Term
| 3 big factors contributing to falls after age 70? |
|
Definition
1. Being in an unfamiliar environment
2. Difficulty communicating b/c of impaired, hearing, vision speech.
3. Impaired Cognition |
|
|
Term
| In many agencies, when is a patient's fall risk assessment done? |
|
Definition
|
|
Term
| What will the nurse do if she is ambulating a patient and the patient begins to fall? |
|
Definition
| Ease the client into the chair, put both arms around the client's waist or grasp the gait belt. Stand with feet apart to provide a broad base of support, Extend one leg and let the client slide against it to the floor, Bend the knees to lower the body as the client slides to the floor. |
|
|
Term
| Are all 4 side rails up considered a physical restraint? |
|
Definition
| Yes, a full set of side rails is considered a restraint if they restrict a client's freedom of voluntary movement in and out of bed. |
|
|
Term
|
Definition
| Temporary means to maintain client safety. |
|
|
Term
| Are restraints dangerous? |
|
Definition
| In some cases people have died from certain restraints, but they are meant for the clients safety. |
|
|
Term
| Is a physician's order required for restraints? |
|
Definition
| Yes and it must specify the type of behavior requiring restraint, the type of restrain and the time limit for the restraints. |
|
|
Term
|
Definition
| the force exerted parallel to the skin resulting from both GRAVITY pushing down on the body and RESISTANCE (friction) between the client and the surface. |
|
|
Term
| What is orthostatic hypotension? |
|
Definition
| a drop in BP when changing form a horizontal to a sitting or standing position. Pt has symptoms of dizziness, pallor and fainting. |
|
|
Term
| What causes orthostatic hypotension? |
|
Definition
| bed rest, hypovolemia, hypokalemia, certain meds, sedatives, hypnotics, analgesics, antihypertensives, antiemetics, antihistamines, diuretics, antianxiety agents. |
|
|
Term
| Why is it important to asses muscular strength prior to transferring a patient? |
|
Definition
| This provides a baseline to determine the clients ability to assist caregivers and to assess the clients progress toward improved activity tolerance and muscular endurance. The plan of care should be adjusted if the client is losing or gaining muscle strength and joint mobility over time. |
|
|
Term
| Why do we assess vision, hearing and altered sensation prior to transferring a pt? WHy do we assess for levels of sedation before transferring a pt? |
|
Definition
| this determines how much the client can help when transferring |
|
|
Term
| Remember to assess for catheters, NG tubes, IVs, etc... before moving a patient, whY? |
|
Definition
| certain tubes limit the amt of movement and you don't want to accidentally pull out any type of tube? |
|
|
Term
|
Definition
|
|
Term
| WHen a pt has dysphagia, what precautions should the nurse be aware of? |
|
Definition
| want to prevent aspiration by maintaining an upright position so gravity can help. |
|
|
Term
| How would you feed a patient with dysphagia? |
|
Definition
| Place food in the mouth opposite of the affected side and watch as they swallow. If patient has a good side, place food on that side. Pt might need verbal coaching through swallow completely. |
|
|
Term
| What do we assess before feeding a pt? |
|
Definition
| The pt's LOC and ability to cooperate, their mobility/activity level and physical limitations. Assess if they want to use the toilet, have clean hands and oral care. Assess they tolerance to certain foods, cultural and religious preferences, food likes & dislikes, measure the clients weight, and whether the client needs an altered diet in any way (nutrient wise), what flavors or consistence would be best. Check their lab values. |
|
|
Term
| How can the nurse assess the swallowing reflex? |
|
Definition
| Place fingers on the clients throat at the level of the larynx, then ask the client to swallow. |
|
|
Term
| Why should suction equipment be nearby when a patients has dysphagia? |
|
Definition
| Just in case the client begins to choke, you need to suction the food out to provide airway. |
|
|
Term
| What is food pocketing and what implication does it have for a dysphagia patient? |
|
Definition
| teaching the client to use the tongue or to massage the cheek externally to move food to a more functional area of mouth. |
|
|
Term
| General guidelines to follow for any transfer procedure: |
|
Definition
| raise sd rail on sd opposite the nurse, elevate bed to a comfortable height, assess clients mobility and strength, determine need for assistance, explain the procedure and describe what is expected of the client, assess for correct body alignment and pressure areas after each transfer. |
|
|
Term
| Immobile patients may have decreased ability for autonomic nervous system to equalize blood supply, resulting in BP dropping when rising to a sitting or standing position. What is the term these patients are at risk for? |
|
Definition
|
|
Term
| A walker fits properly when it is in line with the ______ __________. |
|
Definition
|
|
Term
| A cane fits properly when it is in line with the patients ________ __________. |
|
Definition
|
|
Term
| What measurements are taken for a proper crutch fit? |
|
Definition
| want it 4 inches away from body & 4 inches forward. Want 2-3 fingers to fit under the axilla (armpit) and have a 20 angle of your elbow. |
|
|
Term
| What are the 2 most important body mechanics for safety? |
|
Definition
| 1. bend knees & straighten back 2. Hold the load close |
|
|
Term
| 3 most important body mechanics to teach your patient? |
|
Definition
| 1. Scoot to the edge 2. Nose over Toes 3. Balls behind your knees |
|
|
Term
| What 2 parts of crutches need to be adjusted to a patient? |
|
Definition
|
|
Term
| Which side do you go towards when transferring a patient? |
|
Definition
| Their stronger, unaffected side should lead in transfers |
|
|
Term
| Never pull on the affected arm of ________ patient. why? |
|
Definition
| stroke - b/c the muscles are what keeps the socket in place & with a stroke you NEVER WANT TO PULL ON THEIR BAD ARM! |
|
|
Term
| If manually lifting a patient is impossible, what will you use? |
|
Definition
| A blanket works for total assist. Mechanically, a Hoyer Lift or an Easy Stander (pelvic sling). |
|
|
Term
| What is the best tool ever for safe transfers? It is put around the pt's waist to assist with safe transfers. How tight should it be? |
|
Definition
| Gait Belt, just able to fit hand under |
|
|
Term
| How do you know if your patient has the ability to lift the weight of their own pelvis'? |
|
Definition
| Bridging, knees are bent with feet on mattress & ask them to lift their pelvis in the air. If they can, that is the heaviest part of themselves & they will be able to assist you some. |
|
|
Term
| What are the 3 kinds of pivot transfers? |
|
Definition
|
|
Term
| What do we know about a patient with a Total Hip Replacement's transfer & mobility? |
|
Definition
| A total hip replacement patient is able to be full weight bearing, but they do not have ability to move in any direction. Total Hip Replacement rules: do not bend past 90 degrees, never cross their legs and never let their legs roll inward. |
|
|
Term
| Do we transfer towards a patients strong or weak side? |
|
Definition
|
|
Term
| What kind of chair should a weak patient be put in? |
|
Definition
| One where arms can be removed. |
|
|
Term
| What position is the head of the bed in prior to moving a client? Why? |
|
Definition
| Lower head of bed so they are in a supine position b/c working with gravity requires less effort then working against it. |
|
|
Term
| Do we put our backs to the direction we are moving or face the direction we are moving? Why? |
|
Definition
| We face the direction we are moving b/c then we are not twisting |
|
|
Term
| Why do we bend at knees & hips when moving a client up in bed? |
|
Definition
| bending with the knees and hips flexed uses the longest, strongest muscle groups (legs) and helps prevent back strain. |
|
|
Term
| Why is it imp for the nurse to stand with their legs shoulder width apart, knees flexed and stand as close to the client as possible when moving a client? |
|
Definition
| The principles of body mechanics tell us the wider the base of support, the lower the center of gravity and the closer to the object we are lifting the greater the stability and balance during the move. |
|
|
Term
| Why is it important for the nurse to contract their abd muscles prior to moving a client? |
|
Definition
| This helps prevent ligaments and joints from strain & injury |
|
|
Term
| A pt who is 12 hours post-op needs to be turned. What is important to access prior to turning this client? |
|
Definition
| Assess the level of comfort and the need for analgesia. medicate 15-30 minutes prior to turing. |
|
|
Term
| Why do we raise the level of the bed before turning a client? |
|
Definition
| This brings the client closer to the nurse's center of gravity and helps prevent unnecessary back strain from leaning over. |
|
|
Term
| What are the outcomes of turning clients in bed every 2 hours? |
|
Definition
| pressure is relieved over bony prominences, skin remains intact, and good alignment and comfort are promoted. |
|
|
Term
| What is logrolling a client? |
|
Definition
| Purpose of logrolling clients to keep their spinal column straight to prevent injury. A pillow is placed between the client's knees and the client's arms are crossed across their chest. 2 nurses are positioned on the side to which the client will be turned. One nurse will remain on the other side. (Want more people on the pulling toward side) A draw sheet or bed pad is used to move the client in one smooth, continuous unit on the count of 3. Pillows are placed appropriately to support the client in correct spinal alignment. |
|
|
Term
| If someone is going to sit up in a chair for the first time after surgery, what are the important factors the nurse needs to assess before proceeding? |
|
Definition
| Their LEVEL OF PAIN, ABILITY TO ASSIST YOU, NUMBER OF IV's, TUBES, DRAINS, etc.., Assess need for assistance to ensure safety of patient and nurse. |
|
|
Term
| What is the appropriate way to assist a falling client? |
|
Definition
| Increase base of support (widen legs apart), straightened one leg and allow client to slide down leg, and make sure that clients head does NOT HIT any hard surface. |
|
|
Term
| If the client is mobile, what is the best method to transfer from the bed to a stretcher? |
|
Definition
| "Bridge" or segmental method - where the client moves shoulders, and then hips, until the client reaches the center of the stretcher. |
|
|
Term
| What are the purposes of positioning? |
|
Definition
| Maintain skin integrity, promote good body alignment, prevent contractures, promote circulation, provide sensory stimulation, improve ventilation, and promote comfort. |
|
|
Term
| If a pt is experiencing SOB what position best promotes lung expansion? |
|
Definition
| Semi-Fowlers, Fowlers & High-Fowlers |
|
|
Term
| Sims position is recommended when performing what procedure? |
|
Definition
|
|
Term
| When is the trendelenburg position utilized? |
|
Definition
| Inserting and removing central venous catheters and for postural drainage. |
|
|
Term
| What is the trendelenburg position? |
|
Definition
| Patient is supine, but the head is lower then the feet by 30-40 degrees. Position is good for postural drainage, promoting venous return and she mentioned a slight trendelenburg for moving a patient up in bed (nurse standing by their head). |
|
|
Term
| When are restraints used? |
|
Definition
| when a pt is disruptive and/or agitated and at risk for self-injury or violence to themselves and/or others. Sometimes pt's may be restrained when they are confused and interfere w/ the treatment necessary for their recovery (i.e. they're trying to pull out catheters, IV's, NG tubes). Sometimes clients who are at great risk for falls are restrained, but this is not an automatic utilization. |
|
|
Term
| How often must restraints be reordered? |
|
Definition
|
|
Term
| Every pt. admitted to an acute care facility has a "falls risk" assessment completed on them. Why? |
|
Definition
| many pt's are subject to falls in hospitals d/t meds, loss of sensory perception, unfamiliar settings, etc... Completing a falls risk assessment identifies those clients more likely to fall and therefore the nurse may institute interventsion to keep the client from falling in the hospital. |
|
|
Term
| What conditions require special equipment? |
|
Definition
| If they have had a fall previously, they are at risk for a fall! Severe edema, severe osteoporosis, stoma patients, patients with tubes, patients with very fragile skin, etc.. |
|
|
Term
| How much does the pt's BP levels drop in orthostatic hypotension? |
|
Definition
| Systolic BP drops atleast 15 mmHg and diastolic BP drops 10 mmHg. Client is usually dizzy, pale and faint. |
|
|
Term
| What assessment would make the nurse suspect client had dysphagia? |
|
Definition
| persistent drooling, speech problems, wet/hoarse voice during meal, pockets food and meds in cheek, head posture during eating is extended forward to the left or right, coughing during or after swallowing, client complains of pain or "food getting stuck in throat" with swallow, and/or client reports of difficulty swallowing. |
|
|
Term
| If ANY of the dysphagia symptoms are present, what should the nurse do? |
|
Definition
| the client should remain NPO and notify the physician who needs to write an order for speech pathology see the patient. |
|
|
Term
| If pt has dysphagia, particularly on their left sd, where do you place their food? |
|
Definition
| On the right side (their unaffected side) of the mouth when possible. |
|
|
Term
| What equipment should be in the room when a client has dysphagia? |
|
Definition
|
|
Term
| The step-by-step rules for the safest way to accomplish the task (pt handling or lifting) are called "_______________." |
|
Definition
| algorithms, developed by a group of nursing experts. |
|
|
Term
| Bariatric care is caring for ___________ clients. What is their BMI? Weight max limit for most normal hospital equipment? |
|
Definition
| obese. BMI = 30+. Weight max limit on hospital equipment is 350 lbs. |
|
|
Term
| What question should be asked before seeking employment somewhere? |
|
Definition
| Do you have a "no lift policy?" |
|
|
Term
| What if the patient forgot their cane at home? |
|
Definition
| Get a longer piece of equipment. Adjusting canes, walkers and crutches is the legal & safety responsibility of the nurse. |
|
|
Term
| How should a patient with walker do it? |
|
Definition
| Step through method is best. Walk with affected/hurt leg first, then follow with unaffected leg. |
|
|
Term
| Hemi-walkers and hemi-canes are used for patients who recently had a ________. |
|
Definition
| stroke & are learning to walk again. Hemi means one sd is less strong then the other. Hemi walkers have a handle in the middle for stroke patients. |
|
|
Term
| When we are using a straight cane or crutches, we want the patients arm to have a __ degree bend in the elbow. |
|
Definition
|
|
Term
| What is a NBQC, SBQC, WBQC and a LBQC? |
|
Definition
| narrow base/small based quad cane & a wide based/large based quad cane. Quad canes have a v shape. We want the straight side toward the body. These v-shaped canes give more stability then straight canes, but not as much as walkers would. |
|
|
Term
| What side should your patient use their cane on? |
|
Definition
| Opposite the affected/hurt leg. If their right leg is weaker=cane is held in left hand. |
|
|
Term
| With walkers & canes, we put that out first, then what leg should they lead with? |
|
Definition
| The affected/hurt leg comes out first, following the cane or walker. |
|
|
Term
| General rule for using crutches on stairs is... |
|
Definition
| "Up with the good & down with the bad" or "good go to heaven, bad go to hell" - meaning, when going up stairs you will lead with your better leg & when going down stairs you will lead with your bad leg. |
|
|
Term
| What do you need to know in regard to patients weight bearing abilities? |
|
Definition
| They will be full, partial, Weight bearing as tolerated (WBAT), touch down or toe touch weight bearing (TDWB), or non weight bearing (NWB), or weight on heels (WOH). |
|
|
Term
| Weight Bearing Status' are: |
|
Definition
Non weight bearing: The leg must not touch the floor. The patient must hop. This is a 0% of the body weight.
Touch down weight bearing or Toe touch weight bearing: The weight of the leg on the floor while taking a step should be no more than 20% of the body weight.
Partial weight bearing: The weight can be gradually increased from 30 to 50% of the body weight.
Weight bearing as tolerated: Ranks from 50 to 100% of the body weight. The patient may increase the weight as he or she feels capable to do so.
Full weight bearing: The leg can now carry a 100% of the body weight on a step. |
|
|
Term
| Different levels of assistance are: |
|
Definition
| STAND-BY ASSIST (SBA): attention can be diverted & pt will be ok. CONTACT GUARD ASSIST (CGA): attention cannot be diverted, something could happen - you need to be ready. MINIMAL (MIN): pt performs 75% of the work, you do 25%. MODERATE (MOD): pt performs 50-75% of work, you have to do other 50%. MAXIMAL (MAX): pt performs 25-50% of work, you have to do 74% of work. VERBAL CUES: (VC's) talking pt through a task. HAND HELD ASSIST (HHA): you have to hold pt's hand for them to do well. TOTAL ASSIST: pt can't do a thing. |
|
|
Term
| How do we get a pt back into bed? |
|
Definition
| Use the same technique getting a pt back into bed that you used to get them out. |
|
|
Term
| Every time you transfer to chair, what do you want there just in case? |
|
Definition
| a blanket so you are prepared to do a total assist if worst case scenario happens. Otherwise, it gives them a fresh seat. You never know who used the w/c last. |
|
|
Term
| If you are leaning way out to lift... what happens to the weight? |
|
Definition
| You're lifting 10 fold when lifting way out away from yourself |
|
|
Term
| Patients with total hip replacements can go straight up in down, but ... |
|
Definition
| no farther. They will not be doing "nose over toes." you should tell them to shoot off like a rocket, go straight up. |
|
|
Term
| Why is it so important to know your patient and what they do at home when assisting? |
|
Definition
| B/c what they do at home is what they should do in the hospital or atleast you will understand what will be difficult for them. Expect them to be max assist in hospital b/c they don't normally do that kind of activity. |
|
|
Term
| How do we assess a patients upper body strength? |
|
Definition
| have them do a WC push up. Can they lift their bottoms off the WC? if so, they have good upper body strength. |
|
|
Term
| Assess a patients ability to follow commands first (have them squeeze your hand maybe...) then perform the mobility movements in __________. |
|
Definition
|
|
Term
| Info necessary for parapalegics: |
|
Definition
| need more then 1 person to move, have them get up on elbows, then up on hands, we want them in the long sitting position, hold by their scapula (never by their neck) and bring their legs around (maybe with a bed pad). Want them to wear undies (better to slide in) and keep palms flat (fingers don't get pinched). Use a sliding board (in little increments, not one big swoop!) |
|
|
