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Flashcards in Module 3 Deck (78)
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1
Q

what are the ADLs

A

Bathing, grooming, dressing, eating, toileting, and “being mobile” (walking)

2
Q

is it better for the nurse or patient to do the majority of self care

A

patient to prevent feelings of hopelessness or dependency

3
Q

why are bed baths given less frequently than in the past

A

due to increased understanding of the hazards of immobility

4
Q

does bedrest do more harm or good

A

harm

5
Q

what type of washing should be used most often

A

showers or tub baths should be used whenever possible

6
Q

what are some positives of baths

A

Decrease the likelihood of infections
Promote effective circulation through moving pt. around in bed and rubbing skin with washcloth
Gives you an opportunity to assess the patient in-depth

7
Q

how should you wash

A

cleanest to dirtiest (usually head-to-toe; with perineal care always last

8
Q

what is an important part of perineal care

A

Gloves should always be worn for perineal care for men and women alike

9
Q

what is important to remember about patients with diabetes

A

don’t cut corns or calluses and don’t use a clipper, scissors, or any sharp instrument on feet. Leave to a Podiatrist

10
Q

what should you not use for mouth care

A

Do not use lemon and glycerin mouth swabs

11
Q

what should you use for an unconscious patient’s oral care

A

use a sponge toothbrush (“toothette”).

12
Q

a state of decreased or absent use of an organ or

body part.

A

disuse

13
Q

the inability to move the whole body or a body part.

A

immobility

14
Q

Effects of Immobility/disuse on body systems…

A

can begin within 48 hours of immobility

15
Q

how much muscle is lost when restricted to bed

A

lose about 3% of initial muscle strength per day

16
Q

decrease in size of a tissue or organ due to inactivity

A

atrophy

17
Q

abnormal shortening of a muscle that causes resistance to stretching and eventually, if not managed, a state of permanent flexion.

A

contractures

18
Q

demineralization of bones that makes them brittle and easily fractured. It tends to occur with age, especially in women, but it is accelerated by prolonged immobility since osteoblast activity declines without weight-bearing stress on bones

A

Calcium Resorption/Disuse Osteoporosis

19
Q

a lesion caused by unrelieved pressure that damages
underlying tissue because of diminished perfusion. Occurs when the pressure against the skin exceeds capillary closing pressure

A

pressure ulcer

20
Q

the pressure exerted against the skin in a direction parallel to the body surface. This commonly occurs when the patient “slides down” while in semi-Fowler’s position or gets “pulled up in bed” by staff while skin is in contact with bed linens.

A

shear

21
Q

mechanical irritation to the skin that occurs when it is

“dragged” across a coarse or rough surface

A

friction

22
Q

general term for damage to the epidermis (can be a

scratch, an abrasion, etc.).

A

excoriation

23
Q

softening of the skin due to prolonged contact with water

A

maceration

24
Q

what increases when patient is on bedrest

A

cardiovascular workload (ie pulse)

25
Q

(straining against a closed glottis) often occurs

when weak patients try to move themselves around in bed

A

Valsalva’s Maneuver

26
Q

what can reflex bradycardia result in

A

fainting

27
Q

a drop in Systolic BP of 20 mmHg or more, or b) a drop in Diastolic BP of 10 mmHg or more

A

orthostatic intolerance

28
Q

when patients have restricted mobility blood tends to pool in the lower extremities because the usual “squeezing”/”milking”/ “pumping” effect of the leg muscles during ambulation is lost when patients are immobile

A

venous stasis

29
Q

blood clot in the lungs

A

pulmonary embolus

30
Q

A stationary clot

A

thrombus

31
Q

clot that is “traveling” through the circulatory system

A

embolus

32
Q

the collapse of alveoli due to hypoventilation

A

Atelectasis

33
Q

what respiratory function is decreased when recumbent

A

coughing

34
Q

what aids are important with positioning

A

frequent turning, decrease friction and shear, draw sheet for lifting, trapeze, footboard, trochanter roll

35
Q

at the foot of the bed–feet placed against them to assist in maintaining feet in dorsiflexion

A

footboard

36
Q

prevents external rotation of the hip (which can become a permanent disability) by keeping the hip adducted

A

trochanter roll

37
Q

head of bed raised. Preferred while patient is eating, or when stomach tube is being inserted. Also promotes lung expansion and ease of breathing.

A

Fowler’s

38
Q

types of Fowler’s positions

A

high (60-90), semi (45), low (30)

39
Q

entire frame of bed tilted with feet higher than head. Bed on a “slant”.

A

Trendelenberg

40
Q

Again, entire bed frame is on a slant, but this time with head higher than feet, promotes gastric emptying and prevention of acid reflux in to the esophagus

A

reverse trendelenberg

41
Q

Flat on back (also called dorsal recumbent)

A

supine

42
Q

Chest down; flat (completely) on chest. Face down, or turned to the side.

A

prone

43
Q

Weight on hip and shoulder

A

side lying

44
Q

when should side rails be put up

A

whenever patient is unattended

45
Q

when should you perform hand hygiene

A

you should perform hand hygiene before AND after any patient contact.

46
Q

what are standard precautions

A

good hand hygiene before and after patient contact, barrier precautions (such as gloves, water-impermeable gowns, and eye protection as needed), and proper disposal of used “sharps” (needles, scalpels, etc.) and bio-hazard waste

47
Q

what always require a physicians order

A

restraints

48
Q

how can you prevent stasis

A

patient should not cross legs or put pillow directly under knee and should do leg exercises on footboard

49
Q

are also used to help prevent venous stasis and thrombi in the lower extremities.

A

graded compression stockings

50
Q

what are the three reasons to exercise as a patient

A

maintain strength, preserve ROM, prevent venous stasis

51
Q

tensing muscle and “holding”, or applying

pressure against an unyielding object

A

isometric/resistive

52
Q

The muscle actually contracts and shortens

A

isotonic

53
Q

how many repetitions per joint are used per session in ROM

A

5 repetitions

54
Q

bending a joint in the natural position of movement

A

flexion

55
Q

moving from a flexed to a straight or neutral position

A

extension

56
Q

pivoting on axis

A

rotation

57
Q

movement of a limb away from the midline of the body

A

abduction

58
Q

movement of a limb toward the midline of the body

A

adduction

59
Q

rotation of palm anterior (facing upward)

A

supination

60
Q

rotation of palm posterior (facing downward)

A

pronation

61
Q

flexion of ankle toward floor

A

plantar flexion

62
Q

movement of ankle away from the midline or laterally

A

eversion

63
Q

movement of ankle toward the midline or medially

A

inversion

64
Q

formation of blood clots in the lower extremities:

A

venous stasis

65
Q

When the patients do the exercises by themselves

A

active exercises

66
Q

When the nurse does the exercises

A

passive exercises

67
Q

paralysis of arms legs, and trunk

A

Quadriplegia

68
Q

weakness of arms, legs, and trunk

A

Quadriparesis

69
Q

paralysis of legs and lower trunk

A

Paraplegia

70
Q

weakness of legs and lower trunk

A

Paraparesis

71
Q

paralysis of one side of the body

A

Hemiplegia

72
Q

weakness on one side of the body

A

Hemiparesis

73
Q

Patient can exert no effort for the transfer or to ambulate

A

total assist

74
Q

Patient can exert at least 25% of the effort needed

A

maximal assist

75
Q

Patient can exert at least 50% of the effort needed

A

moderate assist

76
Q

health care workers should not lift more than what

A

not attempt to lift more than 50 lb.

77
Q

means that the device is used to increase the effectiveness of a patient’s gait, even though full weight bearing is allowed

A

correction

78
Q

means that the device is used to keep an injured or surgically-repaired limb from becoming further damaged

A

protection