Fundamentals of Nursing Chapter 13 & 16

The middle point of the body, below the umbilicus and above the pubis, around which its mass is distributed is the __________.

Center of Gravity

A group of specially trained personnel designated to respond tot codes throughout the hospital is the __________.

Code Teams

lithotomy position

lying on back with knees flexed above the hips and legs supported in stirrups- used for vaginal examinations, delivery of neonate, pelvic and gynecological proceedures

sim position

lying on back with the arms at the side

prone

lying on stomach with head turned to the side

lateral position

lying on the right or left side with the back supported, with a pillow between knees and ankles

Slide sheets are different from draw sheets because they are:

made of thin webbed nylon

transfer

move a patient from one place to another

You and an (UAP) are preparing to turn an immobile patient from her back to right side. Which of the following actions will you take first?

move the patient to the left side of the bed

cardiovascular system

pooling of blood int he extremities; increased cardiac workload potentially orthostatic hypotension, blood clots in the extremities, blood clots traveling to lungs, heart and brain

When you position a patient so that his or her extremities are in alignment to maintain the potential for their use and movement, this is called.

position of function

chair or bed monitoring

pressure-sensitive device that generates an alarm when the patient's weight is no longer sensed

The ___________position is described as lying on the stomach with the head turned to the side.

prone

Mass casualty event (MCE)

public health or medical emergency that involves thousands victim

To remove dressing

pull skin taut away from the tape rolling dressing toward the center

fowler's

semi-sitting position with various degrees of head elevation with knees slightly elevated purpose vary based on elevation

_____________occurs when the skin layer is pulled across the muscle and bone in one direction. while the skin slides over the bedsheets in the opposite direction.

shearing

contractures

shortening or tightening of muscles as a result of disue

When you prepare to administer an enema, you will place the patient in the ___________position

sims

integumentary system

skin and capillaries compressed between the bed and bony prominences complications pressure ulcers

The 6 factors that contribute to an unsafe patient environment

1. Age & ability to understand 2. Impaired mobility 3. Communication 4. Pain & discomfort 5. Delayed assistance 6. Equipment

How often must you or an assistant check on a patient who is restrained?

30 minutes, every 2 hours

low fowler's

30% degrees to prevent aspiration during tube feeding

semi-fowler's

45% degrees comfortable for TV, converse with visitors, after abdominal surgery assist patient who have difficulty breathing

high fowler's

90% degrees to eat or drink without choking to assist patients who have difficulty breathing

Center of Gravity

Base of Support

__________ refers to the movement of the muscles of the body for balance and leverage.

Body Mechanics

restraint alternatives

less restrictive ways to help patients patients remember not to get up or to alert the nursing staff if a patient is attempting to do so

A form that gives a numerical rating for each patient's risk for falls is called

Fall Assessment Rating Scale

Even if you delegate checks and releases, what are your responsibilities when a patient must be restrained?

Follow up every to hours to be sure the patient is released from restraints and has been checked on every 30 minutes

You have delegated the checks and release of a patient who requires wrist restraints to an unlicensed assistive personnel (UAP). You have been very busy with other patients all morning. The patient's wife finds you and says that her husband is very restless and has not been to the bathroom for 6 hrs.What actin will you take?

Go yourself and assess the situation as you release the patient and take him to the bathroom

The __________ is the organization responsible for evaluating and accrediting health-care organizations and programs in the United States

Joint Commission

Level one

Morse Fall score 0-24 Action implement level one interventions

Level two

Morse fall score 25-50 Action implement level two interventions

Level three

Morse fall score greater-51 implement level three interventions

Passive ROM

are done with the nurse performing exercising of the patient joints while providing proper support to patient's extremity

You walk into the patient's room and discover that he/she has fallen in the bathroom. What will you do first?

Notify the physician and explain what happened call for help to get the patient off the floor check the patient for obvious injuries, including hip fracture and paralysis

restraints alternatives

are less restriction ways to help patients remember not to get up and try to walk, or alert the nursing staff that the patient is attempting to do so.

P.A.S.S

Pull, Aim, Squeeze, Sweep

R.A.C.E

Rescue, Alarm, Confine, Extinguish

A document that contains information about potential harm caused b exposure to a chemical and the directions for what to do if the product gets on your skin or in your eyes or your mouth is called a __________

Safety Data Sheet (SDS)

The national Patient Safety Goals are established by what organization?

The joint commission

Which assistive device would you use after a patient had fallen to help him/her return to bed?

a battery-operated lift

Leg monitor

a monitor that attaches to the patient and generates an alarm when the leg is in a dependent position.

cardiopulmonary resuscitation (CPR)

actions to restart the heart or breathing in an unresponsive victim who has no pulse or respiration

Heimlich maneuver

an action to relieve choking bu thrusting just below the xiphoid process

dorsiflextion

ankles flexed at 90 degrees so the toes point to the ceiling when the patient is in a supine position

When you assist a patient to a left lateral position where will you place the additional pillows?

between the knees and ankles and the back

rescue breathing

breathing for a person in respiratory arrest who still has a pulse

If a patient who is at risk for falls has a bed or chair alarm in place. you will

check on the patient frequently. ensuring it is in place and turned on

When performing ROM exercises which action will you take first?

check the patient's chart for any contraindications to full ROM exercise

neurological system

decrease in normal cues and activities; decrease balance when initially out of bed potentially complications compression neuropathy, impaired level of consciousness, confusion

psychological system

decrease in normal social interactions; and independent activity potentially depression, anxiety, impaired sleep

respiratory system

decreased lung expansion complication atelectasis, hypoxemia, hypostatic pneumonia

musculoskeletal system

decreased muscle strength and muscle mass- potentially muscle atrophy, foot drop, contractions, osteoporosis

gastrointestinal system

decreased peristalis, decreased appetite, increased intestinal gas complications constipation, flatulence, distension

To perform perineal care, you will place the patient in which position?

dorsal recumbent

syncope

fainting

plantar flexion

foot pointing in a downward position

When injured people come into the hospital after an MEC, if they are unable to provide you with identification, what can be used to help others identify them?

hair color, clothing, approximate age, gender

When you prepare to turn a patient who has had spinal surgery, you will plan to do

have a total of three health-care staff assist with the turn logroll the patient have one person at the patient's head to direct the turn

Urinary system

incomplete emptying of bladder complications urinary tract infection, renal calculi

Drainage

indicated size no odor serosarguihous-color pnk or blush

When you care for your assigned patient with paralysis of both legs, you are concerned about skin breakdown. What nursing interventions would you use?

inspect bony prominence's for redness every 2 hours, I found massage it around the area but not on it dry skin thoroughly but gently after cleansing it with mild soap provide adequate nutrition so that the tissue can repair itself

Active ROM

is performed by patient without assistance

When a patient in a home setting uses supplemental oxygen, what teaching should you provide?

no one can smoke in the same room as the oxygen source no candles can be burned in the same room as the oxygen source patients using oxygen should not use wool blankets or wool sweaters

The position used to assist patients in severe respiratory distress, allowing maximum expansion of the chest for moving air in and out of the lungs, is called

orthopneic

Which position will you use for a patient in severe respiratory distress?

orthopneic

When a patient' blood pressure decreases with change in position, it is referred to as

orthostatic hypotension

footdrop

permanent plantar flexion of the foot

How can you be certain that the wheels of stretcher are locked before transferring a patient?

physically attempt to move the stretcher, even if you have locked the wheels

Incision

pink and healthy approximated- the number of sutures or staples

How will you provide stability as you assist a patient to stand before you begin ambulation?

place your feet in front of the patient's feet and your knees against the patient's knees

The _______position is described as lying on the back with arms at the side.

supine

Why is it important to explain what you will be doing when you assist a patient with position changes?

the patient may be sedated or have an impaired level of consciousness the patient will be more cooperative with the position change the patient can more easily assist with the position change

What has been the cause of death for patients who were restrained?

the restraint was applied incorrectly, which caused choking

What is the purpose of assisting a patient to dangle?

to determine if the patient can tolerate changing positions

Which assertive device will you use to assist a patient with mild right-sided weakness as he moves from the bed to to wheelchair?

transfer belt

A _____________is placed at the at the lateral aspect of the patient's thigh to prevent outward rotation of leg.

trochanter roll

Before applying restraints to any patient, you must take which steps?

try using restraint alternatives without success identify the need for restraints to prevent harm to the patient obtain a physcian's order for the type of restraint and the length of time it is to remain in place

logroll

turn the patient with the body as one unit

To practice good body mechanics you would:

turn your whole body or pivot on one foot, but avoid twisting bend your knees,not your back, to lift an object from a low shelf

What helps prevent respiratory and circulatory complications of immobility?

turning every 2hrs, deep breathing, coughing

ambulate

walk

How can nurses avoid being harmed by radiation exposure?

wear a lead apron during x-ray and fluoroscopy procedures limit the time you spend with patients who have internal or implanted radiation

restraints

which are vest, jackets, or band with connected straps that are tied to the bed, chair, wheelchair, to keep patient safe