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51 Cards in this Set

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What is the single most important method of controlling an preventing spread of infections?
Proper hand washing and hand hygiene
Describe 4 nursing interventions that can be used when a patient starts to fall.
1. Put both arms around client's waist or grasp gait belt
2. Stand with feet apart to provide broad base of support
3. Extend one leg and let client stand against it to the floor
4. Bend knees to lower body as client slides to floor.
What kind of circulatory and skin assessment needs of the restrained patient?
Provide appropriate skin therapy
Reassess need for restraint
Consider alternatives to restraint
Inspect area where restraint is to be placed
Note any nearby tubing or devices
Assess condition of skin
Assess sensation
Assess adequacy of circulation
Assess range of motion
Describe 5 nursing interventions to implement for a restraint-free environment
1. Orient client and family to surroundings. Introduce staff. Explain all treatment and procedures.
2. Meet client's basic needs (toileting, relief from hunger)
3. Use stress reduction techniques such as massage and imagery.
4. Place client in a room that is easily accessible to caregivers.w
Name the 6 elements in the chain of infection
1. Infectious agent (pathogenic organism capable of causing disease)
2. Reservoir (site or source of microorganism growth)
3. Portal of Exit (means organism leaves site)
4. Mode of Transmission (means of spread)
5. Portal of entry
6. Susceptible host (client)

**Review Elkin 63 for medical aseptic practices to reduce microorganism spread for each element.**
Why do we pad side rails and headboard of a patient with a seizure disorder?
Modifications to environment minimize risks associated with seizure activity. Padding reduces risk for traumatic injury. (Don 't use pillows to pad side rails because of suffocation risk)
What is PPE?
Personal Protective Equipment
Give examples of PPE
mask
cap
eyewear
gown
gloves
Is recording and reporting required for applying PPE?
Nope, just use them appropriately and discard properly as necessary
Symptoms of Type 1 allergic reaction to latex gloves
hives. generalized edema, itching
rash, wheezing, brachiospasm, difficulty breathing
laryngeal edema, diarrhea, nausea
hypotension, tachycardia
respiratory arrest, cardiac arrest
**Reactions vary based on type of latex protein and degree of individual sensitivity.**
Nosocomial or Health-care associated infection
infection acquired in the health care setting (usually defined by an infection acquired at least 72 hours after hospitalization)
Isolation procedures- Airborne precautions
Private room, negative-pressure airflow of at least 6 to 12 exchanges per hours, mask or respiratory protection device
Isolation procedures- Droplet precautions
Private room or cohort clients, mask
Isolation procedures- Contact precautions
Private room or cohort clients, gloves, gowns
Isolation procedures- Protective Equipment
Private room, positive airflow with 12 or more air exchanges per hour, gloves, gowns
What is logrolling?
How and why is it done?
Logrolling is the rolling of a patient in one smooth, continuous motion.
Usually requires a minimum of 3 people to assist.
Prevents injury to client and caregivers
Maintains neck and spinal alignment
What is a gait belt?
Why is it used?
A gait belt (transfer belt) is a device that wraps around the torso to assist movement.

It is safe technique for transferring and ambulating patients.

Gait belt allows nurse to maintain stability of client during ambulation and reduces risk of falling.
Preventing lift injuries
(4 Principles & Rationales)
1. When planning to move a client arrange for adequate help. Use lift team if avail. (trained on techniques to prevent injury)
2. Encourage client to assist as much as possible. (Promotes client's abilities and strength while minimizing caregiver workload)
3. Use arms & legs, not back. (Leg muscles are stronger, larger muscles, Proper Body Mechanics)
4. Position self close to client or object being lifted (reduces horizontal reach and stress on back)
5 complications that immobilized, chronically ill, and older patients are at risk for
Loss of Bone Mass
Urinary Stasis
Pressure Ulcers
Joint Contractures
Constipation
Active ROM exercises
Patient able to perform exercises independently
Passive ROM exercises
Performed by nurse or Physical Therapist
Active Assisted ROM exercises
ROM exercises achieved by caregiver and client together
Why is a cane positioned on a patient's stronger side?
The cane offers most support when on stronger side of body. Cane and weaker leg work together with each step.
Describe how you would teach a patient to use a walker
too much for flashcard... look in the book!
Semi-Fowler's
head position raised 60 degrees

Facilitates visiting/diversional activities,
Improves breathing by decreasing pressure on the diaphragm as gravity pulls abdominal contents downward
High Fowler
head of bed raised 90 degrees

recommended for eating
Lateral (side laying)
30 degrees lateral

Removes pressure from bony prominences of back
Sims (semi prone)
alternative to lateral position
client lies somewhat forward onto abdomen
Supine (dorsal recumbent)
lying horizontally on back
Prone
being in horizontal position when lying face downward

improves oxygenation in client's with severe pulmonary problems
Prevents foot drop, maintains proper body allignement
Trendelenburg
head is low and body and legs are on an inclined plane

used in pelvic surgery to displace organs upward or to increase blood flow in hypotension and shock
Reverse Trendelenburg
Lower extremities are placed lower than the body and head, which are elevated on an inclined bed
Lithotomy
position in operating room in which the patient is supine with legs raised and abducted to expose perineal region. The legs are placed in stirrups to maintain position
abduct
to draw away (as a limb) from the midline of the body
adduct
to bring toward the midline of body
center of gravity
midpoint or center of the weight of a body or object (In standing adult human, center of gravity is midpelvic cavity between symphysis pubis and umbilicus)
Continuous passive motion (CPM)
a technique for maintaining or increasing the amount of movement in a joint, using a mechanical device that applies force to produce joint motion without normal muscle function
Contracture
a permanent shortening (as of a muscle, tendon, or scar tissue)
Dangle
sit or lie at edge of bed so feet can hang down, improves blood flow to legs

Prevents fainting, dizziness
Distal
situated away from point of origin or attachment
Extension
"straightening" movement allowed by certain joints of the skeleton that increases angle between two adjoining bones, such as extending the leg
External rotation
turning outwardly or away from the midline of the body
ex- when leg is externally rotated with toes turned outward, away from midline
Flexion
movement by certain joints that decreases angle between two adjoining bones such as bending the elbow
Foot Drop
abnormal neuromuscular condition of lower leg and foot characterized by an inability to dorsiflex, or evert the foot, caused by damage to common peroneal nerve
Internal rotation
turning of a limb about its axis of rotation toward midline of body
Pivot
pivot joint- (trochoid joint) synovial joint where movement is limited to rotation

Pivot transfer- movement of a person from one site to another such as bed to wheelchair (one side immobile)
Pronation
rotation of hand or forearm so surface of palm is facing downward or toward back
Proximal
Close to midline of body
Rotation
gyration of a bone around its central axis

one of four basic movements allowed by various joints of the skeleton
Supination.
rotation allowed by certain skeletal joints such as elbow and wrist joints, which permit palm of hand to turn up
List 5 nursing diagnoses related to safety skills
1. Risk for fall due to alteration in mental status

2. Risk for injury due to application of restraint

3. Risk for impaired skin integrity due to inability to reposition

4. Risk for infection related to nosocomial infections

5. Risk for infection related to alteration in skin integrity