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37 Cards in this Set
- Front
- Back
Hip Precautions Don'ts
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Do not:
-Flex hip more than 90° in relation to trunk -Sit low in chair lean forward while sitting or getting up -Squat -Bend knees while reclining in bed -Lean forward with legs straight out or bent -Roll knees or toes in while lying -Turn knees and/or toes inward towards body -Allow knee to be turned inwards toward the midline even if toes are pointed while sitting or standing -Adduct hip -Cross legs -Roll onto or lie on surgical side |
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Bath
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-Assess need for hygiene, level of independence and comfort needs
-Plan for type of bath required r/t medical and surgical diagnosis and ability to care for self -Intervention do bath and AM care -Evaluation: Is my patient clean, was comfort provided, was the level of care provided appropriate? |
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Performing the procedure and afterwards
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-Perform procedure and monitor patient response
-Finish the procedure -Raise the side rail -Lower bed and check patient response -Replace call light and check for safety before leaving -Leave the environment clean and safe -Wash Hands -Look back into the room, is everything where it is supposed to be? -Document immediately if you can |
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Procedure for entering the room
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-Knock on door
-Identify the patient -Introduce yourself to patient -Explain procedure/getting permission -Gather all equipment -Provide privacy -Move bed and patient into appropriate position -Lower the side rail nearest you -Organize set-up and assess patient |
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Urinary elimination
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-Micturation
-Respond to urge (nurse answer call light) -Use sound of running water |
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Maintenance of hygiene
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-Promote circulation and comfort
-Remove excessive debris and secretions -Maintain skin integrity |
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Intake and output
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-Should be equal (what goes in must come out)
-Intake is anything that is liquid at room temperature e.g. ice cream -Output is any urine stool or drainage |
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Restraints
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-Reassessed time limit:
-Adults: every 4 hours -Children 9 -17: every 2 hours -Children under 9: every 1 hour -The order can be renewed for up to 24h -Visual checks: every 15min -Assess: every 2 hours and allow fluids, nutrition, toileting, provide ROM and skin integrity checks |
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Factors that influence individual hygiene practices
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-Culture
-Religion -Environment -Developmental level -Health and energy level -Personal Preferences |
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Bowel elimination
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-Defecation
-Privacy and timing are essential -Fluids, exercise, and diet are influential |
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Average daily output of an adult
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-Urine: 1500cc
-Feces: 200cc -Insensible losses: --Lungs/skin: 800cc --Sweat: 100cc |
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Hip precaution dos
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Do:
-Have pillows between knees while lying on side, keep knee pointed straight ahead -Keep knee and toes pointing to ceiling when lying on back and keep large pillow between knees -Sit in as high a chair as comfortable (one wiht armrests) -Use a raised toilet seat |
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Identifying dirty to clean
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Dirtiest: toilets, sinks, body-fluids
Dirty: Floor, desks, phones, charts Clean: Washed hands Cleaner: linen Cleanest: sterile material |
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Basics Standards for Safe Nursing Care
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-Demonstrates Accountability and Professional Behavior
-Practices Principles of Asepsis -Provides Physical Safety -Provides Psychological Safety -Organizes Care -Documents and Communicates Care |
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Universal precautions
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-Hand washing
-Gloves -Protective clothing, eyewear, masks -Proper placement of patients -Proper disposal of wastes and linen -Needle disposal -Masks when giving CPR -Treat all patients and body fluids as though they were Contaminated |
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Body Mechanics
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-Maintain balance: use strongest and longest muscles to provide a wide base of support
-Reduce energy requirements by the use of body structure for support and movement -Prevent injury by never twisting your back |
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Medical asepsis
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a clean technique for procedures that reduces the number and transfer of pathogens
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Maslow's Hierarchy of Needs
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-Self-actualization
-Esteem -Belonging -Safety -Physiological |
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AM Care
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-Help patient to use restroom
-Brush hair -Brush teeth or rinse with soft sponge/stick or mouth wash -Get patient dressed (or ready for breakfast) -Wash face and hands -Shave -Apply makeup |
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Surgical asepsis
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is a sterile procedure that establishes and maintains an environment free of microorganisms
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Selecting a restraint
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-It restricts the client as little as possible
-It does not interfere w/client's treatment or health -It is readily changeable -It is safe for the particular client -It is the least obvious to others |
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Kinds of restraints
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-Jacket restraint
-Belt restraint -The mitt or hand restraint -Limb restraint -Elbow restraint -Mummy restraint |
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Client's that are at high risk for decubiti
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-Bedridden
-Incontinent -Decreased mental status -Excessive body heat -Elderly -Unconscious |
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Decubiti Stages
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-Stage 1: redness
-Stage 2: partial thickness skin loss (abrasion, blister, or shallow crater) -Stage 3: full thickness skin loss involving damage of subcutaneous tissue (ulcer like a deep crater) -Stage 4: full thickness skin loss, dameage to muscle, bone, or supporting structures such as tendon or joint |
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Measures to prevent decubiti
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-Keeping skin clean and dry
-Changing position in bed q2h -Good nutrition -Recognizing need for movement before there is any redness |
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Decubiti Stages
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-Stage 1: redness
-Stage 2: partial thickness skin loss (abrasion, blister, or shallow crater) -Stage 3: full thickness skin loss involving damage of subcutaneous tissue (ulcer like a deep crater) -Stage 4: full thickness skin loss, dameage to muscle, bone, or supporting structures such as tendon or joint |
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Abduct
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Moving limbs away from midline of body
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Adduct
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Moving limbs towards midline of body
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Dorsiflex
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Movement that flexes or bends the hand back towards the body or the foot towards the leg
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Eversion
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Movement that turns the sole of the foot outward
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Extend
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The return movement of flexion, the joint angle is increased
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Flexion
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Bending of the joint so that the angle of the joint diminishes
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Hyperextension
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Further extension or straightening of a joint
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Invert
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Movement that turns the sole of the foot inwards
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Opposition
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Touching of the thumb to the top of each finger of the same hand
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Plantar flex
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Movement that flexes or bends the foot in the direction of the sole
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Suppinate
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Turning upward
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