Flashcards for Multiple Skills
What are Active ROM Exercises?
When the patient can perform them
These exercises are designed to enhance the patient’s range of motion through voluntary movement.
What are Passive ROM Exercises?
When you perform them for the patient
These exercises are conducted by a caregiver to help maintain the patient’s range of motion.
How often should ROM exercises be performed?
At least twice daily
How many times should each sequence of ROM exercises be repeated for each joint?
5 times on each side of the body (except for the neck)
Where does skin breakdown usually occur?
Bony areas (sacrum, heels, elbows, hips, back of the head, perineal area)
What is the first stage of skin breakdown?
Redness that doesn’t blanch
What does the second stage of skin breakdown resemble?
Looks like a blister, with surface skin that peels or cracks open
Describe the third stage of skin breakdown.
Lost skin layers and underlying fat and tissue are visible
What characterizes the fourth stage of skin breakdown?
Resembles a crater, with damage all the way through to muscle and bone
What does ‘unstageable’ mean in terms of skin breakdown?
Crater is full of dead tissue
What are the signs and symptoms of infection in wounds?
- Redness
- Swelling
- Fever
- Increasing pain and discomfort
- Warmth around the wound
- Foul odor
- Drainage
What type of drainage is a clear indication of infection?
Purulent drainage (contains pus)
How do you know that a wound dressing needs replacement?
- Moisture or drainage soaking the dressing
- Looseness of the dressing
- Nonadherence of the adhesive portion of the dressing or tape securing it
What should be checked if significant pain is anticipated during dressing change?
Consult with the nurse about the patient getting an analgesic 30 minutes prior to the dressing change
What should you do if the dressing adheres to the skin?
Moisten it with sterile water or sterile normal saline solution
What is required for oxygen therapy to be initiated?
It must be prescribed by a licensed provider
What are the types of oxygen equipment?
- Nasal cannula
- Face mask
- Nonrebreather
What should be done if the patient has symptoms of dryness or the flow rate is greater than 4L/min?
Attach the flow meter to a humidifier
What are the signs and symptoms of hypoxia?
- Anxiety
- Lack of concentration or focus
- Fatigue
- Hypertension
- Cyanosis
- Dyspnea
- Increase/decrease in HR or RR
What is the purpose of suction equipment?
To remove mucus, blood, vomit, and secretions from the patient’s mouth and throat
What should you inform the patient before suctioning?
Suctioning can cause coughing, gagging, and sneezing
What position should the patient be in during suctioning?
Raise the head of the bed to 45 degrees; if unconscious, place the patient on their side
How long should you suction at a time?
No more than 15 seconds
What should the patient do between suctioning?
Cough and breathe deeply
What equipment is used for tracheostomy suctioning?
A sterile suction catheter kit
What should be done before suctioning a patient with a tracheostomy?
Preoxygenate the patient
How should the suction catheter be advanced?
Advance until you feel resistance and then pull back about 1 cm
What is the maximum suction duration when using a catheter?
No longer than 10 seconds
What does TCDB stand for?
Turning, coughing, deep breathing
What does TCDB help prevent?
Respiratory complications
How often should patients be encouraged to cough and take deep breaths?
Every 1-2 hours while awake
What is the purpose of an incentive spirometer?
Breathing exercise to help prevent respiratory complications after surgery
What is the correct technique for using an incentive spirometer?
Inhale, hold for 3 seconds, then exhale
How often should patients be encouraged to use the incentive spirometer?
Every 1-2 hours
