Midterm Flashcards

Question

therapeutic positioning

Answer 1

patients with impaired nervous or musculoskeletal system functioning, increased weakness, or restricted to bed rest benefit from therapeutic positioning for immobile patients, maintain them in the 30-degree lateral position which keeps their arms and legs supported and keep them off bony prominence's

Answer 2

patients who require therapeutic positioning should be repositioned as needed: - at least every 2 hours if they are in bed - every 20-30 minutes if they are sitting in a chair

Answer 3

``` foot boots/splints trochanter rolls wedge pillow side rails trapeze bar hand rolls/splints pillow bed boards ```

Answer 4

``` range of joint motion gait activity tolerance - exercise - activity body alignment pain associated with activity ```

Answer 5

describe changes you've noticed in the ability to ambulate or care for yourself. are you experiencing any stiffness, swelling, pain, or difficulty moving? have you noticed you've become short of breath? describe your daily activities. what do you normally eat in a day? do your days and nights seem long? have you noticed any changes in your skin? have you noticed any problems with urination or defecation?

Answer 6

musculoskeletal system - perform ROM exercises to improve strength skin integrity - perform skin assessment, turn patient q2h elimination system - keep pt. hydrated via either drinking or IV fluids gastrointestinal - provide a high-fiber diet, it encourages digestive movement psychosocial problems - encourage social interactions, regulate sleep-wake cycles developmental changes - maintain normal development (young) - prevent falls via strength build-up, encourage cognitive function (elder) respiratory system - promote expansion of the chest and lungs -- use incentive spirometer - prevent stasis of pulmonary secretions metabolic system - increase intake of protein and vitamins - consider tube-feeding for pt.'s with a lack of appetite cardiovascular system - monitor pulse, blood pressure (especially before performing movements) - encourage pt. to breath out during movement -- discourages valsalva maneuver which leads to syncope prevent blood clots - encourage movement - increase circulating fluids - administer blood-thinners - promote circulation with SED's or ted stockings

Answer 7

21% O2 on room air

Answer 8

``` 1L = 24 O2 on nasal cannula 2L = 28 3L = 32 4L = 36 5L = 40 6L = 44 humidification may be added for comfort (prevents nares drying) may only administer 6L or less ```

Answer 9

5-6L = 40% O2 on simple mask 7-8L = 50 10L = 60 ranges exist because the pt. is breathing in room air as well as the prescribed oxygen

Answer 10

6-10L = 40-70% O2 on partial rebreather should not run below 5L the reservoir bag should never be fully collapsed

Answer 11

delivers 60-80% O2 on non rebreather should not run below 10L the reservoir bah should never be fully collapsed

Answer 12

delivers a specific amount of oxygen

Answer 13

``` hydration - 1500-1600 mL/day (unless contraindicated) humidification - add sterile water to the O2 supply nebulization - adds medication to the humidification chest physiotherapy - removes secretions or mobilizes them through: -- postural drainage -- chest percussion -- chest vibration coughing techniques artificial airways - oropharyngeal - nasopharyngeal - endotracheal - tracheostomy suctioning techniques - oropharyngeal - nasophaaryngeal - orotrahceal - nasotracheal - traccheostomy ambulation - ROM positioning - at a 45 degree semi-fowler's position chest tubes - removes air or fluid from pleural space ```

Answer 14

``` review of systems skin diseases previous bruising general skin condition skin lesions usual healing of sores nutritional status ```

Answer 15

``` skin color distribution skin turgor presence of edema characteristics of any skin lesions particular attention paid to areas that are most likely to break down hyperemia - areas of redness - perform blanching of that area -- if it turns white then back to red, that is normal and indicates short-term injury it is abnormal if it remains red which indicates long-term injury and the first stage of a pressure ulcer incontinence skin around dressings ```

Answer 16

``` location extent of tissue damage wound depth, length, width bleeding foreign bodies associated injuries last tetanus toxoid injection ```

Answer 17

``` appearance size drainage presence of swelling pain status of drains or tubes wound base ```

Answer 18

inspect pressure areas for discoloration and capillary refill or blanch response inspect pressure areas for abrasions or excoriations palpate the surface temperature over the pressure area sites palpate bony prominences and dependent body areas for presence of edema

Answer 19

``` provide nutrition - fluid intake - protein, vitamins, zinc - dietary consult - weight/lab data monitoring maintaining skin hygiene - mild cleansing agents avoid hot water - moisturizing lotions/skin protection -- moisture barrier cream for stage I ulcers to prevent further ulcerification - reduce irritants - reducing pain avoiding skin trauma - smooth, firm surfaces - semi-fowler's position - frequent weight shifts - exercise and ambulation - lifting devices - reposition q2h - turning schedule providing supportive devices - mattresses, beds - wedges, pillows prevent entry of microorganisms prevent transmission of pathogens ```

Answer 20

``` minimize direct pressure over bony prominences improve circulation schedule and record position changes provide devices to reduce pressure areas clean and dress the ulcer using medical asepsis never use alcohol or hydrogen peroxide around wounds to minimize irritation - use saline obtain C&S, if infected teach the pt. provide ROM exercise nutrition check for blanching prevent infection/treat infection color guide for wound care - if it is red, protect - if it is yellow, cleanse - if it is black, debride ```

Answer 21

an escape of blood through ruptured or unruptured vessel walls

Answer 22

invasion off the body by organisms that have the potential to cause disease

Answer 23

a bursting open, splitting, or gaping long natural or sutured lines

Answer 24

protrusion of underlying content through a lesion caused by intentional ie. surgical incision) or unintentional trauma

Midterm Flashcards

(48 cards)