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| The study of the movement of body parts (also called body mechanics) |
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| Most common injury of nurses |
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| Also known as decubitus ulcers or bedsores; occur from pressure on the skin; causes a local area of tissue necrosis (local death of tissue); Most often occurs between a bony prominence and external surface; Another main factor is shearing force |
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| An applied force that causes a downward and forward pressure on the tissues beneath the skin. Occur when a patient slides down in a chair, if bedclothes are pulled from beneath the patient, or the patient is slid up to the head of the bed without lifting the body |
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| Nursing diagnoses commonly used for problems with body movement: |
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Definition
Risk for injury
Impaired physical mobility
Risk for impaired skin integrity
Impaired walking
Risk for disuse syndrome
Powerlessness |
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| Expected outcomes for nursing diagnoses' for body movement |
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Definition
Patient will experience no musculoskeletal injury
Former level of mobility will be reattained within 6 months
Skin integrity will remain intact
Patient will not experience an injury while ambulating |
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| Changing positions accomplishes 4 things: |
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Definition
1) Provides comfort
2) Relieves pressure on bony prominences and other parts
3) helps prevent contractures, deformities, and respiratory problems
4) improves circulation |
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| When patients are resting on their back; recommended after spinal surgery |
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| Variation of the supine position; elevating the head of the bed 60 to 90 degrees |
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| Variation of the supine position; Elevation of 30 to 60 degrees |
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| Unless contraindicated, the knees can be raised __ to __ degrees in the Fowler's and Semi-Fowlers positions |
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Definition
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| Dorsal recumbent position |
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Definition
| Patients are on their back with knees flexed and soles of the feet flat on the bed |
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| Dorsal lithotomy position |
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Definition
| Used for examining the pelvic organs; like the dorsal recumbent position except feet are usually placed in stirrups and legs are farther apart |
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| Also called side-lying; patient is resting on their side; alleviates pressure from bony prominences on the back |
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| Variation of the side-lying position; used for rectal exams, administering enemas or inserting suppositories, or for an unconscious patient; weight is distributed over the anterior ilium, humerus, and clavicle |
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Definition
| patient is lying face down; provides an alternative for patients who are on prolonged bed rest or are immobilized; spinal cord-injured patients often use this position |
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| Variation of the prone position; Patient is face down on the bed with the head turned to one side. The chest, elbows and knees rest on the bed and the thighs are perpendicular to the bed; used for rectal exams and a method to restore the uterus to a normal position |
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Definition
| pillows, boots or splints, footboards, cushioned boots or high-top sneakers, a trapeze bar, sandbags, hand rolls, trochanter rolls, side rails, and bed boards |
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Definition
| Technique to move a patient; Turning the patient as a single unit while maintaining straight body alignment at all times; often used for patients with injuries or surgery to the spine |
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| Range-of-motion exercises |
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Definition
| Full range-of-motion exercises should be performed either actively or passively several times a day |
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Definition
| Used for the patient who independently performs activities of daily living but is immobilized or limited in activity due to injury or surgery |
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| Performed on the patient who cannot actively move; cannot contract muscles, so muscle strengthening cannot be accomplished. All muscles over a joint are maximally stretched; accomplished by moving the muscles to the point of slight resistance but no further; to prevent joint injury, support the limb to be exercised above and below the joint |
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Definition
| Patient position of sitting on the side of the bed with the legs and feet over the side. The feet are either on the floor or supported on a footstool; often the first step before sitting in a chair or ambulating |
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Definition
| Place wheelchair parallel to the side of the bed and lock the wheelchair; place transfer belt on pt if pt is weak or paralyzed on one side; lower bed and side rail, elevate the head of the bed to highest level pt can tolerate; assist pt to turn onto side; help pt sit up and dangle; place slippers on; place chair so it is closest to patient's strongest side; assist pt to stand, pivot pt 90 degrees so back is facing the seat of the chair; assist pts feet into the foot rests |
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| To use a roller board to transfer a pt to a stretcher, turn the pt to one side and place the roller board and lift sheet underneath the pt; return pt to a supine position and place the stretcher against the bed with the side rail down; lock stretcher wheels; one or more nurses on far side of the bed and you and one other nurse on far side of stretcher; lift sheet held as close to the pt as possible; on count of 3, pt is pulled across roller board; the nurses on the other side of the bed support pts head and feet and help guide pt to the stretcher |
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| Also called a transfer belt; may be used to ambulate and/or transfer the weak or unsteady pt; Insert your hand into the belt from the bottom so if the pt falls you will be able to support the weight; Skill 18-6 on pg 283 discusses how to assist a pt to ambulate and how to break a fall |
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| Practice of cleanliness that is conducive to the preservation of health |
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Definition
| Bathing provides exposure to assess the skin |
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| Factors that affect hygiene |
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Definition
| Sociocultural background, different cultures have different views on hygiene practices; economic status, money for supplies may not be available; Lack of knowledge; No ability to perform self-care; personal preference |
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| Pressure ulcer risk factors |
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Definition
Major factors:
Bed or chair confinement
Inability to move
Loss of bowel or bladder control
Poor nutrition
Lowered mental awareness
Contributing factors
Dehydration
Obesity
Excessive diaphoresis
Extreme age causing fragile skin
Edema |
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Definition
| Interference with circulation causes the skin to turn white or, in darker skin, turn pale; if pressure is relieved at this point the skin will become red or a darker color because of vasodilation |
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Definition
| Process in which the blood rushes to a place where there was a decrease in circulation |
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Definition
| Area of red, deep pink, or mottled skin that does not blanch with fingertip pressure. In people with darker skin, discoloration of skin, warmth, edema, or induration (area feels hard) may be signs of a stage I pressure ulcer |
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Definition
| Partial-thickness skin loss involving epidermis and/or dermis. May look like an abrasion, blister, or shallow crater. Area surrounding the damaged skin may feel warmer |
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Definition
| Full-thickness skin loss that looks like a deep crater and may extend to the fascia; subcutaneous tissue is damaged or necrotic; may be damage to the surrounding tissue; bacterial infection and drainage are common |
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| Full-thickness skin loss with extensive tissue necrosis or damage to muscle, bone or supporting structures; sinus tracts may be present. Usually widespread infection; ulcer may appear dry and black with a buildup of eschar (tough, necrotic tissue), or it can appear wet and oozing |
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| Prevention of pressure ulcers |
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Definition
| #1 prevention is good nursing care |
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| Nursing diagnoses for hygiene and skin integrity problems |
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Definition
Chronic low self-esteem
Imbalanced nutrition
Impaired physical mobility
Impaired skin integrity
Ineffective peripheral tissue perfusion
Pain (acute or chronic)
Risk for impaired skin integrity
Self-care deficit, bathing/hygiene
Self-care deficit, dressing/grooming
Sensory perception, disturbed (visual) |
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| Nursing goals for hygiene |
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Definition
The patient's skin integrity will be maintained
The patient's hair is clean and neatly styled each day
The patient's mouth is intact and free from odor |
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| Four basic purposes for bathing |
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Definition
1) cleanse the skin
2) promote comfort
3) stimulate circulation
4) remove waste products secreted through the skin |
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Definition
Cleansing, therapeutic, partial, complete
Pg. 295 |
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| Benefits of a back massage: |
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Definition
Communicates caring
Fosters trust in the nurse-patient relationship
Provides an opportunity to assess the skin on the back
Stimulates circulation of blood to the area
Reduces tension and promotes relaxation |
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| Mouth care for the unconscious patient |
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| A pt who is unconscious should be provided full mouth care at least once every 8 hours; if pt is mouth breathing it should be done every 4 hours; moist swabbing of the mouth is done every 2 hours or as needed |
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Definition
When not in the mouth, dentures should be kept in a labeled denture container containing water or normal saline
Skill 19-3 on pg 306 |
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| Elective surgery, emergency surgery, palliative surgery, diagnostic surgery, reconstructive surgery or curative surgery |
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| Patients at higher risk for surgical complications |
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Definition
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Definition
| Refers to the care of the pt from the time of the decision to have surgery through recovery from the procedure |
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| The surgeon is responsible for obtaining an informed surgical consent |
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| The most common type of bath; generally provided in either a bed, tub, or shower. Bed baths are given to pts who are unable to use a tube or shower. |
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Definition
| Having healing or medicinal qualities. Performed to achieve a desired effect and include several types. |
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| Type of therapeutic bath; done in a bathtub or whirlpool tub. Heat of the water and agitation gently massage the skin. Whirlpools are used to cleanse, stimulate peripheral circulation, and provide comfort. |
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| What type of baths are used for patients with dermatitis? |
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Definition
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Definition
| Used to apply moist heat and clean the perineal or anal area. Promotes healing and relieves pain and discomfort; commonly used after birth and vaginal or rectal surgery |
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Definition
| Usually indicated to cleanse open wounds or apply medicated solutions to an area |
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| known as tepid sponge baths; an order is usually needed before this type of bath may be used to bring down a fever |
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| Mouth care for the conscious pt |
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Definition
| Raise the head of the bed 45 to 90 degrees; wear gloves; if pt is unable to sit up, turn the pt to the side facing you; place a towel under chin; brush from gun line to the edge of the teeth |
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Definition
| Brushing and combing the hair stimulates circulation, which helps promote hair growth, prevent hair loss, distribute oil along hair shafts, and bring nutrients to the roots |
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| A safety razor should not be used when a patient has |
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Definition
| low platelet count, is receiving and anticoagulant, is undergoing chemotherapy, or is on high-dose aspirin therapy |
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Definition
| Toenails of a diabetic pt or one with circulatory disease of the lower extremities should not be cut without a physician's order. Soak nails in warm soapy water for 5 to 10 minutes, clean under nails, push cuticles back, cut toenails straight across |
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Definition
| If crusting is noted, soak the eyelid with a warm, damp washcloth for 2 to 3 minutes to soften the crust and ease its removal |
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Definition
To clean lenses, use clean warm water and a soft cloth.
Moisten contacts and rub it gently between the fingers. It is important to place the lens in the correct compartment of the case |
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Definition
| hearing acuity may be affected if cerumen or foreign material collects in the external ear canal; Remove by washing with a warm washcloth. No object, including ear swabs, should be inserted into the ear canal; If ear wax is dried or excessive you may need to irrigate. In this case, contact physician |
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Definition
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| Why are infants and elderly people at a higher risk of surgical complications? |
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Definition
Immature body systems (infants) or decline in function of various body systems (elderly)
Maintaining core body temp is a concern
Risk for dehydration or overhydration |
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Definition
| removal or destruction of |
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| Joining of two parts, ducts, or blood vessels |
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| to furnish with an outlet |
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| revision, molding, or repair of tissue |
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| fixation, anchoring in place |
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| Laser surgery is common today and is often combined with microscopic, endoscopic, and robotic enhanced procedures. A laser is a tube that contains a medium such as carbon dioxide or another active gas, which is energized by electricity |
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| Light amplification by the stimulated emission of radiation |
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| Allows the use of endoscopes with high resolution video cameras passed through a very small incision; small growths and organs can be removed without making a traditional surgical incision |
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| Goals of anesthesia administration: |
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Definition
1) to prevent pain
2) to achieve adequate muscle relaxation
3) to calm fear, ease anxiety, and induce forgetfulness of an unpleasant experience |
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