test 4

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  1. What are seizure precautions?
    • Padding on every surface the client could hit
    • Suction and O2 hooked up and ready
    • 4 rails up
  2. what are the types of seizures
    • partial/focal- 1 part of the brain
    • Generalized- more than 1 part of the brain
  3. What are the different categories of restraints?
    • chemical
    • physical
  4. different types of restraints
    • behavioral
    • medical
  5. when do nurses use behavioral restraints?
    danger to themselves or others
  6. what are the guidelines for behavioral restraints?
    • Physician must assess the patient within 1 hour of application
    • Restraint usually does not exceed 4 hrs
    • must have continuous visual and auditory monitoring
  7. what are the guidelines for medical restraints?
    • must have order within 12 hrs of applying restraints
    • physician must see pt every day
    • order must be renewed every day
  8. why do nurses use medical restraints
    • if a patient is trying to pull out tubes, IVs..
    • pt is confused
  9. Behavioral Restraint Documentation Guidelines
    • Document every 15 minutes
    • Continues visual and auditory monitoring
  10. Medical Restraint Documentation Guidelines
    • Document previous interventions (what you tried)
    • Document every 2 hours
    • Visually Assess every 30 min
    • Release restraint and provide ROM, assessment, personal needs every 2 hrs
  11. what kind of know is used for tying restraints
    • Quick Release
    • 1 pull to release client
  12. what are the different kinds of restraints
    • mitt/hand
    • limb
    • vest
    • seat belts
    • geri chair/ lap trays
    • mummy
    • elbow
    • cribnets
  13. when is seat belt considered restraint
    when it is tied out of the reach of the client
  14. when are side rails considered a restraint
    • when all four are up
    • Unless it is for a seizure precaution client
  15. when should you reevaluate a client in restraints
    • continually
    • every time you look at them you can assess to see if the restraint is still needed
  16. active ROM
    client does the ROM themselves
  17. passive ROM
    Nurse does ROM exercise for the client
  18. if restraints are taken off when family is present, what must the nurse do?
    • check on the client every 30 mins
    • make sure family understands the reason client had restraints
    • family cannot leave client alone without restraints
  19. What are the different ambulation techniques?
    • walking with client
    • instructing how to use assistive devices
    • walker, cane, crutches
  20. if client is walking independently, what should you do?
    walk on clients weak side
  21. if client is slightly weak and unstable, what should nurse do?
    • grasp the back of the gait belt ad walk behind them and slightly to the side
    • have wheel chair behind
  22. client is moderately weak and unstable, what should the nurse do
    • walk on the weaker side
    • interlock your forearm with clients forearm
    • always use walking belt
  23. client is very weak and unstable, what should the nurse do
    • walk on the client's stronger side
    • with your arm around their waist and other arm holding clients elbow
  24. what are the different assistance devices
    • cane
    • walker
    • crutches
  25. how should cane be used for max support
    • cane on the stronger side
    • 6" from side and 6"from foot
    • move cane 1"forward
    • weak foot
    • strong foot ahead of cane
  26. cane instructions for client gaining strength
    • cane 6" from foot and 6"from side
    • move cane and week leg together
    • strong leg ahead of cane
  27. method for using walker max support
    • elbows should be slightly bent
    • move walker 6" ahead
    • right foot up
    • left foot up
    • then walker again
  28. walker method one leg weaker
    • move walker and weak leg at the same time 6"
    • then stronger leg
    • repeat
  29. what are the different methods for using crutches
    • 4 point gait
    • 3 point gait
    • 2 point gait swing to
    • swing thru
  30. what is 4 point gait crutches
    • right crutch
    • left foot
    • left crutch
    • right foot
    • safest gait
    • must be weight bearing on both legs
  31. what is 3 point gait
    • crutches and bad leg
    • good leg
    • need to be able to bear weight od affected leg
    • point gait
  32. what is swing to gait
    • crutches forward
    • then swing legs the crutches
    • used with paralysis of legs/hips
    • prolonged use caused atrophy of leg muscles
  33. 2 point gait
    • left crutch and right foot
    • right crutch and left foot
    • need partial weight bearing on each foot
    • simulates walking
  34. what is swing thorough gait
    • crutches forward
    • legs swing past crutches
  35. what is goniometer
    a tool that is used to measure the angle of a joint
  36. muscle assessment includes
    • inspection - size, symmetry, contractures, tremors (intention or resting)
    • palpation - flaccidity (uncooked chicken) unused muscle
    • spasticity (very hard muscle/Charlie horse)
    • smoothness of movement
    • muscle strength
  37. joint assessment
    • inspection - swelling, symmetry
    • auscultation - popping or cracking
    • Palpation - tenderness, smoothness of movement, crepitation, nodules, ROM
  38. assessment bone
    • inspection - skeletal deformities
    • Palpation- Edema, tenderness
Card Set:
test 4
2013-09-16 01:11:24

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