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Chapter 18 Skills
Chapter 18 Blueprint for Skills
| Question | Answer |
|---|---|
| What is the disuse syndrome? | collective signs & symptoms that develop as a result of inactivity. The muscles become weak, decrease in muscle tone/strength, decrease in size. |
| What individuals are at an increased risk for disuse syndrome? | Inactive patients, patients with neurological impairment, diabetic patients, & comatose patients |
| Define Atrophy. | A decrease in size or wasting away of a cell, tissue, organ, or part. |
| Define contracture and give the cause. | The adaptive shortening of skeletal muscle tissue rendering the muscle highly resistant to stretching, preventing normal joint movement. It is caused by improper positioning & alignment. |
| What is another name for a clot? | Thrombus |
| What is the most serious urinary complication of inactivity? | Calculi (stone formation) |
| For the nurse what is the most common problem if proper body mechanics are not used when helping patients? | Back problems (lower back strain) |
| Define posture | The way in which we hold our body |
| What is the key factor in proper body mechanics? | Maintaining proper body alignment |
| When sitting why do you need to make sure that the popliteal area is free from the edge of the chair? | To avoid interfering with distal circulation |
| Describe the proper posture when lying down? | It is the same as standing up. The head & neck needs to be centered between the shoulders. The shoulders are level whereas the arms, hips, & knees are slightly flexed. The trunk is straight & the hips level, the legs are parallel to each other. |
| Define body mechanics. | Efficient use of the body. |
| Why is it important to keep a broad base of support? | It will increase your stability therefore increasing your safety |
| Describe how you would move something safely. | Obtain help if possible Bend knees Use the greatest # of muscles Use thigh,arms,or legs instead of back. Use wide base of support Use smooth movements Work close to the body Work at the same level as object Face towards movement Keep trunk str |
| Describe how you head and neck should be aligned when lifting. | It should be aligned with the vertebra |
| For your safety as well as the patients what should you schedule between period of exertion? | Rest |
| How often should the patients position be changed? | Every 2 hours |
| Before turning a patient what are you going to do? | 1. Assess any restrictions for placing a patient in a position 2. Gather supplies 3. Raise the bed 4. Get help if necessary 5. perform hand hygiene 6. Move patient to the head of the bed |
| List some complications from incorrect alignment & positioning. | 1. Pressure Ulcers 2. Muscle cramping & contractures 3. Fluid collection in the lungs |
| You have a patient that has suffered a spinal cord injury and is in the dorsal supine position and they must be turned. What method should you use to turn this patient? | Logrolling technique |
| When you have a patient in the supine position what area of the body do you have to pay close attention to? | Feet |
| What can you use to prevent foot drop? | Foot board or High top shoes |
| Describe the dorsal recumbent position and what procedure might be done utilizing this position? | The patient is lying on their back, extremities slightly flexed with their feet flat on the bed. You might use this position when inserting a Foley catheter. |
| What position could be used to prevent pressure ulcers on the sacrum? | Prone position |
| What are some potential hazards of the patient being positioned in the prone position? | Lordosis (forward curvature of the lumbar spine), & plantar flexion |
| What procedures may be done utilizing the Sim's position? | enemas, rectal temps, & rectal tubes |
| Describe the different Fowler's positions. | High Folwer's - Head of bead is raised 60-90 degrees. Mid Fowler - head of bed is raised 30-60 degrees Low Fowler's - Head of bed is raised 15-30 degrees. |
| What might be done in the High Fowler position? | N/G tubes are inserted, patients eat, & patients that are having respiratory difficulty |
| What might be done in the Mid Fowlers position? | Patient receiving a feeding tube, N/G tube insertion, eating, or a patient with respiratory difficulty |
| What might be done in the low fowlers position? | Patient with a feeding tube or a patient having difficulty breathing |
| How does the orthopneic position facilitate respirations? | It allows maximum chest expansion |
| The Lithotomy position is also known as what if the feet are not in the stirrups? | Modified Lithotomy or Dorsal Lithotomy |
| What procedures are done in the Lithotomy position? | Vaginal or rectal surgeries, vaginal deliveries, or vaginal exams |
| What type of patient would you question the use of the Trnedelenburg position for? | a patient with a head injury |
| When you are assessing your patient to position or align them what should you do? | Be sure to put them at ease |
| Why might you see bedboards used? | Better alignment & support |
| Describe the placement of a turn/lift/draw sheet. | Upper back to the thighs |
| You are assisting one of your fellow nurses to move a patient up in bed using a draw sheet. Where would you be standing in relationship to the patient's body? | Even with their shoulders |
| If you were moving the patients with a draw sheet what would you do to get better leverage? | roll the draw/lift sheet close to the patients body |
| What can you use to prevent the outward/external rotation of the legs or hips? | Trochanter rolls |
| Why would you use handrolls? | to preserve the ability to grasp & pick up and to help prevent contractures |
| If handrolls are not available, what else can be used in there place? | wash cloths or tennis balls |
| What position do footboards keep the feet in and why is this important? | Dorsiflexion to prevent foot drop |
| Describe what you need to do before moving a patient | 1. Dr's orders 2. size up the job 3. have adequate help 4. raise the bed 5. remove pillows & devices 6. make sure tubes are detached 7. if you need a lift sheet get one |
| Why would you elevate limbs? | to reduce swelling & provide comfort |
| Before moving a patient make sure that the wheels are ________ both on the bed and any on the area that you are moving then to. | Locked |
| Why would you lower the head of the bed before moving the patient up in the bed? | it will be easier because you are working with gravity |
| Describe how you would transfer a patient from the bed to a chair. | 1. Have adequate help 2. Place chair parallel to the bed 3. Lift foot rails & apply brakes 4. Keep back straight, knees bent, and pivot (DO NOT TURN) |
| If you have a patient that doesn't move at all, what is another way you can move them safely? | Mechanical lift |
| You are moving a patient with the mechanical lift and they start to panic. What do you do? | Immediately put them back into the bed |
| What is shearing? | the force exerted against the surface and layers of the skin as tissue slides in the opposite but parallel direction |
| What is passive exercise? | Exercise done with assistance from another person |
| What is active exercise? | Exercise done by the patient |
| If a patient is weak what type of ROM would best benefit the patient? | Arm & Leg ROM 2 to 3 times a day |
| How often should passive ROM be done on the patient? | at least 2 times a day |
| Describe how you should support the limb when doing passive ROM. | above & below the joint |
| What do isometric exercises do and give examples. | promote muscle tone & strength. Examples are body building, weight lifting, & contracting & relaxing muscle groups while sitting or standing |
| What is dangling and why is it done? | having the patient sit on the edge of the bed with the feet hanging off.It normalizes blood pressure |
| You are dangling your patient. How would you determine if they are adjusting to the position change? | ask them if they are dizzy, light headed, nauseated. You can also monitor their orthostatic pressure (drop in blood pressure when they stand) |
| What does the transfer belt allow the nurse to maintain? | stability |
| Describe what you would do if a patient you were ambulating suddenly stated that they were feeling weak and couldn't stand? | help them slide safely to the floor |
| What is a nursing diagnosis that a patient will have when beginning an ambulation program? | Risk for injury related to weakness and altered gait |
| What is a goal for an ambulation program? | The patient will not experience any injury while walking or transferring. |
Created by:
Jacksonville VNE
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