Exam 4 Flashcards
In order for rehabilitative nursing to be successful, does the client need to be restored to their previous state?
No
What are symptoms of frailty?
-unplanned weight loss
-Slow walking speed
-Low grip strength
-Fatigue, poor endurance
-Low levels of activity
What is Sarcopenia ?
Muscle loss due to aging. Leads to loss of strength and function
People who need rehabilitation at risk for :
Falls
Disability
Hospitalization
Nursing home
Death
What is coping capacity?
The ability to cope with a new disease
What types of losses come with disability?
Functional
Role
Income
Status
Independence
Anatomic structure
What are the guidelines for rehabilitative nursing?
-know the patience, capacities, and limitations
-Emphasize function rather than dysfunction
-Provide time and flexibility
-Recognize and praise accomplishments
-Do not equate physical disability with mental disability
-Try to prevent complications
-Demonstrate, hope optimism and humor
-Multidisciplinary team effort
What is the supine position?
Laying flat on back
What is the prone position?
Laying flat on stomach with head turned a lot early
What is the lateral position?
Laying on side with head and spine align
What is chair position?
Also known as high, Fowlers, sitting up straight
How often should range of motion exercise be performed?
At least once per day
How should the joint be moved during ROM exercises?
Slowly and smoothly
Where should you provide support on a joint during ROM exercise?
Above and below the joint that is being exercise
What is included in ADLs
Toileting
Feeding
Dressing
Grooming
Bathing
Ambulating
What is included and I ADLs
Tasks required for community living
Shopping
Cleaning up after cooking
Meal prep
Laundry
Housekeeping
Using a phone
Money management
Medication management
What is rehabilitative care?
focus on returning individuals to their previous level of function
However, it is not fully restored does not mean it was not successful
What is restorative care?
maintaining or improving their current level of function.
Avoiding decline and complications
achieving the highest possible quality of life
What is nonmaleficence?
Do no harm
Be careful when giving opioids due to respiratory distress
This is when you prevent harm to Patience, by not directly performing an act that causes harm and buy informing management that staffing is inadequate to provide safe care
What should be provided to a Roman Catholic patient that is showing signs of impending death
Sacraments of the sick
What is palliative care?
Care that relieves suffering, and promotes comfort, when I cure is not possible
Giving analgesics and opioids
Physical needs of patient: eye drops, turning them, oral hygiene, bathing, etc
What is an advance directive?
A written statement of a persons wishes regarding medical treatment in the event they cannot communicate them
What is hospice care?
A way to care for terminally, ill patients and their families
Aids in adding quality and meaning to the remaining period of life
Controls their manifestations (how they live now)
Efforts to assist, physical, emotional and spiritual needs
What services are included in hospice care?
Pain relief
Symptom control
Home care and institutional care
Nurses and physicians
Social workers and counseling services
Medical equipment and supplies
Volunteer assistance and support
Bereavement, following up and counseling
Physical therapy
How often does hospice need to be renewed?
Every six months
What states is assisted suicide practiced in?
Washington, Oregon, California, Colorado, Vermont
What is voluntary euthanasia?
assisted suicide
The nurse is “volunteering” to help with euthanasia after client has requested
What are the signs of impending death?
-decline and BP
-Rapid, weak pulse
-Dyspnea and periods of apnea
-Slower or no pupil response to light
-Perfuse perspiration
-Cold extremities
-Bladder and bowel incontinence
-pallor and molting skin
-loss of hearing and vision
What are the five stages of grief?
Denial
Anger
Bargaining
Depression
Acceptance
Is Hope one of the stages of grieving and if not, what is it?
No, it is not one of the stages
Hope is used as a temporary but necessary form of denial as a rationalization for enduring unpleasant therapies and as a source of motivation
Hope permeates all stages of grief
What is the most appropriate nursing intervention when caring for a diet patient who is experiencing pain?
Prevent the pain before it occurs not after
What are the types of range of motion degrees?
Active - independently done by patient
Active assistive - with assistance to patient
Passive - with no active involvement of patient
What is Reminiscence?
Life review
Helps improve memory, reduce depression, resolves past conflicts, validates existence, enhances quality of life
Improve communication, mood, cognition, and quality of life
What is reality orientation
Helps keeps patient mentally integrated with the world around them
A total approach to keep the patient oriented
Consistency is crucial to promote orientation
What should a nurse do when a patient no longer wants to continue treatment and just wants to die?
Respect their autonomy and that they want to die
Give resources for hospice
Understand beliefs regarding gender if nurse when giving care to Muslim faith
Same gender as patient
Woman nurse for woman patient
Where can spiritual care be provided / in what areas of the hospital or facility?
Intensive care
Hospice
When is the need for support of the family after patient death the highest?
Weeks and month after death
Understand how to provide postmortem care
Is there a particular faith they belong to?
Remove excess machines and equipment
Change bedding
Place arms outside of the sheets
Clean body
Are they a candidate for an autopsy?
How can music therapy help a patient?
Can help them express emotions
Keeps them comfortable
Form of palliative care
Understand walker safety
Hands on walker with elbows slightly bent
Lift walker and set it down to advance forward
Stand up straight
What resource can be provided if a patient cannot go out and get groceries
Meals on wheels
Understand how to use crutches
6” forward and to side
Arms slightly bent
Step with strong side first, bring crutches and weaker side forward
If a patient is immobile what is very important?
Listening to lung sounds every 2 hours
When assessing a patient you should check their vital signs and their…
Medications
Understand about falls
Want to promote safety
-strength exercises
-safety checks
-lock beds and wheelchairs
-bedside table close
-complete safety check of surroundings
When starting an exercise plan, what needs to be evaluated?
Evaluate their walking, if they can walk they may be able to exercise
If a patient is being admitted with dementia what is something you may be able to ask them (during a moment of cognitive moment)
May be able to ask them what they like to eat and cook
What to say to another nurse who is struggling with end of life
Get a grip and come to terms with your feelings about death
If you are participating in an activity with a group and one person does not want to participants, do you stop activity?
No. Continue activity and offer that person an alternative activity
Make sure that all planned activities are…..
Stimulating
Understand examples of the stages of anger
Throw things
Name calling
Get very upset
What do you say to a spouse when their significant other says they want to die ?
We need to respect their position and call the physician and have them withdraw care
What do you say to a patient that tells you they want to die.
Respect their wishes and encourage them to talk to their family and the physician
What do you say when a family member says they are happy their parent died?
Ask them to tell you more and why they feel that way
What is maladaptive grief?
People who suffer from maladaptive grief tend to either push their grief away or react in unhealthy ways.
Examples of someone experiencing maladaptive grief
-not accepting death after 10 years
-not getting rid of others belongings
-talking about their loved one like they are still there
-could revert to old habits
-may have low self esteem
When a patient is depressed what do we want to assess they can still do?
ADLs
When a person has a hematopoiesis (stroke) how will they use a cane?
On their no affected stronger side
What do you do if you find a patient with no pulse and no DNR?
Call the code and alert team
Then start cpr
What would be the manifestations of an unconscious person you are giving a massage to?
-Pulse might equal out and fall within normal range
-droopy shoulders
-face muscles relaxed
What are nursing interventions for suicide prevention?
Counseling
Physician’s order
