NUR 3100 Exam 1

NUR 3100 Exam 1 3 Nursing Process - Diagnosis, interventions, outcome what to do during a diagnosis - risk for injury r/t unsteady gait What do you do during an intervention ? What actions are you going to take? - assist device, gait belt, exercise plan What happens during an outcome? - pt is injury free at discharge What are the four nursing assessments (physical)? - gait, activity tolerance, muscle strength, mobility 3 physiology of movement - skeletal system, muscles, and nervous system what does the skeletal system do? - provides support what do the muscles do? - move the bones around the joints what does the nervous system do? - trigger the contractions movement begins here 4 body mechanices - body alignment balance coordination (nervous system) joint mobility (range of motion) 3 nursing assessment : psychosocial effects - assess mental status assess emotional status assess sleep-wake pattern 3 things a positioning device does? - 1. maintain body alignment 2. prevent contractors 3. promote comfort types of devices - trochanter roll hand roll special beds pillows what does a trochanter roll do - provide support to the trochanter to prevent the hip from popping what is a hand roll? - wash clothe special beds? - Immobile patients are at risk for? - ure injuries due to decrease circulation red oxygen exchange to tissues 3. edema 4. atelectasis leading to pneumonia 5. blood clot formation 6. depression 7. constipation/ileus Fowlers position degree Semi-Fowlers position degree High Fowlers position degree - 60, 30, 90 Positioning the patient: 1.Orthopneic 3. lateral recumbent 4. sims 5. supine or dorsal recumbent - 1.90 with tripod support lying with bent legs lying with straight legs 4. 5. on back but dorsal recumbent is with legs up in a mechanical lift the ____ does the work - machine in a standing assist device it - support to help you stand but from a sitting position 8 Factors Affecting Mobility and Activity - 1. developmental stage: depends on age 2. nutrition: malnutrition 3. lifestyle: sedatory 4. stress 5. environmental factors 6. diseases and abnormalities 7. trauma 8. disorders of CNS Quality and Safety Education for Nurses is to - minimize risk of harm to patients and providers through both system effectiveness and individual performance What are some never events - 1. falls and trauma 2. foreign object left in clients 3. air embolism 4. catheter associated UTI 5. Blood incompatibility 6. Surgical site infections The joint commission : ____ events - sentinel event is a patient safety event that reaches a patient and results in any of the following: 1. death 2. permanent harm 3. severe temporary harm and intervention required to sustain life Risk for fall assessment: done at the time of ____ and at _____ intervals until _____ - time, regular. discharge for clients at risk for falls, repeat the risk assessment every ___ hours and monitor the patient _____ ______ - 8, more frequently Risk for fall assessment: verify _____ that increase the risk for falling - medication Morse Fall Scale - a simple method used to assess a client's likelihood of falling Morse fall scale consists of ____ variable that are quick and easy to score. Higher total number the _____ at risk you are - six; higher risk of falling varies greatly with different patient ______, _____ of ____, and different _____ of the patients illness - populations, times day, stages Get up and go test is used when - the patient reports having had a single fall or if you observe any difficulty with ambulation Restraint order: treatment must be prescribed by a provider in writing based on a ___ to ____ assessment of the clietn - face/face In a restraint order, it must include the____ , ___ and ____ of restraint and how long it may be used and the _____ ___ ______ that demonstrated by the client to warrant the restraint - reason, type, location type of behavior full range of motion - every joint you have in your body that extends and able to bring it up all the way active range of motion - independent how much you can do on your own passive range of motion - full extent you can do with the help of someone else baseline activity - standing, walking slowly, lifting light weights