Editing Fundamentals of Nursing – LPN Flashcards (section)

== Comfort, safety, and reporting ==

;What are the rules for applying heat or cold?
:Always use a barrier between the device and the skin, limit application to about 15 to 20 minutes, and check the skin frequently. Use heat for muscle spasm and stiffness and cold for acute injury, swelling, and inflammation. Use extra caution with impaired sensation, older adults, and confused patients.

;What precautions reduce aspiration risk during meals?
:Sit the patient fully upright, allow rest before the meal, minimize distractions, offer small bites and unhurried pacing, avoid talking while swallowing, check for food pocketed in the cheeks, and keep the patient upright for at least 30 to 60 minutes afterward.

;What checks are required for a patient in restraints?
:Assess circulation, sensation, movement, and skin every 15 to 30 minutes per policy, and release the restraint at least every 2 hours for range of motion, repositioning, toileting, and fluids. Secure ties to the movable bed frame with a quick release knot, never to a side rail. Report cool, dusky, or numb extremities immediately.

;Which findings must be reported to the registered nurse promptly?
:Any change from the patient's baseline, new confusion, chest pain, difficulty breathing or oxygen saturation below the ordered parameter, a fall, new or worsening pain, new nonblanchable redness over a bony prominence, coughing or a wet gurgly voice with food or fluid, urine output below the ordered minimum, unexpected bleeding, and any medication error.

;What information belongs in an SBAR report to the registered nurse?
:Situation, the immediate concern; background, the relevant history and current treatment; assessment or data collected, including vital signs and observed changes; and recommendation or request, what you believe the patient needs or what you are asking the registered nurse to do.

[[Category:Fundamentals of Nursing]]
[[Category:Licensed Practical Nurse (NCLEX-PN)]]
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