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
