💊 Convalescence is the recovery phase after an illness or infection — when the patient’s body is healing and returning to normal health.

🔥 Cardinal Signs of Inflammation

(Also called the “Local Signs of Inflammation”)

🧠 Quick Tip:

“Red, hot, swollen, painful, and can’t move it = inflammation.”

🩺 FUNDAMENTALS — WEEK 5 STUDY GUIDE

⚖️ Safety & Environmental Standards

🧬 Scientific Base Knowledge

• Safe environment: Check surroundings for hazards and remove weapons or unsafe objects. Search patient belongings if policy requires.
• Maslow’s Basic Needs:
• Meet physical comfort — e.g., warm blankets in a cold room.
• Be cautious with diabetic patients — decreased sensation increases burn risk.
• Oxygen safety: Highly flammable — no smoking or open flames near O₂.
• Temperature risk: Homeless or elderly patients may experience hypothermia.
• Physical hazards: Cluttered rooms, overloaded outlets, and non-approved equipment increase fire/burn risk.

🚗 Common Safety Risks

🧍 Patient Safety Across the Lifespan

• Infants/Toddlers: Risk for falls and choking — use side rails and supervision.
• School-age children: Teach helmet use, electrical safety, and proper car seating.
• Teens/Adults: High-risk behaviors (drugs, peer pressure) — focus on education and prevention.
• Elderly: At risk for falls due to mobility, sensory, or cognitive changes (stroke, neuropathy).

🏠 Lifestyle & Environmental Factors

• Smoking, alcohol, and poor nutrition increase injury risk.
• Label all syringes to avoid medication errors.
• Provide interpreters for non-English speakers — language ≠ communication barrier.
• Economics: Underserved groups may have less access to safety resources.

💊 Medication & Clinical Safety

• Medical errors: wrong medication, wrong dose, wrong patient → use the Seven Rights.
• Speak Up Program: Encourage patients to ask questions and advocate for their safety.
• Patient-inherent accidents: e.g., climbing out of bed — use call lights and safety rounds.
• “Time-Out” Procedure: Stop before any invasive procedure to verify patient, site, and procedure.
• Equipment Safety: Remove faulty devices immediately and report to maintenance.
• Risk Management: Report near misses, verify ID using 2 identifiers (name + DOB).
• Name alerts: Post on patient board if two patients have the same name.

📈 Quality & Performance

• Quality improvement: Hospitals are paid for performance (better outcomes = better reimbursement).
• Use military time for accuracy.
• Know documentation standards and organizational policies.

🧩 Critical Thinking in Safety

• Call lights should always be within reach, even in bathrooms.
• Less staff at night → ensure nightlights and orientation for safety.
• Assess patient before moving.
• Use assistive devices (crutches, walkers, wheelchairs) properly.

🚫 Restraints

• Avoid when possible — use alternatives (sitters, reorientation).
• Requires a provider order to apply or continue.
• Order must specify reason and criteria for removal.
• Remove once patient is calm or safe — no new order needed for release.
• Check circulation every hour and ensure it’s not too tight.
• Mitt restraints (not tied to bed) don’t require orders but still need close monitoring.

• Never restrain during seizures — protect head and airway instead.
• Bed rails: 2–3 rails = okay; 4 rails = restraint unless for seizure protection.
• Use low beds and pads for fall prevention.

☢️ Special Safety Units

• Oncology units: Wear exposure badges and protective clothing for radiation.

🧫 Infection Control

✋ Hand Hygiene

• Use alcohol-based sanitizer unless visibly soiled or patient has C. difficile.

⚠️ Specific Risks to Patient Safety in Health Care Settings

🧩 Risk Management Process

1. Identify possible risks (e.g., falls, med errors).
2. Analyze how and why risks could occur.
3. Act to reduce or prevent harm (education, policy, environment).
4. Evaluate results and update procedures as needed.

📈 Performance Improvement & Safety Programs

🗂️ Guidelines for Quality Documentation F.A.C.C.O

🧠 Good documentation = Legal protection + Safe continuity of care.

📋 Documentation Formats

🧾 Flow Sheets

• Record routine data (vitals, intake/output, hygiene) quickly and efficiently.

🗒️ Progress Notes

• Describe changes in condition or response to interventions.

⚡ Charting by Exception

• Document only abnormal findings — normal data assumed unless stated otherwise.

🩺 Narrative Charting

• Traditional, paragraph-style description of care in chronological order.

🧠 Best for detailed reports and emergencies.

📚 Problem-Oriented Medical Record (POMR)

Organized around patient problems rather than body systems.

Includes:

1. Database – assessment info (history, exams, lab data).
2. Problem List – identified health issues.
3. Care Plan – goals and interventions for each problem.
4. Progress Notes – updates using SOAP format:
• S: Subjective data
• O: Objective data
• A: Assessment
• P: Plan

📋 Documentation Formats & Nursing Safety Concepts

🧾 Charting Formats

⚠️ Nursing Diagnoses — Safety Risks

🧠 Each diagnosis helps identify interventions to keep patients safe and prevent harm.