Lab 2_Safe Patient Handling

What is meant by "dangling" the client?

- Assisting the client to sit up at the edge of the bed w/ the legs hanging independently - Monitor for orthostatic hypotension & allow BP to readjust before moving client

When does venous stasis occur?

- Occurs with immobilization or absence of active range of motion in the calf muscle - During prolonged bed rest and other occasions when the legs aren't moving normally, blood flow slows because the calf muscles aren't contracting and squeezing the blood toward the heart

What are body mechanics?

- good body position & alignment - important for the nurse & client to reduce the likely hood of injury - maintain a wide, stable base w/ your feet apart; lower your centre of gravity; stabilize your spine; avoid twisting your spine & knees; put the bed at the correct height; keep your arms as close to your body as possible to minimize reaching; use weight shifts w/all safe Pt handling techniques

What are the disadvantages of the prone position?

- hyperextension of the neck & lumbar spine - plantar flexion

A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? a. Friction b. Impaired circulation c. Localized pressure d. Shearing forces

d. Shearing forces

What are the interventions that should be included for all clients to monitor for and/or reduce the risk of falls?

- mobilize - bedside environment - ROM exercises - isometric exercises - anti-emboli stockings - sequential compression devices - frequent rounds to check on clients - put personal items close to client - remove clutter - ensure client has call bell & knows how to use it - lock brakes on beds & chairs - bed in lowest position - side rails in use appropriately

Which of the following techniques imposes the greatest strain on the nurse's back? a. Helping clients ambulate. b. Lifting with the large muscles of the legs. c. Transferring clients in and out of bed. d. Turning immobilized clients in bed.

d. Turning immobilized clients in bed.

What 3 forces are involved in skin breakdown & increased risk for pressure ulcers?

- Shear - Friction - Prolonged ischemia

What safety measures should be considered prior to moving a client from bed to chair?

- Position chair - Bed height for client - Patient handling guidelines - assessment as above - Environment clear of clutter - Transfer belt available - Non-skid footwear

What are the prevention strategies for Deep vein thrombosis (DVT) or venous thromboembolism (VTE)?

- Proper positioning in bed - Range of motion exercises - Strength: isometric exercises - Elastic stockings (antiemboli) to counter orthostasis - Early mobilization - sitting, chair, walking - Have client assist/perform self-care (ADLs) - Increase sensory stimulation

What is the advantage to using a transfer (gait) belt?

- Provides a way for the nurse to have a safe "hold" on the client when assisting w/moving and ambulation

What is a contracture?

- a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints

What is shear(ing)?

- a force that exerts downward and forward pressure on tissues beneath the skin - can occur when the patient slides downward while sitting in a bed or chair, or when bedclothes are forcibly pulled from under the patient);

What is an advantage for using a risk assessment tool such as a Braden Scale?

- assess risk factors for development of pressure ulcers so that the nurse (HCP) can implement strategies to prevent or reduce the development (source)

What factors may impact a client's mobility?

- disease or illness - surgery - unfamiliar environment - use of restraints or side rails

What are the disadvantages of the Sim's position (semi-prone)?

- lateral flexion of the neck - internal rotation - adduction - lack of support to the shoulders & hips - lack of support for the feet

What are the disadvantages of side-lying (lateral)?

- lateral flexion of the neck - shoulder and hip joints internally rotated - lack of support for feet

What are the most common factors contributing to falls in hospital?

- previous falls w/in the last 6 months increases risks - cognitive impairment/disorientation - physical hazards such as equipment - acute illness that predisposed to weakness - orthostatic hypertension - balance of gait impairment - mobility impairment - personal items not w/in reach - incontinence - poor lighting

What interventions can the nurse implement to prevent problems related to immobility?

- repositioning - assisting w/ ADL's - mobility aids - planning for activity and rest - client teaching

What are the risk factors for pressure ulcer development & common sites for pressure ulcer development?

- sensory changes - hydration & nutrition - mobility - circulation - incontinence - prolonged pressure - shear forces - friction - moisture

What are the disadvantages of the supine position?

- shoulders unsupported and internally rotated - elbows extended - hips externally rotated - pressure points at the lumbar vertebrae, elbows & heels

What is deep vein thrombosis (DVT) or venous thromboembolism (VTE)?

- the formation of blood clots - may develop in people who lie in a hospital bed for several days w/out sufficiently moving their legs - there's potential for these clots to travel (embolism) to other areas or organs of the body such as the lungs, brain, or heart and cause serious problems such as pulmonary embolism or stroke

What factors can impact the older adult's safety in a hospital setting?

- unfamiliar environment - multiple medications - acute illness - mobility restrictions - multiple caregivers/interactions (pt. identification is critical) - infection risks - deconditioning & malnutrition - communication or special needs (ie: difficulty hearing or w/vision problems) - need for a translator - cognitive impairment

What is a bedside safety checklist?

Bed in low position (an ambulating client needs the bed adjusted to an individually comfortable height so when sitting on the edge of the bed their feet are flat on the floor - Side rails up or down? - Brakes locked? - Call bell within reach? - Personal items within reach - Remove clutter/obstacles - Regular checking - Regular toileting routine - Allow time for moving and getting to the bathroom - Hip protectors - Floor mats

What are the nursing assessments that must be performed prior to moving a client?

Review safe patient handling guidelines: - Can client weight bear? - Ability to follow instructions & cooperate - HCP skill level - Assess the client's motor strength & ability - Any contraindications - Limitations or restrictions to movement - Physical environment for safety hazards prior to initiating a transfer

To assess the joints, a nurse asks a client to perform various movements. What client ability is the nurse evaluating if a client is asked to move his arm away from the midline? a. Abduction b. Adduction c. Protraction d. Retraction

a. Abduction

a) What are the effects of bed rest on the muscular system? b) What are the functional outcomes?

a) -Atrophy at rest lose 3 - 5 % strength daily (more severe in older adult) - Contractures due to muscle shortening - Decreased tendon and ligament strength b) Decreased ability to walk - increased risk of falls - lengthy recovery time

a) What are the effects of bed rest on the bones system? b) What are the functional outcomes?

a) Greater % bone reabsorption than bone formation - 6-40% decrease in bone density - hypercalcemia --> muscle weakness, arrhythmias, kidney stones b) increased risk for fractures - loss in 10 days bedrest takes 4 months to restore

a) What are the effects of bed rest on the cardiovascular system? b) What are the functional outcomes?

a) HR 30-40 beats higher in response to sub-maximal activity - stroke volume (SV) decreases 30% - fluid shifts --> orthostatic hypotension - baroreceptor dysfunction --> postural hypotension - blood flow slows in extremities; venous stasis --> VTE; edema b)- dizziness - orthostatic intolerance increased risk for falls

a) How should you ensure the client is correctly aligned in bed? b) Why is this important?

a) Look at body alignment and position of joints - Joints should be slightly flexed - Use devices to support position (e.g. pillows, rolls etc.) b) Need to maintain good body alignment to promote healthy joints and muscles andprevent problems e.g. injury to joint; contractures

What is the role of a) the forces of pressure, b) shear, and c) friction in impairment of skin integrity?

a) Prolonged pressure compromises blood flow to the tissues b) Shear damage is caused when the skin layers adhere to the linens while the deeper tissue layers move downward which causes reduced blood flow to the tissues c) Friction is the mechanical force of 2 surfaces moving over each other that causes blisters or skin tears - moisture compromises the protective barrier of the skin making it more susceptible to breakdown

a) What are the effects of bed rest on the respiratory system? b) What are the functional outcomes?

a) Reduction in ventilation, decreased pO2 - diminished cough strength - increased risk for pulmonary emboli b) Atelectasis (incomplete expansion- the collapse of lung tissue because of airway obstruction, an abnormal breathing pattern, or compression of the lung tissue), pneumonia - impaired activity tolerance, endurance

a) What are the effects of bed rest on the other systems (GU, skin, GI, metabolic, sensory? b) What are the functional outcomes?

a) urinary stasis --> UTI - skin atrophy & breakdown - constipation & loss of appetite - negative nitrogen balance - decreased sensory input b) incontinence - pressure ulcers - malnutrition/dehydration - reduced muscle strength - delirium, anxiety, depression, apathy

The nurse is preparing to help a client with weakness in the right leg move from the bed to a chair. Where should the nurse place the chair? a. 45 degrees to the bed on the left side. b. 45 degrees to the bed on the right side. c. Perpendicular to the bed on the left side. d. Perpendicular to the bed on the right side.

a. 45 degrees to the bed on the left side.

When performing an assessment, the nurse identifies the following signs and symptoms in the client: decreased muscle strength, limited range of motion, and reluctance to move. Based on these symptoms, the nurse should perform which of the following interventions? Select all that apply. a. Assessing the client using a falls risk tool. b. Encouraging client repositioning every 2 hours. c. Having the call bell within easy reach. d. Having four-side rails up when client is in bed. e. Wearing a gown and gloves when in the room.

a. Assessing the client using a falls risk tool. b. Encouraging client repositioning every 2 hours. c. Having the call bell within easy reach.

An older client is admitted to the unit after falling in a nursing home. The client is orientated to person, place and time and can follow directions. Which of the following actions by the nurse are appropriate to decrease the risk of falls for this client? (Select all that apply) a. Complete a fall risk assessment. b. Ensure that the client's call bell is in place. c. Keep the bed in the low position with full side rails up. d. Place a belt restraint on the client when his is sitting on the bedside commode. e. Provide the client with nonskid foot wear.

a. Complete a fall risk assessment. b. Ensure that the client's call bell is in place. e. Provide the client with nonskid foot wear.

Which of the following techniques is appropriate when the nurse changes a client with lower leg weaknesses in bed? Select all that apply. a. Having the client help lift off the bed using a trapeze. b. Pulling the client when moving the client up in bed. c. Rolling the client onto the side. d. Sliding the client to move up in bed. e. Using two nurses and a transfer sheet when moving the client.

a. Having the client help lift off the bed using a trapeze. c. Rolling the client onto the side. e. Using two nurses and a transfer sheet when moving the client.

A client who had a hip replacement is lying on the side, and the nurse is placing pillows between his legs. What is the nurse trying to prevent? a. Abduction of the thighs. b. Adduction of the hip joint. c. Flexion of the knees. d. Hyperextension of the knees

b. Adduction of the hip joint.

A nursing instructor is assessing a student's knowledge of how to help an obese client sit up. What should the instructor say to the student to ensure that good principles of body mechanics are used during the move? (Select all that apply). a. After raising the bed up, grab onto the draw sheet and pull the client up. b. Ask the client to help as much as possible. c. Bend at the knees, keep your back straight and then pull the client up. d. Keep your back straight and lift with your thigh muscles. e. Keep your elbows straight and use your thigh muscles to bear the weight.

b. Ask the client to help as much as possible. d. Keep your back straight and lift with your thigh muscles.

The nurse is caring for an elderly patient who needs help with ADLs. Which of the following is most important for the nurse to understand when implementing care in order to avoid injury? a. A client's level of consciousness and ability to cooperate are not important factors during transfer. b. Bending and twisting while providing care may cause injury. c. The center of gravity is located at the waist. d. Tightening the abdominal muscles and tucking the pelvis may strain the lower back.

b. Bending and twisting while providing care may cause injury.

It is important to prevent skin breakdown and maintain skin integrity in older clients. What factor places these clients at a greater risk for skin breakdown? a. Altered balance. b. Changes in sensory perception. c. Impaired hearing ability. d. Impaired visual acuity.

b. Changes in sensory perception.

The nurse is assessing a client at home for risk of a fall. What is the most important factor for the nurse to consider in this assessment? a. Amount of regular exercise the client has. b. Correct illumination of the environment. c. The client's resting pulse rate. d. The amount of salt intake.

b. Correct illumination of the b. Correct illumination of the environment.

The nurse is assisting a client with new-onset vision loss to transition to home from the hospital. The client can see shadow and light in the right eye only. When at home, the client is at greatest risk for which of the following? a. Denial of changes in vision b. Injury from falls c. Isolation from social activities d. Loss of sensory perception

b. Injury from falls

Two nurses plan to move a client with right sided weakness into a wheelchair. What should the nurse who is instructing the client say to ensure the move is made using safe transfer techniques? a. Hold on to the side rail at the bottom of the bed before standing. b. On the count of three use your arms to push up from the bed. c. Put your feet behind the nurse's feet. d. Use the IV pole as a lever when rising up from the bed.

b. On the count of three use your arms to push up from the bed.

Which statement correctly describes the prone position? a. The client is lying on his back. b. The client is lying on his stomach. c. The client's head is lowered 30°. d. The client's head is raised 15°.

b. The client is lying on his stomach

A client is worried about how he will manage his pain after surgery. He asks the nurse, "If I lie still and avoid turning, I will avoid pain. Isn't this right?" What is the nurse's best response? a. "It is always a good idea to rest quietly after surgery, which will help minimize further pain." b. "The physician will probably order you to lie flat for 24 hours after surgery." c. "Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement." d. "Why don't you decide about activity after you return from recovery?

c. "Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement."

Which of the following interventions will best prevent falls in older adults? a. Encourage the client to not use assistive devices because they reduce independence. b. Instruct the client not to exercise painful joints. c. Instruct the client to rise slowly from a supine position. d. Turn on bright lights in the room so the client can see items in the room.

c. Instruct the client to rise slowly from a supine position.

A nurse is caring for a client with a history of falls. What is the nurse's first priority when caring for a client at risk for falls? a. Instructing the client to not get out of bed without calling the nurse for assistance b. Keeping the bedpan available for the client who cannot make it safely to the bathroom c. Keeping the bed in the lowest position d. Placing the call bell on the bedside table

c. Keeping the bed in the lowest position

A nurse is preparing to lift an object. Which of the following illustrates that the nurse is using proper lifting techniques? a. Knows to lift no more that 50% of own body weight. b. Lifts the object with flexed knees and hyperextended back. c. Lifts the object with the large muscles of legs, abdomen and arms. d. Puts the object to be lifted 12 inches from feet.

c. Lifts the object with the large muscles of legs, abdomen and arms.

Your primary nurse informs you that your client needs to be turned from side to side every two hours. What is the best way to turn your client? a. Ask a second nurse to assist you in turning the client to his/her side. b. Explain to the client how you will assist in turning the client. c. Place a sliding sheet under the client to assist in turning. d. Use a mechanical lift to move the client every two hours.

c. Place a sliding sheet under the client to assist in turning.

The nurse is observing a client who is recovering from back strain lift a box as shown in the accompanying image (bent knees, low to ground, rounded back) What should the nurse do? a. Advise the client to bend from the waist rather than stretching her back in this position. b. Inform the client that she should keep her back straight by squatting with both knees parallel. c. Praise the client for using correct body mechanics. d. Suggest to the client that she put both knees on the floor before attempting to lift the box.

c. Praise the client for using correct body mechanics.

A nurse is working with a client who has limited mobility. The nurse is preparing to assist the client from the bed up to a standing position. Which of the following actions should the nurse perform? a. Put socks on the patient's feet. b. Place the client's hands around the nurse's neck before attempting to stand. c. Instruct the client to keep the feet touching side to side in order to promote stability. d. Allow the client to sit on the edge of the bed for a few minutes before trying to stand.

d. Allow the client to sit on the edge of the bed for a few minutes before trying to stand.

The nurse is making rounds and observes a client who is unconscious (see figure - Pt laying on R side w/ pillow between knees & under L arm). The student nurse has just turned this client from lying on her back. What should the nurse instruct the student to do before raising the side rail? a. Add a pillow under the right arm. b. Elevate the head of the bed 30° c. Move the client closer to the head of the bed. d. Inspect the skin at pressure points from the back-lying position.

d. Inspect the skin at pressure points from the back-lying position.

When a nurse is preparing to transfer a client from a bed to a chair what body mechanics principle indicates that the nurse is performing the move safely? a. Keeps feet as close together as possible. b. Keeps knees straight and stiff and bends at the waist. c. Stands an arm's length away from the client. d. Uses a rocking motion while helping the client to stand.

d. Uses a rocking motion while helping the client to stand.