what are the ADLs
Bathing, grooming, dressing, eating, toileting, and “being mobile” (walking)
is it better for the nurse or patient to do the majority of self care
patient to prevent feelings of hopelessness or dependency
why are bed baths given less frequently than in the past
due to increased understanding of the hazards of immobility
does bedrest do more harm or good
harm
what type of washing should be used most often
showers or tub baths should be used whenever possible
what are some positives of baths
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
how should you wash
cleanest to dirtiest (usually head-to-toe; with perineal care always last
what is an important part of perineal care
Gloves should always be worn for perineal care for men and women alike
what is important to remember about patients with diabetes
don’t cut corns or calluses and don’t use a clipper, scissors, or any sharp instrument on feet. Leave to a Podiatrist
what should you not use for mouth care
Do not use lemon and glycerin mouth swabs
what should you use for an unconscious patient’s oral care
use a sponge toothbrush (“toothette”).
a state of decreased or absent use of an organ or
body part.
disuse
the inability to move the whole body or a body part.
immobility
Effects of Immobility/disuse on body systems…
can begin within 48 hours of immobility
how much muscle is lost when restricted to bed
lose about 3% of initial muscle strength per day
decrease in size of a tissue or organ due to inactivity
atrophy
abnormal shortening of a muscle that causes resistance to stretching and eventually, if not managed, a state of permanent flexion.
contractures
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
Calcium Resorption/Disuse Osteoporosis
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
pressure ulcer
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.
shear
mechanical irritation to the skin that occurs when it is
“dragged” across a coarse or rough surface
friction
general term for damage to the epidermis (can be a
scratch, an abrasion, etc.).
excoriation
softening of the skin due to prolonged contact with water
maceration
what increases when patient is on bedrest
cardiovascular workload (ie pulse)
(straining against a closed glottis) often occurs
when weak patients try to move themselves around in bed
Valsalva’s Maneuver
what can reflex bradycardia result in
fainting
a drop in Systolic BP of 20 mmHg or more, or b) a drop in Diastolic BP of 10 mmHg or more
orthostatic intolerance
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
venous stasis
blood clot in the lungs
pulmonary embolus
A stationary clot
thrombus
clot that is “traveling” through the circulatory system
embolus
the collapse of alveoli due to hypoventilation
Atelectasis
what respiratory function is decreased when recumbent
coughing
what aids are important with positioning
frequent turning, decrease friction and shear, draw sheet for lifting, trapeze, footboard, trochanter roll
at the foot of the bed–feet placed against them to assist in maintaining feet in dorsiflexion
footboard
prevents external rotation of the hip (which can become a permanent disability) by keeping the hip adducted
trochanter roll
head of bed raised. Preferred while patient is eating, or when stomach tube is being inserted. Also promotes lung expansion and ease of breathing.
Fowler’s
types of Fowler’s positions
high (60-90), semi (45), low (30)
entire frame of bed tilted with feet higher than head. Bed on a “slant”.
Trendelenberg
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
reverse trendelenberg
Flat on back (also called dorsal recumbent)
supine
Chest down; flat (completely) on chest. Face down, or turned to the side.
prone
Weight on hip and shoulder
side lying
when should side rails be put up
whenever patient is unattended
when should you perform hand hygiene
you should perform hand hygiene before AND after any patient contact.
what are standard precautions
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
what always require a physicians order
restraints
how can you prevent stasis
patient should not cross legs or put pillow directly under knee and should do leg exercises on footboard
are also used to help prevent venous stasis and thrombi in the lower extremities.
graded compression stockings
what are the three reasons to exercise as a patient
maintain strength, preserve ROM, prevent venous stasis
tensing muscle and “holding”, or applying
pressure against an unyielding object
isometric/resistive
The muscle actually contracts and shortens
isotonic
how many repetitions per joint are used per session in ROM
5 repetitions
bending a joint in the natural position of movement
flexion
moving from a flexed to a straight or neutral position
extension
pivoting on axis
rotation
movement of a limb away from the midline of the body
abduction
movement of a limb toward the midline of the body
adduction
rotation of palm anterior (facing upward)
supination
rotation of palm posterior (facing downward)
pronation
flexion of ankle toward floor
plantar flexion
movement of ankle away from the midline or laterally
eversion
movement of ankle toward the midline or medially
inversion
formation of blood clots in the lower extremities:
venous stasis
When the patients do the exercises by themselves
active exercises
When the nurse does the exercises
passive exercises
paralysis of arms legs, and trunk
Quadriplegia
weakness of arms, legs, and trunk
Quadriparesis
paralysis of legs and lower trunk
Paraplegia
weakness of legs and lower trunk
Paraparesis
paralysis of one side of the body
Hemiplegia
weakness on one side of the body
Hemiparesis
Patient can exert no effort for the transfer or to ambulate
total assist
Patient can exert at least 25% of the effort needed
maximal assist
Patient can exert at least 50% of the effort needed
moderate assist
health care workers should not lift more than what
not attempt to lift more than 50 lb.
means that the device is used to increase the effectiveness of a patient’s gait, even though full weight bearing is allowed
correction
means that the device is used to keep an injured or surgically-repaired limb from becoming further damaged
protection