Term
| Sensitivity or allergy to what foods may indicate you have a latex allergy?? |
|
Definition
| sensitivity or allergy to kiwifruit, papayas, avocados, bananas, potatoes, or tomatoes |
|
|
Term
| True or False: It may be necessary to perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination of different body sites. |
|
Definition
|
|
Term
| Should you wear gloves while performing oral care? |
|
Definition
| Yes. You will be in contact with saliva which is a body fluid. |
|
|
Term
| Always wear gloves when you may have to touch mucus membranes or non intact skin. |
|
Definition
|
|
Term
| You are about to change a patient's dressing. You know you need to follow principles of asepsis. This includes wearing what type of gloves. |
|
Definition
| Sterile gloves and maintaining a sterile field. |
|
|
Term
| What PPE should you wear when caring for someone with TB? |
|
Definition
| TB is a airborne pathogen. I need to follow "Airborne" precautions as well as standard precautions. I MUST WEAR a HEPA or N95 respirator. |
|
|
Term
| You are caring for a patient who has been administered a soap sud enema. You are now going to their room to help the nurse aide with a brief change as the patient could not control his bowels. Which PPE should you wear? |
|
Definition
| Gloves, gown, possible shoe covers if it is on the ground. |
|
|
Term
| What the five steps of the nursing process? |
|
Definition
ADPIE
Assessment, Diagnosis, Planning, Interventions, Evaluation |
|
|
Term
| You have a patient who tells you: "I feel so nauseated. I think I am going to vomit." What type of data is this? Is this a primary or secondary source? |
|
Definition
| Subjective data. (You are being told this data and can not measure it!) This is a primary source since it is coming directly from the horse's mouth. |
|
|
Term
You are reviewing a pt chart and are reviewing notes from physical therapy. In the notes you read, "Patient states she does not want to walk today because she is exhausted."
What type of data is this? What source? |
|
Definition
| This is subjective data (Data is only apparent to pt... no one else can feel her exhaustion) This is a secondary source since someone other than the pt has said it. |
|
|
Term
| Subjective data includes the following: |
|
Definition
| Usually obtained during health hx. Subjective data includes: pt's feelings, perceptions and description of own health status. Subjective data is apparent only to the pt. |
|
|
Term
|
Definition
| Usually obtained during a physical exam. Objective data can be: measured, felt, seen, heard, smelled. A nurse has to use HER senses for objective data. |
|
|
Term
Subjective data = symptoms
Objective data = signs |
|
Definition
|
|
Term
| Documentation of the data must be thorough, concise, and accurate. |
|
Definition
|
|
Term
| What is the proper format to write a nursing diagnosis? |
|
Definition
| Problem statement r/t etiology AEB defining characteristics (often objective data) |
|
|
Term
| What is a nursing diagnosis? |
|
Definition
| It specifically describes a pt's actual or potential REACTION to a health problem that the nurse is licensed and skilled to treat. |
|
|
Term
| What is the difference between a medical dx and a nursing dx? |
|
Definition
A medical dx is the actual physiological health problem. (Examples of medical dx are: asthma, Crohn's Disease)
A nursing dx, is based on a rxn to the person's health diagnosis. (For example, a nursing diagnosis is: "Risk for impaired tissue perfusion") It is because the pt has asthma that they have the nursing diagnosis. |
|
|
Term
| SO what is the big deal between nursing dx and medical dx? |
|
Definition
| Well, nurses are not LEGALLY allowed to make a medical dx. Nursing dx are are about how to care for the "body's reactions" to the pts medically diagnosed problem. A medical diagnosis is aimed directly at the disease. |
|
|
Term
| Why would a nurse write an "at-risk" nursing diagnosis? |
|
Definition
| Because there are risk factors that are likely to cause the problem. Dx is based on presence of risk factors. Allows nursing care to focus on reducing risk factors and preventing the problem. |
|
|
Term
| Why would you want to use an "at-risk" nursing dx? |
|
Definition
| To prevent a problem from occurring. |
|
|
Term
| What is an "Actual nursing" diagnosis? |
|
Definition
| When the clients problems exist at time of diagnosis. (Pt is not at risk... they have problem now!) Nursing care then focuses on resolving the problem. |
|
|
Term
| What would the nursing care focus on in an actual nursing diagnosis? |
|
Definition
| The nursing care would focus on resolving current problem. |
|
|
Term
| What would nursing care be focused on with an at risk diagnosis? |
|
Definition
| The nurse would focus on preventing the problem from occurring. |
|
|
Term
| What is a syndrome nursing diagnosis? |
|
Definition
| Signifies a problem that has common signs and symptoms that almost always present together. |
|
|
Term
| What is a wellness diagnosis? |
|
Definition
| When a client is ready for improved health status... (what??) |
|
|
Term
| What tool can be used to determine the priority of nursing care? |
|
Definition
| Maslow's Hierarchy of Needs. |
|
|
Term
| What can a etiology consist of? |
|
Definition
| One or more of the probable causes of the health problem, Factors contributing to the problem, related or risk factors of the problem, Situational factors contributing to the problem. |
|
|
Term
| What mnemonic device should you use to write goals? |
|
Definition
SMART
Specific, measurable, attainable, realistic and timely.
Goals should always be: PATIENT CENTERED and mutually agreed upon. |
|
|
Term
| What do you mean patient centered? |
|
Definition
When writing a goal use a phrase such as: "Client will have an O2 sat of 98%..."
Instead of saying, "Administer oxygen until client reaches 98%" This is nurse centered. |
|
|
Term
| So what is the difference between a client outcome and a client goal? |
|
Definition
A client outcome will identify measurable criteria that will determine success or failure of goal.
A client goal focuses on the desired client status. |
|
|
Term
| What is a nursing intervention? |
|
Definition
| Any nursing treatment or action that will enhance/achieve the client's outcome's. |
|
|
Term
Try to achieve an outcome.
Set a patient goal. |
|
Definition
|
|
Term
| There are 3 type of Patient Interventions: Name em... |
|
Definition
1. Nursing/independent interventions.
2. Physician/dependent interventions
3. Collaborative interventions |
|
|
Term
| What is a dependent/nurse initiated intervention? |
|
Definition
Autonomous intervention based on scientific evidence that is expected to benefit the client.
(ie: turning pt every two hours to prevent skin break down) |
|
|
Term
| What is a physician/dependent intervention? |
|
Definition
| Nurse initiate as a result of PCP's order. (ie: inserting a foley catheter) |
|
|
Term
| What is a collaborative intervention? |
|
Definition
| nurse carries out in collaboration with other healthcare providers. |
|
|
Term
| What is the nursing care plan? |
|
Definition
| End product of the "planning" step. The NCP is organized for quick id of the client's nursing dx, outcomes, and interventions to be implemented. |
|
|
Term
| What skills might the nurse use during the "Implementation" phase? |
|
Definition
| Intellectual skills (problem solving, critical thinking, creative thinking), Interpersonal skills (communication, teaching) and technical skills. |
|
|
Term
| what is the purpose of the evaluation phase of the nursing process? |
|
Definition
| To determine the effectiveness of care. Nurse gathers data based on nursing outcome criteria. |
|
|
Term
| Questions the nurse should ask during the Evaluation stage? |
|
Definition
"Were the desired outcomes met?"
"Were the interventions appropriate/ effective?"
"Does any outcome/ intervention need to be modified?" |
|
|
Term
| Client outcomes that are stated in specific, measurable terms are easier to evaluate |
|
Definition
|
|
Term
| What are the reasons pt goals fail? |
|
Definition
| Incomplete data obtained (not enough), Unrealistic pt outcomes, Nonspecific interventions, inadequate time for goal to be reached. |
|
|
Term
| What type of data is the following: "My pain is a 5 on a scale of 10" |
|
Definition
|
|
Term
| What type of data is the following: "The patient has a regular pulse of 78 bpm" |
|
Definition
|
|
Term
| During evaluation... reassess the pt and any goals/outcomes. Are the interventions working? Have goals been achieved?? This is the evaluation process. |
|
Definition
|
|
Term
| In what stage of the nursing process do you establish client centered outcomes and prioritize interventions? |
|
Definition
|
|
Term
| The cues and clues that a nurse chooses to use in the nursing diagnosis label are considered the...? |
|
Definition
| Defining characteristics (This come after "As evidenced by" |
|
|
Term
| In what stage of the nursing process do you gather information about pt to determine if outcomes and goals have been met? |
|
Definition
|
|
Term
| In what stage of the nursing process do you organize resources to proceed implementing interventions? |
|
Definition
|
|
Term
| In what stage do you determine priority of nursing interventions? |
|
Definition
|
|
Term
|
Definition
| Cognitive process a nurse uses to make nursing judgments. |
|
|
Term
|
Definition
| A mindset that affects how a nurse approaches a problem. |
|
|
Term
| What are professional standards in nursing? |
|
Definition
| Demonstration of professional responsibility, evaluation that relies on EBP, nursing judgment based on ethical criteria. |
|
|
Term
| Basic nutrients required by the body include: |
|
Definition
| Carbs, fats, protein, vitamins, minerals, water |
|
|
Term
| What are the fat soluble vitamins? |
|
Definition
|
|
Term
| What nutrient provides the body's main energy source? |
|
Definition
|
|
Term
| How is protein used in the body and why do we need to know about it? |
|
Definition
| Proteins are used for body growth and repair. And this includes wound healing. If a pt has low protein intake or low serum prealbumin you can bet there is going to be delay in wound healing. This is very important in patients with pressure ulcers. They often have poor diet and do not have enough protein. |
|
|
Term
| What % of caloric intake should come from fats? |
|
Definition
|
|
Term
| What are water soluble vitamins? |
|
Definition
|
|
Term
| How might medications affect nutrition? |
|
Definition
| Meds can alter the taste and appetite. Also some meds might make a person sleepy or nauseated. Meds can also interfere with absorption. |
|
|
Term
| Religious practices may guide a client's food choices. |
|
Definition
|
|
Term
| How might one's socioeconomic status affect nutrition? |
|
Definition
| Someone may not be able to afford foods that are high in proteins vitamins and minerals. Also, it may be hard for someone to get fresh fruits and veg if they do not have mode of transportation. |
|
|
Term
| How does affect nutrition? |
|
Definition
| Adolescents require more calories while young adults and older adults have a decreased demand for calories. |
|
|
Term
| What two minerals are needed especially for women beginning at young adult? Why? |
|
Definition
| Calcium and iron. Women have a decreased iron store and are prone to anemia r/t menstruation. Young women should have calcium to prevent osteoporosis. |
|
|
Term
| Why do older adults require fewer calories? |
|
Definition
| They have a decreased metabolism and tend to be more sedentary. |
|
|
Term
| Anorexia nervosa ofetn presents how? |
|
Definition
| When a client's body weight is 85% of ideal, client states "fear of getting fat" and "feeling fat". In female clients there has been no menses for 3 consecutive months. |
|
|
Term
| What diseased is described here: A cycle of binge eating followed by purging (vomiting, use of laxatives, exercising) |
|
Definition
|
|
Term
| How is Obesity determined? |
|
Definition
|
|
Term
|
Definition
|
|
Term
| What should the diet hx include? List as many as possible. |
|
Definition
Number of meals/day
Fluid intake
Food preferences and amounts
Food prep/purchasing (include access to food)
Taste
Allergies
Chewing and swallowing
Elimination patterns
Use of any meds |
|
|
Term
| What lab values are important pertaining to nutrition? |
|
Definition
| Cholesterol, triglycerides, hemoglobin, electrolytes, albumin |
|
|
Term
| I&O should be monitored on any pt with fluid/electrolyte alterations. |
|
Definition
|
|
Term
| Examples of who should be on strict I & O. Can you think of any others? |
|
Definition
| Pt with IV, Pt with TPN, Pt with Hyper/Hypo natremia, pt receiving blood/plasma |
|
|
Term
| Review as a group clinical assessment of poor nutrition. ATI pg. 517 |
|
Definition
|
|
Term
| Here are some of the best signs someone has poor nutrition. |
|
Definition
Loss of SubQ fat
Dry, brittle hair
Dry, scaly skin
Dry, dull eyes |
|
|
Term
| What are common NANDA nursing diagnosis r/t nutrition? |
|
Definition
| Constipation, deficient/excess fluid volume, imbalanced nutrition: more/less than body requirements, Self-care deficit: feeding |
|
|
Term
| How would you implement this nursing intervention? |
|
Definition
| Assist the client in advancing diet as disease process allows |
|
|
Term
| How would you implement this nursing intervention? |
|
Definition
| Provide education on diet regimen |
|
|
Term
| How would you implement this nursing intervention? (give examples) |
|
Definition
| Educate client on meds that may affect nutritional intake |
|
|
Term
| How would you implement this nursing intervention? |
|
Definition
| Provide interventions to promote appetite |
|
|
Term
| How would you implement this nursing intervention? |
|
Definition
| Assist the client with feeding to promote optimal independence |
|
|
Term
| How would you implement this nursing intervention? |
|
Definition
| Assess for and prevent aspiration |
|
|
Term
| Give details on how you would help prevent aspiration: |
|
Definition
Position client in high fowler's
Support upper neck, back, and head
Have client tuck chin while swallowing (helps food move down esophagus)
Observe for aspiration or pocketing of food
Maintain client in Semi fowler's 1 hour post prandial
Provide oral hygiene after sancks/meals |
|
|
Term
| What degree is High Fowlers? Fowler's? Low Fowler's? |
|
Definition
High = 90 degrees
Fowler's = 45 degrees
Low Fowler's = 30 degrees |
|
|
Term
| What would you give a pt on a clear liquid diet? |
|
Definition
| any liquid that is clear and liquid at room temp |
|
|
Term
| What do you have to be worried about in a client with dysphagia on a liquid diet? |
|
Definition
| Pt could aspirate liquids. Intervention: thicken all liquids with a thickening agent to prevent aspiration |
|
|
Term
| If a patient aspirates, where is the foreign object most likely to be found and why? |
|
Definition
| The right lung because the right Brochus is larger than the left (fun fact) |
|
|
Term
| What is included on a full liquid diet that is not included on a clear liquid diet? |
|
Definition
| Milk, ice cream, soups, puddings, strained fruits and veg |
|
|
Term
| What is the benefit to full liquid diet over clear liquid diet? |
|
Definition
| Full liquid has more variety and more nutritional value. However, if this diet is going to be ordered for 3+ days than high protein, high supplements may be added to prevent excessive weight loss. |
|
|
Term
| The full liquid diet is contraindicated for who? |
|
Definition
| Pts who are lactose intolerant and those w/ hypercholesteremia (i don't know why for the latter) |
|
|
Term
| t/f. When possible, oral feedings are preferred. |
|
Definition
|
|
Term
| Define "Enteral" nutrition: |
|
Definition
| When the GI tract is used to provide nourishment. |
|
|
Term
| Who should the nurse collaborate with for nutritional/dietary concerns? |
|
Definition
| Dietitian (on staff a most hospitals) |
|
|
Term
| What might you add to a pureed diet if you were needing to add calories to the diet? |
|
Definition
| Broth, gravy, milk, cream, soup, tomato sauce or fruit juice substituted for water in recipes. |
|
|
Term
| When is a soft bland diet indicated? |
|
Definition
| When clients are transitioning from a full liquid to regular diet, those with chewing difficulties, acute infections, and GI disorders |
|
|
Term
| What is a benefit to the soft bland diet vs a pureed diet? |
|
Definition
| Food texture may be smooth, creamy or crisp. |
|
|
Term
| What foods are excluded from a soft bland diet? |
|
Definition
| Fruits, veggies, coarse breads, and cereals, beans or any gas forming foods. |
|
|
Term
| What does the mechanical soft diet include? |
|
Definition
| Foods that require minimal chewing before swallowing. |
|
|
Term
| The mechanical soft diet is a FULL diet that has been altered in TEXTURE! |
|
Definition
|
|
Term
| What is diet as tolerated? |
|
Definition
| an order to permit a client's food preferences and ability to eat be considered. Nurse may assess for hunger, appetite and nausea when selecting diet for pt. (consult w. dietitian) |
|
|
Term
| Diet is progressively increased following major surgeries. Why? |
|
Definition
| Because the bowel are going to be hypoactive after surgery. The diet should be progressed at the bowels "wake up" |
|
|
Term
| What should the nurse assess for before determining diet post-op? |
|
Definition
| Bowel sounds. Nurse should assess for return of bowel function AEB bowel sounds before advancing clients diet. |
|
|
Term
| A nurse can increase a pts satisfaction with diet by being courteous, assisting with tray, displaying a positive attitude about food and explaining why the pt is on a specific diet (and benefits for pt) |
|
Definition
| That's right. No bitchin about how gross the food is! haahahaha |
|
|
Term
| Summarize clear liquid diet: |
|
Definition
| leave little residue. Clear liquids. |
|
|
Term
| summarize full liquid diet: |
|
Definition
| Clear liquids plus dairy products, all juice ans pureed fruits and veg |
|
|
Term
|
Definition
| clear and full liquid diet plus pureed meats, pureed fruits and veg, and scrambled eggs |
|
|
Term
| Summarize soft/low residue diet: |
|
Definition
| foods that are low in fiber and easy to digest |
|
|
Term
| summarize high fiber diet: |
|
Definition
| whole grains, raw and dried fruits |
|
|
Term
| summarize low sodium diet: |
|
Definition
| no added salt; 1-2 g sodium per day |
|
|
Term
| Summarize low cholesterol diet: |
|
Definition
| No more than 300 mg/day of dietary cholesterol |
|
|
Term
|
Definition
| balanced intake of protein, carbs, and fat; total calories 1800 |
|
|
Term
| summarize Dysphagia diet: |
|
Definition
| pureed foods with thickened liquids |
|
|
Term
| summarize Dysphagia diet: |
|
Definition
| pureed foods with thickened liquids |
|
|
Term
| What restrictions does a regular diet have? |
|
Definition
|
|
Term
| What lab values would you want to have to monitor a pt on TPN? |
|
Definition
| Blood glucose and electrolytes |
|
|
Term
| What are ways to maintain a fluid balance: |
|
Definition
| restricting fluids if indicated (remove pitcher of H2O, communicate with staff); Encouraging intake of fluids (provide fresh water and ask pt drink preferences) |
|
|
Term
| Describe a soft/low residue diet: |
|
Definition
| Foods that are easily digested and low in fiber |
|
|
Term
|
Definition
| Clear and full liquids plus pureed meats and fruits and scrambled eggs |
|
|
Term
| What is a pressure ulcer? |
|
Definition
| tissue injury caused by external forces that result in unrelieved pressure that results in ischemia and damage to underlying tissues |
|
|
Term
| What is the number one way to prevent pressure ulcers? |
|
Definition
|
|
Term
| Primary treatment of pressure ulcers? |
|
Definition
1. Prevention
2. Relieve pressure and provide good nutrition and hydration. |
|
|
Term
| Pressure ulcers are a significant source of morbidity and mortality among people who suffer from immobility. |
|
Definition
|
|
Term
| Risk factors for developing pressure ulcers? |
|
Definition
| Immobility, Skin changes related to aging, Incontinence, skin friction and shearing, vascular disorders, obesity, Inadequate nutrition, anemia, Impaired circulation, edema, SENSORY deficits, Chronic diseases, sedation that impairs repositioning |
|
|
Term
| How can we prevent pressure ulcers? |
|
Definition
| Maintain clean dry skin (change brief immediately after incontinence), Use tepid water (not hot) when cleaning skin and pat dry (not rub dry), inspect skin frequently, APPLY a moisture barrier to skin |
|
|
Term
| What would I be assessing if I were to use the Braden scale? |
|
Definition
|
|
Term
| How often do you position clients (bed and chair)? |
|
Definition
1-2 hours in bed
1 hour in chair (if pt can move themselves, instruct pt in chair to shift weight q15 min) |
|
|
Term
| T/F. You should document position changes. |
|
Definition
|
|
Term
| Pressure sores or skin breakdown? |
|
Definition
| Do not massage bony prominences! |
|
|
Term
| What are important to know r/t bed positioning of a person with skin breakdown? |
|
Definition
1. Do not pull a pt! Lift the pt with a draw sheet (this reduces skin shearing)
2. Prevent pt from sliding down in bed (sliding pulls tissue layer apart and causes shearing)
3. FLOAT heels off bed to prevent PU
4. Place pillows strategically between bony surfaces
5. Maintain head of bed at or below 30 degrees to reduce pressure |
|
|
Term
| What nutritional concerns do we have with people w/ skin breakdown or Pressure ulcers? |
|
Definition
1. Provide adequate hydration (2000-3000ml/daily)
2. Meet protein and calories needs (promote healing) |
|
|
Term
| Note: If serum albumin levels are low (< 3.5 g/dl) r/t lack of protein, pt is at greater risk for skin breakdown, slowed healing, and infection |
|
Definition
|
|
Term
| What are 2 common complications of pressure ulcer? |
|
Definition
1. Deterioration (of pressure ulcer) to higher stage and/or infection.
2.Systemic infection |
|
|
Term
| What interventions should you consider to prevent systemic infection in someone with a Pressure ulcer? |
|
Definition
1. Sterile dressing changes
2. Provide good nutrition to promote immune response and healing.
3. Provide for adequate rest to promote healing
4. Give antibiotics as ordered.
3. |
|
|
Term
What stage is the following pressure ulcer?
Epidermal involvement; Lightly pigmented skin: redness; Skin color: blue, purple or darker red.
REVERSIBLE IF PRESSURE IS RELIEVED. |
|
Definition
|
|
Term
What stage is this pressure ulcer?
Partial skin thickness loss; abrasion, shallow crater, or blister; may appear swollen and may be painful; Takes several weeks to heal. |
|
Definition
|
|
Term
What stage is the following pressure ulcer?
Full skin thickness loss; deep crater lesion; May have foul odor and drainage;
Yellow slough and necrotic tissue in would bed;May require months to heal. |
|
Definition
|
|
Term
What stage is this pressure ulcer?
Extensive damage to underlying structures (tendons, muscles, bones); local infection can spread easily causing sepsis; May take months to years to heal. |
|
Definition
|
|
Term
What stage of pressure ulcer is the following:
A ulcer covered with eschar (dark, leathery scab of necrotic tissue) and wound bed can not be visualized. Often causes mortality. |
|
Definition
| Unstagable pressure ulcer. |
|
|
Term
| Name some interventions for Stage I pressure ulcers: |
|
Definition
1. Relieve pressure
2. Frequent turning/repositioning
3. Implement pressure relieving devices
4. Keep pt clean and dry
5. Keep pt hydrated and good nutrition |
|
|
Term
| Interventions for Stage II pressure ulcer? |
|
Definition
1. Maintain moist healing environment
2. Nutritional supplements prn
3. Analgesics as ordered |
|
|
Term
| Interventions for Stage III pressure ulcer: |
|
Definition
1. Clean and/or debride
2. Wet to dry dressing or surgery
3. Administer Analgesics
4. Administer nutritional supplements prn |
|
|
Term
| Interventions for Stage IV pressure ulcers: |
|
Definition
1. Non adherent dressing changes q12 hours
2. Tx may require skin grafts
3. Nutritional supplements prn
4. Analgesics as ordered. |
|
|
Term
| Describe Fowler's position: |
|
Definition
Head of Bed: ~45 degrees
Kness can be at: 15 degress |
|
|
Term
| Why would Fowler's position be used? |
|
Definition
Allows for chest expansion and better ventilation.
Good for drainage post abdominal surgery |
|
|
Term
|
Definition
| Head of bed: ~80-90 degrees. |
|
|
Term
| Why would we use High Fowlers? |
|
Definition
To prevent aspiration/ during feeding
To allow for great chest expansion |
|
|
Term
| Describe Supine (dorsal recumbent) posititon: |
|
Definition
| Lying flat on back; may have pillow under shoulders/head. |
|
|
Term
| If you positioned a pt in prone position, how would they be laying? |
|
Definition
|
|
Term
| Why would you place a pt in prone position? |
|
Definition
| To promote oral drainage in pts who had throat/ oral surgery. |
|
|
Term
| When is prone position contraindicated? |
|
Definition
1. Pt has spinal abnormalities (spine is not properly aligned)
2. Long periods of time
3. When someone has difficulty breathing |
|
|
Term
| When would you place a pt in: orthopenic position (tripod)? |
|
Definition
| When they have a chronic lung disease (such as Emphysema or COPD). This position allows for maximum chest expansion. Also, pts can use the table to push up on diaphragm. |
|
|
Term
| When would you place someone in Sim's position? |
|
Definition
1. Many find it comfortable to sleep this way
2. Promotes oral drainage
3. Often used to give enemas/ look at perineum |
|
|
Term
| If you were in Trendelenburg position... how would you be laying? |
|
Definition
You'd be laying on your head.
Trendelenburg is when the head of the bed is lower than foot of bed. |
|
|
Term
| When would a pt be placed in Trendelenburg? |
|
Definition
| To promote venous return in someone with hypotension. |
|
|
Term
| Describe Reverse Trendelenburg and when it might be used? |
|
Definition
When the foot of the bed is lower than the head of the bed.
Prevents esophageal reflux and promotes gastric emptying |
|
|
Term
| Nursing interventions for immobile client: |
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Definition
1. Turn, cough and deep breathe to reduce stasis of secretions in lungs and promotes lung expansion which decreases risk for pneumonia.
2. Assess lung/breath sounds (decreased breath sounds in dependent are of lungs?)
3. Position pt q2 hours and check for skin breakdown. |
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Term
| Why would you want an immobile pt to turn cough and deep breath? (or use incentive spirometer?) |
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Definition
| To expand lungs and reduce stasis of secretions in lungs. This decreases the chances of Pneumonia. |
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Term
| Why would you need to assess an immobile pts circulation? |
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Definition
| Immobile pts are at great risk for DVT. Assess for: cap refill, pulses and skin temp in feet and lower legs. |
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Term
| 3 risk factors for developing DVT? (Virchow's Triad) |
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Definition
1. Hypercoagubility of the blood
2. Stasis of blood
3. Injury to vessel wall |
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Term
| What is the #1 way to prevent a DVT postop? |
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Definition
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Term
| What can someone do why can not ambulate to help prevent DVT? |
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Definition
| Leg exercises, fluids and position changes to prevent stasis and promote circulation. |
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Term
| 3 support treatments used to prevent DVT: |
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Definition
1. TED hose- promotes venous return and helps decrease stasis
2. SCD's promotes venous return through external pressure (acting as skeletal muscles)
3. Medications (such as anticoagulants and platelet inhibitors) |
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Term
| Why should you consider using assistive devices with pts? |
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Definition
| Improves safety and prevents injury to yourself and pt. |
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Term
| Where is human center of gravity? |
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Definition
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Term
| Avoid twisting the spine or bending at waist to minimize risk for injury when moving weight. |
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Definition
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Term
| What is the proper way to lift something? |
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Definition
| Pg. 439 ATI fundamentals book |
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Term
| Sliding, rolling, and pushing requires less energy than lifting and has less risk for injury. |
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Definition
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Term
What is safer and easier?
a. to pull toward the center of gravity (to self)
b. push away from center of gravity (away from self) |
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Definition
| a. it is easier/safer to pull toward |
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Term
| Who has lower center of gravity? Courtney or Jordan? |
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Definition
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