Set 7 Flashcards
What side should a patient hold their cane on?
Strong/unaffected side
At what height should a patient’s cane or walker be?
Height of patients wrist or greater trochanter
T or F: the pads of crutches should be up against the axilla (armpit)
False! Crutches should be 2 inches (2-3 finger width) below the axilla to prevent cutting off circulation to important nerves and blood vessels
Crutches patient education
Place weight on hands (handgrip), NOT the axilla; elbows should be flexed about 30 degrees
Crutch gait in which the patient moves the injured side’s crutch at the same time as the non-injured leg. Then the patient will move the non-injured side’s crutch at the same time as the injured leg
Two-point gait
Crutch gait in which the patient moves the injured side’s crutch, then moves the non-injured leg, then moves the non-injured side’s crutch, then moves the injured leg (NOTE: this is similar to the two-point gait BUT the crutch and leg move separately rather than at the same time)
Four-point gait
Crutch gait in which the patient does not let their injured leg touch the ground by moving both crutches and injured leg forward together and then moving the non-injured leg
Three-point gait
Crutch gait in which the patient moves both crutches forward, then swings both legs forward to the same point as the crutches
Swing-to-gait
Crutch gait in which the patient moves both crutches forward and then swings both legs forward and past the crutches
Swing-through-gait
Patient education for going upstairs with crutches
Move good/unaffected leg up onto step first, then move the bad/affected leg and crutches onto the step
Patient education for going downstairs with crutches
Move both crutches down onto the step and then moves the bad/affected leg down, then move the good/unaffected leg down
Patient education for sitting down with crutches
Back up to chair until felt with non-injured leg, move both crutches to injured side and grip for support, keep injured leg extended out and slightly bend non-injured leg, feel for chair seat with non-injured side and sit down
Patient education for getting up from a chair with crutches
Keep injured leg extended out forward and put both crutches on the injured side and group the hand grips of crutches, lean forward and push up with the arm of the non-injured site on the chair’s seat and by using the hand grips on the crutches (which is on the injured side), branch crutches into tripod position once standing
Describe tripod position
Each tip of crutch will be 6 in to the side of feet diagonally
Fall prevention at home
- remove scatter rugs
- have good lighting, especially over stairs and mark the edges of steps with colored or reflective tape
- tape down electrical cords behind furniture or against a wall if possible
- install grab bars in shower and have a nonslip Matt on shower floor
- educate patients on using assistive devices properly
Order requirements for restraints
Provider must do an in-person assessment of the patient within 24 hours of the order; the order only lasts for 24 hours (new order must be obtained if patient continues to need restraints)
Restraints documentation
Rationale for restraints, time of restraint, patient assessment findings, what care was offered and provided to the patient
Nursing care for tying restraints
Restraint must be tied in quick-release fashion and tied to a part of the bed frame
How often should the nurse assess a patient in restraints?
Every 15 min (due to risk for positional asphyxia)
How often should the nurse take vitals, provide ROM, and offer fluids and toileting to a patient in restraints?
Every 2 hours
When are restraints discontinued?
As soon as the patient is no longer a risk to themselves or others
Pressure injury risk factors
Immobility, older age, incontinence, poor nutrition, perfusion issues, smoking, corticosteroids
A Braden scale less than ___ indicates a patient is at risk for pressure injury
18
How often should Braden scale be done?
At least every shift
Tool used to screen client’s risk of skin breakdown
Braden scale
What risk factors are considered with the Braden scale?
Sensory perception, moisture, activity, mobility, nutrition, friction & shear
Pressure injury prevention
Reposition patient every 2 hours, place patient on pressure redistribution mattress if possible, keep HOB less than or equal to 30 degrees, elevate feet up off bed so that heels are dangling freely through pillows or heel elevation boots, pad bony prominences
How often should the nurse instruct the patient to redistribute their weight when sitting to prevent pressure injuries?
Every 15 min
Pressure injury limited to the epidermis characterized by nonblanchable, intact skin with erythema
Stage 1
Pressure injury with damage to the epidermis and dermis characterized by nonblanchable erythema and shallow erosion (may look like scrape or an open blister)
Stage 2
Pressure injury with damage to the hypodermis (subcutaneous tissues) characterized by visible adipose tissue
Stage 3
Pressure injury with damage extending beyond the subcutaneous tissue characterized by visible muscles, tendons, bones, etc.
Stage 4
A wound is considered _________ if you cannot see the wound bed (due to slough or Eschar)
Unstageable
Intact or nonintact skin that is nonblanchable and deep purple or maroon color
Deep tissue injury
What are the four main phases of wound healing?
Hemostasis, inflammation, proliferation, remodeling
What is the goal of hemostasis?
To stop bleeding
How is hemostasis accomplished?
Through the process of vasoconstriction, clotting cascade and activation of platelets
Which phase of wound healing is characterized by reddening, heat, and pain and can last up to six days?
Inflammation
Which phase of wound healing is characterized by the formation of granulation tissue and can take between four and 30 days?
Proliferation
Which phase of wound healing is characterized by the creation of strong skin to replace the temporary tissue in the area and can last up to 12 months?
Remodeling
Wound healing by _________ intention means that the edges of the wound are well approximated (brought together well)
Primary (ex: surgical wounds, paper cuts)
Wound healing by _________ intention is when a wound is intentionally left open to heal through granulation, contraction, and epithelialization (healing from the inside out)
Secondary (Ex: pressure injury)
Healing by _________ intention carries a higher risk of infection and longer healing times
Secondary
Healing by _________ intention is when the closure of a wound is intentionally delayed so that the wound can be irrigated, debrided, and observed usually for about a week followed by surgical closure when risk for infection is lower
Tertiary
Complication of wound healing in which a previously closed wound opens back up
Dehiscence
Complication of wound healing characterized by dehiscence WITH organ protrusion
Evisceration
Nursing interventions for evisceration
Put saline-moistened gauze over the opened area, lower HOB (maybe even put patient in trendelenburg), notify the provider immediately
Barriers to wound healing
Chronic illnesses (DM), immunosuppression (corticosteroids)
Normal, watery, clear/off-white wound drainage
Serous drainage
Wound drainage composed of serous fluid mixed with blood, giving it a pink tinge
Serous-sanguineous
Bright red, bloody wound drainage
Sanguineous
Thick, cloudy, white, yellow or beige pus that is malodorous coming from a wound
Purulent drainage (indicates infection)
Describe the appearance of a healthy looking wound
Red, beefy appearance (indicates good circulation)
A wound that is yellow indicates
The wound may need to be cleaned
A wound that is black indicates
Debridement is needed
