Exam 3 Study Guide Flashcards
Stage 1 pressure ulcer
Intact skin with
nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; Its color may differ from the surrounding area.
Stage 2 pressure ulcer
Partial-thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed without slough. May also present as an Intact or open/ruptured, serum-filled blister.
Stage 3 pressure ulcer
Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage 4 pressure ulcer
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often Includes undermining and tunneling.
Duration of wound healing for pressure ulcers
- Stage 1: 1-7 days
- Stage 2: 5-90 days
- Stage 3: 30-180 days
- Stage 4: 180-360 days
turning and positioning schedule
- Hospital Bed: Reposition every 2 hours (waking hours)
- Seated in W/C: Pressure relief Every 15-30 minutes
Joint contracture
caused by shortening of muscles, tendons, ligaments, and joint capsules or by heterotopic ossification.
Common joint contractures in supine
- Hip and knee flexors
- Ankle plantar flexors
- Shoulder extensors, adductors and IR/ER rotators
Common joint contractures in side lying
- Hip and knee flexors
- Hip adductors and internal rotators
- Shoulder adductors and internal rotators
Common joint contractures in sitting
- Hip and knee flexors
- Hip add and internal rotators
- Shoulder add, ext, IR
Common joint contractures in prone
- Ankle plantar flexors
- Shoulder ext, add, IR/ER
- Neck rotators R or L
Positioning After a Total Hip Arthroplasty (posterolateral approach)
- Avoid hip flexion beyond 60° to 90°.
- Avoid hip adduction past 0°.
- Avoid hip internal rotation past 0°.
Independent transfer
a transfer by which the individual requires no human assistance to perform.
Modified independent
The patient requires an assistive device or aid, requires more than a reasonable amount of time or there is a safety risk in completing the activity.
Min assist transfer
pt does 75% or more
Mod assist transfer
pt does 50% to 74%
max assist transfer
pt does 25-49%
Dependent transfer
total assist, some sources say <24%
You can teach the pt 3 different ways to position themselves at the edge of the chair.
- Depression lift
- R and L unweighting and scooting
- Backwards lean
Motor Control
the ability to regulate or direct the mechanisms essential to movement
Stages of Motor Control
Mobility, Stability or static postural control, Controlled Mobility or dynamic postural control, and skill
Mobility
availability of range of motion to assume a posture and the presence of sufficient motor unit activation to initiate a movement
Stability or static postural control
the ability to maintain a static steady position in a weight bearing, antigravity posture
Controlled Mobility or dynamic postural control
the ability to maintain a dynamic posture/position in a weight bearing, antigravity posture (standing or sitting weight shifts, controlled movements)
Skill
Mobility is superimposed on stability in non weight bearing conditions
- Also requires a specific goal and a coordinated movement sequence to achieve the goal.
- Skills have a specific purpose, they have voluntary movement control and require a quality of performance (consistency, fluency, timing, economy of effort)
Cognitive
Attempting to understand task
Develop plan
Evaluate response
Associative
Strategy selected
Refinement of skill
Less attention required
Autonomous
Requires little to know attention Can perform other tasks in conjunction
Phases of the sit to stand
Weight shift/flexion momentum
Bottom leaves the seat
Lift/extension
Stabilization
Intrinsic feedback(patients have altered intrinsic feedback)
Feedback that comes to the individual simply through the various sensory systems as a result of the normal production of the movement
Extrinsic feedback
- Augments intrinsic feedback through cueing.
- Example: Telling a patient to lift their leg higher to clear an object while walking
Knowledge of Performance
Feedback relating to the movement pattern used to achieve a goal
Knowledge of Results (form of extrinsic feedback)
Terminal feedback regarding the outcome of the movement
NWB (non–weight-bearing)
foot does not touch ground
TTWB (toe-touch or touch-down WB)
foot contacts ground for balance only or up to 20% of body weight
PWB (partial WB)
usually 20% to 50% of body weight
WBAT (WB as tolerated)
limited only by patient tolerance (>50%)
FWB (full WB)
no restriction (100%)
Four Point Gait Pattern
- Requires use of bilateral ambulation aids
- Very slow and stable pattern (good to use in crowded areas)
- Low energy demand
- Approximates a “normal” gait pattern
3 Point Gait Pattern
- Used when one LE is full weight bearing and the other is NWB
Two Point Gait Pattern
- Used with two or one AD
- Low energy, similar to normal gait
- Requires more coordination and is less stable
“Step to” or “Swing to” Gait Pattern
- The trail LE will only advance as far as the lead LE
- More stable
- Good for cognitive stage of learning
- Slower speed, more taxing
“Step through” or “Swing through” Gait Pattern
- The trail LE with advance past the lead LE
- Increased speed and improved energy conservation
- Decreased stability, requires increased control/balance
Parallel bars advantages
o Maximal stability, support and safety to build skills
o Great place to initiate gait training, balance training and to evaluate fit of other ADs
parallel bars disadvantages
- Severely limits mobility (progress pt as soon as possible)
- Bars must be wide enough for pt to ambulate through
- Not practical
Walkers advantages
- Used when Maximal stability, support, and mobility are required
walkers disadvantages
- Difficult to store/transport, difficult or impossible to use on stairs, decreases speed of ambulation, difficult to perform a normal gait pattern, difficult to use in narrow areas
walkers w/ Trough/Platform Attachments advantages
- Used for patients who are unable to bear weight through their wrists and hands OR have severe deformities of the UE
- May help those with UE amputation or are unable to extend elbow
- Provides additional stability
walkers w/ Trough/Platform Attachments disadvantages
- Unable to use triceps
- May require additional assist
- Not as effective on stairs
- Difficulty to manage in home environment or around obstacles
Crutches advantages
greater selection of gait patterns and able to increase gait speed but still offer stability, adjustable, easily stored, can be used in narrow or crowded spaces.
Crutches disadvantages
less stable than a walker, injury to axillary vessels and nerves if not used or measured properly, need good standing balance, functional strength of the UE and trunk must be considered. Difficult for the elderly to use.
Lofstrand crutches advantages
Able to reach for objects with the crutch remaining on the UE. Eliminate pressure to the axillary vessels and nerves, more functional on stairs and in narrow confined places.
Lofstrand crutches disadvantages
provide less stability and support than axillary crutches, walker or parallel bars, require functional standing balance, UE strength for many gait patterns, forearm cuff can make it difficult to remove, elderly pts feel insecure
Canes advantages
Used to compensate for impaired balance or to improve stability/confidence. More functional on stairs and in narrow confined areas/community areas. Easily transported.
canes disadvantages
very limited BOS due to the base of the cane, not ideal for a 3 point gait pattern or anyone with a weight bearing limitation due to lack of stability.
Nasogastric tube
provides feedings for patients who are unsafe to swallow food. Keeps the stomach empty after surgery and rests the bowel.
Nasal cannula
Delivers supplemental oxygen
Closed face mask
form of oxygen mixed with room air, allows for collection of O2 around mouth and nose
Tracheostomy collar
provide supplemental humidified oxygen or air
Ventilator
provides maximum breathing support, pt may be connected via tracheostomy tube or less permanent endotracheal tube
Ventriculotomy
assists with and monitors intracranial pressure drainage
Sequential compression device
to prevent the risk of blood clots in the lower extremity, promotes venous return
continuous passive motion machine
to promote movement and attempt to reduce loss of ROM after surgery
pulse oximeter
to monitor oxygen saturation at rest and during activity
peripheral IV line
temporary administration of liquid medications or fluids, electrolytes, nutrients, or blood product transfusions.
Peripherally inserted central catheter (PICC)
for long term IV administration of medications, fluids, blood products, or chemotherapy
patient controlled analgesia pump (PCA)
IV pain medication that allows patient to determine when it is administered via a hand held button
chest tube
removes air or fluid from the pleural or mediastinal spaces, prevents drainage
portable telemetry
HR and rhythm are continually monitored from a remote room at a facility
Percutaneous endoscopic gastrostomy (PEG) tube
can be long term or permanent form of nutrition, fluids, or medication delivery to bypass the gastrointestinal system
Foley catheter
to drain urine from the bladder
external urinary catheter (condom catheter)
used to collect urine when patient is incontinent, reduces risk of urinary tract infection
Closed suction drain with bulb (Jackson Pratt drain)
device used to drain blood/fluid after surgery or infection
Hemovac
to collect blood/fluid after surgery, allows more suction than Jackson Pratt drain
Rectal tube
continuous collection of feces
wound vac
used to promote wound healing by “pulling” wound edges closer together via negative pressure, removal of fluid and bacteria.
ostomy
surgically re-route stool collection
Healthcare-Associated Infection (HAI)
infections acquired in any healthcare setting.
Nosocomial
infections are acquired in the hospital.
pseudomonas aeruginosa
at risk populations are patients with severe burns, on mechanical ventilation, cancer, and immunosuppression
Staphylococcus aureus
at risk populations are patients who have undergone surgical procedures or invasive techniques (catheter, dialysis ports), immunocompromised, and patients who have ingested contaminated food.
C diff
antibiotic associated diarrhea, at risk populations are individuals who have prolonged use of antibiotics, immunocompromised, who have undergone gastrointestinal surgery, or are older.
e coli
Pneumonia, UTI’s, diarrhea, at risk populations are individuals with severe burns, who have undergone surgical procedures
Norovirus
Gastroenteritis
5 main routes of transmission
contact, droplet, airborne, common vehicle (food, water, medications, etc), and vector borne (bugs, rats)
Standard precautions
apply to the care of all patients in all healthcare settings. Includes hand hygiene, PPE, respiratory hygiene, sharps disposal
Transmission-based precautions
Standard precautions PLUS transmission specific precautions. Includes contact, droplet, airborne, and protective precautions.
Medical Asepsis
Practices that help to reduce the number and spread of microorganisms
Surgical Asepsis
Practices that render and keep objects and areas free of all microorganisms
