assess for Battle's sign? B) Observe the area behind Jeff's ears.
The care assistant may also hold the cup or glass for the service user as a precaution against spills or dropping the glass/ cup. This falls into the moving and handling principle. A(iv) As there is a care plan in place for the service user, the nurse on the day trip with the residents should know that service user C is a type two diabetic and should have the necessary tablets and medication that this service user needs. If the nurse did not read the care plan for this person and this scenario were to happen, this could prove to be dangerous and stressful. By following the care plan the nurse was able to know that she needed a sugary drink with her and that the service user had taken her tablets before the trip began.
She is diagnosed with pressure ulcers, while also suffering from diabetes and osteoarthritis. The IDT team that was involved in her treatment comprised of medical officer, occupational therapist, speech language pathologist, incontinence and tissue viability nurse, nutritionist and the nurse. The medical officer reaches a medical diagnosis and prescribes the medical treatment necessary. The use of supportive tools to the patient such as walking aides, use of pillows to sleep on and comfortable mattresses should be prioritized by the occupational therapist; depending on the case. This helps to prevent pain and reduce the probability of skin tear.
Safety Techniques Nurses need to know and apply proper hand washing techniques, wear gloves during patient care, and use anti-bacterial hand lotion or soap. Nurses need to know the location of the bio-hazard containers and when to use them so as to limit the spread of infection. Nurses need to apply the 3 reads and 5 rights when administering medication to avoid any form of error. (The unintended). Nurses need to apply safety during patient transfer.
Cognitive learning theorists believe that learning is an internal process in which information is integrated into one’s cognitive structure. Learning occurs through internal processing of information. One example of how cognitive learning is used within healthcare settings includes nurses and doctors learning how to take the patients’ blood pressure, this is a complex task when you first try to learn it. The nurse or doctor must learn how to physically manipulate the blood pressure manometer, learn how to hear blood pressure sounds, and understand the meaning of the sounds. Each of these tasks can be practiced as a separate activity, then combined to be able to complete the task altogether.
The nurse assists the paramedics as they prepare Jonathan for transport to the trauma center. 2. If respiratory compromise occurs, what action should the nurse take to keep the airway open without compromising Jonathan's spine further? A) Logroll to side while maintaining neutral alignment. INCORRECT This action would be used to move an injured person from a prone position to supine if respiratory compromise occurs.
When a resident is observed to have a condition change, the nurse performs an assessment and makes a decision whether or not to notify the physician and the resident’s family or guardian. The most common symptoms that resulted in the transport of residents to a hospital emergency room were respiratory distress, altered mental status, gastrointestinal symptoms, and falls (Ackermann, Kemle, Vogel & Griffin, 1998). The changes in mental status could