NUR101 EXAM 3: Assessment Objectives (Units 4 & 5, SL 5)

Assess the pressure points created by various positions

yep

Perform ROM exercises

yepppp

Demonstrate appropriate use of assistive devices for ambulating clients

yes

Demonstrate correct body mechanics when assisting clients to move

yes

Discuss criteria for selecting restraints

yes

Examine factors influencing a person's body alignment and mobility (Slide 14 Activity & Exercise, Treas p. 1183, 1192)

~BODY ALIGNMENT~ 1. Excessive weight & obesity - if patient's weight is not evenly distributed 2. Accidents, injuries, falls 3. Careless sitting, standing, or sleeping habits - avoid standing in one position for long periods of time - do not lock your knees when standing upright - do not bend forward at waist or neck when in low position - do not slump when you sit - use a chair that supports your back - sit with feet flat on the floor & with knees below hips 4. Foot problems or improper shoes - avoid wearing high heels & platforms for long periods of time 5. Occupational stress 6. Poor sleep support (mattress) - sleep with firm, but not extremely hard mattress 7. Poorly designed workspace - work at comfortable height while at desk - sit close to your work 8. Visual difficulties 9. Weak muscles or muscle imbalance - keep stomach muscles tight to support back 10. Skeletal misalignment or malformation ~MOBILITY~ 1. Developmental Stage - older adults are least active, but most likely to participate in fitness activities - younger adults are most active, and most likely to participate in sports & outdoor activities 2. Nutrition - obesity often leads to chronic health problems, which reduces activity (joint & back problems most prevalent) - movement becomes more difficult as body size increases - chronic disease may cause a negative nitrogen balance that is, inadequate protein stores to maintain or repair body tissue. Muscle wasting and fatigue occur, leading to reduced activity levels 3. Lifestyle - personal values determine when or whether exercise becomes apart of routine (e.g. swimming may not be acceptable due to the need to wear a bathing suite) 4. Environment - Weather: activity is avoided when it is cold, damp, hot, or humid - Pollution: suggest indoor activity when air is polluted - Neighborhood: crime & lack of parks - Finances: some fitness centers & sports may not be feasible - Support System: family & friends may influence positively ~Both~ 1. Congenital anomalies of the musculoskeletal system 2. Diseases related to bone formation or metabolism 3. Diseases affecting joint mobility 4. Problems affecting bone integrity 5. Trauma 6. Disorders of the central nervous system

Recognize effects of exercise and immobility on major systems (Treas p. 1196)

~Exercise~ 1. Lowers the risk of early death, heart disease, stroke, type 2 diabetes, hypertension, hyperlipidemia, metabolic syndrome, colon & breast cancers, & depression 2. Brisk walking promotes weight loss, lowers risk of disability & bone density loss, & promotes better heart & lung function 3. Moderate intensity walking improves strength, balance, muscle tone, & stamina, which all prevents falls & improves overall feelings of well being, clarity, & memory. 4. Physical activity along nutritious diet, social engagement, & mentally stimulating activities are associated with a reduced risk of cognitive decline & Alzheimer's disease ~Immobility~ 1. Prolonged immobilization causes psychological changes - Moodiness, depression, anxiety, hostility, disturbed sleep, apathy, poor body concept - Decreased concentration, recall, & problem-solving - Change in ability to perform self-care 2. Prolonged immobilization causes physiological changes in almost every body system A. Muscles & Bones >1st system effected >10% atrophy per week >wasting of gastrocnemius, soleus, & leg muscles that control flexion & extension of the hip, knee, & ankle >joints become stiff >the strongest muscles, the flexors, pull the joints, which lead to contractures, or joint ankylosis B. Heart & Vessels >leads to increased cardiac & venous stasis >HR and SV increase to maintain blood pressure >Cardiac Reserve decreases, which means the heart is less able to respond to the body's demands >W/o muscle activity, gravity causes blood to pool, which leads to edema (fluid in tissue more prone to pressure injury) >Leads to compression & injury of the small vessels in the legs and decreased clearance of coagulation factors, causing blood to clot faster (risk of DVT) >Inactivates the baroreceptors involved with vasoconstriction & dilation (less able to regulate BP, thus orthostatic hypotension, risk of dizziness & light headedness) C. Lungs >Decreased strength in all muscles, decreased chest wall expansion, which effects ventilation >Shallow respirations, secretions pool in lungs, which block air passages and alveoli >Decreased air-gas exchange, and often lead to atelectasis (collapse of air sacs) or pneumonia D. Integumentary System >Compresses capillaries >Decreases circulation, which causes pressure injury E. Metabolism >Increased serum lactic acid thus decreased ATP energy >Metabolic rate drops; protein & glycogen synthesis decreases, fat storage increases >Causes glucose intolerance and decreased muscle mass >Triggers release of thyroid hormones, epinephrine, nonrepinephrine, ACTH from pituitary, & aldosterone from kidneys - same as stress response >Affects parathyroid function, calcium, metabolism, & bone formation resulting in osteoporosis, calcium depletion in joints, & renal calculi (kidney stones) due to increased excretion of calcium >Increased risk for fractures with minimal trauma F. Gastrointestinal System >Slows peristalsis leading to constipation & gas >Paralytic ilesus can occur (cessation of peristalsis) >Appetite diminishes and food digested more slowly, often leading to decreased calorie intake >Muscle is broken down as fuel source G. Genitourinary System >Being supine inhibits drainage of urine from kidney to bladder, causing urine to become stagnant, which causes infection >Increased calcium levels & stone formation >Decreased muscle tone leads to decreased bladder tone, which leads to urinary retention >Pt have difficult voiding in a bedpan or urinal

Discuss delegation of hygiene activities to NAP (Treas p. 711, Slide 15)

-If pt is able to bathe independently, NAPs can deliver necessary supplies for self-bathing -If pt is unable to bath independently, determine how stable pt is: --->Yes, pt is stable enough = delegate bath w/ supervision & observe skin condition, presence of lesions, special attention to bony prominences and under abdominal folds & breasts --->No, pt is not stable enough = do not delegate Assess prior to delegating. Instruct nursing assistive personnel (NAP) regarding -Client's limitations -Amount of assistance needed -Use of assistive devices -Presence and care of tubes -Observations to make during hygiene care

Describe essential aspects of assessing a client's posture, gait, joint appearance and movement, capabilities and limitations for movement, muscle mass and strength, activity tolerance, and problems related to immobility (Treas p. 1197-1198)

1. Assess gaits in patients with injury, neurological issues, or if have abnormal gait: >Antalgic Gait -- limp to avoid pain when bearing weight on one side >Propulsive Gait -- stooped, rigid posture, with the head & neck bent forward, small, shuffling steps, with involuntary acceleration. Aka festinating gait, common in Parkinsons >Scissors Gait -- legs flexed slightly at the hips and knees with the thighs crossing in a scissors-like movement; common with cerebral palsy, stroke, or spinal tumor >Spastic Gait -- a stiff, foot-dragging walk caused by one-sided, long-term muscle contraction; seen with cerebral palsy, head trauma, or brain tumor > Steppage Gait -- an exaggerated motion of lifting the leg to avoid scraping the toes of a foot with footdrop (foot appears floppy with the toes pointing down); seen with Guillain-Barré syndrome >Waddling Gait -- distinctive rolling motion in which the opposite hip drops; seen in patients with muscular dystrophy or developmental dysplasia of the hip; characteristic gait in late pregnancy not complete

Describe the basic elements of body mechanics (Treas p. 1182-1183)

1. Body Alignment (proper posture) <>Maintaining posture by: -not locking your knees when standing upright -keeping your stomach muscles tight to support your back. -not bending forward at the waist or neck when you are working in a low position -working at comfortable height when you are seated at your desk -not wearing high-heeled/platform shoes for long periods of time -not slumping when you sit -sitting close to your work -using a chair that supports your back in a slightly arched position -sitting with your feet flat on the floor and your knees below your hips -sleeping on a mattress that is firm but not extremely hard 2. Balance -when moving objects, place your center of gravity closest to your base of support (squat), and stand with your head erect, buttocks pulled in, abdominal muscles tight, chest high, shoulders pulled back, and feet wide apart to avoid injury -the broader the base of support, the lower the center of gravity, and the easier it is to maintain balance -avoid standing in one position for a lengthy period. If you cannot change positions, elevate one foot on a stool or box and alternate foot placement frequently. 3. Coordination -the Cerebral Cortex initiates involuntary movement -the Cerebellum coordinates movement & controls proprioception -the Basal Ganglia assists with coordinating movement 4. Joint Mobility -Range of motion is the maximum movement possible at a joint. -Active range of motion (AROM) is movement of the joint performed by the individual without assistance. -Passive ROM (PROM) involves moving joints through their ROM when the patient is unable to do so for himself.

Describe how personal hygiene relates to personal health and well being (Treas p. 714)

1. Health <>Bathing -decreases infection & disease/Promotes health -increases circulation -removes perspiration, bacteria, & debris -stimulates deeper respirations -stimulates sensory input -relaxes muscles <>Oral Hygiene -removes food particles, preventing cavities -reduces the incidence of healthcare-acquired pneumonia <>Hair Care -maintains body temperature -serves as a receptor for tactile sensation 2. Well-being <>Bathing -promotes social interaction -promotes pleasure -promotes relaxation -promotes comfort -promotes feelings of well-being -promotes a positive self image <>Oral Hygiene -promotes a better appetite <>Hair Care -influences self image

Discuss safety hazards in the community (Treas p. 672)

1. Motor Vehicle Accidents >Leading cause of accidental death in US >Older drivers have more risk for being injured or killed in car crash 2. Pathogens --<>Food Born Pathogens = Food Poisoning ----Caused by: Improper food storage, Raw Foods, Poisonous Chemicals --<>Vector Born Pathogens ----Mosquitos & other insects, Animals --<>Water Born Pathogens ----Caused by: Poor sanitation, Water supplies, & drinking supplies 3. Pollution --<>Any harmful chemical or waste material --<>Air Pollution -----Motor vehicle, powerplant, & factory emissions, asbestos, toluene, mercury, lead ----Water Contamination ---->Lakes, rivers, & streams effects recreation & food production ---->Caused by inappropriate quantities of agricultural, industrial, and human wastes 4. Weather Hazards --<>Heat most common, lighting, tornados, etc

Discuss safety hazards in the home (Treas p. 670)

1. Poisoning <> young children are frequent victims --- inappropriate storage of household chemicals, medicines, vitamins, & cosmetics --- lead-based paint can still be found in older homes & foreign toys --- lead can also be found in soil <> older children & adolescents --- may attempt suicide by overdosing on medicines --- can accidentally overdose by experimenting with street and prescription drugs <> there has been a rise in adult poisonings over the past 20 years --- due to illegal drug use --- misuse or abuse of prescriptions (narcotics, tranquilizers, antidepressants) --- prescription painkillers have seen a tremendous increase in deaths 2. Carbon Monoxide Exposure <> a colorless, tasteless, odorless toxic gas <> exposure can cause headaches, weakness, nausea, & vomiting <> prolonged exposure leads to seizures, dysrhytmias, unconsciousness, brain damage, & death <> causes 500 deaths per year, most occurring at home, involving females, children under the age of 17, and adults up to 44. <> accounts for the majority of deaths at the scene of a fire <> common among suicides <> many deaths occur during cold weather among older adults and the poor who are seeking heat unconventional ways (e.g. gas ranges, ovens) 3. Scalds & Burns <> Scald Inuries --- hot water, steam, grease are the most common scalds among children under 3 --- scalding burns, especially on both feet or both hands, and cigarette burns in children should always prompt to asses for abuse <> Warming Food or Formula in the Microwave <> Sunburn --- can cause 1st or 2nd degree burn <> Contact Burns --- may occur from contact with metal surfaces and hot vinyl seats from the sun <> Chemical Agents ---Acid, alkali, or other organic compounds 4. Fires <> Home Fires --- major cause of death and injuries --- older adults & children under 5 at greatest risk --- cooking fires are the number 1 cause, but smoking, heating equipment, home oxygen equipment, unsupervised kids playing with matches, improper use of candles, & faulty wiring --- the most fatal fires occur while residents are asleep, with most deaths occurring from smoke inhalation 5. Firearm Injuries <> 3rd leading cause of of injury related deaths, and the leading cause for adults <> gun ownership is controversial, keep in mind when addressing patients <> gun safety especially important when children & substance abusers live in the household 6. Suffocation/Asphyxiation <> drowning, choking, or inhaling gas or smoke <> Infants --- suffocation by smothering is the leading cause of death for infants --- excess bedding, pillows, or toys hung from ribbons inside --- entanglement in cords from windows & blinds --- ribbon string used to hang pacifiers around neck <> Kids upto 18 --- risks for drowning especially ages upto 4 7. Take-Home Toxins - hazardous substances transported from work to the home - pathogenic microorganisms, asbestos, lead, mercury, arsenic, pesticides, caustic farm products, and dozens of other agents - contamination occurs via any of three sources: ---Direct skin-to-skin contact or direct contact with contaminated clothing ---Arthropod vectors, such as ticks ---On dust particles that are inhaled (e.g., anthrax spores, arsenic in mine and smelter dust) 8. Falls - third leading cause of injury-related deaths—the leading cause for older adults - most falls occur at home, and 80% involve 65 and older, 75 and older at the most risk

Plan, implement, evaluate nursing care related to the nursing diagnoses "Risk for Injury" and "Risk for Falls" (Ackley p. 558 & )

1. Risk for Injury --<>Plan >Remain free of injuries in home environment for 30 days >Explain methods to prevent injuries in home environment >Demonstrate behaviors that decrease the risk of injury in home environment --<>Implement >Client education session that teaches and demonstrates methods to prevent injury in home environment >Encourage client to wear glasses and hearing aids >Encourage client to use assistive devices --<>Evaluate >Evaluate client for injuries >Evaluate that client understands the methods and demonstrations taught 2. Risk for Falls --<>Plan --<>Implement --<>Evaluate

Evaluate why restraints are used and safety ramifications (Treas p. 676)

1. Why restraints are used ... --for the purpose of restricting a patient's freedom of movement or access to his body, with or without his permission 2. Safety Ramifications -Promote a commitment to use restraints as the very last resort -Educate caregivers before taking part in any restraint-related activity. -Document restraint episodes specifically, in detail. -Maintain one-to-one viewing of patients in restraint and seclusion. -Include staff when considering a safe alternative to traditional restraint devices. -Budget for enough qualified staff to attend to patients. -Understand that siderails, considered a restraint, can lead to serious falls & injuries, and they should not be used to secure a knot for a restraint device

Demonstrate correct body mechanics when assisting clients to move

>List the assistive devices needed for each patient type: 1. Complete Dependence (immobile): --mechanical lift with full sling 2. Extensive Dependence (holds on to device, min strength): --mechanical lift with full sling or stand/sit lift 3. Moderate Dependence (lifting from floor pt cannot assist) --mechanical lift with full sling or manual transfer with help 4. Limited Mobility (limited pt assist) --transfer belt or gait belt 5. Limited Dependence --stand/assist lift or friction-reducing device --stand/assist lift or friction reducing device >Raise the height of the bed and overbed table to waist level >Get help to move a heavy object or patient. >Use assistive devices at all times to limit injury. >Maintain competency in using all assistive and transfer devices. >Use Your Body Correctly ---Use a wide base of support ---Minimize bending and twisting to avoid stress on the back. ---Instead, face the object or person and bend at the hips or squat. ---Squat to lift heavy objects from the floor ---Use the muscles in your legs as the power for lifting ---Bend your knees, keep your back straight, and lift smoothly ---Keep objects close to your body when you move them ---Use both hands and arms when you move carry heavy objects. ---Do not stand on tiptoes to reach an object ---Push, slide, or pull heavy objects whenever possible ---Maintain a good grip on patient before attempting to move them. ---Keep your elbows bent when you carry an object. ---Avoid sudden or jerky motions.

Identify and discuss safety hazards in healthcare facilities (Treas p. 673, 677)

Hazards to patients: 1. Medical Errors = 400,000 deaths per year 2. The Joint Commission Patient Safety Goals (to avoid death) --Identify patients correctly --Improve staff communication --Use medications safely --Use alarms safely --Prevent infection --Identify patient safety risks (especially suicide risks) 3. Organizational Factors That Contribute to Errors ---Poor design, maintenance failures, unworkable procedures, shortfalls for training, less than adequate tools & equipment, inadequate staffing, disruptive behavior & intimidation in the workplace, culture of disrespect 4. Never Events: healthcare-acquired complications (e.g. sponge left in site of surgery) Hazards to nurses: 1. Back Injury --52% report chronic back pain, likely from not using proper body mechanics 2. Needlestick Injury --ER high risk area, surgeons experience the most sharps injuries --OSHA standards require employers to maintain a log of sharps injuries and to purchase needleless systems and safer medical and needle devices = 36% decline in sharps injuries --The risk of needlestick injury increases for nurses who: Work in stressful environments Work varying or long shifts (12 consecutive hours or longer) Have low skill level, based on education or experience 3. Radiation Injury 4. Violence

Describe ways to prevent falls in the home and healthcare facility (Treas p. 684 & 691)

Home 1. Exercise at least 30 minutes per day to improve balance, coordination, flexibility, & strength 2. Learn to use assistive devices correctly 3. Keep walking aids by the bed at night 4. Do not rush (more likely to fall when tired, sick, upset, or rushing) 5. Get out of the bed or chair slowly & check your balance before walking 6. Carry small loads, being sure can see over them 7. Use bags with handles 8. Have eyes checked at least once per year 9. Clean glasses regularly 10. Adaquatley light rooms 11. Ensure shoes fit properly 12. Avoid loose, trailing clothes 13. Use nonskids on assistive devices 14. Use stepstools 15. Tape cords to baseboard 16. Clear furniture & clutter to provide wide walking areas 17. Remove all rugs or at least make sure they have nonskid pad 18. Wipe all foods and fluid from floor immediatley 19. Add ice-melt to stoops and sidewalks 20. Use caution on and keep stairs well lit 21. Keep stairs free of clutter 22. Install sturdy handrails Healthcare Facilities 1. It is recommended to remove or lower side rails to prevent falls from patients attempting to climb over them 2. Keep the bed in the lowest position (except for when giving care) 3. Lock bed wheels & wheelchair wheels 4. Provide nonskid slippers 5. Keep water, urinal, bedpan, tissues, remote, & call bell within reach of pt (have pt demonstrate proper use of call bell) 6. Provide a night light to pt 7. Keep floors dry & clutter free 8. For pt with risk of falls, place warning sticker on chart or door 9. Review & suggest needed modification of medicines 10. Provide gait training & appropriate use of assistive devices 11. Orient the pt to their surroundings (e.g. bathroom, chairs, label items) 12. Offer to assist with toileting and transfer activities 13. Educate the pt and family regarding fall prevention strategies 14. Consider instituting hourly rounds on your unit. This has proved effective in reducing the number of falls 15. Place disoriented patients in rooms near the nurses' station 16. Provide regular nursing surveillance of hospitalized older adults 17. Ask patients at risk for falling to wear red or brightly colored socks to alert caregivers. 18. Communicate falls risk status during handover and transfer reports.

Discuss the importance, for both the clients and nurses, of maintaining proper body alignment and use proper body mechanics (Slide 6, Activity & Exercise; Treas p. 1183)

Overall importance: to move your body without causing injury 1. Proper Body Alignment (proper posture) -places the spine in a neutral resting position -maintains the 4 natural curves in the spine -allows movement to occur w/ less stress & fatigue -allows the muscles, joints, bones to work at peak efficiency -contributes to normal functioning of the nervous system -contributes to positive feelings of well being -prevents back injury 2. Proper Body Mechanics -using proper balance when moving objects, line of gravity must pass through your center of gravity, and your center of gravity must be close to your base of support, avoids injury -proper joint movement allows us to sit, stand, bend, walk, and perform other activities -proper coordination makes movement smooth

Evaluate the importance of bathing

See question 15

Maintain the physical comfort and safety of a client when making a bed

bed

Discuss facts about hygiene techniques used to maintain the health of the skin, hair, nails, feet, mouth, eyes, and ears

bog

Assess muscle strength, body alignment, stance, gait, and range of joint motion

dang

Apply restraints correctly

dog

Demonstrate medical aseptic techniques, practices, and proper body mechanics when changing beds

dog

Perform bedbath, backrub using principles of safety and asepsis

dog

Practice documentation of assessment findings on the nursing assessment form

form

Place and remove a bedpan and urinal using principles of safety and asepsis

go

Discuss alignment problems to be prevented in various positions

n0

Apply the nursing process to common hygiene-related problems

na

Describe cleaning techniques to various areas of the body

na

Plan, implement, & evaluate nursing care related to the nursing diagnoses "Bathing Self-Care Deficit" and "Toileting Self-care Deficit"

na

Plan, implement, and evaluate nursing care related to the nursing diagnoses of "Deficient Diversional Activity", "Impaired Physical Mobility", "Self Care Deficit: feeding and dressing"

na

Demonstrate proper techniques for moving, transferring, and ambulating clients

sure

Demonstrate and discuss rationale for placing clients in various body positions

surree

Define and discuss the importance of safety (Treas P. 668)

~Safety Definition~ - the basic human need, second only to survival needs such as oxygen, nutrition, & fluids ~Importance~ - fundamental to providing safe, effective, high quality care - prevention of injuries by being aware of hazards and taking precautions - Many healthcare organizations are campaigning for safer patient care in an effort to reduce the cost of healthcare and the burden of suffering - Accidental injuries are the 4th leading cause of death in the U.S, with an estimated 130,000 people dying each year, or 1 person dies in an accident every 5 minutes - Poison is listed as the number 1 cause of unintentional death, followed by motor vehicle accidents, firearms, falls, drowning, & fires - Millions of other people received injuries from accidents