Mark K lecture 4 Flashcards
How do you measure length of crutches
o Holding it vertically and placing the tip on the ground
o Having 2 to 3 finger widths between the pad and the
anterior axillary fold
o The tip is located to a point lateral (6 inches) and slightly in
front of foot (6 inches)
* Rule out landmarks on
Handgrip measurement for crutches
Handgrip measurement
o The angle of elbow flexion is 30 degrees
o The wrists should be
2 point gait
move a crutch and
opposite foot together, then the other
crutch with other foot together
* Together (Right leg & Left crutch)
! Together (Left leg & Right
crutch)
* For mild bilateral leg weaknesses
3-point gait—
move (2 crutches & bad leg)
together ! Followed by unaffected leg
* The gait goes 3-1, 3-1, 3-1
* The affected (bad) leg is not on the
ground
* The unaffected (good) leg is on the
ground
4-point gait
move everything separately
* Move crutch ! Move opposite foot ! Followed by other crutch ! Followed by opposite
foot
* Right crutch ! Left foot ! Left crutch ! Right foot
* 4-point gait is very slow but very stable
Swing-through is for
for non-weight bearing (amputees)
* Similar to 3-point gait
* The unaffected foot get pass the tip of both crutches
* The person may be an amputee or does not bear weight on the leg at all
* Can move really fast
When do you use these gaits?
Use Even-point gait for even weakness distribution
odd-point gait for uneven weakness bilaterally
Use the even numbered gaits when weakness in the feet is evenly distributed
o 2-point for mild problems
o 4-point for severe
* Use the odd numbered gait when one leg is affected
o 3-point for one leg
* If pt cannot bear weight or amputation
o Swing-through
A pt affected with early stages of rheumatoid arthritis. What gait should the pt use?
- Both legs affected (because it is a systemic disease)
- Early stage—mild
- 2-point gait
A pt has left ATK (above the knee) amputation 2 days ago. What gait should the pt use?
- Non-weight bearing
- Swing-through
Pt is first day postop, right knee, partial weight bearing allowed. What gait should the pt use?
- One leg affected
- Odd-numbered gait
- 3-point gait
Pt is in advanced stages of ALS
- Bilateral leg weakness (because it is a systemic disease)
- Even-numbered gait
- Advanced stages = Severe
- 4-point gait
Pt with left hip replacement, 2nd day postop on non-weight bearing instruction. What gait should
the pt use?
- Non-weight bearing of 1 leg
- Swing-through gait
Going Up and Down the Stairs With Crutches
* Remember this phrase
“Up with the Good, and Down with the Bad”
When you go up the stairs, the good foot move up first
o When you go down the stairs, the bad foot move down last
Hold the cane on the ___ side
Hold cane on the unaffected (strong) side
* Advance cane with the opposite side for a wide base of support
* Handgrip should be at the level the wrist
Correct way to use a walker
The walker is on the side of the pt, the pt “Picks it up … Sets it down … Walks to it”
o Once the walker is in front of the pt, the pt “Holds on to chair, Stands up, Then grabs
walker”
* Don’t tie belongings to the front of the walker—Tie them to either side so it won’t tip over
* The NCLEX board does not like tennis balls or wheels on walker can create problem
First thing to ask in a psych question is:
“Is the pt psychotic or non-psychotic?”
* The answer to this question will determine care plan, treatment, length of stay, legality, etc.
A Non-psychotic person has insight and is reality
based. What kinds of answers do you pick for these
people? What techniques do you use?
- Good therapeutic communication … Looks
like a Med/Surge pt - Examples of therapeutic communications
o That must be very difficult/overwhelming for
you
o How are you feeling?
o Tell me more about your …
o The exam is looking for “reflection, clarification, amplification, restatement, etc.”
Delusions
false, fixed belief or idea or
thought. There is no sensory component. It is
all in your head. It is just a thought
3 types of delusion
o Paranoid—People are out to get/kill me
o Grandiose—“I’m Christ” … “I am the
President” … “I am the world’s smartest
person”
o Somatic—Body part (I have x-ray vision,
there are worms inside my arm)
types of hallucinations
o Auditory (1st m c)—voices telling you to
harm yourself
o Visual (2nd m c)—I see bugs on the wall
o Tactile (3rd m c)—I feel bugs on my arm
(Most common = m c)
o Gustatory (taste)
o Olfactory (smell)
Illusion
a misinterpretation of reality. It is sensory. ex thinking nurse is murderer
Differentiation between hallucination and illusion
- With illusion there is a referent in reality
o A referent is something that both the clinician and the pt can refer to … There is actually
something there
o The cord is a snake - With hallucination, there is nothing there
There are 3 types of psychosis
- Functional psychosis
- Psychosis of dementia
- Psychosis of delirium
Functional psychosis
they can function in everyday life
* 90% of the followings make up this category
* Chemical imbalance in the brain
* They are “Skeezo, Skeezo, Major, Manics”
o Schizophrenia, Schizoaffective disorder, Major depression (not depression), Mania
Psychosis of dementia
- Actual Brain destruction/damage
o Due to Alzheimer, stroke, organic brain syndrome
o Anything that says Senile/Dementia falls in the category
Psychotic Delirium
temporary, sudden, dramatic, episodic secondary to something else
* Loss of reality
o Due to UTI, thyroid imbalance, adrenal crisis, electrolytes, medications/drugs
Approach to Answering Psychiatric Questions
* First thing to ask is
o Is the pt non-psychotic? Or, is the pt psychotic?
* Pt is non-psychotic
o Address pt as you would address any Med/Surg pts
Use therapeutic communication
* Pt is psychotic
o Next, ask if they are functional, demented, or delirious?
Functional approach
(1) Acknowledge feeling, (2) Present reality, (3) Set limits, and (4) Enforce
these limits
Demented
(1) Acknowledge their feeling, and (2) Redirect them—give them something
they can do
Delirious
(1) Acknowledge feeling, (2) Reassurance about safety and temporariness of
their condition
dealing with a patient using Functional approach
- Schizo, mood disorders thought process, and mania (chemicals out of whack)
- This pt has the potential to learn reality (no brain damage)
- Your role as a nurse—teach reality
- Use the 4 step process to teach reality
o (1) Acknowledge feeling, (2) Present reality, (3) Set limits, and (4) Enforce these limits
1.The answer acknowledges pt’s feeling (look for the word “feel”)
You seem upset … That is so sad … It’s been so difficult … Tell me more about how you’re
feeling
2. Now, present reality … “I know you see that demon, but I don’t see a demon” … Or, “I am a
nurse, this is hospital, this is your breakfast”
3. Set limit. ”We are not going to address that. Stop talking about…”
4.Enforce limit. “I see you’re too ill, so our conversation is over.” Ends the conversation.
You’re not punishing the client by taking away privileges
Example of talking to a psychosis of dementia pt
- They cannot learn reality … Don’t present it! They can’t learn it! Thus frustrates them, and
may discourage you! - Deal with their problems in 2 steps
o (1) Acknowledge their feeling, and (2) Redirect them—give them something they can do
Do not confuse not presenting reality with reality orientation (Person, place, and time)
* Reality orientation = Pt is oriented to person, place, and time
Example
* Alzheimer lady is the lobby of waiting area of her nursing home. It is Sunday and she is all
dressed up. You day to her, “Mrs. Smith, you are all dressed up.” She said, “Yeah! My
husband is going to pick me up. We are going to church.” The problem is that the husband
has been dead for 10 years.
o She has a false, fixed belief
o She is delusional (or she is psychotic)
o What do you say to her?
o First, acknowledge her … You say, “That sounds nice.” (acknowledging)
o Second, redirect her … You say, “Why don’t we sit down here and talk about church? …
What church do you go to?” (redirecting)
o Don’t tell her husband is dead!, which is presenting reality
A pt with delirium tremens who during your conversation points to 2 people talking across the
room and says, “You see these people, they are plotting to kill me”
- Delirium tremens …
- “That must be scary”
- But you are safe. Your fear will go away when you get better
A pt with Alzheimer disease who during your conversation points to 2 people talking across the
room and says, “You see these people, they are plotting to kill me”
- Alzheimer Disease—category is dementia
- Acknowledge feeling—“I understand you seem to be scared”
- Redirect—Let’s go somewhere you feel safe
A pt with schizoaffective disorder who points to 2 people talking across the room. The pt says,
“Those people are plotting to kill me.” What would you say? What is the most important word in
the vignette?
- Schizoaffective—psychosis
- I can see that would be frightening. They are not plotting.
- We are not going to talk about that. I can see you are too ill. We are ending the conversation
Flight of Ideas
Rapid flow of though
Word Salad
Throw words together and toss
out … (Sicker than flight of ideas)
Neologisms:
Make it up
Psychosis of delirium approach
- This is temporary, sudden, dramatic, episodic, secondary loss to reality
- Usually due to some chemical imbalance in the body
- Causes—UTI, thyroid imbalance, adrenal crisis, electrolytes, medications/drugs
- To manage these pts, treat the underlying cause
o Acknowledge feeling
o Reassure them of safety and temporariness of their condition - They lost touch with of reality—Redirect them is futile
Narrowed self-concept:
When a psychotic
refuse to change their clothes or leave the
room. Leave them alone
o This is a functional psychosis
o “Don’t make a psychotic do something they don’t want to do”
Idea of reference:
You think everyone is talking about you
