Funds. Quiz 1

supine

patient is on back w/ head

foot support, prevents foot drop, alignment

dorsal recumbent

spine touching the bed, flat,

low fowlers

45°-60°, head elevated

NG tube insertion/ suctioning, assist w/ lung expansion

semi fowlers

30°-45°, head elevated

• prevents regurgitation & aspirations

• gtube feeding for patients, or breathing

high fowlers

60°-90°

• lung expansion w/ lower diaphragm= relieves dsypnea

• helps w/ aspiration & eating

orthropnoic

patient sits in bed w/ pillow on overbed table, arms resting on table

• chest expansion w/ patients with COPD

• lungs can open up, or receiving epideral

prone position

flat on abdomen, chest flat on one side

• relaxation w/ knee flexion, encourage drainage of respiratory secretion, free hip & knee joints= prevent contractions

semi prone recumbent

on side halfway between lateral & prone

• drainage of secretions & reduces pressure on sacrum & hips

lateral

laying on side

• spinal alignment, reducing pressure on sacrum & heels

Trendelenberg

bed is titled w/ head of the bed lower than foot of the bed

• bringing blood towards patient’s upper body (venous return & postural drainage

reverse trendelenburg

bed titled w/ foot of the bed lower than heart

• prevent gastric emptying & prevents esophageal reflux

lithotomy

hips flexed up at 80–100°, hips and knees flexed, legs abducted/in stirrups)

• vaginal/pelvic exams, childbirth

Patient w/ kidney infections

can spread to their URI. tract

patient’s who are immobile

can likely experience UTI

Vital signs: fever, tachycardic, confusion

Elderly patients who are confused receiving urinary catether’s, nursing intervention?

urine analysis & urine culture are test to check infection of the urinary tract

symptoms: urinary frequency, urinary urgency

mobility support device

• walk a cane on unaffected side, right side

• climbing stairs same level of the unaffected side

• same cane level same time as the affected side on step #2, move cane to step 2

• advance cane forward, then unaffected leg, then affected leg

6-10 inches forward, ambulate

How to assess patient for mobility?

have patient sits on the bed to assess mobility, w/ feet dangling & touching the floor

constipation

uncommon bowel movements, where hard stool is unavailable to move= blockage

nursing interventions to help w/ constipation

increase patient fluids, drink warm fluids, help move the bowel faster, including high fiber: grains, broccoli, granola,

peristalsis

muscle contractions that aid w/ intestine, to help move food, fluids, & waste (GI) tract

body mechanics

bending from a hips, not our knees, shoulder apart, holding object close to body

waist level to patient

autonomy

allowing them choices

i.e asking patient & letting patient what they want to eat first

Bathing

stimulate circulation, provide relaxation, and enhance healing

• washing from top to bottom, face first

when cleaning a male patient

clean urinary meatus outward, then shaft motion circulation

Allow patient..

respect, autonomy, culture preferences- understand patient preferences

oral care

unconscious patient: be cautious how we insert

turn the client on side (lateral) , before oral care, hold brush at 45 degree angle, do not put fingers in mouth, gently brushing teeth

Bedmaking

never place soil linen on floor, designed linen basket

hold away from body when walking

never shake, roll to middle

foot care

use warm water to reduce injury

do not use moisturizer on feet> fungi infection

do not soak patient’s feet> skin breakdown

foot care for diabetic patient’s

do not soak

inspect for any cuts, sores

excessive glucose

dentures

carefully, remove by dry gauze, place wash cloths in to prevent damage

cleaning: no tooth paste, denture cleaner

rinse denture, use cold water to prevent damage

Neuromuscular Assessment

assessment of nervous system; function & circulation

normal cap refill- 3sec if > than 3= poor blood circulation

why assessment for nervous system?

check if skin color is pink, temperature, movement, sensation, pulses, capillary refill, & pain

no assist

patient can walk in place w/o assistance or object

minimal assistance

patient can raise self from sitting w/ cane & walker to stand,

gait belt needed

moderate assistance

patient can place feet on the floor, but can’t stand up
mechanical lift/ sit to stand lifts

maximum assistance

patient cannot stand/sit
mechanical lift/ slide boards