NCLEX: Mark Klimek - Lecture 4 (Crutches/Canes/Walkers & Psychiatry)

How do you measure the length of crutches?

- 2-3 finger widths (cm) between the pad and the anterior axillary fold

- The tip is located to a point lateral (6 in.) and slightly in front of the foot (6 in.)

- RULE OUT any answers measuring with axilla or any landmarks on foot

How do you measure the handgrip measurement?

- The elbow flexion is 30 degrees

- The wrists should be at the level of the handgrip

What is a 2-point gait?

Move a crutch and opposite foot together, and then the other crutch with opposite foot.

When is a 2-point gait used?

EVEN number, so BILATERAL mild leg weaknesses

What is a 3-point gait?

Move both crutches with affected leg that's not on the ground, then move the good leg.

3-1, 3-1

When is a 3-point gait used?

ODD number of leg is affected... so one.

What is a 4-point gait?

Move everything separately. Move one crutch, then foot, then crutch, then foot.

When is a 4-point gait used?

EVEN number, so BILATERAL severe weaknesses

What is a swing-through gait?

Self-explanatory... Swing through the tip of the crutches.

When is a swing-through gait used?

For non-weight bearing and/or amputees.

A pt is affected with early stages of rheumatoid arthritis. What gait should the pt use?

Bilateral = even number

Early stages = mild

2-point gait

A pt has left ATK (above the knee) amputation 2 days ago. What gait should the pt use?

Left ATK = odd number

Fresh amputation = Non-weight bearing

Swing-through gait

Pt is first day post-op, right knee, partial weight bearing allowed. What gait should the pt use?

Right knee = odd number

First day post-op = severe

3-point

Pt is in advanced stages of ALS. What gait should the pt use?

ALS = bilateral

Advanced stages = severe

4-point gait

Pt with left hip replacement, 2nd day postop on non-weight bearing instruction. What gait should the pt use?

Non-weight bearing

Swing-through gait

Pt with bilateral (B/L) total knee replacement first day postop. Weight bearing is allowed. What gait should the pt use?

Bilateral = even

First day post-op = Severe

4-point gait

Pt with bilateral total knee replacement 3 weeks postop. What gait should the pt use?

Bilateral = even

3 weeks post-op = mild

2-point gait

What phrase will help you remember going up and down stairs with crutches?

"Up with the good, down with the bad."

Go upstairs with good foot first.

Go downstairs with bad foot last.

ALWAYS move crutches with the bad leg.

How do you hold a cane?

Handgrip should be at level of wrist.

Hold it on the unaffected (strong) side.

Advance with the opposite side.

How do you use a walker?

Hold onto your chair, stand up, then grab the walker. Pick up the walker, set it down, walk to it.

Where do you tie your belongings on the walker?

If you must, tie it on the SIDE so it won't tip over.

* Are tennis balls or wheels on walker okay? *

NO!! NCLEX does not like that.

What is the first thing to ask in a psych question?

"Is the patient psychotic or non-psychotic?"

How do you determine a person is non-psychotic?

The person has insight and is reality-based.

What communication technique do you use for a non-psychiatric patient?

Therapeutic communication

NCLEX is looking for "reflection, clarification, amplification, restatement, etc."

How do you determine a person is psychotic?

The person has NO insight and is NOT reality-based. They don't think they're sick - everyone else has the problem.

What are the symptoms of a psychotic person?

Delusions, hallucinations, & illusions

What is a delusion?

A false fixed belief, idea or thought.

This has no sensory component.

It's all in your head.

What is an example of a paranoid delusion?

"People are out to get me... They want to kill me."

What is an example of a grandiose delusion?

You think you are superior. "I am the president... I am the world's smartest person... I am JESUS CHRIST."

What is an example of a somatic delusion?

Body part. "I have x-ray vision... there are worms inside of my arm... these bugs are crawling in me."

What is a hallucination?

Perception of an object or event w/o an existing external stimulus.

What are the types of hallucination?

- Auditory (1st most common): Voices telling you to harm yourself

- Visual (2nd most common): I see bugs on the wall.

Tactile (3rd most common): I feel bugs in my arm.

Gustatory (Taste)

Olfactory (Smell)

What is an illusion?

A misinterpretation of reality. It is a sensory experience.

What is the difference between hallucination and illusion?

With illusion, there's a referent in reality.

With hallucination, there's nothing there.

The pt staring at the empty wall says, "Listen, I hear demon voices." Is that statement from the pt a hallucination and an illusion?

Hallucination

The same pt overhears nurses and doctors laughing and talking at the nursing station, and says, "I hear demon voices." Is that statement from the pt a hallucination and an illusion?

Illusion

What is the first question to ask after knowing a patient is psychotic?

"What type of psychosis does the patient have?"

What are the 3 types of psychosis?

Functional psychosis

Psychosis of dementia

Psychosis of delirium

What is functional psychosis?

Chemical imbalance of the brain, but they can still function in everyday life.

What are the types of functional psychosis?

"Skeezo, skeezo, major, manics."

Schizophrenia, schizoaffective disorder, major depression, and mania

90% of them make up this category.

Depression and mania =

Bipolar disorder

Bipolar pts are only psychotic in what type of psychosis?

Acute mania = functional psychosis

What is psychosis of dementia?

Actual brain destruction/damage.

What are some causes of dementia?

Alzheimer

Stroke

Organic brain syndrome

Anything that says "senile" or "dementia"

What is psychosis of delirium?

Temporary, sudden, dramatic, episodic loss of reality usually caused by some chemical imbalance in the body that is secondary to another issue.

What are some causes of delirium?

UTI

Thyroid imbalance

Adrenal crisis

Electrolytes

Medication/drugs

What is the approach to answering Functional Psychotic questions?

(1) Acknowledge feeling

(2) Present reality

(3) Set limits

(4) Enforce these limits

What is the approach to answering Psychosis of Dementia questions?

(1) Acknowledge feeling

(2) Redirect them to do something else

What is the approach to answering Psychosis of Delirium questions?

(1) Acknowledge feeling

(2) Reassure their safety and temporariness of their condition

Alzheimer lady is the lobby of waiting area of her nursing home. It is Sunday and she is all dressed up. You say to her, "Mrs. Smith, you are all dressed up." She said, "Yeah! My

husband is going to pick me up. We are going to church." The problem is that the husband has been dead for 10 years. How would you communicate with her?

(1) Acknowledge = "That sounds nice."

(2) Redirect = Let's sit down and talk about church. What church do you go to?"

A pt with schizoaffective disorder who points to 2 people talking across the room. The pt says, "Those people are plotting to kill me." What would you say?

Functional psychosis

(1) Acknowledge: "You seem frightened."

(2) Present Reality: "Those 2 people are my nurse co-workers. They are not plotting to kill you."

(3) Set limits: They are not trying to kill you. Let's talk about something else.

(4) Enforce them: I can see you are too ill. We'll end the conversation here.

A pt with Alzheimer disease who during your conversation points to 2 people talking across the room and says, "You see these people, they are plotting to kill me."

Alzheimer = Dementia

(1) Acknowledge: "You seem frightened."

(2) Redirect: "Let's go over somewhere you feel safe."

A pt with delirium tremens who during your conversation points to 2 people talking across the room and says, "You see these people, they are plotting to kill me"

Delirium tremens = Delirium

(1) Acknowledge: "You seem frightened."

(2) Reassure: "You are safe. Your fear will go away when you get better."

What are flight of ideas?

Rapid flow of thoughts

What is word salad?

Incoherent mixture of words.

They are sicker than flight of ideas.

What is neologism?

Inventing word that has no real meaning except for the person.

What is a narrowed self-concept?

When a psychotic patient refuses to change their clothes or leave their room. Functional psychosis.

DO NOT make a psychotic pt do something they don't want to do.

What is an idea of reference?

You think everyone is talking about you.

What is the hallmark of dementia?

Memory loss and inability to learn