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Basics Unit 2 1of2
| Question | Answer |
|---|---|
| Guidelines for Moving and Lifting (Principles of body movement) | get help; ask the pt to help; bend/flex knees; use greatest # of muscles possible; use wide base of support (ft shoulder's width apart); use smooth, coord. movements; pull and pivot; face direction of movement; keep trunk straight; use arms as levers p260 |
| Keep elbows close and work _________ to your body. | close |
| Work at the _________ level or height as the object to be moved; keep the load near your center of __________. | same; gravity |
| Pulling actions require less effort than ________ or ________. | pushing; lifting |
| Face the __________ of movement. | direction |
| Use arms as __________ when pulling toward you; lock elbows and __________ back on your heels; using weight of your body to move the patient. | levers; rock |
| Use leg muscles to prevent __________. | back strain |
| Avoid __________ or sudden pulling. | jerking |
| Encourage pt to _________ when transferring if _________. | assist; possible |
| Use the greatest number of ___________ possible. | muscles |
| Two principles for body movement and alignment for patients: | maintain correct anatomic position; change position frequently |
| Hazards of the patient being in improper alignment (3): | interference with circulation which may lead to pressure ulcers; muscle cramps and possible contractures; fluid collection in the lungs |
| Correct standing alignment. | pg. 260 |
| When standing correctly, hold your head ____ and keep eyes ______________. | up; straight ahead |
| Standing: chest should be out and abdominal muscles ____________. Your back and neck should be _______________. | tucked in; straight |
| Arms should be ___________ and at your sides when standing correctly. | relaxed |
| When standing correctly, your knees should be ____________ and your feet __________ with toes forward. | slightly flexed; straight |
| Correct sitting body alignment is sitting with the head erect and centered over the shoulders. The pt's weight should be ______________________ over the buttocks and thighs. Knees should be flexed at about ________ with feet resting on the floor. | disributed evenly; 90° |
| A ____________ should be used if the patient's feet do not reach the floor. The arms should lie ______________ in the lap or be supported by the chair ___________. | footstool; comfortably; armrests |
| Pressure ulcers are also known as ____________ or ___________. | decubitus ulcers; bedsores |
| Pressure ulcers occure when pressure on the skin causes an area of ____________. They occur most often between a ___________________ and an external surface. | local tissue necrosis; bony prominence |
| Pressure ulcers can be cause by ___________ as force is applied downward and ___________ on tissue beneath the skin. | shearing; forward |
| Common nursing diagnosis with problems of body movement: | risk for injury; impaired physical mobility (can cause contractures); risk for impaired skin integrity (pressure ulcers); impaired walking (need to retrain body) |
| The _________ must be considered when planning care for the patient. | home setting |
| 4 objectives that positioning a patient can accomplish: | 1. provides comfort 2. releives pressure on bony prominences and other parts, decreasing the pt's risk of developing pressure ulcers 3. prevents contractures,deformities, and respiratory problems 4. improves circulation |
| pt lying on back | supine position |
| supine with HOB elevated 60-90° | Fowler's position |
| supine with HOB elevated 30-60° | Semi-Fowler's position |
| supine with HOB elevated 15-30° | Low-Fowler's position |
| supine with knees flexed and feet flat on the bed; used for many procedures and examinations | dorsal recumbent position (variation of supine) |
| supine with feet in stirrups and legs spread farther apart; used in pelvic exams | dorsal lithotomy position (variation of supine) |
| pt lying on their side; alleviates pressure on bony prominences o the back | side-lying lateral position |
| removes presure from shoulder and hip; easier for pt | oblique side-lying position |
| variation of side-lying used for rectal exams or insertions of tubes or suppositories | Sim's position |
| pt lying face down; often used for pts with spinal cord injury; not generally well tolerated | prone position |
| face down with chest, knees and elbows resting on bed; used for rectal exams | knee-chest position |
| Positioning devices: | pillows; boots or splints; footboards; high-top sneakers; trochanter rolls; sandbags; hand rolls; trapeze bars, side rails, bed boards |
| used to support the body or extremities | pillows |
| used to maintain dorsiflexion and help prevent sores on heels | boots or splints |
| used to maintain dorsiflexion | footboards and high-top sneakers |
| used to prevent external rotaton of the leg | trochanter rolls |
| used to immobilize an extremety, provide support, and maintain body alignment | sandbags |
| used to help prevent contractures of the hands and prevent dorsiflexion of the wrist | hand rolls |
| used to enhance pt mobility, provide pt safety, and support pt's back | trapeze rolls, side rails, bed boards |
| Use a ___________ when moving the patient in bed. | lift sheet |
| Using a lift sheet requires at least _____ people standing on ____________ sides of the bed. | 2; opposite |
| When using a lift sheet, both people should face the bed and use the lift sheet to ______________. | move the pt up in the bed |
| Moving a pt with a lift sheet is a _______________. The pt is ___________, not dragged. | coordinated effort; lifted and moved |
| turning the pt as a single unit | logrolling |
| When logrolling, ________________________ is maintained at all times. | body alignment |
| Logrolling is used to ___________ and can be performed with or without a ___________. | change bed linen; lift sheet |
| Patients may transfer __________ or require different levels of assistance. | independently |
| Always _________ a pt at bedside before transferring to a wheelchair, and observe for ___________ or _________. | dangle; dizziness; nausea |
| Remember to _______________ on wheelchairs or gurneys before attamptng to transfer a pt. | lock the wheels |
| Stretcher used for transporting a pt who is _____________________. | unable to sit in a wheelchair |
| Either lift equipment or 2 nurses should transfer a pt to a wheelchair if pt is _________________. | unsteady, weak, or heavy |
| Use a ____________ belt when ambulating pts. | gait |
| transfer devices | pull or lift sheets (drawsheet); mechanical lifts; roller boards; slide boards; transfer or gait belts |
| Wrinkles in sheets can cause __________. | tears in skin |
| Use your _________ to break a pt's fall. | knees |
| the observation of health rules and methods or means of preserving health | hygiene |
| Hygiene doesn't just stop with the bath and skin care. Pts need care for their _______________ also. | hair, nails and teeth |
| Remember when talking about baths, you may not __________________ as the pt. | have the same hygiene practices |
| You may have to make _____________ for the pt's personal care if they have limitations such as ____________. | modifications; limited mobility, vision problems, etc. |
| largest of all body organs; belongs to integumentary system | skin |
| one of the nurse's biggest responsibilities: | keeping the skin clean and dry |
| outer layer of skin | epidermis |
| second layer of skin | dermis |
| third layer of skin | subcutaneous |
| Functions the skin serves: | temperature regulation; secretion and sensory information; maintain fluid and chemical balance; converting precursors to vitamin D |
| Main functions: | protection, sensation, excretion, secretion |
| With age, the hair: | becomes thinner and grows more slowly |
| With age, the skin: | is more fragile becaue of loss of collagen fibers; wrinkles and sags and sebaceous gland activity is decreased. |
| With age, nail growth: | decreases |
| Although we can't have our skin sterile, hygiene can _______________ the amount of germs present. | remove or limit |
| If the nurse does not administer the bath, it is their job to: | make sure that it is done. |
| Skin assessments should be done: | before, during and after the pt's care. |
| Skin assessments should include: | assessing for pressure ulcers, skin tags, or other skin problems. |
| When an abnormal skin problem is found, it should be ________________ and _____________. | reported to the charge nurse; documented |
| Determine the condition of the pt's skin by observing: | it's color, texture, thickness, turgor, temperature, and hydration |
| Normal skin will be: | intact without abrasions, warm and moist, localized changes in texture acoss the surface, good turgor (elastic and firm), generally smooth and soft; skin color varies from body part to body part |
| If skin breakdown can't be prevented, we must provide good nursing interventions that include: | optimal healing of impaired skin; decrease in pt's discomfort, decrease in the length of hospitalization; decrease in the cost of ongoing care |
| Skin that is not intact or that has injury will ____________. | increase the pt's risk for infection that could become a systemic infection |
| Pts at highest risk for pressure sores: | chronically ill, debilitated, unconscious, older, disabled, underweight or overweight, incontinent, spinal cord injuries, limited mobility, poor overall nutrition |
| Areas of the body where pressure sores may develop: | sacrum, ischial tuberosities, trochanter areas of the hips, heels and malleoli of the ankles |
| _______________ can also cause abrasions to the skin. | sheering and friction |
| A pt with a a pressure ulcer should be kept __________. | off the area where the break is located. |
| Pressure ulcer stage - skin is nonblanchable, has erythema (redness) and is intact. | Stage I |
| process in which the blood rushes at a pace where there was a decrease in circulation | reactive hypermia |
| when skin feels hard | induration |
| pressure ulcer stage - partial-thickness skin loss involves epidermis, dermis, or both; ulcer is superficial and manifests clinically as an abrasion, blister, or shallow crater | Stage II |
| pressure ulcer stage - full thickness skin loss involving damage or necrosis or subQ tisue that may extend down but not through the underlying fascia; deep crater with or without undermining (tunneling); usually drainage present | Stage III |
| necrotic tissue which is black, tough, and hard | eschar |
| If eschar is present, ulcer ____________. | cannot be staged |
| pressure ulcer stage - full thickness skin loss occurs with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures | Stage IV |
| Interventions for Stage IV pressure ulcer include ongoing assessment for evaluating whether or not improvement is occuring. Assessment data includes: | size, depth of ulcer, amount and color of exudate, presenceof pain or odor, color of exposed tissue |
| Initial care of a Stage IV pressure sore is: | debridement (go in and remove debris from the wound) |
| Practice _______________ when caring for pressure ulcer. | surgical asepsis |
| Never ___________ reddened areas. | massage (massage is for prevention) |
| Treating pressure sores: | nutritional support; observe hydration; turn pt every 2 hours and reassess area after about 30-45 minutes of turning for reactive hyperemia; reposition chair-bound pts every hr |
| Pts who are at risk for skin impairment should be on a _______________. | pressure relieving mattress |
| Be _____________ when reporting and charting any abnormal findings. Give a visual picture of the area. | specific |
| Type of bath a pt generally takes will depend on: | socioeconomic status, knowledge, personal preference, physical condition, cultural variables |
| Things besides bathing you can help a pt do to have good hygiene: | use antiperspirants/deodorants; wear cologne; wear clean clothing and undergarments |
| Benefits of a bath for a pt: | reduces chance of infection; stimulates circulation; cuts down on odor; stimulates circulation; feels more refreshed; relaxing; improves the way they feel about themselves; allows exercise to the body parts |
| Use __________ water when giving a pt a bath. | warm (not hot) |
| Make a ____________________ when giving a pt a bath. If the pt's condition changes,you must stop and allow the pt to rest and resume later if possible. | continuous assessment |
| Types of baths: | bed baths (partial or complete); tub bath, shower, sitz bath, sponge bath, tepid bath, medicated bath, whirpool bath. |
| Be sure to provide __________ during a bath. | privacy |
| Wash the pt's ________ first when giving a bath. | eyes |
| Bath done while pt is in bed; they are washed and rolled from side to side; fold washcloth so ends will not rub against pt's skin causing irritation | complete bed bath |
| nurse will bathe the body parts the pt can't reach; for pts that have limited use of hands and arms; will assist to wash where needed | partial bed bath |
| bath where buttocks and peri area are submerged in water continuously; may be ordered by dr for pt that has undergone rectal or vaginal surgery (such as hemmorrhoid surgery, vaginal delivery, etc); type of bath promotes healing and provides pain relief | sitz bath |
| Moist heat feels __________ and damages the skin _________ than dry heat. | warmer; faster |
| Pts with broken skin may not tolerate ______ as well. | heat |
| Things to assess during sitz bath: | syncope (faintness/weakness), vertigo (dizziness), pressure on back of legs, increased pulse, chilling - any of these problems need to be reported to the charge nurse |
| Bath given to reduce fever; can last 25-30 minutes; do not give for a long amount of time because you may get the rebound effect. | tepid bath |
| Pt with dry, itchy skin (dermatitis) would need a ________ bath or a ________. | tepid; medicated |
| may be ordered to be performed more often than a bath; if not done correctly could cause a UTI for the pt | peri care |
| Peri care for female: | wash between the labia majora and minora; clean from front (perineum) to back (rectum); work from inner areas to outer areas |
| Peri care for male: | retract uncircumszed foreskin to cleanse underneath (must be replaced to prevent discomfort, constriction and edema - this could be dangerous for the pt if not done); clean from end of penis down the shaft |
| Before you begin shaving a pt, determine what kind of __________ is needed. | razor |
| Pts with a low __________ count do not clot well. An electric razor should be used on them. | platelet |
| Use caution when shaving ____________ pts. | chemotherapy |
| Before shaving, apply warm moist towels to ____________. | soften the beard |
| If changing a pt's gown and the IV needs to be taken down, be sure to ____________. | adjust the flow of the infusion (could overload the pt) |
| __________ is always included in the morning bath and involves keeping the teeth and oral cavity clean and free of odor. (Also includes care of dentures and other devices.) | Oral care |
| Keeping the mouth clean encourages the pt to __________ and ___________. | eat; helps food taste better. |
| dried crusts containing mucus, microorganisms, and epithelial cells that shed from the muous membranes; common on lips and teeth of unconcious pts; offer mouth care to prevent this | sordes |
| A ____________ should not be used to brush teeth. | hard bristle toothbrush |
| When a toothbrush can't be used, you can use: | a toothette, gauze, or wash cloth |
| Place a ___________ in the bottom of the sink when caring for dentures. Do not use ________ because it could damage the plastic | wash cloth or towel; hot water |
| If dentures are placed in a denture cup (in water or denture cleanser), be sure the cup isn't left on the: | dietary tray |
| The __________ could be responsible if you break or lose dentures. | hospital or facility |
| When providing care for an unconscious pt, be sure to raise the bed to ______________ and position pt flat on their side wth head slightly lowered to prevent __________. You may also use ___________. | comfortable working position; aspiration (inhaling and choking on fluids); suctioning |
| Oral care should be done on an unconscious pt every ____________ or PRN. | 8 hours |
| If NPO, orgal care should be done every 2 hours on an unconsious pt to keep the oral cavity ____________. | moist |
| While combing or brushing a pt's hair, you should assess for: | open sores, scratches, marks, pressure aras, or presence of lice or nits |
| A pt can have lice on their: | head, skin, body, eyelids, eyelashes or in the pubic region |
| Loss of hair that may be caused due to illness or medications: | alopecia |
| If pt can't get up, remove the tangles in their hair using ___________ on small sections then brush or comb, holding scalp in the area you are caring for. | alcohol or water |
| A nurse is allowed to shampoo a pts hair with _________. If pt isn't allowed to get up, a special device is used, allowing the pt to ____________ while washing their hair | a doctor's order; remain in bed |
| If a new pt comes into the hospital from home or a nursing home and their hair is up, you must ___________. Pins can cause pressure sores in the head. | take it down to assess their hair. |
| Care of the hands, feet and nails are often neglected until: | problems arise |
| Care of hands, feet and nails should be part of ___________. | morning care |
| Soak the hands and feet in warm water; cuticles should be pushed back and lotion applied to prevent drying; clean under nails with something blunt; cut nails straight across (if not contraindicated) | nail care |
| You must have a doctor's order to cut nails of a: | diabetic patient |
| washing and drying eyes, appling meds, compresses, and protecting eyes from injury | eye care |
| When caring for glasses, make sure they are stored in a: | safe place (never laying on top of bedside table or overbed table) |
| Glasses can be cleaned with __________ and mild soap. Do not use hot water - it may damage the glasses. Rinse well and dry with cloth (not tissue). | tepid water |
| A tissue could __________ glasses. | scratch |
| If a pt cannot remove their contact lens, be careful not to damage the eye when taking it out. If unable to remove the lens, there is a _________ that can vacuum the contact out. Contact should be kept in a safe place and properly ____________. | suction device; labeled |
| If unable to remove contact lenses: | Place a piece of tape on the forehead of the pt that states "Contact Lenses Intact). |
| To remove an artificial eye: | press on the lower eyelid. |
| An artificial eye can be washed with: | soap and water (rinse well). |
| An enucleated eye socket can be rinsed with: | water or saline |
| Wash ears during bath; do not wash what is not easily accessible with wash cloth; use cotton swabs only on outer ear; teach pt to blow their nose gently so eustachian tubes are not blocked (do not block off nostrils) | ear care |
| Wash nose excretions with soap and water if dried around outside of nose. Teach pt to blow their nose safely so eustachian tubes aren't blocked and ear drums aren't damaged. | nose care |
| When cleaning a hearing aid: | never immerse in water; clean ear mold with water, but dry thoroghly; do not use alcohol; store them correctly (L and R) |
| If you hear feedback (loud, shrill noise caused from hearing aid not being positioned correctly): | adjust and reposition the hearing aid in the ear canal. |
| Florence Nightingale addressed these factors more than a century ago: | temperature, ventilation and humidity, lighting, odor, noise, neatness, privacy |
| Infants and older adults require: | warmer rooms |
| Room temps should be kept between: | 68° and 74°F |
| Operating rooms and critical care areas are kept: | cooler |
| supplying a room with fresh air continually | ventilation |
| Fans are discouraged because of: | infection control concerns |
| amount of moisture in the air | humidity |
| humidity levels are comfortable at: | 30-50% |
| Too little humidity will: | dry respiratory passages |
| should be adequate to perform tasks and prevent accidents and injury; should be bright enough to see, but soft enough to prevent sharp shadows; should be able to be controlled by pt | environmental factor: lighting |
| empty and rinse bedpans, commodes, and urinals promptly; dispose of dressings and used equipment; nothing odorous in trash in pt's room; avoid source of odor; remove old flowers and stagnant water | environmental factor: to control odors |
| main source in hospital is people; pt may experience sensory overload; soft, pleasant background music can mask other sounds and promote relaxation | environmental factor: noise |
| Reduce noise by: | avoiding long conversations in the hallways; encourage staff to speak in lowered voices; avoid jokes and laughter at the nurse's station; answer alarms on IV pumps and equipment promptly |
| straighten pt's unit after making the bed and whenever appropriate; remove trays and dishes after meals; keep over-the-bed table clear of unnecessary clutter or equipment | environmental factor: neatness |
| always knock gently and identify yourself before entering room; close the curtain around pt for personal tasks when multiple-pt room; post sign on the door informing others when caring for pt, so they will not enter | environmental factor: privacy |
| Changes such as colorful bedspreads and draperies in hospitals are done to: | promote comfort by providing a home-like environment for the pt |
| Beds usually have a ______ matress covered with a material that can be cleaned between pts; side rails should not present a ________. Always lock wheels on a bed when ______________ and leave in the ______ postion when not performing a procedure on a pt. | firm; hazard; not moving it; low |
| should be made when the pt is out of bed in the chair or out of the room for a diagnostic procedure or therapy | unoccupied bed |
| Made only if the patient absolutely cannot be out of bed | occupied bd |
| Bed linens should be: | neat, orderly, and free of wrinkles. |
| Primary concern when caring for your patients; needed to prevent accidents and possible injuries to pts, visitors, and health care personnel | safety |
| Most common pt accidents/incedents: | falls, burns, cuts and bruises, fights with others, loss of possessions, chocking, electrical shock |
| 3 common factors with falls: | impaired physical mobility; altered mental status; sensory andor motor deficits |
| Patients at risk for falls may need a: | leg or bed alarm |
| Senses a change in position or pressure of pt and sounds an alarm to alert workers or family members that pts are attempting to get out of bed or chair | leg or bed alarm |
| Review pg 324 Box 20-3 |
Created by:
akgalyean
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