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47 Cards in this Set
- Front
- Back
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Pivot
Definition Prevention |
Def: Turn or change the direction with your feet while remaining in a fixed place
Prevent twisting of the body & possible injury to the nurse |
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What is the 1st Rule about moving a heavy person when you can’t handle it?
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Get help
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When it comes to (mobility) transferring a pt, you want to keep in mind
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Correct Alignment
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How would you determine who has correct alignment & what kind of disease process will give you an incorrect alignment
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eg. Stroke, scoliosis
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When someone develops a pressure ulcer, what do we do
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Keep them off of it
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Know the difference position in bed: def of ea
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Sims (variation of lateral)
Lateral, side-lying (on side) Prone (lying face down) Semi Fowler’S(30-60) Fowler’s (60-90) Low Fowler’s (15-30) Dorsal Recumbent (supine, knees flexed, feet flat on bed) Dorsal Lithotomy (supine, knees up, feet in stirrups) Knee Chest (chest on bed, knees on bed, lower legs on bed) Supine (lying on back) |
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Know the uses:
SIMS LATERAL,SIDE LYING PRONE *FOWLER’S, SEMI FOWLER’S , LOW FOWLER’S DORSAL RECUMBENT DORSAL LITHOTOMY KNEE CHEST SUPINE (lying on back) |
-rectal exams, enemas, suppositories, unconscious pt
-Lay on side -prolonged bed rest, immobilized, spinal cord injuries -Improve cardiac output & resp. promote urinary & bowel elimination, NOT abdominal surgery unless ordered -variety of procedures & examinations -pelvic exams eg giving birth -Rectal examination & a method for to restore Uterus to a normal position NOTE: not for joint abn or arthritis -after spinal surgery, & after spinal anesthesia |
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What keeps feet dorsiflexed?
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High Tops Snickers
Bed Boards |
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What is called when a pt sits on the side of the bed with feet hanging down
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dangling
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What are you monitoring ( signs) as they sit on side of bed
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HTN
Nausea Dizziness |
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When is logrolling used?
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For spinal surgery pt.
Roll them as a single unit or as a whole |
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What can you use to prevent hand contractures?
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Handrolls & splints Use a hand towel
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you are using a gait belt to ambulate a pt. The pt says "I am getting dizzy" or " I am going to pass out" p 269
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slide pt to the floor using your legs
increase exercise |
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When pt is weak from inactivity: what kind of exercise does a nurse offer & how often is it done
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Active ROM
book says several times but @ least twice a day |
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If pt is immobile how much do they drink? What do you make sure they get
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3000 ml
fiber adequate diet (eat) |
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If a pt is comatose what nsg intervention do you do?
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Talk to pt
Hearing is the last thing to go |
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Know what the purpose of "Buck Traction" is
AKA "skin traction" |
Reduce Spasm that accommpanies fractures
Noninvasive |
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If you put a pt in skeletal traction what kind of drainage should you expect in 48 hrs
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clear drainage
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How long does it take for a synthetic fiber glass cast to dry
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30 mins
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Know what part of hand to use on a cast
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-Palms
-flat part of fingers NO FINGER TIPS |
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What does skin look like when you take cast off?
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Dry
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which type of pt would you omit form an air fluid bed
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Not for spinal surgery
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CPM machine bed: What kind of lining is used?
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sheep skin
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When performing head to toe assessment of the immobilized patient, be alert to indicator of circulatory impairment
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-redness
-pale -blue color -coldness -diminished or absent pulse |
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Triangle bandage sling ???
Read 802 read about applying it |
is used when no commercial sling is at hand
end around neck, under the injured arm then over, tie both ends at neck Note: triangle toward elbow -hand 4" above elbow |
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Walkers
know the correct height |
Pt's elbow is bent @ a 15 to 30 deg while standing upright & grasping the handgrips
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Most common type of occupational injury for nurses
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lower back injury
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Nsg Diagnosis: pt @risk for injury r/t rt side weakness as evidence of unsteady gait. What is my expected outcome or goal?
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Free of injury while ambulating or transferring
Remember Safety 1st |
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Gait Belt/ transferring belt
read entire paragraph p268 |
-hand is inserted @bottom/ under belt
-belt tightened just enough to allow for your hand to grasp it from the rear |
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Know what part of hand to use on a cast
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-Palms
-flat part of fingers NO FINGER TIPS |
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What does skin look like when you take cast off?
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Dry
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which type of pt would you omit fro an air fluid bed
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Not for spinal surger
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CPM machine bed: What kind of lining is used?
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sheep skin
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When performing head to toe assessment of the immobilized patient, What alert are there to indicate circulatory impairment
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-reddness
-pale -blue color -coldness -diminished or absent pulse |
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Triangle Sling
Read 802 about applying it |
-is used when no commerical sling is at hand
-behind neck, under arm (triangle is formed at elbow)& behind arm then tied at neck hand is 4" above elbow |
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Walkers
Know correct height it needs to be |
pt's elbow is bent @15 to 30 deg while standing upright & grasping the handgrip
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Most common type of occupational injury for nurses
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Lower back injury or strain
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Nsg Diagnosis: pt @ risk for injury related to rt side weakness as evidence of unsteady gait: What's my expected outcome or goal?
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Free of injury while ambulating or transferring a pt
NOTE: Safety 1st |
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Gait belt/ transferring belt
Read 268 entire paragraph |
Belt is tighten just enough to allow hand placement @ rear and bottom/under belt
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Passive ROM Exercise: Knee & hip
Where is the placement of hand |
placement hand is under knee and heel of foot for support
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Elastic Bandage: SPIRAL REVERSE TURN what is the important part?
p 800 or 798 |
Overlap turns of bandage equal 2/3 of the width
Remember Distal to proximal Assess skin, distal circulation & sensation |
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Mechanical lift
NOTE: Look @ #7 closely P 803 |
Eg; Hoyer Lift
takes two people to use it safely NOTE never leave a pt in lift or in whirlpool tub unattended |
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Crutches
Order of which goes first upstairs & downstairs |
-Upstairs Good leg, then injured leg & crutch next
-Downstairs crutch & injured leg then good leg next |
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Skeletal traction: What do you make sure about wt?
P 798 |
That the wt is free hanging
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CNS check: during blanching the capillary refill should be what
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3mins
5 mins for elderly (65) NOTE for a 64 y/o male whose capillary refill is 5 mins is called delayed capillary refill |
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Pt w/ leg cast: How do you alleviate or reduce edema other than bivalve (cut in half lengthwise) P 788
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elevate cast using 1 or 2 pillows
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What are complications of immobility
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clots
hypostatic pneumonia contractures - contractures -muscles cramps -respiratory problems |
