A client with end-stage lung cancer and metastasis to the brain has been admitted to the medical-surgical unit. After trying all options to provide a safe environment, the nursing staff is required to apply restraints. W
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A client with end-stage lung cancer and metastasis to the brain has been admitted to the medical-surgical unit. After trying all options to provide a safe environment, the nursing staff is required to apply restraints. Which nursing intervention is required for this client?
A.Checking the restraints every 1 to 2 hours
B.Releasing the restraints at least every 2 hours
C.Using chemical sedation instead of restraints
D.Using the most restrictive devices to prevent falls correct answerB.Releasing the restraints at least every 2 hours
Definition of Safety correct answerSafety is the ability to keep the patient and staff free from harm and minimize errors in care
Definition of The Scope of Safety correct answerThe scope of safety can be described as:
1- unsafe: possible causing harm or even death
2- safe: to prevent harm or negative outcomes
Definition of The Attributes of Safety correct answerBest safety practices reduce error and harm through established protocols, memory checklists, and systems such as bar-code medication administration
QSEN Competencies correct answerPatient-Centered Care: the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient's preferences, values, and needs
-cultural competence
-family-centered care
Teamwork and Collaboration: functioning effectively within nursing and inter-professional team, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care
Evidence-Based Practice: the integration of the best current evidence and practices to make decisions about patient care
Quality Improvement: a process in which nurses and the inter-professional health care team use indicators (data) to monitor care outcomes and develop solutions to change and improve care.
Safety: the ability to keep the patient and staff free from harm and minimize errors in care
-critical rescue
-action alert
-drug alert
Informatics & Technology: the access and use of information and electronic technology to communicate, manage knowledge, prevent error, and support decision-making
SBAR report correct answerIntroduce Yourself.
Situation: tell the "meat of the situation. Why are you calling?
Background: what lead to or relates to the situation
Assessment: assessment findings
Recommendation: state what is needed/desired outcome
Delegation correct answerProcess of transferring a selected nursing task or activity to a competent UAP
The nurse is always accountable for the task/activity delegated
Supervision correct answerGuidance or direction, evaluation, and follow-up by the nurse to ensure a task/activity is performed appropriately
Five Rights of Delegation correct answer1- Right task: within the UAP's scope?
2-Right circumstances: patient care settings and resources are appropriate
3-Right Person: UAP competent?
4-Right communication: clear and concise communication
5-Right supervision: guide, direct, evaluate, and follow-up
Don't share your TEAACUP correct answerNever delegate:
Teaching
Evaluation
Assessment
Advanced interventions
Collaboration
Unstable patients
Planning
Rapid Response Team correct answerCritically care trained nurses, physicians
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