- Always knock or announce your entrance into the patient's room or area and introduce yourself.
- Orient the patient to the environment, counting steps
... [Show More] with him or her to the bathroom
- Help the patient place objects on the bedside table or in the bed and around the bed and room and do not move them without the patient's permission
- Remove all objects and clutter between the patient's bed and the bathroom.
- Use a normal tone of voice.
What are some nursing interventions for visual impairment?
anisocoria
a condition in which the pupils are unequal in size
exophthalmos
protrusion of the eyeballs, as seen in Graves disease
enophthalmos
sunken eyes, eyeballs are recessed
ptosis
prolapse, downward displacement, dropping
- Put in lower conjunctival sac
- Do not drop in center of eye
- Stabilize hands on facial structures (bony prominences)
- Hold the inner eye to avoid systemic effects (punctal occlusion)
- Do not let dropper touch their eye
- Wash hands before
Patient education for instilling eye drops
punctal occlusion
Drainage of topical drops from the eye and their systemic absorption can be prevented by _________ _________?
· Blurred vision
· Clouded vision
· Decreased color perception
· May think that glasses are smudged
· Double vision
· Halos around objects
· Problems with ADL'S
· Affects reading and driving
· Impaired night vision
· Frequents changes in eyeglass prescription
· Without surgical intervention blindness follows
Signs and symptoms of cataracts
· Wear dark glasses and avoid bright sunlight
· Do not drive
· Develop a schedule for the administration of post-op eye drops. Be sure client or family can demonstrate the correct technique for administering the drops.
· Report Worsening Vision
· Observe for increasing eye redness
· Decrease in vision
· Floaters
· Sharp, or sudden pain in eye
· Green or yellow drainage on the lids and lashes
***avoid anything that increases IOP like...
· Do no bend at the waist
· Lift more than 10 pounds
· Sneeze or cough
· Blow your nose
· Strain to move bowels
· Have sexual intercourse
· Vomit
· Keep head in a dependent position
· Wear tight shirt collars
Patient Education for post-op cataract surgery
glaucoma
When the intraocular pressure increases it leads to compression of the retinal blood vessels and photoreceptors and their nerve fibers resulting in hypoxemia and death of the tissue and permanent loss of vision
- Sudden severe pain around the eyes radiating over the face
- Headache or brow pain
- Nausea and vomiting
- Seeing colored halos around lights
- Sudden blurred vision
- Reddened sclera
- Foggy cornea
- Moderately dilated pupil that does not react to light
- Cupping and atrophy of the optic disc
Signs and symptoms of glaucoma
10 mm Hg - 21 mm Hg
What is the normal intraocular range pressure?
reduce intraocular pressure
What is the goal of treatment for glaucoma?
tonometry - measures IOP
ultrasonic imaging of the retina and optic nerve - creates a three-dimensional view of the back of the eye; tells us the TYPE of glaucoma
How do you test for glaucoma?
corneal staining
dye outlines irregularities of corneal surface (used for corneal trauma, problems caused by contacts, or presence of foreign bodies, abrasions, ulcers, or other corneal disorders).
Assess vital signs (specifically BP and P)
These drugs (like timolol) potentiate the effects of systemic beta blockers and can cause an unsafe drop-in heart rate and blood pressure
Before administering eye drops, what must the nurse assess and why?
Meniere's disease
Abnormal condition within the labyrinth of the inner ear that can lead to a progressive loss of hearing. The symptoms are dizziness or vertigo, hearing loss, and tinnitus (ringing in the ears).
Patient should not drive
Can be intermittent.
Cause is unknown/genetic
Can be dangerous to patient (fall risk!)
***build-up of fluids
- Turn head slowly
- Stop smoking
- Reduce sodium intake (so less fluid buildup/pressure)
- Use medications as directed
Patient education for Meniere's disease
monitor vital signs
Post surgical care for tympanoplasty
Weber test
The ________ test is performed by placing a vibrating tuning fork on the middle of the patient's head and asking him or her to indicate in which ear the sound is louder.
Sound heard equally in both ears
What are normal results of the Weber test?
systolic (90-120)
diastolic (60-80)
Normal blood pressure ranges for systolic and diastolic
60-100 bpm
Normal pulse range
Temperature (96.4-99.5 F)
- Oral (98.6 F)
- Tympanic (99.6 F)
- Rectal (99.6 F)
- Axillary (97.6 F)
Normal temperature ranges per thermometer type
12-20 bpm
Normal respiratory rate range
94%-100%
Normal pulse oximetry range
- spread your feet far apart to lower the center of gravity
- lifting an object from the floor, flex your hips,
knees, and back.
- bring the object to thigh level, bending your knees and keeping your back straight.
- stand up while holding the object as close as possible to your
body, bringing the load to the center of gravity to
increase stability and decrease back strain.
- face the direction of movement
*ATI Ch. 14 p.73-76
How does a nurse maintain balance and body posture when lifting?
to stretch (before and after exercise) to promote ROM
Patient education for flexibility
· Improves pulmonary circulation (keeping the tissue well oxygenated, healthy, and elastic.)
· Improves gas exchange at the alveolar-capillary membrane, and overall aerobic capacity.
· Dilates bronchioles to increase ventilation/gas exchange.
What are the benefits of regular exercise on the Respiratory System?
· Improves skeletal development in children.*****
· Increases muscle mass, strength, power, and endurance.
· Improves flexibility.
· Increases coordination.
· Helps maintain joint structure and function; reduces risk of osteoarthritis.
· Improves bone mass and mineral density.***important for our older patients
· Improves gait speed, stability, and balance.
· Facilitates weight management.
· Decreases adipose surrounding organs.
What are the benefits of regular exercise on the Musculoskeletal System?
· Improves appetite.
· Improves abdominal muscle tone.
· Decreases risk of colon cancer.
· Walking increases peristalsis***
What are the benefits of regular exercise on the Gastrointestinal System?
· Improves skin tone as a result of improved circulation (so improved turnover of skin cells).
What are the benefits of regular exercise on the Integumentary System?
· Reduces susceptibility to minor viral illnesses.
· Reduces systemic inflammation.
· Improves bone mass with aging; reduces risk of osteoporosis.
· Reduces risk of falls and helps older adults maintain an independent lifestyle.
· Important for patients with an inflammatory disorder***
What are the benefits of regular exercise on the Immune System?
· Boosts energy level.
· Release endorphins, which assist with pain control and stress management.
· Improves self-esteem and body image.
· Provides a nonpharmacological way to relieve symptoms of anxiety and depression.
· Leads to positive outlook and sense of optimism.
· Promotes clearer thinking and improved memory in older adults.
· Enhances feelings of well-being and diminishes depressive symptoms.
· Relieves some stress.
· Can be a source of social interaction.
What are the benefits of regular exercise on Mental Health?
45-60 degrees
What degree is the headrest for Fowler's Position?
30-45 degrees
What degree is the headrest for Semi-Fowler's Position?
60-90 degrees
What degree is the headrest for High-Fowler's Position?
High Fowler's Position
What position would you set the bed for a patient that is having trouble breathing?
Supine (totally flat)
What position would you set the bed for a patient that has low BP?
➤Use a friction-reducing device to move the patient if the patient can assist with movement. Use a full body sling if the patient cannot assist.
➤ Remove the pillow. Have the patient flex her neck, fold her arms across her chest, and place her feet flat on the bed.
➤ Position a nurse on either side of the patient.
➤ Use a wide base of support.
➤ Have the patient, on the count of 3, push off with his heels as you shift your weight forward
What do we instruct the patient to do when we are moving them off the bed?
- increases workload of the heart
- venous stasis (leads to DVT)
p. 831 Funds book
What are the effects of immobility on the Circulatory System?
o contractures and ankylosis can occur (fusion of joints)
o loss of muscle mass and strength
o muscles stiff and inflexible
o affects parathyroid function and calcium metabolism-therefore bone formation, leading to osteoporosis and renal calculi (kidney stones) due to increased excretion of calcium
p. 831 Funds book
What are the effects of immobility on the Musculoskeletal System?
o decreases strength of all muscles, but also those involved in chest wall expansion, affecting ventilation
o secretions pool in airways (because alveoli collapse) and lose strength to effectively cough** and expectorate secretions (clear airways)***
o Depth of respiration decreases
o leads to compression and injury of small vessels in the legs and decreased clearance of coagulation factors, causing blood to clot faster-aka Virchow's triad- (stasis, activation of clotting, and vessel injury, trilogy of symptoms associated with great chance of DVT)
o orthostatic hypotension
p. 831 Funds book
What are the effects of immobility on the Respiratory System?
- slows peristalsis (so risk for constipation)
- appetite diminishes
- food digested slowly
- decreased calorie intake/inability to meet protein demands
body muscle then broken down as food source
-in extreme situations, paralytic ileus can occur
p. 831 Funds book
What are the effects of immobility on the Gastrointestinal System?
atrophy
decrease in the size of muscle tissue due to lack of use or loss of innervation.
hemiplegia
paralysis of one side of the body
paraplegia
paralysis of the lower half of the body
parasthesia
numbness, tingling, or burning due to injury of the nerve(s) innervating the affected area
Flexion
decreases the angle of the joint and brings two bones closer together
extension
increases the angle of a joint and brings two bones farther apart
abduction
movement away from the midline
adduction
movement toward the midline
pronation
movement that turns the palm down
supination...."up and sup"
movement that turns the palm up
circumduction
the circular movement at the far end of a limb
elevation
raising a body part
depression
lowering a body part
inversion
Turning the sole of the foot inward
eversion
turning sole of foot outward or laterally; standing with weight on inner edge of foot
active range of motion
Range of motion exercises completed by the resident without assistance
passive range of motion
the process of putting a joint through its full extent of movement by someone other than the patient
§ Cancer or chemotherapy
§ Surgical procedure longer than 30 minutes
§ History of smoking
§ Obesity
§ Heart disease
§ Prolonged immobility
§ Oral contraceptives or hormones
§ History of VTE complications
§ Older adults (especially with hip fractures)
Risk factors of DVT
Redness over a vein
Warmth over a vein
Tenderness over a vein
Ropiness/Hardening ("induration") over a vein
Swelling of the calf
Signs and Symptoms of DVT
Measure calf circumference
How do we assess for DVT?
• Patient education
• Leg exercises
• Early ambulation
• Adequate hydration
• Graduated compression stockings
• Intermittent pneumatic compression, such as sequential compression devices (SCDs)
• Venous plexus foot pump
• Anticoagulant therapy
p. 473 Med Surg book
What can patients do to prevent DVT?
promoting client independence
What is the goal of adaptive devices?
-positioning: high-fowlers/orthopenic position; reduces risk of aspiration during meals
-mechanic vent/trach/nasal cannula
-incentive spirometer (forces pt to take deep breaths)
-deep breathing exercises, teach to cough
What are some interventions to promote respiratory function?
· Immobility
· DM
· Obesity
· Lack of perfusion (vascular problems)
· Poor nutrition (if they are not getting protein, body tissue is breaking down!)
· Chronic diseases can cause complications
Risk factors for pressure ulcers
rest, ice, compression, elevation
sprains
What does RICE stand for? and what is it used for?
weak, porous bone tissue
Why are osteoporosis patients prone to fractures?
after age 50
When should we screen for osteoporosis?
• increase consumption of dairy products/dark green leafy veggies
• sun exposure/adequate vitamin D in diet
• smoking cessation
• weight loss
• avoid excessive alcohol
• encourage daily exercise-regularly scheduled walking, swimming, water aerobics, yoga, tai chi, low impact***
• avoid jarring exercise-horseback riding/jogging
Patient education for osteoporosis
-educate about medications (antibiotics! ***...finish prescription, etc.)/encourage compliance and to follow regimen
-inform about s/s (watching for complications such as increasing pain, things not healing right...)
-provide comfort w/rest and positioning
-assist in ADL
-coordinate PT while in hospital to improve mobility, especially after surgery
-provide mobility assistance devices
Patient education for osteomyelitis
reduced circulation...so slower healing...sore and injuries on lower extremities take longer to heal
Common complication of Plantar fascilitis
floating cartilage and bone fragments
What is crepitus caused by in the joints?
o Reflexes
o Neuro testing - sensations (dull, sharp)
o Edema
• Pain
• Movement
• Sensation
• Warmth
• Temperature
• Distal pulses
• Capillary refill (not as reliable as the above indicators)
p. 1024 Med Surg book
Components of a Neurovascular assessment
provocative/palliative, quality, region/radiation, severity, timing
What does PQRST stand for?
o Is the patient pregnant?
o Does the patient have ferromagnetic fragments or implants, such as an older-style aneurysm clip?
o Does the patient have a pacemaker, stent, or electronic implant?
o Does the patient have chronic kidney disease?
o Can the patient lie still in the supine position for 45 to 60 minutes?
o Do they have anxiety?
o Did the patient get any tattoo more than 35*** years ago? (If so, metal particles may be in the ink.)
o Is the patient claustrophobic?
What are some MRI screening questions?
complete fracture
The break is across the entire width of the bone in such a way that the bone is divided into two distinct sections. If bone alignment is altered or disrupted, the fracture is also referred to as a displaced fracture.
The ends of bone sections of a displaced fracture are more likely to damage surrounding nerves, blood vessels, and other soft tissues.
incomplete fracture
The fracture does not divide the bone into two portions because the break is through only part of the bone.
This type of fracture is not typically displaced.
displaced fracture
A fracture in which bone fragments are separated from one another and not in anatomic alignment.
open/compound fracture
one in which the bone is broken and there is an open wound in the skin
These fractures are often graded to define the extent of tissue damage
closed/simple fracture
A _____ fracture does not extend through the skin and therefore has no visible wound.
1. hematoma
2. fibrocartilage
3. soft callus
4. hard callus
5. remodeling
List the 5 stages of bone healing (simplified)
In stage one, within 24 to 72 hours after the injury, a hematoma forms at the site of the fracture because bone is extremely vascular.
What happens during Stage 1 of bone healing?
Stage two occurs in 3 days to 2 weeks when granulation tissue begins to invade the hematoma. This then prompts the formation of fibrocartilage, providing the foundation for bone healing.
What happens during Stage 2 of bone healing?
Stage three of bone healing occurs as a result of vascular and cellular proliferation. The fracture site is surrounded by new vascular tissue known as a callus (within 3 to 6 weeks). Callus formation is the beginning of a nonbony union.
What happens during Stage 3 of bone healing?
As healing continues in stage four, the callus is gradually resorbed and transformed into bone. This stage usually takes 3 to 8 weeks.
What happens during Stage 4 of bone healing?
During the fifth and final stage of healing, consolidation and remodeling of bone continue to meet mechanical demands. This process may start as early as 4 to 6 weeks after fracture and can continue for up to 1 year, depending on the severity of the injury and the age and health of the patient.
What happens during stage 5 of bone healing?
1. hematoma (24-72 hours)
2. fibrocartilage (3 days-2 weeks)
3. callus (3-6 weeks)
4. hard callus (3-8 weeks)
5. remodeling (4-6 weeks after the fracture, can continue up to 1 year)
List the time frames of each of the stages of healing:
1. hematoma
2. fibrocartilage
3. soft callus
4. hard callus
5. remodeling
heat (checking for necrosis)
pain level
odor
inspect every 8-12 hours for drainage, alignment, and fit
Nursing interventions for cast care (what nurses monitor)
monitor for "hot spots" (infection)
smell for odor (infection)
monitor for fever (infection)
monitor for complications
don't put anything down the cast to scratch (skin damage)
Patient education for cast care
pain, pressure, paresthesia, pallor, paralysis, pulselessness
The 6 Ps of Compartment Syndrome
OREF because the pins are external
Which is more prone to infection and why? OREF vs ORIF
delayed union
________ is a fracture that has not healed within 6 months of injury.
Some fractures never achieve union; that is, they never completely heal (nonunion). Others heal incorrectly (malunion). These problems are most common in patients with tibial fractures, fractures that involve many treatment techniques (e.g., cast, traction), and pathologic fractures. Union may also be delayed or not achieved in the older patient due to poor bone health. If bone does not heal, he or she typically has chronic pain and impaired MOBILITY from deformity.
venous thromboembolism
VTE stands for
Venous Thromboembolism (VTE)
deep vein thrombosis (DVT) followed by pulmonary embolism (PE) is called?
Complex Regional Pain Syndrome (CRPS)
dysfunction of central and peripheral nervous system that leads to chronic pain
-occurs in feet or hands
-genetic factors may contribute
- S/S: changes in color, temperature, sensitivity, excessive sweating, edema
traction
a pull to the arm or leg muscles to bring a bone back into place when it is dislocated or fractured
- It is also used as a last resort to decrease muscle spasm (thus relieving pain) and prevent or correct deformity and tissue damage
- keep extremity properly aligned
monitor for patient pain
monitor neurovascular checks of affected limb
monitor pin sites for infection
monitor for immobility issues
check traction equipment every 8-12 hours
weights usually are not removed without a prescription.
weights should not be lifted manually or allowed to rest on the floor.
weights should be freely hanging at all times.
inspect the skin at least every 8 hours for signs of irritation or inflammation.
remove the belt or boot that is used for skin traction every 8 hours to inspect under the device.
Nursing interventions for traction
running traction
In _______ traction, the pulling force is in one direction, and the patient's body acts as countertraction. Moving the body or bed position can alter the countertraction force.
Balanced suspension traction
_______ traction provides the countertraction so the pulling force of the traction is not altered when the bed or patient is moved. This allows for increased movement and facilitates care
skeletal traction
a method of immobilization and reduction of a long-bone fracture in which traction is applied by means of pins and wires
buck's traction
Boot attached to 5 - 10-pound weight used to relieve muscle spasm pain from a hip or proximal femur fracture.; we use it frequently with the hip if the patient cant have surgery or pre-surgery
knee immobility; dont adjust weights
Halo (cervical) traction
Halo type bar that encircles the head screws are inserted into the outer table of the skull. The halo is attached to bed or rods that is secured to a rest
Russel's traction
for fracture of femur or lower leg
skeletal or skin; leg is flat and straight
*seen in tv shows/movies commonly
Skin
Circulation
Watching weights
Name the traction priority assessments
lordosis
abnormal increase in the forward curvature of the lumbar spine
kyphosis
abnormal backward curvature of the thoracic spine (humped-back condition)
scoliosis
an abnormal lateral curvature of the spine
-handrails in bathrooms
-ramps instead of stairs
-wear rubber sole shoes
-adequate lighting
-avoid scatter rugs
-prevent clutter
-avoid slippery floors
Fall risk reduction for the home
• Swelling
• Increased joint pain attributable to mechanical injury
• Thrombophlebitis
• Infection
• Bleeding
• VTE
• Severe joint or limb pain post discharge-teach PT to contact physician immediately!
Orthopedic surgery complications
High BP
High Pulse
High RR
Low O2 Sat %
VTE vital signs
chest pain
SOB
difficulty breathing
Signs/Symptoms of the respiratory system of someone with VTE
➤Avoid standing in one position for a lengthy period. If you cannot change positions, elevate one foot on a stool or box, and alternate foot placement frequently.
➤ Do not lock your knees when standing upright.
➤ Keep your stomach muscles tight to support your back.
➤ Do not bend forward at the waist or neck when you are working in a low position.
➤ When you are seated at your desk, work at a comfortable height.
➤ Do not wear high-heeled or platform shoes for long periods of time.
➤ Do not slump when you sit.
➤ Sit close to your work.
➤ Use a chair that supports your back in a slightly arched position.
➤ Sit with your feet flat on the floor and your knees below your hips.
➤ Sleep on a mattress that is firm but not extremely hard.
Tips to maintain proper posture
Stretching before exercise helps warm up the muscles and prevents injury during exercise.
Stretching after exercise cools the muscles and limits post-exercise stiffness.
As we get older, joints and muscles become stiffer. A regular flexibility program helps maintain mobility as aging occurs
Name the benefits of stretching/flexibility training
clonus
is spasmodic contraction of opposing muscles resulting in tremorous movement.
hypertrophy
an increase in the size or bulk of a muscle or organ
paresis
is a partial or incomplete paralysis
paresthesia
is numbness, tingling, or burning due to injury of the nerve(s) innervating the effected area
spasticity
is a motor disorder characterized by increased muscle tone, exaggerated tendon jerks, and clonus
grab bars in the shower or tub area
elevated commode
adapted eating utensils
Give some examples of adaptive devices
get the doppler!
What do you do if you can't palpate the pedal pulses? [Show Less]