Examples of Physical restraints

• side rails- need dr. order
• Geriatric chairs w/ attached belt
• attachment of wrist/ankle/waist
• posy vest

examples of chemical/pharmalogical restraints

• tranquilizers
• sedetives
• sleeping pills

reasons for physical restraints

• restrict extremity movement
• keep client from pulling out tubes/removing dressing
• reminders
• combative ptnts.(alzheimers/dementia)

 what hospitals say and what study shows

• say restraints keep clients from falling
• study shows restraints cause 3x's more falls

federal/state/jcho mandates:

• restraints used as last resort

who says  restraints should be by prescription only?

FDA: Food and Drug administraion

physical hazards associated with restraints

• suffocation
• impaired circulation:twists of restraint
• altered skin integrity
• pressure ulcers
•  contractures
• Diminished musc/bone mass
• fractures
• altered nutrition and hydration
• aspiration/breathing diffuculties
• incontinece
• sensory deprivation
• emotional distress

ambularm

• worn on leg
• signals when leg in dependent position( over rail, on floor)

integral bed alarm

• beeps if ptnt weight off mattress for more than a few seconds

Use restraints

• PRN
• when ptnt. suicidal

R-E-S-T-R-A-I-N-T

protocol

R:espond to present> elavuate current need

E:valuate potential for injury to self/others

S:peak to family members

T:ry alternative meausres first

R:eassess ptnt.>if alternative measures effective

A:lert family/physician

I:nuvidualize restraint

N:ote important info on ptnt. (document)

T:ime> release ptnt. as soon as no longer risk

Restraint order must include

• type
• reason necessary
• criteria for removal
• intended duration of use

How often restraint need order &

how often released?

• Dr. Order needed q24 hrs
• restraint to be realease q2hrs & excercised

need what for restraint

Documentation for restraints

• date/time applied
• alternatives attempted & results
• That dr. & family notified
• frequency of assessment
• interval restraints removed
•  any nrsng. interventions

ORIF

THA

total hip arthroplasty

DVT

deep vein thrombosis

PE

pulmonary embolism

PAS

pulsating anti-embolism stocking

WBAT

weight bearing tolerated

PWB

Partial weight bearing

FWB

Full weight bearing

TDWB

touch down weight bearing

(can touch foot but no weight)

traction

• method>pulls structures of musculoskeletal system
• requires countertraction

countertracion

• clients own weight
• bed may be in trendelenburg
• necesary for effectivness

Purpose of traction

• Relax/relieve muscle spasms
• correct/prevent contractures
• reduce dislocations
• maintain immobilization
• (may be temporary)

skin traction

• pulling force to skin/soft tissues
• indirectly affects muscles&bones

Bucks traction

• Most common
• traction boot attached to rope w/weights hanging off bed

Skin traction purpose

• used to
  • immobilize
  • decrease pain/spasms
  • temporary use b-4/waiting for surgery

disadvantages of skin traction

• skin
• elimination      >      PROBLEMS
• resp.

usual weight of skin tracion

skeletal traction

• applied directly to bone
• use of wire/pin/cranial tongs
• pull from connecting attachment from ptnt. to ropes/pullys/weights on bed

usual weight and disadvantages of skeletal traction

• 20-30lbs
• infection from insertion area

types of skeletal traction

• Kirschner
• steinman
• crutchfield(cervical skeleton uses crutchfield tongs/halo)
• external fixation devices>for complex fractures

traction weights must...

skin problems with traction to be assessed

• breakdown/pressure ulcers
• infection at puncture site
• must be removed and assessed once q shift

CMS check

C:irculation>temp., pallor, capillary refill, pulses

M:movement> ROM in all parts

S:enasation> pain level>sharp/dull sensation on

   up& lo of extremity

Diet for tissue growth

• protein
• calcium
• vit. c
• fiber
• zinc
• FF

• Constipation
  • Fiber,FF,excerise,prune juice, laxatives,
• anorexia:
  • good oral care, good diet

Nrsng interventions for hypostatic phemonia

• cough
• deep breath
• IS
• exercise

Nrsng. interventions for thrombo phlebitis

• Ted hose
• movement

Nrsng interventions for osteoporosis

• increase activity

nrsing intervention for disorentation and boredom

• sensory stimulatoin
  • radio
  • TV
  • reading
  • etc...

Pin Care

• Assess 4 infection/no damage
• use steril salin on cotton tip
• clean pin outward & remove crust

higher incidence of hip fracture

• higher in women cuz
  • more prone to osteoporosis
  • live longer
  • have wider hips

S&S of hip fracture

• Sever pain increases w/movement
• may radiate down to knee
• extremity externally rotated(toes out)
• affected extremity shorter
• swelling/bruising

    ( SMEAS)hint

femoral neck  hip fracture

• also trancervical fracture
• intracapsular bleeding contained
• interfere w/blood supply to femur head
• reduced by ORIF w/pin/nail

hip fracture of intertrochanteric region

• fracture btwn. > & < trochanters
• Risk for large blood loss
• pinning is treatment of choice

hip fracture of subtrochanteric region

• below trochanters
• risk of large blood loss
• pin/nail treatment of choice

nrsng interventions of hip surgery

• bucks traction
• foley
• wound drain (1-2 post-op)
• dressing
• turn q 2 hrs/positioning
• IS, TCDB
• Teds
• amb asap

TCDB

• turn
• cough
• deep breathing

Medicate prior to:

• physical therapy/dressing change

cast composition

• fiberglass
• polyester
• thermoplastic material

guidlines for using walker

• stand btwn. back legs of walker,aligned w/hands
• lead with bad leg first
• never use on stairs

angle of arms  and fit for walker

• should extend from floor to hip joint
• 30°

canes with single tip

• minimum support
• can use on stairs
• handle straight or curved  (?ask if difference)

3-4 leg prong cane

for ptnts with poor balance

fit and arm angle for canes

• 30 degrees
• extend from floor to ptnt hip jnt

using cane

• held on strong side( opposite of bad)
• first cane>bad leg first(ask??)>then strong leg 

cane should be adanced...

4-12 inches( ask??)

measuring for axillary crutches

lying down

• measure from anterior fold of axillary down to heal & add 1 inch

measuring axillary crutches standing up

• pos. pad 3 inch below axilla
• bottom of crutch to side of heal 4-6 inches

guidlines for crutches

• not nesseled into armpit
• use hand to support weight
• when sitting/standing...both crutches in 1 hand on strong side

crutches on stairs

• up: good leg> bring crutches up>then bad leg
• down:crutches first>bad leg>then good

2 pnt gait

• partial weight bearing, on both feet
• advance foot and opposite crutch at the same time

• non wieght bearing
• advnace 1 foot, then other foot and both crutches

• partiel wieght bearing, both feet

• weight bearing both feet
• advance both crutches, then both feet next to crutches

swing through gait

• weight bearing. both feet
• advance crutches, swing both feet through in front of crutches

Granulation tissue

• new tissue (proliferation phase)when healing
• beefy red color
• CT w/ good blood supply

fibroblasts

• any cell that develops CT

Ischemia

• Inadequate blood supply

Necrosis

• death of cells/tissue

pressure ulcer

• lesion caused by unreleaved pressure
• damage to underlying tissue

shearing force

• force created when layers of tissue move on 1 another

epithelialization

• (maturation phase) stage of wound healing
• epithelial cells move acros wound
• color of ground glass to pink

eschar

• thick, black,leathery scab or dry crust
• necrotic tissue
• must be removed for adequate pressure ulcer staging to occur

exudate

• flow of fluid from wound/cavity
• may contain
  • serum
  • blood
  • cellular debris
  • bacteria
  • white blood cells

integument

integumentary syst.

• system of skin
  • epidermis
  • dermis
  • sub-q tiss.
  • hair
  • nails

• protection
• regulate temp.
• sensory
• excretory
• maintains fluid/electrolyte balance
• produces/absorbs vit. d

• pressure over area>capillary collapse>poor profusion to tissue>necrosis/ulcer formation

those at risk for shearing/fritction forces

• those pulled and not lifted
• those partially sitting up in bed> slides down

poorly nourshied cells>

maceration

• softening of skin
• causes skin breakdown

excoriation

• denuting superficial layer of skin from chemicals

main cause of wounds

• impaired circulation

pre-ulcer changes in beggining

stage 1 ulcer

• Non-blanchable>redness doesnt go away
• skin still intact
• itching/pain at site
• treat by releiving pressure

stage 2 ulcer

• partial thickness of skin loss
• superficial layer gone(abrasion or shallow crater)
• Treated with moist dressing/hydrogel dressing(duoderm)

duoderm

stage 3 ulcer

• full thickness of skin loss
• damage/necrosis to Sub.q layer
• extends down to, not through faschia
• treatment: debridament, wet 2 dry dressings, surgery, protein enzymes

faschia

stae 4 ulcer

• full thickness skin loss, tissue necrosis
• damage to muscle/bone/supporting structures
• Treatment: cover w/ nonadherent dressings-change q 8-12 hrs, debridament,skin graph

documents of pressure ulcer

• location
• size
• depth(bulls eye)
• drainage

COCA

(drainage)

C: olor

O: dor

C: consistency

A: amnt.

use what for cleaning ulcer

how long ahead should you med. ptnt for wound dressing?

assesses pressure ulcer risk factor

what to remeber about red areas

Diagnosis:

Risk for impaired skin integrity

• have 1/more risks for skin breakdown

 Diagnosis:

Impaired skin integrity

• Have damage to epidermis/dermis
• Stage 1-2 ulcer

diagnosis:

Impaired tissue integrity

• when wounds extended in-2 sub.q layer,muscle,bone
• Stage 3-4 ulcers

 Diagnosis:

Risk for impaired tissue integrity

• when have impaired skin integrity & @ high risk 4 delayed healing

Diagnosis:

Risk for infections

• has tramatic wound: is
  • immunosuppressed
  • undernourished
  • immobile

primary responsibility of nurses

discharge planning starts:

what goes with ptnt, to new facility

• NOT CHART
• discharge summary
• MD order
• DOCUMENT

AMA

• against medical advice
• Must be signed to release dr./hospital from responsibility if ptnt. leaves against advice
• if ptnt. sneeks out> document

makes sure  family/ptnt does what when discharged

• demonstrates not just verbalize how to do procedure