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NUR 309 Skills Test 1 > Chapter 24, 32 & 39 > Flashcards

Chapter 24, 32 & 39 Flashcards

1
Q

Safety

A

A basic human need concerning patient safety and personal safety

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2
Q

Body Mechanics for Staff Safety

A 
Feet Spread Apart
Minimize bending and twisting
Bend knees (don't bend at waist)
Lift with leg muscles
Keep objects close
Use both hands
DON'T stand on tip toes
If possible, avoid lifting!
Push, slide, or pull
Keep elbows bent
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3
Q

What is one of the leading causes of death in during patient safety?

A

Accidents that may lead to life changing injuries

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4
Q

Safety Factors

A

Developmental Status
Individual
Environment (Home, community, hospital)

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5
Q

Hospital Safety

A

Medication
Surgical
Communication
Physical

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6
Q

What are restraints meant to prevent?

A

Intentional self inflicted harm
Protective medical device harm
Staff harm

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7
Q

Restraints: Mechanical Devices

A 
Belt
Vest or Jacket
Wrist or Ankle
Mitt
Enclosed bed (canopy bed or 4x rails up)
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8
Q

When using restraints for safety purposes, what measures should be taken first?

A

Less restrictive measures

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9
Q

When using restraints for safety purposes, what must be obtained?

A

Physician order (timing of order to be determined by facility protocol)

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10
Q

How often must the order be renewed and moved?

A

Renew at least every 24 hours

Remove ASAP and every 2 hours to assess patient and sites

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11
Q

When applying restraints,

A

Never tie to a movable parts of bed or chair
Secure with quick-release knot
Assess restraint site and distal to site
a RN mist be presence for the removal

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12
Q

Common Bed Positions

A

Semi-Fowlers
High-Fowlers
Trendelenberg
Revers Trendelenberg

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13
Q

Semi-Fowlers

A

Head of bed elevated to 45 degrees

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14
Q

High-Fowlers

A

Head of bed elevated to 90 degrees

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15
Q

Trendelenberg

A

Bed flat with feet elevated and head down

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16
Q

Reverse Trendelenberg

A

Bed flat with head elevated and feet down

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17
Q

Correct bed position is vital to

A

Promote comfort
Prevent injury
Provide sensation

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18
Q

Positioning for Semi-Fowler’s & High-Fowler’s

A 
Small pillow
Support arms and hands on pillows
Small pillow under thighs
Small pillow under ankles
"Float" heels
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19
Q

Supine Position

A 
Head of bed flat
Small pillow under lumbar area
Pillow under head, neck and shoulders
Trochanter rolls parallel to lateral surface surface of thighs
"Float" heels with pillow under ankle
Use footboard or high top sneakers to prevent foot drop
Pillows under forearms
Hand rolls or splints
20
Q

Prone

A

Roll patient to one side with arm alongside body
Roll client over arm
Position on abdomen in center of bed
Turn head to one side to support with one pillow
Place a small pillow under abdomen
Place arms i flexed position at shoulders
Support lower legs with pillows to elevate toes

21
Q

30 degree lateral (side-lying)

A 
Lower HOB
Position client to side of bed opposite side being turned to
Flex knees and turn patient on side
Pillow under back to support
Pillow under head and neck
Bring dependent shoulder forward
Position arms in slightly flexed position with pillow
Place pillow under semi flexed upper leg
22
Q

Sims’ (semiprone)

A 
Lower HOB 
Place in supine postion
Roll client on side
Position  on lateral side, lying partially on abdomen
Lift dependent shoulder and place arm at side
Small pillow under head
Pillow under flexed upper arm
Pillow under flexed upper leg
23
Q

Logrolling

A

Requires 3 people
Small pillow between knees
Cross arms on chest
Use draw sheet
One nurse grasps draw sheet at lower hips and thigh area
Other nurse grasps draw sheet at shoulders and lower back
Roll as unit in one smooth continuous motion
“Single” nurse places pillow along length of patient for support or cleans patient
Gently lean the client as a unit back towards the pillow for support or back on the surface of the bed

24
Q

Positioning aids

A

Trochanter roll
Hand roll
Cradle boots
Hip Abduction pillow

25
Q

Transferring bed to stretcher

A

Get help!
Bend at knees when lifting
Keep siderail up on side patient moving towards
Use transfer board or friction reducing reducing device as appropriate
Keep bed locked
Keeps patient’s physical conditions in mind

26
Q

Ambulating

A

Consider patient’s condition and gait
Allow patient to dangle before ambulating
Instruct patient to notify of any dizziness or discomfort
Use gait belt if available
Place chair close to bedside
Brace patient’s leg against your foot and knee
If patient falls, don’t try to stop.

27
Q

Assistive devices when ambulating

A

Canes
Walkers
Crutcher

28
Q

Canes

A

Hold stronger side

Move cane simultaneously with weaker side

29
Q

Walker

A

Pick walker up to move as stepping forward

Don’t advance to far causing reaching

30
Q

Crutches

A

Make triangle with crutches 6 inches ahead of body
Multiple gaits based on need
When using stairs: up-lead with strong leg and down-lead with weak leg

31
Q

Gaits

A 
Antalgic Gait
Propulsive Gait
Scissors Gait
Spastic Gait
Steppage Gait
Waddling Gait
32
Q

Antalgic Gait

A

Limp to avoid pain when bearing weight on the affected side

33
Q

Propulsive Gait

A

Stooped, rigid posture with neck and head bent forward; movement forward is by small, shuffling steps with involuntary acceleration

34
Q

Scissors Gait

A

Legs flexed slightly at the hips and knows with the thighs crossing in a scissor-like movement

35
Q

Spactic Gait

A

A stiff, foot-dragging walk caused by one-sided, long-term, muscle contraction

36
Q

Steppage Gait

A

An exaggerated motion of lifting the leg to avoid scraping the toes of a foot with foot drop

37
Q

Waddling Gait

A

A distinctive rolling motion in which the opposite hip drops

38
Q

Range of Motion

A

Maximum amount of motion possible

Can be active or passive

39
Q

TCDB

A

Turn, Cough, Deep Breath

40
Q

TCDB encourages

A

Lung expansion

Mobilizes secretions

41
Q

TCDB Process

A

Place patient in Fowler’s
If abdominal or chest incision, provide pillow to splint and brace site
Teach patient to breath with diaphragm slowly
After 2-3 deep breaths, encourage patient to lean forward and cough

42
Q

What helps patients take deep breaths after surgery to prevent respiratory complications?

A

Incentive Spirometer

43
Q

What are TEDs and SCDs?

A

Thromboembolic devices

Sequential compressive devices

44
Q

TEDs

A

Promote venous return by maintaining pressure on superficial veins and prevent venous pooling
Prevents passive dilation of veins & tears

45
Q

SCDs

A

Air pump, connecting tubing, and sleeves that sequentially inflate & deflate
Drives superficial blood into deep veins & prevents venous stasis/pooling

46
Q

Removal of TEDs

A

Remove when patient gets out of bed to prevent injury or use slippers if up briefly
Remove once a shift for 15-30 minutes

NUR 309 Skills Test 1 (1 decks)

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