FUNDS: pain, sleep, ambulation, restraint, seizure, patient handling, bariatric, hygiene, cane, ROM, sequential compression devices

A patient reports sharp, aching pain at the site of a recent ankle sprain. The nurse notes swelling and redness. Which type of pain is the patient most likely experiencing?

B. Somatic pain

A nurse is caring for a patient with chronic cancer pain that has lasted for 6 months. The patient reports persistent discomfort with occasional flare-ups. Which characteristic is typical of chronic/persistent pain?

B. Poorly localized and may cause depression

A nurse is caring for a patient who reports a “phantom limb” after an amputation. Which nursing action is most appropriate?

B. Document the pain and treat it aggressively

A nurse is planning care for a patient with insomnia. Which interventions are appropriate to promote sleep? Select all that apply.

A. Offer caffeine drinks in the afternoon
B. Control noise and light in the environment
C. Promote bedtime rituals and relaxation
D. Schedule nursing care to avoid unnecessary disturbances
E. Use hypnotics routinely for all patients

BCD

A nurse is providing care for a bariatric patient. Which interventions are appropriate for safe hygiene and skin care? Select all that apply.

A. Lift and separate skin folds to assess for infection
B. Use harsh soaps to clean skin thoroughly
C. Dry skin completely after cleansing
D. Limit perineal care to once daily
E. Use non-soap cleansers

ACE

A patient is learning to walk with a cane after a right leg injury. Which instruction is correct?

C. Advance the cane one small stride ahead and move the weaker leg forward parallel to it

Which range-of-motion exercise describes movement of a joint so that the front of the body faces downward?

A. Pronation

A nurse is applying sequential compression devices (SCDs) for a patient at risk of deep vein thrombosis. Which actions are correct? Select all that apply.

A. Ensure the patient has a physician’s order
B. Attach the SCD sleeves directly to the skin without socks
C. Remove SCDs if the patient attempts to ambulate
D. Encourage the patient to walk while SCDs are inflated
E. Make sure tubing and sleeves are free from kinks

ACE

acute/transient pain

rapid onset & varies in intensity

protective - warns the person of tissue damage

pain disappears once healing occurs

VS may change —> increase BP & HR

chronic/persistent or intermittent pain

pain that persists or recurrent for more than 3 months

poorly localized

can lead to withdrawal, depression, anger, changes in weight

VS do not change

can have a flare up of pain or disease can be there but no signs of pain

cutaneous (superficial) pain

pain on skin or subcutaneous tissue

ex: paper cut

somatic pain

scattered pain originates from tendons, ligaments, bones, blood vessels, nerves

ex: ankle sprain

visceral (splanchnic) pain

pain poorly localized & originates in body organs like in thorax, cranium, and abdomen

can happen from disease or when organs stretch abnormally, be inflamed, become ischemic (lack of blood supply)

referred pain

pain perceived in a location other than its source

ex: MI

nociceptive pain

pain from tissue damage but nerves are intact.

dependent on stimulus pain is typically sharp, aching, thorbbing

neuropathic pain

pain due to damage of PNS (ex: phantom pain) or CNS (ex: pain from spinal cord injury)

intractable pain

pain that doesn’t respond to usual therapy may need multiple therapies

phantom pain

pain perceived in a limb that has been amputated or is no longer present. MUST recognize it as real pain and treat it aggressively

Preparing a restful environment

Control noise and light to promote patient sleep

Promoting proper sleep hygiene/bedtime rituals

Encourage consistent bedtime routines and habits that facilitate sleep

Promote comfort/relaxation

Use techniques to make the patient physically and mentally comfortable before sleep

Promoting safety

Ensure the patient’s environment is free from hazards to prevent injury during sleep

Respecting the patient’s normal sleep-wake patterns

Align care with the patient’s usual sleep schedule whenever possible

Stress reduction

Take time to sit and talk with patients who are unable to sleep to reduce anxiety and tension

Controlling physiological disturbances

Address factors like pain, hunger, or medical equipment discomfort that disrupt sleep

Offering bedtime snacks & beverages

Provide light snacks or warm milk to enhance sleep readiness

What should patients avoid after noon to promote sleep in the evening

caffeinated drinks

Meds you can offer for sleep (NOT TYPICAL TREATMENT)

• Nonbenzodiazepines - preferred tx (treatment); zolpidem (Ambien), zaleplon (Sonata)

• Benzodiazepines - oxazepam, lorazepam, temazepam

• Hypnotics - induce sleep - loses effect after 1-2 weeks of use

• Eszopiclone (Lunesta) - used for chronic insomnia

When helping a patient ambulate:

stand on weak side, support patient at waist

Chemical restraints:

medications to manage a patient’s behavior. Not a standard treatment.

examples of chemical restraints

Xanax, Valium, Ativan, Zoloft, Haldol, and Ketamine.

inject into muscle = faster distribution

Physical restraints:

manual method or device used to immobilize patients

Examples of physical restraints

side rails, vest, mittens, and wrist.

includes all 4 rails up

Seclusion:

involuntary confinement of a person alone in a room or area where the person is physically prevented from leaving.

LAST RESORT, must follow institution policy, have doctor orders, D/C ASAP

complications of restraints

• Immobility, not being turned and positioned 

• Pressure ulcers

• Breathing and circulation 

  • Quick knot ties: patients can easily untie and hurt themselves; wrapped around their neck, too tight around their wrists etc.

• Death

• Skin breakdown under restraints 

• Risk for falls

• Psychosocial implications

  • Affects sanity

purpose of restraints

• Reduce the risk of patient injury from falls.

• Reduce the risk of injury to others by the patient. 

• Prevent the interruption of therapy.

Alternative to restraints

• Reorientation 

  • Agitation, confusion → calm them down, tell them where the calling devices are (call bell)

• Assess frequently and respond promptly

• Encourage family to stay 

  • Helps patients with mental capacities, they are more calmer

  • They know their family member (patient) better

• Offer reassurance, de-escalate 

• Bed alarm 

  • Detection and alerts when a patient gets off the bed

• Make sure basic needs are met

  • Make sure everything is WITHIN REACH

• Staff at bedside like a 1 to 1

Seizure precautions: what to do

1- assist pt to floor, support head, STAY WITH PATIENT

2- have head flexed forward (Chin to chest to prevent head banging)

3- if pt in bed, remove pillows, raise side rails (pad side rails)

4- DO NOT RESTRAIN PTS & DO NOT PUT ANYTHING IN MOUTH

safe patient handling

proper body mechanics, correct ergonomics, special equipment, no manual lifting policy without assistive devices

bariatric means

obese

What to do with bariatric pts skin

assess skin adequately by lifting & separating folds

use non soap cleansers & dry skin thoroughly

incontinent pts

• assess skin frequently

• provide perineal care AS NEEDED

• avoid using soap & excessive force while cleaning

infants/young children

• never leave child unattended

• have all materials within reach

older adults

• pts require less bathing

• avoid hot water & dry cleaning products

• increased dental issues

Cane use

COAL (cane opposite affected leg); cane will be on strong leg

1- advance the cane forward 4-12 inches

2- move weaker leg parallel to cane

3- move stronger leg to complete step

Four-point gait:

most support. The left crutch is advanced followed by the right leg, right crutch and at last, the left leg.

Three-point gait:

most used. The left and right crutch along with the injured leg are both advanced while the uninjured leg supports the body weight. Next, the uninjured leg is advanced.

Two-point gait:

left crutch and right leg move forward followed by the right crutch and left leg.

When walking with walker

elbows bent at 30 degrees

how to position crutches when sitting/rising from chair

Position the crutches on the unaffected side when sitting or rising from a chair

to go up stairs with crutches

up with good, follow with crutches and injured leg

to go down stairs with crutches

1- place crutches on lower step

2- step down with bad leg

3- bring strong leg down

Abduction:

movement of a limb away from the body 

Adduction:

movement of a limb toward the body 

External rotation:

rotation of joining outward or away from catheter 

Internal rotation:

rotation of a joint inward or toward the center 

Extension:

movement of increasing the angle two adjoining bones 

Flexion:

decreasing two adjoining bones; bending of a limb

Dorsiflexion:

flexion of the foot and toes upward toward the ankle 

Pronation:

movement of a body part so that the front faces down

Supination:

movement of a body part so that the front faces up

Outcomes of ROM:

• Pt completes the exercise 

• Pt maintains or improves joining mobility 

• Muscle strength is improved or maintained 

• Muscle atrophy and contractures are prevented 

sequential compression devices (SCDs)

• Fabric sleeves containing air pockets that apply pressure to the legs.

• The pressure is intermittent.

• It pushes blood from the smaller blood vessels into the deeper vessels and into the femoral veins.

• Enhances blood flow and venous return 

• Prevents thrombosis

SCDs require what

doctor order

remove if patient wants/needs to ambulate