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56 Cards in this Set

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  • Back
How should you use a cane?
-maintain 2 points of support on the ground at all times
-keep the cane on the stronger side of the body
-support body weight on both legs, move the cane forward 6-10in, then move the weaker leg forward toward the cane, lastly advance the stronger leg
Dentures:
-what type of strength should you use with brushing & flossing?
-how should you removing dentures?
-Clts c fragile oral mucosa require gentle brushing & flossing
-provide denture care if clt is unable to do so
-remove dentures c a gloved hand, pulling down & out at the front of the upper denture, & lifting up & out at the front of the lower denture
-How do you brush dentures?
1. place dentures in a denture cup or emesis basin
2. brush them c a soft brush n denture cleaner
3. rinse them c water
4. store the dentures, or assist the clt c reinserting the dentures
How does music therapy work as a type of pain management?
-decreases physiological pain, stress & anxiety by diverting the person's attention away from the pain & creating a relaxation response
-music produces an altered state of consciousness through sound, silence, space, & time
-highly effective in reducing post-op pain
How should music therapy be implemented?
-let clt select the type of music
-must be listened to for 15-30 mins to be therapeutic
-earphones help clt concentrate on music while avoiding other clts or staff
-if pain is acute, increase the vol of music
Why is it important to have continuous bladder irrigations after having prostate surgeries?
-to maintain the patency of indwelling urinary catheters (b/c blood, pus, sediment can collect c/in tubing resulting in bladder distention & build up of stagnant urine)
-after prostate surgery, irrigation is done to remove clotted blood from the bladder & ensure the drainage of urine
If bladder is going to be manually irrigated after prostate surgery, how much solution should be instilled?
-50 ml
--> 50 ml of irrigating solution is instilled & then withdrawn c a syringe to remove clots that may be in bladder & catheter
What should the nurse assess when a clt has continuous bladder irrigation (CBI)?
-rate of infusion: rate of infusion is based on the color of drainage
-->ideally drainage should be light pink c/out clots
-continously monitor the inflow and outflow
-patency of catheter
-->of outflow<inflow: assess catheter patency for clots/kinks. If outflow is blocked & patency cannot be reestablished by manual irrigation, the CBI is stopped& physician is notified immediately
-record I&Os: q8hr OR per orders
How does the nurse obtain urine output when the clt is on continous bladder irrigation (CBI)?
-to obtain urine output, subtract amount of fluid instilled into bladder from total output
What are the steps when implementing intermittent irrigation?
1. place clt in dorsal recumbent or supine position
2. avoid cold solution b/c bladder may spasm
3. clamp cath just below soft injection port
4. clean injection port c antiseptic swab (specimen collection port)
5. insert needle through port @ 30* angle
6. slowly inject fluid into cath & bladder
7. withdraw syringe remove clamp & allow solution to drain into drainage bag
--> if ordered by MD, keep clamp closed to allow solution to remain in bladder for short time (20-30 min)
What should the nurse document in regards to closed continous irrigation?
-doc type & amount of irrigation solution used
-doc amount returned as drainage & character of drainage
-doc (& report) any findings: complaints of bladder spasms, inability to instill fluid into bladder &/presesnce of blood clots
What should be documented/report when the nurse is providing continuous irrigation?
-document type and amount of irrigation solution used, amount returned as drainage, & the character of drainage
-doc & report any abnormal findings (c/o of bladder spasms, inability to instill fluid into bladder &/or blood clots)
Kegel exercises are advised for....
-clts c urinary incontience
-->menopause, after child birth
How do you teach a clt to preform kegel exercises?
1. sit on toliet c knees far apart & tighten muscle to stop the flow of urine (to learn the muscle)
2. Practice tightening this muscle at non-voiding times
3. instruct clt to contract muscle for a count of 3, hold then release for a count of 3, & repeat 10x
4. repeat cycles for 25-30x, 3x/day for 6 months
What color should a normal stoma be?
-pink
When a stoma is dusky blue in color, this indicates...
-ischemia
A black-brown stoma color, indicates...
Necrocsis
T/F: it is normal after creating a stoma to see mild to moderate swelling in the first 2-3wks after surgery.
True
How long can skin barriers around a stoma stay in place for?
-3 to 5 days
--> intact barries c no evidence of leakage
What preparation around the stoma area should the nurse teach the clt to do before appling a skin barrier?
-skin should be washed c mild soap, warm water, & dried thoroughly before the skin barrier is applied
When applying a pouch around a stoma, how much larger should the opening be in regards to the stoma?
the opening around the appliance should be no more than 1-16in larger than the stoma
T/F do stoma's shrink?
True; stoma's shrink & they do not reach usual size for 6-8wks
How full should the colostomy bag be before it is appropriate to empty the pouch?
-1/3 full; to prevent leaking
What interventions can the clt take to prevent skin breakdown & malodor?
-cleanse the skin
-use skin barriers
-use deodorizers
If using barrier paste to fill in the creases next to the stoma, how long should you wait before you apply the pouch?
1-2 mins to allow the paste to dry
In what way should the clt/nurse apply non-allergic paper tape around the skin barrier?
-in a picture frame method
What techniques can the nurse use as distraction methods before the burn clt has dressing changes?
-Relaxation tapes
-visualization
-guided imagery
-biofeedback
-meditation
-->used as ajuncts to traditional pharmacologic tx of pain
What questions can the nurse ask the clt when attempting guided imagery?
-nurse can ask the clt about a favorite hobby/recent vacation
-nurse can explore these areas further by asking questions that make the clts visualize & describe a favorite hobby or recent vacation
What type of relaxation technique would be benefical to use when assisting a clt to go to sleep?
-relaxation tapes
What do cold and heat applications help relieve?
-cold & heat applications relieve pain & promote healing
Moist heat can help relieve pain from...
-tension HA
Cold heat can reduce the acute pain from...
-inflamed joints
How can the nurse avoid skin injury when applying heat and cold therapy?
-avoid injury to skin by checking the temp & avoiding direct application of the cold or hot surface to the skin
What population is esspecially at risk for skin injury when using heat & cold therapy?
-spinal cord
-other neuro injury
-older adults
-confused clts
T/F: Ice massage/cold therapy are particularly effective for pain relief.
-True
How should the nurse perform ice massage?
-apply the ice c firm pressure followed by slow, steady, circular massage
T/F: cold may be applied to pain site on the opposite side of the body corresponding to the pain site or on a site located btwn the brain & the pain site
-True
What is more effective: application of cold near the actual site of pain or farther away?
-application near the actual site of pain tends to work best
-->each clt responds differently to the site of application
How long is it appropriate to apply cold therapy?
-5-10 minutes
What sensations can a clt experience when experiencing cold therapy?
-clt feels cold, burning & aching sensations & numbness
--> when numbness occurs, the ice should be removed
Cold is particularly effective for tooth/mouth pain when the ice is placed...
-on the web of the hand between the thumb & index finger
T/F: Cold applications are effected before invasive needle punctures
-True
Is it appropriate for clts to lay on heating applications?
-No because burning can occur
Before applying heat or cold applications what should the nurse should assess?
-clts physical condition for ssx of potential intolerance to heat & cold
-observe the area to be tx
What types of issues can increase the risk of clts injury in regards to hot/cold therapy?
-alterations in skin integration
-open wounds
-edema
-bruising
-bleeding
-localized areas of inflammation
Why is it important to have a baseline skin assessment before starting cold & heat therapy?
-provides a guide for evaluating skin changes that might occur during therapu
If an area of the body is actively bleeding, would it be appropriate to cover the area with a warm application?
-No. An active area should not be covered by a warm application b/c bleeding will continue
If a clt has a localized inflammation, is a warm application around the area appropriate?
-No. Warm applications are contraindicated when clts have an acute, localized inflammation such as appendicitis b/c the heat could cause the appendix to rupture
T/F: if a clt has cardio vascular problems, it is ok to apply heat to lrg portions of the body.
-False: it is unwise to apply heat to lrg portions of the body to a clt c CV prob b/c the resulting mass vasodilation may disrupt blood supply to vital organs
If the site of injury is edematous, is application of cold appropriate?
-No. Cold is contraindicated if the site of injury is already edematous.
-Cold further slows circulation to the area & prevents absorption of the interstitial fuild.
-if a clt has impaired circulation (arteriosclerosis), cold further reduces blood supply to affected area
T/F: cold is contraindicated in presence of neuropathy?
-True. Neuropathy: clt unable to preceive temp changes
T/F: cold is contraindicated in shivering.
-True. Cold intensifies shivering & dangerously increase body temp
What should the nurse ***** when applying cold therapy to the lower extremities?
-assess for cap refill
-observe skin color
-palpating skin temp
-assess distal pulses
-observe for any edematous areas
--> if ssx of circulatory inadequacy, question order
If cold/heat therapy was ordered & the clt is confused or unresponsive, should the nurse question the order or continue c the tx plan?
-the nurse should continue c the tx plan.
-if a clt is confused or unresponsive, make freq observations of skin integrity after therapy begins
Is it in the nurse scope of practice to ***** the condition of the equipment being used on a clt in regards to cold/heat therapy?
-yes it is. The nurse should always assess the condition of equipment being used.
What knowledge base should the RN know before starting heat/cold therapy?
-understanding normal body responses to local temp variations
-assess the integrity of the body part
-determine the clts ability to sense temp variations
-ensure proper operation of the equipment