fundamentals ch 37 - 2 s
Terms
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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?
- Axillary
- 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.
- hands
- 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
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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.