Lecture 3 & NSC 3

Question 1

What is nursing ?

Answer 1

Nursing is the therapeutic relationship that enables the client to attain, maintain or regain optimal function by promoting the client’s health through assessing, providing care for and treating the client’s health conditions. This is achieved by supportive, preventive, therapeutic, palliative and rehabilitative means. The relationship with an individual client may be a direct practice role or it may be indirect, by means of management, education or research roles.

Question 2

What are the broad domains of practice ?

Answer 2

The helping role: competencies related to establishing a healing relationship, providing comfort measures,

The teaching coaching function: readying pt for learning, assisting with life-style changes, motivating change.

The diagnostic and patient monitoring function: competencies associated with ongoing assessment and anticipating outcomes.

Effective management in rapidly changing situations: ability to match resources with demands and manage care in a crisis.

Administering and monitoring therapeutic interventions and regimens: competencies related to preventing complications during drug therapy, hospitalization

Monitoring and ensuring the quality of health practices: competencies associated with safety, CQI, collaboration & consultation with other health care providers, self-evaluation & management of technology.

Organizational and work-role competencies: competencies in priority-setting, team building, coordinating & providing continuity.

Question 3

What is person and family centred care ?

Answer 3

Nurses have a unique role to play in partnering with clients facing health decisions.

A client centred partnership means that nurses respect and advocate for clients – as experts in their own lives – to lead the healthcare team.

Nurses – as professional experts – have a central role in providing/sharing clinical expertise to facilitate clients’ decision making on areas where they need or want more information.

This partnership aims at strengthening clients’ ability to reach decisions that are well-informed and best for them

PFCC

Practice recommendations are directed primarily to nurses and other health-care providers on the interprofessional team who provide direct care to persons in health-system settings (e.g., acute, long-term care, and home health care) and in the community (e.g., primary care, family health teams, and public health).

Question 4

How to develop PFCC Skills ?

Answer 4

• Guiding patients to appropriate sources of information on health and healthcare
• Educating patients on how to protect their health and prevent occurrence or recurrence of disease
• Eliciting and understanding patients’ preferences
• Communicating information on risk and probability
• Sharing treatment decisions
• Providing support for self-care and self-management

Fast access to reliable health advice

Effective treatment delivered by trusted professionals

Participation in decisions and respect for preferences

Clear, comprehensible information and support for self-care

Attention to physical and environmental needs

Emotional support, empathy and respect

Involvement of, and support for, family and carers

Continuity of care and smooth transitions

Question 5

What are the aspects of PFCC and Nursing process ?

Answer 5

PFCC

1. Identifying Concerns/needs
2. Making decisions
3. Caring and service
4. Evaluationg outcomes

Nursing Process

1. Assessment
2. nursing diagnosis
3. Planning
4. Implementation
5. Evaluation

Question 6

What are the sources of Data ?

Answer 6

• Client
• Family & significant others
• Health care team
• Medical records
• Literature
• Nurse’s own experience

Question 7

What are the general guidelines for setting priorities ?

Answer 7

1. Take care of immediate life-threatening issues
2. Safety issues
3. Client-identified issues
4. Consideration of time & resources required

Question 8

What are the three types of goals ?

Answer 8

1. Client Centred Goal: A specific & measurable behavioural response- Relatively immediate - Example: The client will perform self care hygiene independently
2. Short Term Goals: Outcomes achievable in a few days or up to 1 week•Developed from the problem portion of the diagnostic statement•Also client-centered•Measurable•Realistic•Accompanied by a target date
3. Long term goals: Desirable outcomes that take weeks or months to accomplish i.e. for clients with chronic health problems

Question 9

What are the components of outcome ?

Answer 9

Subject: who is the person expected to achieve the outcome?

Verb: what actions must the person take to achieve the outcome?

Condition: under what circumstances is the person to perform the actions?

Performance criteria: how well is the person to perform the actions?

Target time: by when is the person expected to be able to perform the actions?

Question 10

What does documenting the plan of care consist of ?

Answer 10

1. Prioritized client identified problems/concerns
2. Client goal/expected outcomes
3. Interventions: The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects

Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders

Must involve the client

The types of interventions are: I(1) ndependent: acts which do not require direction or orders from other HCP (2) Dependent: actions which require orders or direction from physicians or other HCP with prescriptive authority (3) Interdependent: collaborative- therapies that required combined knowledge, skill & expertise of a number of HCP (4) Direct interventions: actions performed through interaction with clients (5) Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.

4.Evaluation criteria

Question 11

What are examples of Direct Care ?

Answer 11

1. Activities of daily living (ADLs): Eating, dressing, bathing
2. Instrumental activities of daily living: Shopping, preparing meals
3. Physical care: Med administration, changing dressings
4. Lifesaving measures: CPR
5. Counselling
6. Teaching
7. Controlling for adverse reactions: Knowing potential side effects of meds
8. Preventive measures: dentification of risk for illness

Question 12

What is the Evaluation Process ?

Answer 12

1. Indentifying evaluative criteria & standards
2. Collecting data to determine whether the criteria or standards are met
3. Interpreting & summarizing findings
4. Documenting findings & any clinical judgment
5. Terminating, continuing or revising the care plan

Question 13

What are the Nursing responsibilites ?

Answer 13

• Recognize, notice health problems
• Analyze/interpret information
• Plan care
• Anticipate complications
• Initiate actions to ensure appropriate and timely treatment
• Evaluate and reflect on your responses to the client’s needs

Begin to think CRITICALLY !!!!!!

Question 14

what is the nursing process missing ?

Answer 14

Analysis, interpretation or critical thinking or decision making

Question 15

what are some common terms for the elderly population ?

Answer 15

• Older adult: >65 years of age
• Elderly: > 85 years of age
• Frail older adult: decline in physical functioning with ↑ susceptibility to illness - not a natural consequence of aging
• Ageism: stereotypes that promote negative views of older adults
• Gerontology: the study of aging and older adults

Question 16

What are some myths of aging ?

Answer 16

• People feel old based on their health & functional ability, not chronological age
• 80% of older adults are cared for by families
• People never lose their capacity for psychological growth
• A few areas of cognitive function decline but other areas improve
• Older adults are capable of learning new things, it may just take longer
• Sexual performance does not decline; however, loss of partner, disease & medications may reduce desire.
• 1/3 of older people exhibit depressive symptoms; however, depression is treatable at all ages.

Question 17

whata are some changes that occur in older/aging adults ?

Answer 17

• System changes
• Cognition
• Skin (special attention!)
• Functional and psychological changes

Question 18

What are some cardiac changes that occur in elderly populations ?

Answer 18

• Reduced cardiac output & stroke volume
• Reduced elasticity & ↑ rigidity of arteries
• ↑in diastolic & systolic BP
• Orthostatic hypotension
• ↑ rigidity & thickness of heart valves, ↓ contractile strength
• ↑calcium deposits in muscular layer
• Inelasticity of systemic arteries & ↑ peripheral resistance
• Reduced sensitivity of BP regulating baroreceptors

Heart rate at rest does not change with age. However, it is slow to respond to stress & slower to return to normal after periods of physical activity.

Reduced arterial elasticity may result in diminished blood supply especially to legs & brain- c/o calf pain on exertion or dizziness

Question 19

What are some pulmonary changes that occur in the elderly population ?

Answer 19

• Weakened thoracic muscles, calcification of costal cartilage making rib cage more rigid with ↑ AP diameter; dilation from inelasticity of alveoli
• Diminished delivery & diffusion of O2 to the tissues to repay O2 debt: exertion or changes to both respiratory & vascular tissues.
• ↓ability to expel foreign or accumulated matter
• ↓ lung expansion, less effective exhalation, reduced vital capacity & ↑residual volume
• Dyspnea following intense exercise
• ↓ elasticity & ciliary activity

Respiratory muscle weaken & chest wall stiffens= decrease compliance

Kyphoscoliosis, calcification of intercostal cartilage, arthritis of costovertebral joints, weakening diaphragm, increased rigidity of trachea & connecting airways= can result in inadequate gas exchange, smaller volume of inhaled air.

Total lung volume is not reduced but rather it is redistributed. Greater volume of residual air is left in lungs after exhalation.

Increased susceptibility to respiratory infections and respiratory complications during the post operative period.

Question 20

What are some hastrointestinal changes that occur in elderly populations ?

Answer 20

• Delayed swallowing time
• ↑ tendency for indigestion
• ↑ tendency for constipation
• Alterations in swallowing mechanism
• Gradual ↓in digestive enzymes, reduction in gastric pH & slower absorption rates
• ↓ muscle tone of the intestines, ↓peristalsis, ↓free body fluid

Gradual decrease in digestive enzymes: ptyalin in salivary secretions which converts starch; pepsin & trypsin which digest protein & lipase, a fat-splitting enzyme.

Alterations may lead to constipation, diarrhea or flatulence

Question 21

What are some Urinary changes that occur in elderly populations ?

Answer 21

• ↓ filtering ability of the kidney & impaired renal function
• Less effective concentration of urine
• Urinary urgency & frequency
• Tendency for nocturnal frequency & retention of residual urine
• ↓ number of functioning nephrons & arteriosclerotic changes in blood flow
• ↓ tubular function
• Enlarged male prostate/weakened muscles supporting bladder or weakness of urinary sphincter
• ↓bladder capacity and tone

Excretory function of kidneys diminishes with age but not significantly below normal levels unless associated with disease.

Nocturnal frequency is common and disrupts sleep. Retention of residual urine predisposes client to bladder infections.

Question 22

What are some genitalia changes that occur in elderly populations ?

Answer 22

Female

• Shrinkage & atrophy of vulva, uterus, fallopian tubes & ovaries; reduction in secretions, changes in vaginal flora
• ↓ in vaginal lubrication & elasticity
• Diminished secretion of female hormones & more alkaline vaginal pH

Male

• Prostate enlargement (benign)
• longer time for sexual arousal
• ↓ firmness of erection & ↑ refractory period

** possibly cause of endocrine problems**

Question 23

What are some Immunological changes that occur in the elderly population ?

Answer 23

• Decreased immune response; lowered resistance to infection
• Poor response to immunization
• Decreased stress response
• T-cells less responsive to antigens; B-cells produce fewer antibodies
• Immune system changes may precipitate insulin resistance

Called “T” because they develop in thymus gland – immune response cells, i.e., destroy infected cells and other functions

Called “B” because they develop in bone marrow – produce antibodies

Question 24

What are some endocrine chages in th elederly populations ?

Answer 24

Increased insulin resistance & Decreased thyroid function

Question 25

What are some neuromuscular changes in elderly populations ?

Answer 25

• speed & power of skeletal muscle contractions
• Slowed reaction time
• Loss of height
• Loss of bone mass
• Joint stiffness
• Impaired balance
• Greater difficulty in complex learning & abstraction
• ↓ in muscle fibres
• Diminished conduction speed of nerve fibres & ↓ muscle tone
• Atrophy of inter-vertebral discs, ↑ flexion at hips & knees
• Bone re-absorption outpaces bone reformation
• Drying & loss of elasticity in joint cartilage
• ↓ muscle strength, reaction time & coordination, changes in center of gravity
• Fewer cells in cerebral cortex

Loss of speed & power of muscle contractions and muscle wasting in the elderly results in lack of strength and they fatigue easier; plan activities to minimize fatigue

Delayed reaction time leads to cautious behaviours (slower driver)

Slight loss of overall stature is normal; over exaggeration often associated with muscle weakness can lead to kyphosis

Osteoporosis a decrease in bone density can lead to serious fractures (pathological fracture); common causes-poor dietary intake of calcium, women after menopause, immobilization or physical inactivity.

Degenerative joint changes can lead to joint stiffness- regular activity & proper nutrition will slow bone loss & decrease muscle atrophy and stiffness. Regular exercise programs also added benefit of socialization.

Question 26

What are some sensory & perceptual changes ?

Answer 26

• Loss of visual acuity
• ↑ sensitivity to glare & ↓ability to adjust to darkness
• Acrus senilis (cataract)
• Degeneration leading to lens opacity; presbyopia
• Changes in ciliary muscles, rigid pupil sphincter, ↓ pupil size

Acrus senilis: partial or complete white circle around the periphery of the cornea (cataract)

Presbycusis: gradual hearing loss affects people over 65, hearing loss is greater at high frequencies. Older adults will hear speakers with low, distinct voices best.

Presbyopia: loss of flexibility of lens, less ability to focus on near vision, begins around 40.

Shrunken appearance of eyes: loss of orbital fat, slowed blink reflex, looseness of eyelids especially the lower due to poorer muscle tone.

Loss of taste and smell may affect appetite and increase risk of poor nutrition.

Loss of skin receptors: may not be able to distinguish hot from cold or sense the intensity of heat. Increased risk for injury and burns.

• Possible nerve conduction & neuron changes
• ↓ number of taste buds in tongue due to tongue atrophy - ↓sense of taste
• ↑threshold for sensations of pain, touch & temperature
• Changes in the structure & nerve tissues in the inner ear; thickening of ear drum- Presbycusis (hearing loss)
• Atrophy of olfactory bulb at base of brain - ↓sense of smell

Question 27

What are the aspects for the physiology of movement ?

Answer 27

1. Skeletal system: Support & Movement
2. Skeletal muscle Muscles associated with movement & Muscles associated with posture

Bones have 5 functions: support, protection, movement, mineral storage and hematopoiesis. In relation to movement our bones provide a framework and contribute to the shape, alignment and positioning of body parts. In movement bones together with their joints constitute levers for muscle attachment. Muscles contract and shorten pulling on bones producing joint movement.

Muscles of movement: located near skeletal region, movement is caused by lever system. Muscles attached to bones of leverage provide the necessary strength to move objects. Example- muscles of humerus, ulna and radius & associated joints.

Muscles & posture: gravity constantly pulls on the body, muscles exert a pull on bones in opposite direction- low level of sustained contraction

Nervous system: major voluntary motor area located in cerebral cortex is the precentral gyrus. Transmission of impulses from nervous system to MSK system is an electrochemical transmission & requires a neurotransmitter- chemicals that transfer electric impulses across the myoneural junction to stimulate muscle movement. Disorders associated with altered neurotransmitter production- Parkinson’s. Altered transfer from neurotransmitter to muscle- myasthenia gravis. Altered activation of muscle activity- MS.

Proprioception: the awareness of the position of the body. Proprioceptors are located on nerve endings in muscles, tendons and joints. Allows people to walk without watching their feet.

Question 28

What are the types of exercises ?

Answer 28

Isotonic (dynamic): muscles shorten to produce muscle contraction & active movement. Includes most physical conditioning exercises (walking), ADLs & active ROM exercises. Examples for isotonic bed exercises, pushing or pulling against a stationary object, using the trapeze to lift body off bed, lifting buttocks off bed pushing hands against mattress. These types of exercises enhance circulatory and respiratory functioning, increase muscle tone, strength and mass, and promote bone formation (osteoblastic activity).

Isometric (static): change in muscle tension but no muscle or joint movement takes place. Bed exercise, squeezing a towel or pillow b/w knees while tightening the muscles in front of the thighs by pressing the knees downward. Helps to maintain muscle strength and prevent muscle wasting.

Isokinetic (resistive): muscle contraction or resistance against an object. Usually machines or devices used to provide resistance, generally affect 1 muscle group. i.e. planking these activities help to build muscle strength and also promote osteoblastic activity.

Activities:

Aerobic: amount of oxygen taken in is greater or equal to requirements, intensity measured by reaching target heart rate, talk test (laboured breathing but still able to carry on conversation), Borg scale of perceived exertion

Anaerobic: activities in which muscles cannot draw out enough oxygen from blood and anaerobic pathways are used (weight lifting, sprinting, marathons)

Exercise programs for clients should be chosen based on their activity tolerance and abilities and should include a combination of activities that provide various benefits for the client.

Question 29

What are the effects of exercise ?

Answer 29

Cardiovascular

◦↑ cardiac output

◦Improved myocardial contraction

◦Decreases resting HR

◦Improved venous return

Pulmonary

◦Improved alveolar ventilation

◦↓ work of breathing

◦Improved diaphragmatic excursion

Activity tolerance

◦Improved tolerance

◦Decreased fatigue

Musculoskeletal

◦Improved muscle tone

◦Increased joint mobility

◦Increased muscle mass (possible)

◦Reduced bone loss

Psychosocial factors

◦Improved tolerance to stress

◦Feelings of general “well-being”

◦Reports of decreased illnesses

Metabolic

◦↑ basal metabolic rate, use of glucose & fatty acids

◦↑ triglyceride breakdown, gastric motility

◦↑ production of body heat

Question 30

What are the body mechanics ?

Answer 30

The coordinated efforts of the MSK & nervous systems to maintain balance, posture & body alignment during lifting, bending, moving & ADL’s, ↓ injury, facilitates mobility & allows for efficient use of energy

• Body Alignment
• Body balance- center of gravity
• Friction

—Wider base of support=greater stability

—Lower center of gravity=greater stability

—Equilibrium of an object is maintained as long as the line of gravity passes through its base of support

—Facing direction of movement reduces twisting

—Dividing balanced activity between arms & legs ↓ back injury

—Leverage, rolling, turning, pivoting less work than lifting

—When friction is reduced, less force is required to move it

—Reducing force of work ↓ risk of injury

—Good body mechanics reduces fatigue

—Alternating periods of rest and activity reduces fatigue

Some Pathological influences in body mechanics & Movement:

—Congenital abnormalities

—Degenerative disorders

—Other chronic diseases

—Episodic illness

Question 31

What are some ways to prevent lifting injuries ?

Answer 31

1. Arrange for help when moving clients, use a lift team
2. Use patient handling equipment (ceiling-lifts, slide sheets, air-Amattress on maximum inflate, adjust height of bed)
3. Encourage client to help as much as possible (AFTER your assessment)
4. Keep back, neck, pelvis & feet aligned
5. Avoid twisting
6. Flex knees, keep feet wide apart
7. Position yourself close to client, use arms & legs (not your back)
8. Use a pull sheet to move pt towards you, & slide board to move client from bed-stretcher
9. The person with the heaviest load coordinates efforts by counting to 3, then move client together
10. Perform manual lifting as a last resort & only if it doesn’t involve lifting most or all of a client’s weight

Question 32

How does one assess the mobility of the patient ?

Answer 32

Body Alignment: standing, sitting, recumbent

Mobility: ROM, gait, exercise, activity tolerance

Patient Expectations:

◦Motivation, expectation of pain or undue fatigue with movement, perception of need for activity- Assessment of pt mobility focuses on ROM, gait, exercise & activity tolerance, body alignment. When unsure of the pts abilities, start with the most supportive position & move to higher levels according to pt tolerance.

Question 33

What is the Range of Motion (ROM) ?

Answer 33

The maximum amount of movement available at a joint in one of the 4 planes of the body

Nurse assesses ROM before mobilizing client, while laying in bed

Active ROM: client performs the exercises, is able to move all joint through motions

Passive ROM: nurse performs for the client, who is weak or unable to move the joints

We encourage range of motion exercises in clients in order to promote circulation, prevent contractures and muscle wasting.

Mobility & Immobility

Metabolic: negative nitrogen balance

Respiratory: atelactasis (partial or complete collapse of the lung or partial)

CVS: orthostatic hypotension, thrombus, embolus

MSK: atrophy, osteoporosis, joint contracture, foot drop

Urinary: stasis (urinary retention - your bladder cannot completly empty)

Integumentary: pressure ulcer

Psychosocial: depression, changes in sleep-wake cycles, withdrawn, passive, hostility, fear, anxiety,….

Question 34

What are the different positioning for comfort ?

Answer 34

Fowler’s position:HOB 45-60 degrees - Increases comfort, improves ventilation, promotes relaxation

Prone position: Pillow under head reduces flexion or hyperextension of cervical vertebra - Pillow under abdomen reduces pressure on breasts and reduces hyperextension of lumbar-reducing low back strain - Pillow under lower legs reduces external rotation of hips, prevents foot drop

High Fowler’s HOB 60-90o: This position is frequently used when feeding a client (especially one on feeding precautions, client at risk for aspiration), radiology needing to take a specific type of x-ray at the bedside, client experiencing severe dyspnea, client receiving a breathing treatment (nebulized aerosol) dependent drainage after abdominal surgery, grooming.

Supine position: Rolled towel under lumbar area supports lumbar spine - Pillow under head, neck & upper shoulders prevents flexion contractures of cervical vertebrae - Pillow under heels prevents pressure sores - Footboard maintains dorsiflexion of feet and prevents foot drop - Rolls or sandbags along legs prevents external rotation of hips - Hand rolls reduces extension of fingers and abduction of thumb

Lateral side Laying: Removes pressure from bony prominences on back and buttocks - Pillow under head & neck reduces lateral neck flexion & reduces strain on sternocleidomastoid muscle - Shoulder flexed forward prevents weight directly on shoulder joint - Pillow under upper arm decreases internal rotation & adduction of shoulder - Pillow under semi flexed upper leg prevents pressure on bony prominences

Question 35

How to apply Thromboembolic hose on patients ?

Answer 35

Elastic stockings or TEDS: aid in maintaining external pressure on the muscles of the lower leg, promoting venous return. Need to be measured to find the correct size with a tape measure, assess circulation, remove & reapply every shift, do not apply if (skin lesions, gangrenous conditions, recent vein ligation as will compromise circulation). Teach exercise to prevent thrombus (foot circles, ankle pumps knee flexion)

A method to prevent thrombus/embolus in immobile pts. Or bedridden. Usually also on blood thinners such as S/C low-molecular weight heparin (tinzaparin, enoxaparin, daltaparin) as prophalaxis or DVT.

SCT’s: sleeves wrapped around the calf of each leg, attached to a tubing, with a motor. The pump inflates & deflates the tubes intermittently, it increases venous return through the deep veins of the legs.

Question 36

What are different ambulation devices ?

Answer 36

Gait Belts: Walk slowly•Client sets the pace•Walk on the client’s weaker side•Hold the handrail, if available, with client’s strong arm

Walkers: Indication: Some imbalance or weakness - must be able to Weight bear on at least one foot & use of hands & arms - Proper Use:•Standing straight with elbows slightly flexed•Provide instructions for use & then evaluate - Used for the client who requires some support when walking due to imbalance or weakness.- Must be able to bear weight on at least one foot, remain balanced in an upright position, have use of hands & arms.- Height is adjusted so that the client is standing straight with elbows slightly flexed.- When moving a rigid frame walker it should never be slid along the floor or ground. Always instruct the client to move the walker forward by lifting it up. The feet should remain still until the walker is moved ahead.- Assist the client to a standing position by straightening your legs as you lift with the gait belt and the client pushes down with his hands on the mattress. - Instruct the client to position his body within the frame of the walker. - Instruct the client to move the walker forward by lifting it up, moving it forward, and setting it down.- Instruct the client to take a step forward with the affected (weak) leg.- Instruct the client to move unaffected (strong) leg forward. - Instruct the client to take short steps and keep his head up and eyes looking forward - This helps to maintain good posture.

Canes: Indication: Weakness or paralysis on one side - Safe Use: •Hold on unaffected side •Height- elbow slightly bent when walking•Three-point and four-point canes •Six to ten inches to the outside of the foot•Check rubber tip

Question 37

What are some fall prevention mechanisms ?

Answer 37

• Manage underlying health conditions (osteoporosis, delirium, infections)
• Exercise programs
• Strategies to promote continence
• Ensure use of aids (glasses, walkers)
• Monitor medications, reduce polypharmacy
• Bed-exit alarm
• Appropriate footwear
• Minimize environment clutter
• Minimizing effects of orthostatic hypotension

Risks for falls:

confusion, disorientation, impulsivity

symptomatic depression

altered elimination

dizziness, vertigo

male sex

administration of anti-epileptics (or dosagechanges or cessation)

administration of benzodiazepines

poor performance in the “Get-Up-and-Go” test of rising from a seated position

The Hendrich II Fall Risk Model: is a tool used to assess fall risk. Individualized care plans can be developed to minimize risk according to how the individual client scores. www.hartfordign.org

Question 38

What are some factors contributing to falls ?

Answer 38

Falls account for up to 90% of all reported incidents in hospital

Factors contributing to falls:

• age
• previous falls
• gait disturbance
• balance
• mobility problems
• medications
• postural hypotension
• sensory impairment
• urinary & bladder dysfunction
• certain medical diagnoses

Question 39

How does one assess for fall risk ?

Answer 39

Using the Hendrick II Fall Risk: & categories:

• Confusion or disorientation: acute or chronic earn same score (interview, patterns of behaviour)
• Depression: history or diagnosis, observed signs or client’s expression
• Altered elimination
• Dizziness or vertigo: client’s expression or observed
• Gender - Male
• Medications: anti-epileptics & benzodiazepines
• Get-Up-and-Go test (scoring mobility)

Hendrich II Fall Risk Model: course website

Confusion of disorientation: (4)

• impulsive or unpredictable behaviour
• Hallucinations
• Agitation
• Changes in attention, cognition, psychomotor level, LOC, sleep-wake states
• Disoriented to time, person or place
• Inability to follow directions, self-care deficits

Depression: (2) history of depression or current diagnosis

• Prolonged feelings of hopelessness, helplessness or being overwhelmed
• Tearfulness, flat affect, loss or lack of interest in life, melancholy mood
• Withdrawn or client’s statement of feeling depressed.

Altered elimination: (1)

• Urinary or fecal incontinence, diarrhea, frequency
• Urgency or stress incontinence, nocturia

Dizziness or vertigo (1)

Based on client’s report. Can also be assessed by performing Get-Up-and-Go test

Male sex (1)

Medications: antiepileptics (2) & benzodiazepines (1)- affect central nervous system & can cause cerebellar ataxia, weakness & gait changes

Get-Up-and-Go: 0-4 depending on assistance required

Total score: 5 or greater=high risk for falls

Question 40

How does one transfer patient from bed to chair ?

Answer 40

Note: if your patient has a weakness on one side, instruct patient to place unaffected foot forward and weak leg back, instruct to pivot on strong leg while your knee supports the weaker leg.

• One nurse- patient who can assist
• Explain procedure first
• Chair beside bed with back same plane as HOB
• Consider transfer belt
• Use good body alignment

Question 41

How does one transfer from bed to bed stretcher ?

Answer 41

• Requires minimum 3-person carry
• Similar heights-center of gravity on is the same plane
• Use of draw sheet to“cradle”
• Establish a leader
• Maintain patient’s alignment

Question 42

what is a stand aid lift ?

Answer 42

•Assessment prior to using: cognition, predictability, trunk control

Stand lift- suitable for clients who are able to weight bear or partial weight bear.

Cognition: scientific term for mental processes. These processes include attention, remembering, producing and understanding language, solving problems, and making decisions

Clients responses must be predictable, clients who have erratic behaviour, uncontrolled muscles movements, uncontrolled seizures would not be appropriate .

Clients must have trunk control; refers to the ability to control the trunk (torso). Ability to hold body upright when sitting or moving. Loss either partial or complete may be associated with stroke, brain or spinal cord injury, Parkinson’s disease or multiple sclerosis.

Question 43

what are the twp mechanical lifts ?

Answer 43

• Ceiling models
• Floor models

Principles:

Requires 2 persons for safe client transfers – never by yourself

Use proper sling size and position properly under client

Ensure proper support of head and neck

Careful attention to increased pressure on skin, pad for comfort.

Remove sling after client transferred, reduces skin breakdown.