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fundamentals ch 37 - 2 s


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In using a CPM machine, what is the nurse responsible for?
Making certain the machine is attached properly and that the settings are what the surgeon ordered.
Full ROM should be performed actively or passively how often?
Several times a day
What do you look for in a head-to-toe assessment of a patient that's immobilized?
reddened areas, pale or blue skin, coldness, diminished or absent pulses,
shallow breathing, rapid or depressed respiratory rate, cough, abnormal lung sounds, use of accessory muscles, retractions, grunting
For pts with a cast, look for what?
Foul odor (sniff!)
What is perfusion?
Circulation of blood
What should be done for the immobilized patient?
Pressure relief devices, regular turning, coughing, deep breathing, ROM exercises, assisted ambulation, visitation
When the cast is new, how often should you turn the pt?
every 2 hours
How do you apply an elastic bandage?
Elevate the limb and support it while applying the bandage.
When applying a bandage, face the patient and do what?
Wrap from distal to proximal
A wrapped bandage should be removed how often?
Twice a day
Circular turns are used when?
To anchor the bandage and terminate the wrap.
Spiral turns are used when?
On uniform parts of the body, such as upper arm or upper leg
When is the spiral reverse turn used?
To bandage nonuniform circumference body parts.
Where is a figure-of-eight bandage used?
elbow, knee, ankle
Where is the recurrent turn bandage used?
On body parts such as fingers, skull, or an amputation stump
Why is a sling used?
To support and immobilize an extremity. The sling holds the extremity in an elevated position to avoid edema and fatigue.
When must a patient never be unattended?
In a lift or while in the tub or whirlpool bath
When ambulating with a cane, what normally is the order? Cane is on good side.
Cane - Bad leg - good leg
How do you know if the height of the walker is correct?
if the patient's elbow is bent at a 15 to 30 degree angle.
What kind of crutches are used for short term use?
Resting the bodies weight on what is bad?
The axillary bar
When standing, the crutch pads should be how far away from the axilla?
1 1/2 to 2 inches
The ______ support the weight in crutch walking.
What is used to strengthen and support parts of the body affected by weakness or paralysis??
Splints, braces, prostheses
Range of motions exercises promote circulation in the patient by:
Contracting the muscles surrounding a vein, forcing lood to move toward the heart.
A nursing measure to keep a patient in traction from developing hypostatic pneumonia is:
Making sure she is turned every two hours
A potential musculoskeletal problem that a person in traction could develop is
Decreased joint mobility
In addition to good skin care and frequent turning, what can be done to prevent pressure ulcers in a patient in traction?
encourage adequate nutritional and fluid intake
When moving a patient up in bed who has traction attached to a lower extremity, you would??
Using a pull sheet, steadily and slowly pull the patient up in bed
The amount of weight exerted by traction is determined by:
The amount of weight placed on the traction ropes.
When measuring for crutches, you know that the axillary bar should be ____ beneath the axilla, and the elbow should be at ____ degrees
3 finger breadths; 15 degrees
When assessing a new cast. you find that the cast is tight and flush to the skin.
What do you do?
Question the patient as to whether the arm has been kept elevated.
After applying an elastic bandage to an ankle, you know it is too tight if:
The toes are bluish and cool to touch
When caring for traction pins and wires, it is most important to:
use strict aseptic technique to prevent infection.

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