ATI Chapter 31: Musculoskeletal and Neurosensory Systems, ATI Chapter 30, ATI Chapter 29- Thorax, Heart, Abdomen, ATI chapter 28 Head and Neck, ati chapter 26, ATI chapter 40, ATI Chapter 14, ATI chapter 12
how to measure chest expansion
hands flat on tenth ribs back side, have pt take a deep breath and see how your thumbs move outwards should be roughly 2 in when pt takes a breath in
elimination
goal: maintain urinary and bowel elimination
Thought process...
note processing differences, such as a rapid change of topic (flight of ideas) and use of nonsense words ("hipsnippity")
Thought content...
note the presence of delusions, hallucinations, and other ideas the client presents during the interview
antiembolic stockings
nursing actions for _________ include: perform hand hygiene assess skin measure calf turn stockings inside out to the heel put stocking on foot pull stocking to cover heel and up leg smooth wrinkles remove and assess skin every 8 hours
heat/ cold
nursing actions for ___________ include: assess for: redness or pallor pain or burning numbness shivering blisters decreased sensation mottling of skin cyanosis
what is the best position to hear extra sounds and murmurs?
sitting, slightly turned towards left side
what sounds would you hear auscultating the vesicular area?
soft low pitched, inspiration three time longer than expiration
tumor
solid mass, deep, larger than 1 or 2 cm
S
squeeze the handle
indication of cyanosis
Hypoxia or impaired venous return
Expected Changes with Aging: Voice
Rise in pitch, loss of power and range
Internal Rotation
Rotating joint inward
External Rotation
Rotating joint outward
when do the mitral and tricuspid valves close?
S1 heart sound, during systole
when do the aortic and pulmonic valves close
S2 sound, during diastole
Eversion
Turning body part away for midline
Inversion
Turning body part toward midline
Pronation
Ventral surface facing down
Supination
Ventral surface facing up
safety
____________ is freedom from injury; providing for ____________ and preventing injury are major nursing responsibilities
ROM exercises
____________ should be performed hourly while awake instruct clients to perform ankle pumps, foot circles, knee flexion
restraints
_____________ can be physical devices or chemicals
changes in emotional status
_____________ r/t immobility include: depression, alteration in self concept, and anxiety
restraints
_____________- can cause complications including pneuomnia, incontinence, and pressure ulcers
Assess position...
by repositioning the client's appendages and asking him to report whether each is positioned up or down.
Assess temperature...
by using two test tubes containing water (one warm and one cold), and ask the client to identify which he feels
Stuporous
client requires painful stimuli (pinching a tendon or rubbing the sternum) to achieve a brief response. The client may not be able to respond verbally.
Obtunded
client responds to light shaking but may be confused and slow to respond
falls
clients at increased risk of ____________ include: those with decreased visual acuity, generalized weakness, urinary frequency, gait and balance problems, and cognitive dysfunction
generalized seizures
clients at risk for _______________ should have a saline lock in place for immediate IV access
seculsion
clients may voluntarily request temporary ______________ if the enviornment is disturbing or seems too stimulating
C
contain/ confine the fire by closing doors nad windows nad turning off any sources of oxygen and any electrical devices; ventilate clients on life support with a bag-valve mask extinguish the fire if possible using appropriate fire extinguisher
gums
coral pink and tight against the teeth with no bleeding on gloves from palpation
CN II CN III
corneal light reflex pupillary reaction to light
Ability for calculation...
count backwards from 100 in serials of 7
rhonci
course sounds during inspitation or expiration, from fluid, mucous, or trouble clearing airway
Expect Muscles that are...
firm symmetric in size and strength. The dominant side is usually slightly larger; <1cm difference is not significant.
scale
flakes of skin that exfoliate ex: dandruff, psoriasis, eczema
knee flexion
flex and extend the legs at the knees
Comatose: Decorticate rigidity
flexion and internal rotation of upper extremity joints and legs
Expected Response for Biceps
flexion of elbow
if you percuss a patients chest and hear dullness what could be wrong?
fluid is in the lungs could indicate pneumonia or a tumor
Inspect and Palpate: Trachea
for any deviation from the midline. Masses in neck or mediastinum and pulmonary abnormalities cause lateral displacement.
document
for restraints, _______________: client's behavior while in restraints type and frequency of care condition of body part in restraints client's response to removal of restraints medication administered
document
for restraints, ________________: precipitating events and ehavior of the client alternative actions to avoid sclusion/ restraints time of application and removal type of resteraints/ location
therapeutic techniques
foster communication and create rapport that promote optimal data collection
standardized formats
framework for obtaining information about clients physical, developmental, emotional, intellectual and spiritual dimensions
breasts with aging?
glandular tissues atrophy, adipose tissue replaces it, softer more pendulous, nipples no longer erect, may invert
respriatory
goal: maintain airway patency, achieve optimal lung expansion and gas exchange, and mobilize airway secretions
psychosocial
goal: maintain an acceptable sleep/wake pattern, achieve socialization, and complete self-care independently
cardiovascular
goal: maintain cardiovascular function, increase activity tolerance, and prevent thrombus formation
integumentary
goal: maintain intact skin
musculoskeletal
goal: maintain or regain body alingment and stability, decrease skin and musculoskeletal system changes, achieve full or optimal ROM, and prevent contractures
metabolic
goal: reduce skin injury and maintain metabolism
pleural friction rub
grating sounds from an inflamed visceral and parietal rubbing against each other during inspiration and expiration
Tonsils: 2+
halfway to the uvula
how to measure tactile fremitus ?
hands flat on the pts chest, have them say 99 each time you move ur hands to measure the equal symmetric vibrations...should be more pronounced at the top than at the bottom
Assess active ROM by...
having client repeat movements nurse demonstrates.
common skin lesion in adults
lentigines (liver spots) seborrheic keratosis acrochordons (skin tags) sebaceous hyperplasia
soft palate
light pink intact smooth/symmetric moves with vocalization ( CN IX, X)
fissure
linear crack ex: tine pedis
indication of jaundice
liver dysfunction, RBC destruction
erosion
lost epidermis, moist surface, no bleeding ex: ruptured vesicle
amplitude
loud or soft
what sounds would you expect to hear over to bronchial when auscultating?
loug high pitched , expiration is longer than inspiration over trachea
Primary lesions include
macule, papule, nodule, vesicle, pustule, tumor, wheal, atrophy
flatus looks like?
mainly midline protrusion no flanks
cane instructions
maintain two points of support on the ground at all times keep cane on stronger side of body support weight on both legs
rescue equipment
make sure ______________ is on hte bedside, including oxygen, an oral airway, suction equipment, and padding for the side rails
pulmonary embolism
manifestations of ___________ include: shortness of breath, chest pain, hemoptysis, decreased BP, rapid plse
thrombophlebitis/ DVT
manifestations: pain, edema, warmth, and erythema at the site
protect himself
many factors affect the client's ability to _____________, including age, with the young and old at greater risk; mobility; cognitive and sensory awareness; emotional state; ability to communicate; and lifestyle
what sounds would you hear auscultating the bronchovesicular area?
medium pitch, equal inspiration an expirations
submental nodes
midline under the chin
CN XII (hypoglossal)
motor -- tongue movements
cane instructions
move cane forward 6-10 inches move weaker leg forward toward the cane advance stronger leg past cane
Assess passive ROM by...
moving client's joints through his full range of movements. Do not move joint pass point of pain or resistance.
heat/ cold
nursing actions for ___________ include: discontinue application at predetermined time (15-30 mins) document: location, type, and length of application condition of skin before and after application client tolerance
pulmonary embolism
nursing actions for ___________ include: prepare to give thrombolytics or anticoagulatns position client in high-Fowler's position obtain pulse ox administer oxygen prepare to obtain blood gas anaysis monitor frequent vital signs
promoting venous return
nursing actions to _____________ include: elastic stockings position techniques to reduce compression of leg veins ROM exercises antiembolic stockings increases fluid intake notify PCP if poor venous return of thrombosis is suspected
thrombophlebitis/ DVT
nursing actions: notify PCP immediately posiiton client in bed with leg elevate avoid pressure on inflammed site anticipate giving anticoagulants
heat/ cold
nursing actiosn for __________ include: apply to the area make sure the call light is within reach assess site every 5-10 minutes
if there is hyper-resonance when percussing a pt's chest what could be wrong?
presence of air, could mean pneumothorax or emphysema
Palpate Maxillary Sinuses
press upward at the skin crevices that run from the sides of the nose to the corner of the mouth.
Palpate Frontal Sinuses
press upward with thumbs from below eyebrows on either side of the bridge of the nose
common skin lesions in adults
primary contact dermatitis tine pedis psoriasis labial herpes simplex
Assess muscle strength...
by pushing/pulling against resistance
where to hear the pulmonic valve?
left of the sternum, second ICS
CN II
visual acuity (Optic)
eye cover
visual fields
CN II
visual fields (optic)
temporary
___________ lasts a short time, such as following knee arthroplasty
Flexion
Movement that decreases angle
Tonsils: 1+
barely visble
S
sweep the extinguisher from side to side, covering area of fire
Mini Mental Exam Assesses
**to assess cognitive status objectively. Orientation to time and place Attention and calculation of counting backward by sevens Registration and recalling of objects Language, including naming of objects, following of commands, and ability to write Reading
External Ear: Inspect and Palpate
*Alignment: top of the auricles meting an imaginary horizontal line that extends from the outer cants of the eye *Ear color matching face color *No lesions or tenderness *No foreign bodies or discharge *No cerumen
Musculoskeletal: Inspect and Palpate
*Assess passive ROM by.. *Assess active ROM by... *Assess joint for ... Expect Muscles that are... *Size Variations *During ROM, Assess tone... *Assess strength of muscle groups by... *Assess for muscle tremors Inspect and palpate spine from back for any lateral deviation or scoliosis.
Size Variations include:
*Hypertrophy: enlargement of muscle due to strengthening *Atrophy: decrease muscle size due to disuse; feels soft and boggy.
Inspect and palpate spine from back for any lateral deviation or scoliosis...
*Instruct client to bend at the waist with arms reaching for toes *Inspect and palpate down the spine using thumb an forefinger. *Inspect and palpate spine again with client standing *Expected Finding: No tenderness, with spinal vertebrae that are midline.
Standardized Screening Tools
*Mini Mental State Examination *Glasgow Coma Scale
pts should preform monthly breast exams when? when should post menopausal women do it?
2-3 days after period , postmenopausal is same day each month
Rinne test
-tuning fork see when they cant hear the sound no longer air conduction greater than bone conduction 2-1 ratio
Rosenbaum chart
14 inches from the clients face (testing for impaired near vision or farsightedness)
sellen chart
20 ft from it, cover one eye, read smallest line, the first number is feet away, second number is the distance where the visually unimpaired eye can see the line clearly
Graded DTR responses
4+ very brisk with clonus 3+ more brisk than average 2+ expected 1+ diminished 0 no response
normal range of abdom sounds per min?
5-35/min
A nurse educator is teaching a module on proper body mechanics during employee orientation. Which of the following statements by a newly hired nurse indicates the need for further teaching? A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible."
A
a nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical exam. Which of the following findings should the nurse expect? Select all that apply. A. Capillary refill less than 2 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on soles of feet E. Numerous light brown macule on the face
A D E
Weight
A quantity of matter acted on by the force of gravity.
A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? (Select all that apply.) A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. C. Keep the knees slightly lower than the hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints and muscles.
A. B. D
Judgement...
Ask the client about the solution to a specific dilemma. ("What would you do if you locked your keys in your car?")
Assess strength of muscle groups by...
Asking client to push or pull against resistance. Expected findings: strength equal or slightly stronger on dominant side of body.
If thyroid is enlarged
Auscultate: A bruit indicates an increase in blood flow to the area, possibly due to hyperthyroidism
The hips and knees are straight
Avoid twisting the thoracic spine and bending the back when...
A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg
B
A nurse is performing an integumentary assessment for a group of clients. Which of the following finding should the nurse recognize as requiring immediate intervention? A. Pallor B. Cyanosis C. Jaundice D. Erythema
B
A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? (Select all that apply.) A. Range of motion B. Skin color C. Edema D. Skin lesions E. Skin temperature
B C E
A nurse is completing discharge teaching to a client who has COPD. The client verbalizes understanding of the orthopneic position when he states, "When I have difficulty breathing at night, I will A. lie on my back with my head and shoulders elevated on a pillow." B. lie flat on my stomach with my head to one side." C. sit on the side of my bed and rest my arms over pillows on top of my raised bedside table." D. lie on my side with my weight on my hips and shoulder with my arms flexed in front of me."
C
A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply) A. Thin, parchment - like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin Elasticity E. Excessive wrinkling
C B D
Plantar Flexion
Bending foot and toes downward
Scoliosis
Exaggerated lateral curvature
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional personnel to assist with the transfer. C. Use a transfer belt and assist the client to bed. D. Assess the client's ability to help with the transfer.
D
A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (select all that apply) A. Acne B. Warts C. Psoriasis D. Herpes simplex E. Varicella
D E
Assess light touch...
by asking the client to report when and where he feels a cotton ball touching his skin
Expected Changes with Aging: Nose
Decreased sense of smell
Expected Changes with Aging: Mouth
Decreased sense of taste, reduced number of taste buds, tooth loss, pale gums, gum disease due to inadequate oral hygiene.
Expected Changes with Aging: Eyes
Decreased visual acuity Decreased peripheral vision Diminished ability to see close objects or read small print (Presbyopia) Decreased ability to accommodate extreme changes in light (glare, darkness) Difficulty distinguishing colors Intolerance to glare Delayed pupillary reaction to light Yellowing of the lens Thin gray-white ring surrounding the cornea Loss of lateral third of eyebrows
Presbyopia
Diminished ability to see close objects or read small print
Neurological Questions to ask
Dizziness or headaches? Seizures? Triggers? Head injury or LOC? Changes in vision, speech, thinking, loss of memory, change in memory or behavior? Weakness, numbness, tremors, or tingling?
Lordosis
Exaggerated curvature of the lumbar spine (common during the toddler years and pregnancy)
Kyphosis
Exaggerated curvature of the thoracic spine (common among older adults)
Expected Response for triceps
Extension of the elbow
Expected Response for patellar
Extension of the lower leg
Hyperextension
Extreme Extension
Dorsiflexion
Flexing foot and toes upward.
Expected ROM of Joint Movement
Flexion Extension Hyperextension Supination Pronation Abduction Adduction Dorsiflexion Plantar Flexion Eversion Inversion External Rotation Internal Rotation
Musculoskeletal Assess...
Gait Alignment Symmetry, Muscle Mass Muscle tone ROM Any Involuntary Movements Signs of Inflammation (Redness, Swelling, Warmth, Tenderness, Loss of Function) Gross Deformities
By lowering the center of gravity and broadening the base of support.
Greater stability and balance occurs by
Presbycusis
Hearing loss, loss of acuity for high-frequency tones
Expected Changes with Aging: Ears
Hearing loss, loss of acuity for high-frequency tones (Presbycusis) Cerumen accumulation in the ear canal Thickening of the tympanic membrane.
Distribute the weight between the large muscles of the arms and legs.
How to decrease the strain on any one muscle group and avoid strain on the smaller back...
The nurse overcome the weight of the object and know the center of gravity of the object.
How to lift an object
With the use of good body mechanics & mechanical lift devices.
How to reduce the risk of injury to the clien tand the nurse
Neurological examination includes
Mental status examination to test cerebral function Assessment of cranial nerves Motor function to test cerebellar function Sensory function Reflexes
CN VIIMotor - Test facial movement by having pt smile, frown, puff out her cheeks, raise her eye brows, close her eyes tightly, and show her teeth.
Motor - Test facial movement by having pt smile, frown, puff out her cheeks, raise her eye brows, close her eyes tightly, and show her teeth.
CN V
Motor - Test the strength of the muscle contraction by asking the client to clench her teeth while you palpate the master and temporal muscles, and then the temporomandibular joint. Joint movement should be smooth. Sensory - Test light touch by having client close her eyes while you touch her face gently with a whip of cotton. Ask her to tell you when she feels the touch.
CN III (Oculomotor), IV (trochlear), VI (abducens)
Motor -- PERRLA, six cardinal positions of gaze
CN XI (spinal accessory)
Motor -- turning head, shrugging shoulders
Abduction
Movement of an extremity away from midline.
Adduction
Movement of an extremity toward midline
Extension
Movement that increases angle
Comatose: Decerebrate rigidity
Neck and elbow extension, with the wrists and fingers flexed
PERRLAP: Pupils Clear E: Equal and between 3 to 7 mm in diameter R: Round RL: Reactive to light both directly and consensually when you direct light into one pupil and then the other A: Accommodation of the pupils when they dilate to look at an object far away and then converge and constrict to focus on a near object.
P: Pupils Clear E: Equal and between 3 to 7 mm in diameter R: Round RL: Reactive to light both directly and consensually when you direct light into one pupil and then the other A: Accommodation of the pupils when they dilate to look at an object far away and then converge and constrict to focus on a near object.
Musculoskeletal Questions to Ask
Pain in joints or Muscles? Stiffness, weakness, or twitching? Fallen recently? Able to care for yourself? Any physical problems limiting activities? Do you exercise or participate in sports on a regular basis? For postmenopausal women: Maximum height? Take calcium supplements?
Client Positioning
Pillows, bath blankets, hand rolls, boots, splints, trochanter rolls, ankle support devices, and other aids are used to maintain proper body alignment for the client.
Stereognosis
Place a familiar object (key, cotton ball) in the client's hand, and ask him to identify it.
CN XI
Place hands on pt shoulders and ask her to shrug her shoulders against resistance .
Expected Response for achilles
Plantar flexion of the foot
Good body mechanics
Promotes safety for the client as well as for health care providers when positioning and moving clients
Expected Response for brachioradialis
Pronation of the forearm and flexion of the elbow
Range of Motion
ROM
Chin to Chest
ROM: Flexion
Chin up
ROM: Hyperextension
Ear to shoulder bilaterally
ROM: Lateral Flexion
Assess memory in two ways...
Recent - Ask the client to repeat a series of numbers or a list of objects. Remote - Ask the client to state his birth date or mother's maiden name (verifiable).
CN X (vagus)
Sensory -- gag reflex Motor -- swallowing, speech sounds
CN V (trigeminal)
Sensory -- light touch sensation to the face Motor -- jaw opening, clenching, chewing
CN I (olfactory)
Sensory -- smell
CN VII (facial)
Sensory -- taste (salt/sweet) Motor -- facial movements
CN IX (glossopharyngeal)
Sensory -- taste (sour/bitter) Motor -- swallowing, speech, sounds, gag reflex
CN II (optic)
Sensory -- visual acuity, visual fields
During ROM, Assess tone...
Slight resistance of the muscles during relaxation.
Broadening the base of support
Spread the feet apart
Musculoskeletal: Inspect
Symmetry: observe and compare both sides Height: measure comparison over time. Gradual height loss is a common finding as a person ages. Posture: Observe when client unaware. Expected Findings: client standing with head erect. Both shoulders and both hips at same height bilaterally. Spine: Insect from the side. *expected Curvatures (posteriorly) **Concave cervical spine **Concave thoracic spine **Concave lumbar spine **Concave sacral spine Unexpected Findings **Kyphosis **Lordosis **Scoliosis
Is the center of a mass.
The center of gravity.
high fowlers position
The client lies supine with the head of the bed elevated approximately 90°, and his knees may or may not be elevated. › This position promotes lung expansion by lowering the diaphragm and is used for clients experiencing severe dyspnea.
Ergonomics
The factors or qualities in an objects and/or use that contribute to comfort, safety, efficiency, and ease of use.
Before attempting to move the client
The nurse should perform a mobility assessment, ROM, balance, gait, & exercise.
Body Mechanics
The proper use of muscles to maintain balance, posture, and body alignment when performing physical tasks.
Sliding, rolling, and pushing
These require less energy than lifting and offer less risk for injury.
Assess joint for ...
Warmth, inflammation, edema, stiffness, crepitus, deformities, tenderness, limitations, and instability. Assess joint: *Temporomandibular Joint (TMJ) *Shoulders *Elbows *Wrist and Hands *Spine (scoliosis) *Hips *Knees *Ankles, feet
Removing obstacles
What should you prepare the environment before assisting?
Bringing a load as closer as possible to your body to the center of gravity
What will the stability and decrease back straining when lifting and object?
The closer the line of gravity is to the center to the center of the base of support.
When is an individual the most stable...
Flex the hips, knees, and back. Get the object to thigh level
When lifting an object from the floor...
Tightening the abdominal muscles
When lifting the major muscle groups to prevent back strain are to...
Nurses use body mechanics
When providing care to clients by lifting, bending, and carrying out the activities of daily living.
Widen the base of support.
When pushing or pulling a load...
Use your own weight to counterweight
When pushing or pulling to make the movement easier...
Keep the knees slightly higher than the hips.
When sitting for long periods of time
Flex the hip and knee through the use of foot rest.
When standing for too long
The center of gravity is in the pelvis
When the human body is in the upright position...
immobility
________ can be temporary, permanent, sudden onset, or slow onset
permanent
_________ can occur following paraplegia
sudden onset
__________ can occur because of a fractured arm and leg following a motor-vehicle crash
class C fire extinguisher
__________ if for electrical fires
moist cold
__________ include: cold water compresses cold soaks
dry heat
__________ include: hot packs or aquathermia pad with distilled water warming blanket
moist heat
__________ include: warm compreses warm soaks sitz baths
dry cold
__________- include: ice bag, ice collar, ice gloves, or a cold pack cooling blanket
slow onset
___________ can occur bebcause of MS
alignment
___________ focuses on mobility, ROM, gait, exercsie status, activity tolerance, and body alingment while standing, sitting, and lying
body mechanics
___________ involves coordination between the muscloskeletal and nervous systems, and the use of alognment, balance, gravity, and friction
older adults
___________- are affected by immobility by: alterations in balance resulting in a major risk for falls and injuries steady loss of bone mass resulting in weakened bones decreased coordination slower walk with smaller steps alterations in functional status increased dependence on staff and family
adults
____________ are affected by immobility by: alterations in every physiological system alterations in family and social systems alterations in job identity and self-esteem
adolescents
____________ are affected by immobility by: imbalanced growth spurt possibly altered with immobility delayed development of independence social isolation
thrombophlebitis/ DVT
____________ are inflammation of a vein that results in clot formation
movement
____________ depends on an intact skeletal system, skeletal muscles, and nervous system
class B fire extinguisher
____________ if for flammable liquids nad gas fires
fire safety
____________ involves the RACE acronym
nursing actions
_____________- for client safety include: use risk assessment tools to evaluate clients and their environment for safety encourage clients to speak up and take an active role in their health care create a culture of checks and balances communicate risk factors and plans of care use protocols for responding to dangerous situations
infants, toddlers, and preschoolers
______________ are affected by immobility by: slower progression in gross motor skills and intellectual and musculoskeletal development body aligned wit line of gravity, resulting in unbalanced posture
nursing actions
______________ for client safety include: adopt quality care priorities use current evidence to promote safety know facility's disaster plan identify and document incidents and responses know location of safety data sheets/ hazardous chemicals use equipment only after adequate instruction and safety inspection
class A fire extinguisher
______________ is used on combustibles such as paper, wood, upholestry, rags, and other types of trash fires
behavioral changes
______________ r/t immobility include: withdrawal, altered sleep/ wake pattern, hostility, inappropriate laughter, and passivity
restraints
______________ should never interfere with treatment restrict movement as little as necessary fit properly nad be as discreet as possible be easy to remove/ change
nursing actions
______________ to prevent falls include: place clients at risk for falls near the nurse's station provide hourly rounding make sure bedside items are within easy reach keep bed in the low position and lock breaks keep side rails up for clients who are sedated/ unconscious avoid use of full side rails for clients who get OOB provide nonskid footwear use gait belts and additional safet equipment keep floor clean and dry keep assistive devices nearby
nursing actions
_______________ to prevent falls include: complete fall risk assessment be sure the client knows how to use call light respond to call lights quickly ues fall-risk alerts, such as color coded wristbands provide regular toileting nad orientation of clients provide adequate lighting orient client's to the setting to make sure they know how to use all devices
seizure precautions
_________________ are measures to protect clients from injury during a seizure and are impeartive for clients who have a history of seizures that involve the entire body and may cause unconsciousness
during a seizure
_____________________: stay with the client, call for help maintain airway patency and suction PRN administer medications not duration of seizure and sequence and types of movements administer medications
during a seizure
_____________________: stay with the client, call for help maintain airway patency and suction PRN administer medications not duration of seizure and sequence and types of movements administer medications determine mental status and measure oxygenation saturation and vital signs explain what happened, and provide comfort, understanding, and quiet environment document seizure with any precipitating behavior and description of the event and report it to the provider
during a seizure
_________________________: determine mental status and measure oxygenation saturation and vital signs explain what happened, and provide comfort, understanding, and quiet environment document seizure with any precipitating behavior and description of the event and report it to the provider
pulmonary embolism
a __________ is a potentially life threatening cocclusion of blood flow to one or more of hte pulmonary arteries by a clot; the clot or embolus often originate sin the venous system of the lower extremities
seizure
a _______________ is a sudden surge of electrical activity in the brain; it can occur at any time due to epilepsy, fever, or a variety of medical problems; partial _______________ are due to elecrical surges in one part of the brain and generalized __________ involve the entire brain
tympany is
a low pitched, drum-like resonance sound
Assess vibration...
by having the client report when and where he feels the handle of the vibrating tuning fork on his skin.
supraclavicular nodes
above the clavicals
restrain
advise all caregivers and family to not ____________ the client during a seizure but to lower him to the floor or bed, protect head, remove nearby furniture, provide privacy, put him on side with head flexed slightly forward, and loosen clothing
A
aim at base of fire
crackles or rales
air passing thru fluid in the lungs, fine or course popping (crunching sounds)
A
alarm: activate the facility's alarm system and then report fire details and lcoation
anterior cervical nodes
along the sternocleidomastiod muscle
edema
an accumulation of fluid in the tissues most often from direct trauma or impaired venous return
indication of pallor
anemia, shock, lack of blood flow
tonsillar nodes
angle of the mandible
Abstract thinking...
ask the client the interpretation of a cliché such as, "A bird in the hand is worth two in the bush."
Level and fund of knowledge...
ask the client what he knows about his current hospitalization or illnes
Assess coordination...
asking the client to extend his arms and rapidly touch his finger to his nose, alternating hands, and then doing it with his eyes closed. Expected findings include smooth, coordinated movements.
adolescents
assess growth and development level of independence social activities
CN VIII
assess the ears for hearing (auditory CN)
CN VII
assess the face for sysmetrical movement (facial )
CN V
assess the face strength and sensation (trigeminal)
CN XI
assess the head and shoulders for strength (spinal accessory)
CN IX and CN X
assess the mouth for movemnt of the soft palate and gag reflex. assess swallowing and speech (glossopharyngeal and vagus)
CN VII and CN IX
assess the mouth for taste (facial or glossopharyngeal )
CN I
assess the nose for smell (Olfactory CN)
CN XII
assess the tounge for movemnet and strength (Hypoglossal )
older adults
assess: balance coordination gait functional status level of independence social isolation
psychosocial
assess: emotional status mental status behavior nad decision making skills monitor mobility status
infancy-school age
assess: gross motor skills, intellectual and musculoskeltal development body alignment/ posture developmental tasks
adults
assess: physical systems family relationships social status meaning of career/ job
psychosocial
assess: sleep/ wake cycle coping skills family support and relationships social activities
metabolic
assessment: ascultate bowel sounds check skin turgor review laboratory values of electrolytes, serum total protein, and BUN
musculoskeletal
assessment: assess ROM capability assess muscle tone and mass observe for contractures monitor gait monitor nutritional intake of calcium monitor use of assistive devices for ADLs
thrombophlebitis/ DVT
assessment: measure bilateral calf and thigh circumference daily; unilateral increase is early indication of thrombosis
cardiovascular
assessment: measure orthostatic blood pressure and pulse palpate apical and peripheral pulses ascultate heart for S3 palpate edema in sacrum, legs, and feet assess for DVT measure circumference of both calves and thighs
integumentary
assessment: observe teh skin for breakdown, warmth, and change in color look for pallor or redness, or purple observe bony prominences check skin turgor use a Braden scale assess at least every 2 hr observe for urinary or bowel incontinence
elimination
assessment: assess I&O assess teh bladder for distension observe urine for COLAC ascultate bowel sounds observe feces for COLAC
metabolic
assessment: record anthropometric measurements of height, weight, and skinfolds assess I&O assess fluid intake review urinary and bowel elimination status assess wound healing
respriatory
assessment: complete every 2h observe chest wall movement for symmetry ascultate lungs and identify diminished breath sounds, crackles, or wheezes, observe for productive cough, and note COLAC of secretions
when should pts start having mammograms ?
at age of 40
what does the s4 heart sound indicate?
atrial contraction can happen in older and athletic adults/children use bell to find
occipital nodes
base of skull
Use the Glasgow Coma Scale to obtain...
baseline assessment of the client's level of consciousness and for ongoing assessment. Looks at eye, verbal, and motor response, and assigns a number value based on the client's response. The highest value possible is 15, indicating full consciousness.
inspection
begins with first interaction and continues throughout the exam
Lowering the center of gravity
bending the hips and knees
what are bruits?
blowing or swishing sound that means that the peripheral blood flow is obstructed can be heard with the bell of the stethoscope
spider vein
bluish, spider shaped or linear,
where are the bronchial, vesicular, and bronchovesicular regions of the lungs
bronchial is around the neck, bronchovesicular is on the sternum area, and vesicular is where the lungs are located
Assess pain sensation...
by alternating sharp and dull objects on the skin and asking the client to report what he feels
if a dysrhythmia exists what should you do?
check for a pulse deficit
lungs with aging?
chest shape changes barrel chest like, decrease in capacity, cough reflex diminishes, cilia become ineffective at removing particles, alveoli diminish, kyphosis: curvature of spine reduces lung capacity/expansion.
Lethargic
client is able to open his eyes and respond but is drowsy and falls asleep readily
Alertness
client is responsive and able to open his eyes and answer questions spontaneously and appropriately.
Lips
darker pigmented skin than the face and are moist, symmetric, smooth, soft with no lesions, nontender
cold
decreases inflammation prevents swelling reduces bleeding reduces fever diminishes muscle spasms decreases pain by decreasing velocity of nerve condnuction
common skin lesions in children
diaper dermatitis intertrigo impetigo atopic dermatitis (eczema)
visiual acuity
distant vision- sellen and rosenbaum charts, eye cover, Ishihara test for color blindness near vision-hand held card
crutch instructions
do not alter crutches after fitting follow prescribed gait support weight at hadn grips with elbows flexed at 30 degrees position crutches on unaffected side when sitting or rising from a chair
crust
dried blood, serum, or pus ex: scab
gag reflex
elicit by using a tongue blade to stimulate the back of the throat (CN IX and X)
infancy-school age
encourage parents to stay with children incorporate children's involvement in their treatment place children in a room with others who are age appropriate
alopecia can result from
endocrine disorders and poor nutrition
airway patency
ensure rapid intervention to maintain ________________
secondary lesions include
erosion, crust, scale, fissure, ulcer
restraints
explain the need for _____________ to the client and family, emphasizing that restraints keep the client safe and are temporary
CN III, CN IV, CN VI
extrocular movements (Oculomotor) (Trochlear) (abducens)
mobility
factors affecting __________ include: alterations in muscles injury to the musculoskeletal system poor posture impaired CNS health status and age
lateral position
he client lies on his side with most of his weight on the dependent hip and shoulder. His arms should be exed in front of the body. A pillow is placed under his head and neck, the upper arm, and under the leg and thigh to maintain body alignment. › This is a good sleeping position, but the client must be turned regularly to prevent development of pressure ulcers on the dependent areas. A 30° lateral position is recommended for clients at risk for pressure ulcers.
falls
health care facilities must actively prevent ___________, especially because medicare and medicaid no longer reimburse for treating injuries resulting from ____________
wheezes
high pitched, whistling sound, air passing thru narrowed/obstructed airways (louder on expiration)
cardiovascular
immobility affects the _________ system by: orthostatic hypotension less fluid volume in the circulatory system stasis of blood in the legs diminished autonomic response decreased CO leading to poor cardiac effectiveness, which results in increased cardiac workload increased oxygenation requirement increased risk of thrombus development
metabolic
immobility affects the __________ system by: altered endocrine system decreased BMR changes in protein, carb, and fat metabolism decreased appetite with altered nutritional intake negative nitrogen balance
musculoskeletal
immobility affects the __________ system by: decreased muscle endurance, strength, and mass impaired balance atrophy of muscles decreased stability
musculoskeletal
immobility affects the __________ system by: foot drop altered joint mobility
genitourinary
immobility affects the __________ system by: urinary stasis change in calcium metabolism with hypercalcemia resulting in renal calculi decreased fluid intake, poor perineal care, and indwelling catheters resulting in UTIs
musculoskeletal
immobility affects the ___________ system by: altered calcium metabolism osteoporosis pathological fractures contractures
gastrointesitinal
immobility affects the ___________ system by: decreased peristalsis decreased fluid intake constipation, then fecal impaction, then diarrhea
respiratory
immobility affects the ___________ system by: decreased respiratory movement resulting in decreased oxygen adn CO2 exchange stasis of secretions and hypostatic pneumonia decreased cough response
integumentary
immobility affects the ___________ system by: increased pressure on skin, which is aggravated by metabolic changes decreased circulation to tissue causing ischemia which can lead to pressure ulcers
metabolic
immobility affects the ____________ system by: decreased protein resulting in loss of muscle loss of weight alterations in calcium, fluid, and electrolytes resorption of calcium from bones decreased urinary elimination of calcium resulting in hypercalcemia
neurologicla/ psychosocial
immobility affects the _____________ system by altered sensory perception ineffective coping
pre auricular nodes
in front of the ear
seclusion/ restraints
in general, use _________________ duration necessary and only if less restrictive measures are not sufficient
heat
increases blood flow increases tissue metabolism relaxes muscles Eases joint stiffness and pain
rebound tenderness?
indication of irritaion or inflammation somewhere in the abdom cavity, should apply pressure for 4 seconds then release and observe pts response
indication of Erythema
inflammation, localized vasodilation, substance use, sun exposure, rash, elevated temp
infancy-school age
initiate events stimulating physical and psychosocial systems increase mobility and inve play use measures to prevent falls develop strategies to enhance developmental process
client environment
inspect the ______________ for items that could cause injury during a seizure, and remove items that are not necessary for current treatment
when assessing the abdomen what is the order of steps?
inspect, auscultate, percuss, palpate
how to assess the thorax and lungs?
inspect, palpate, percuss, auscultate
order of examining
inspect, palpate, percuss, auscultate FOR ABDOMEN. inspect, auscultate, percuss, palpate
Assess mood by...
inspecting mannerisms and actions during interactions. Expected findings: client makes eye contact, and emotions correspond to the conversation and situation
what affects does a mastectomy have on the lymph system?
it can cause lymphedema due to the impaired lymph system draining on the affected side
seclusion/ restraints
it is inappropriate to use _____________ for: convience of staff punishment for the client clients who are physically/ mentally unstable clients who cannot tolerate decreased stimulation
provider's responsibility
it is the ________________ to assess, report, and document clients' allergies and to provide care that avoids exposure to allergens
where to hear the apical/mitral valve
left midclavicular line at 5th ICS
where to hear the tricuspid valve?
left of sternum, 4th ICS
heat
nursing considerations: monitor bony prominences carefully avoid use of heat applications over metal devices do not apply heat to abdomen of pregnant woman do not place a heat application under a client who is immobile do not use heat applications the first 24 horus after traumatic injury
psychosocial
nursing interventions: assist in using usual coping skills or developing new skills maintain orientation to time, person, and place develop schedule of therpaies have client swith limited mobility placed in a room with an alert roommate
musculoskeletal
nursing interventions: cluster care to promote a proper sleep-wake cycle request PT for clients who have decreased mobility assist client with ambulation; use assistive devices as needed
integumentary
nursing interventions: identify clients at risk for pressure ulcer development position using corrective devices turn every 1-2 hours teach clients to turn at least every 15 mins provide clients twho are sitting in a chair wit ha device to decrease pressure limit sitting in a chair to 1 hr; instruct clients to shift weight every 15 minutes use a therapeutic mattress for clients in bed for an extended time monitor nutritional intake provide skin and perineal care
cardiovascular
nursing interventions: increase activity ASAP by dangling feet on side of bed or transferring to a chair instruct clients to perform isometric exercises to increase activity tolerance change position as often as possible move client gradually during position changes
adolescents
nursing interventions: initiate care that facilitates independence provide stimuli to promote socalization
cardiovascular
nursing interventions: instruct clients to avoid Valsalva maneuver give a stool softner to prevent straining teach ROM adn antiembolic exercises instruct clients to avoid placing pillows under knees or lower extremities, crossing legs, or wearing tight clothes use elastic stockings
elimination
nursing interventions: maintain hydration instruct clients to consume a diet taht includes fruits and vegetables give stool softener, laxative, or enema provide perinenal care teach bladder/ bowel training insert a catheter to relieve/ manage bladder distension promote urination
musculoskeletal
nursing interventions: make sure clients change position q2h encourage active/ passive ROM 2 or 3 times daily instruct clients to perform ROM while bating, eating, grooming, and dressing a CPM device may be prescribed
older adults
nursing interventions: plan care with clients teach staff to facilitate client's independence provide stimuli encourage familites to visit plan for staff to spend time and visit with clients
metabolic
nursing interventions: provide a high-calorie, high-protein diet with vitamin B and C supplements monitor and evaluate oral intake
adults
nursing interventions: provide care promoting activity in systems discuss importante of interaction with clients discuss social involvement discuss meaning of career/ job
psychosocial
nursing interventions: provie stimuli such as books, crafts, television, newspapers, and radio help clients maintain body image by performing hygiene have nurses interact on a routine and informal social basis
respriatory
nursing interventions: revmove abdominal binders every 2 hours and repalce correctly use chest physiotherapy ascultate lungs to determine effectiveness of physiotherapy instruct clients to consume 200 mL in fluids per day monitor ability to cough up secretions use suction if unable to expotorate secretions
cardiovascular
nursing interventions: use sequential compression devices or intermittent pneumatic compression increase fluid intake administer low-dose heparin or enoxaparin contact PCP if there is an absence of pulse in BLE
respriatory
nursing interventions: reposition evert 1-2 hr instruct client to turn, cough, and breath deeply every 1-2 hr while awake instruct clients to yawn eevry hour while awake instruct clients to use an incentive spirometer
Assess appearance by...
observing hygiene, grooming, and clothing choice. Expected findings: client is clean and dressed appropriately for the environment or situation.
data collection
obtaining subjective information from the client- health history
falls
older adults can be at increased risk for _________ due to decreased strength, impaired mobility and balance, improper use of mobility aids, unsafe clothing, environmental hazards, endurance limitations, and decreased sensory perception
internal structures
ophthalmoscope
postauricular nodes
over the mastriod
bony prominences
pad _______________ to prevent skin breakdown
what are thrills?
palpable vibration from a murmur or cardiac malformation, measure using palm of hand to check for vibrations
external structures
penlight or ophthalmuscope gloves
extraocular movements (EOMs)
penlight or opthalmoscope light eye cover
Insight...
perform an objective assessment of the client's perception of illness
uvala
pink midline intact moves with vocalization
mucous membranes
pink and moist with no lesions
PASS
pneumonic for using fire extinguishers
ankle pumps
point toes toward the head and then away from the head
posterior cervical node
posterior to the sternocliedomastiod muscle
how to assess thorax
posterior with pt sitting or standing, anterior with pt sitting standing or lying.
hernias look like?
protrusion thru muscle wall,
physical examination/ diagnostic tests
provide objective data
PRN restraints
providers cannot write _______________ orders for restraints
P
pull the pin
R-
rescue nad protect clients in proximity to the fire by moving them to a safer location; clients who are ambulatory may walk independently to a safer location
vascular lesions
result from aging changes or blood vessel damage in or near the skin
manufacturer's instructions
review the _______________ for correct application
where to heart the aortic valve?
right of the sternum, second ICS
foot circles
rotate feet in circles at the ankles
fingertips
sensitive to pulsation, position, texture, turgor, size and consistency
CN VIII (auditory)
sensory -- hearing and balance
vesicle
serous fluid filled blister, herpes simplex, varicella
what indicates arterial insufficiency?
shiny and translucent skin without hair on the toes and foot
Internal Ear: Inspect and Palpate
straighten ear canal by pulling auricle up and back for adults and older children. Down and back for younger children Inspect: use otoscope insert speculum slightly down and forward 1 o 1.5 (0.4 to 0.6 in) falling, but not touching ear canal to visualize: * Tympanic membrane that are pearly gray and intact, free from tears *light reflex that is visual and in well-defined cone shape *Umbo and Manubrium landmarks that are readily visible *Ear canals that are pink with fine hairs.
cardio system with aging?
systolic hypertension due to atherosclerosis, CVD, CO decreases, peripheral circulation decreases, heart valves stiffen
what should you palpate last?
tender areas
ishihara test
testing for color blindness
provider
the ____________- must prescribe seclusion or restraints in writing, after a face to face assessment of the client
Wisper test
the client can hear use wisper softly from 30-60 ft away
weber test
the clients hears equally in both ears (negative weber test) -virbating tunking fork
what does fluid in the abdomen look like?
the flanks protrude, protrusion moves with dependency
Comatose
there is no response to repeated painful stimuli.
atrophy
thinning of skin with loss of normal skin furrow. - skin is shiny and translucent
the right lung has how many lobes
three
position techniques
to reduce compression of leg veins ask clients to avoid: crossing legs sitting for long periods wearing restrictive clothing on the lower extremities putting pillows behind the knees massaging legs
Tonsils: 4+
touching eachother
Tonsils: 3+
touching the uvula
Graphesthesia
trace a number on the client's palm with the blunt end of a pencil and ask him to identify it.
left lung has how many lobes
two
expected sound when percussing over abdomen?
tympany over most, low pitch tympany over upper left quad due to liver
quick release knot
use a ____________ to tie the restraints to the bed frame where thy will not tighten with raising or lowering the bed
backchanneling
use active listening phrases such as "go on" and "tell me more" to convey interest and get the whole story
tongue
use gauze pad to hold tip and move back and forth -dorsal surface is pink with presence of papillae and symmetric -assess test with CN VII, CN IX -test strength with CN XII
palpation
use of touch to determine the size, consistency, texture, temp, location, and tenderness of an area
Two point discrimination
use open paper clips to determine the smallest distance between the two points at which the client can still feel the two points on his skin and not just one. Compare bilaterally.
dorsal surface
used for temperature
palmar surface of fingers
used for vibration
Assess balance...
using Romberg and Heel to toe walk
what is the S3 heart sound indicate?
ventricular gallop, use bell to find it
abdomen with age?
weaker muscles, rounder more protruding, can have inflammation and rebound tenderness, saliva and gI secretions/pancreatic enzymes decrease, slower GI motility and peristalsis.
resonance should be heard why and when?
when percussing due to full and reverberating sound that air is in thorax.
how to inspect jugular veins
when pt is lying 30-45 degrees, assess on the right side for signs of heart failure if distended, JVD is if more than 1 in
Assess gait...
when the client is unaware of the assessment. Expected finding: Gait is steady, smooth, and coordinated.
hard palate
whitish, intact,symmetric, concave
general survey
written summary of appraisal of overall health
reverse trendelenburg position
› Client remains at with legs elevated above the level of the heart. › This position is used to prevent and treat hypovolemia and facilitates venous return.
sims position
› The client is on his side halfway between lateral and prone positions. (Weight is on the anterior ileum, humerus, and clavicle.) The lower arm is behind the client while the upper arm is in front. Both legs are exed, but the upper leg is exed at a greater angle than the lower leg at the hip as well as at the knee. › This is a comfortable sleeping position for many clients, and it promotes oral drainage.
prone position
› The client lies at on his abdomen with his head to one side. › This position promotes drainage from the mouth for clients following throat or oral surgery, but inhibits chest expansion.
supine position
› The client lies on his back with his head and shoulders elevated on a pillow. The client's forearms may be placed on pillows or placed at the side. A foot support prevents footdrop and maintains proper alignment.
Semi-fowlers position
› The client lies supine with the head of the bed elevated approximately 30°, and his knees may be slightly elevated (about 15°). › This position is frequently used to prevent regurgitation of enteral feedings and aspiration in clients who have dif culty swallowing.
fowlers position
› The client lies supine with the head of the bed slightly elevated approximately 45°, and his knees may be slightly elevated (about 15°). › This position is frequently used during procedures such as nasogastric tube insertion and suctioning. It allows for better chest expansion and ventilation, as well as better dependent drainage, after abdominal surgeries.
orthopneic position
› The client sits in the bed or at the bedside. A pillow is placed on the over-bed table, which is placed across the client's lap. The client rests his arms on the over-bed table. › This position allows for chest expansion and is especially bene cial to clients who have COPD.
modified trendelenburg position
› The entire bed is tilted with the foot of the bed lower than the head of the bed. › This position promotes gastric emptying and prevents esophageal re ux.
trendelenburg position
› The entire bed is tilted with the head of the bed lower than the foot of the bed. › This position is used during postural drainage, and it facilitates venous return.
Musculoskeletal changes with aging
›Reduced muscle mass ›Declines in speed, strength, resistance to fatigue, reaction time, coordination ›Osteoporosis (fragility of bones, loss of bone mass and height) ›Greater risk of fractures and vertebral compression ›Degenerative alterations in joints ›Limited range of motion ›Flexed elbows, hips, and knees ›Thinning intervertebral discs, kyphosis (with height loss), wider stance altering posture
Neurological changes with aging
›Some short-term memory decline ›Diminished/slowed reflex and motor responses, impulse transmission, and reaction times ›Altered vibration, position, hearing, vision, smell, and deep pain and temperature sensation ›Slower fine finger movement (no change in superficial pain and light touch sensation, standing balance) ›Decline in mental function probably related to less cognitive stimulation and solitude ›Fewer brain cells, smaller brain volume, deteriorating nerve cells, fewer neurotransmitters ›With infection, delirium more common than fever ›Greater risk of depression
Guidelines to Prevent Injury
◯ Know your agency's policies regarding lifting and safe patient handling. ◯ It is preferred that two or more personnel assist with any positioning. ◯ Plan ahead for activities that require lifting, transfer, or ambulation of a client, and ask others to be ready to assist at the planned time. ◯ Prepare environment to remove obstacles prior to procedure. ◯ Explain process to client and assistants to clarify roles. ◯ Be aware that the safest way to lift a client may be with the use of assistive equipment. ◯ Rest between heavy activities to decrease muscle fatigue. ◯ Maintain good posture and exercise regularly to increase the strength of arm, leg, back, and abdominal muscles, so these activities will require less energy. ◯ Use smooth movements when lifting and moving clients to prevent injury through sudden or jerky muscle movements. ◯ When standing for long periods of time, ex the hip and knee through use of a foot rest. When sitting for long periods of time, keep the knees slightly higher than the hips. ◯ Avoid repetitive movements of the hands, wrists, and shoulders. Take a break every 15 to 20 min to ex and stretch joints and muscles. ◯ Maintain good posture (head and neck in straight line with pelvis) to avoid neck exion and hunched shoulders, which can cause impingement of nerves in the neck. ◯ Avoid twisting the spine or bending at the waist ( exion) to minimize the risk for injury.
lifting
◯ Use the major muscle groups to prevent back strain, and tighten the abdominal muscles to increase support to the back muscles. ◯ Distribute the weight between the large muscles of the arms and legs to decrease the strain on any one muscle group and avoid strain on smaller muscles. ◯ When lifting an object from the oor, ex the hips, knees, and back. Get the object to thigh level, keeping the knees bent and the back straightened. Stand up while holding the object as close as possible to the body, bringing the load to the center of gravity to increase stability and decrease back strain.
When pushing or pulling a load:
◯ Widen the base of support. ◯ When opportunity allows, pull objects toward the center of gravity rather than pushing away. ◯ If pushing, move the front foot forward, and if pulling, move the rear leg back to promote stability. ◯ Face the direction of movement when moving a client. ◯ Use own body as a counterweight when pushing or pulling to make the movement easier. ◯ Sliding, rolling, and pushing require less energy than lifting and offer less risk for injury. ◯ Avoid twisting the thoracic spine and bending the back while the hips and knees are straight.
transfers and Use of Assistive Devices
◯Assess the client's ability to help with transfers (balance, muscle strength, endurance). ◯ Determine the need for additional personnel or assistive devices (transfer belt, hydraulic lift, sliding board). ◯ Assess and monitor the client's proper use of mobility aids (canes, walkers, crutches). ◯ Include assistance or mobility aids needed for safe transfers and ambulation in the plan of care.
