N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide o The principles of surgical asepsis must be implemented whenever invasive procedures are done or when there is a break in the skin. o Patient positioning is critical and the patient must be as mobile as possible during the healing process. If wounds exist, the patient should be positioned such that pressure is not on the healing wound. o Heels, the sacrum area, and any other areas prone to breakdown can be covered to prevent the breakdown. o Wound care should be done as ordered. o Adequate nutrition should be provided, including adequate fluid intake. The nurse must understand the diet restrictions that might be ordered, but, when possible, patient likes and dislikes should be considered. o General hygiene and oral care must be done daily. If the patient is capable of doing this, the nurse must still evaluate the skin and mucous membranes. o Cold or heat applications may be ordered to increase or decrease circulation to an infected area. These compresses may provide pain relief. Unless otherwise ordered, these applications must be monitored so that the skin under the hot or cold pack is not injured. o Antibiotics, anti-inflammatory, or antipyretic medications may be ordered to combat an infection or the fever and pain associated with the infection. • Documentation of the plan of care with measurable criteria. Implementation/Intervention During the implementation phase the nurse, healthcare team, patient, and the family work together to put the plan of care into action. All of the interventions identified in planning should be attempted. If an intervention does not accomplish the identified goals, the nurse and patient should alter the plan of care to either try different interventions or reset the patient's goal. Regardless of other specific interventions identified with the patient, the nurse must ensure that all the visitors and healthcare workers do the following: • Wash hands before, during, and after each patient contact and any time the handsbecome visibly soiled. • Dispose of any infectious waste according to facility policy. • Dispose of contaminated sharps immediately and in appropriate sharps containers only. • Assess the patient's skin and mobility during each assessment, noting any changes. • Obtain consults and referrals as needed. Evaluation As with all nursing care, the evaluation phase is ongoing throughout the process. Keeping patients free from nosocomial infections or injuries (infections and injuries that are a result of treatment in the hospital) should be an ongoing priority. Frequent contact with and assessment of the patient and

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