NUR300 topic 3

Question 1

determine appropriate techniques for safe client handling including care of an older adult experiencing impaired mobility

Answer 1

• body mechanics: a term that describes the coordinated efforts of the musculoskeletal and nervous system, knowing how patients initiate movement and understanding your own movements requires a basic understanding of the physics surrounding body mechanics
• body alignment: means that an individual’s center of gravity is stable
• gait: particular manner or style of walking
• Range of motion: hip is ball and socket, knee and ankle is a hinge, foot is gliding and toes are condyloid

Question 2

assess the client care environment for safety hazards in order to reduce and eliminate risk

Answer 2

-safe environment: includes meeting basic needs, reducing physical hazards and transmissions of pathogens, controlling pollution, parasites is reduced, and sanitation is maintained

Question 3

identify safety and mobility issues that commonly affect the older adult population

Answer 3

safety issues: motor vehicle accidents, poison, falls, fire, disasters, individual risk factors (lifestyle, impaired mobility, sensory or communication impairment, lack of safety awareness
mobility issues: postural abnormalities, muscle abnormalities, damage to the central nervous system, direct trauma to the musculoskeletal system (atrophy), systemic effects, psychosocial effects

Question 4

discuss the consequences of impaired skin integrity and identify interventions to prevent complications

Answer 4

• older adults admitted to acute and long term facilities are a vulnerable population
• preventions of

Question 5

Skin

Answer 5

2 layers consisting of the epidermis (superficial) an dermis (deep)

Question 6

discuss the consequences of impaired skin integrity and identify interventions to prevent complications

Question 7

Pressure ulcer : At risk patients

Answer 7

older adults who experienced trauma, spinal cord injuries, sustained a hip fracture, long term homes or community care, individuals with diabetes, patients in critical care settings

Question 8

Blanching

Answer 8

occurs when the normal red tones of the light skinned patient are absent

Question 9

nonblanchable

Answer 9

occurs when you apply pressure and doesn’t blanch, deep tissue damage is probable

Question 10

risk factors of pressure ulcer development

Answer 10

impaired sensory perception, impaired mobility, alteration in LOC, shear force, friction, moisture, nutrition, tissue perfusion, infection, age increase the patient’s risk for pressure ulcer development

Question 11

Classifications of pressure ulcers

Answer 11

Stage 1: nonblanchable redness, intact skin presents w. nonblanchable redness of localized area, usually over bony prominence

Stage 2:partial thickness- loss of dermis presents shallow, open ulcer with red pink wound bed w/o slough

Stage 3: full thickness skin loss- loss subcutaneous fat may be visible, but bone, tendon, and muscle are NOT exposed

Stage 4: fill thickness tissue loss- loss with exposed bone, tendon or muscle, subcutaneous fat may be visible, but bone, tendon or muscle are NOT exposed

Unstageable: full thickness skin or tissue loss- in which actual depth of an ulcer is completely obscured by slough and/or eschar in the wound bed is unstageable

Question 12

Slough and eschar

Answer 12

slough- yellow, tan, gray, green, or brown

eschar- tan, brown or black

Question 13

reduction of physical hazards

Answer 13

• environmental factors such as broken stairs, icy sidewalks, inadequate lighting, throw rugs, decreasing clutter and exposed electrical cords
• older adults who wander have special safety challenges
• decrease hazards in the home is effective

Question 14

nursing interventions for promoting safety are…

Answer 14

individualized for patient’s developmental stage, lifestyle, and environment