Movement & protection notes, Quizzes of Nursing

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Movement &

Protection

(notes from the powerpoint)

Proper positioning for specific procedures/situations:

o (^) Lumbar puncture – place supine for recovery o (^) Air embolism – left side, head down o (^) Pulmonary embolism – Semi-fowlers o (^) Shock – flat w/ legs raised o (^) Buck’s traction – elevate foot of bed o (^) Umbilical cord prolapse – Trendelenburg or knee-chest o (^) Non reassuring fetal heart tones – mom on left side o (^) Spina bifida – prone o (^) Myringotomy – lay on affected side o (^) Thyroidectomy – Semi-fowlers, support head, neck, & shoulders o (^) Hip replacement – no sleeping on affected side, no hip flexion > degrees, no bending past 90* o (^) Pneumonia – good lung down o (^) Pneumonectomy – do not roll on side of intact lung

How to use crutches o (^) Two point: 2 points on the ground at all times  (^) Move crutch on injured side & non injured side together Example: right crutch/left foot o (^) Four point: move like 2 point, but only one @ a time – very slow/stable o (^) Three point: move both crutches & injured leg o (^) Swing to/Swing through: for NON-WEIGHT BEARING!  (^) Amputations  (^) Check order!

How to use crutches (cont.) o (^) Names tell you what they should do:  (^) 2 points = 2 points touch down together  (^) 3 point = 3 move together  (^) 4 point = everything moves separately  (^) “Even for even, odd for odd”  (^) Even # of gait for even # of extremities affected  (^) Two point for mild  (^) Four point for severe  (^) Example – Early OA, RLE  (^) Early OA  (^) Right AKA  (^) L TKA – partial weight  (^) R TKA NWB  (^) Advanced Parkinson’s

Crutches practice questions…

Stairs & Chairs

• (^) Good side 1 st

= going UP

• (^) Bad side 1 st

= going DOWN

• (^) Chair (to sit)
  • (^) Back up to the chair until you feel it against your legs
  • (^) Move both crutches to the injured side
  • Bend non-injured leg, keeping injured leg straight
  • (^) Reverse process for standing up

Canes

• (^) Proper fit
  • (^) Top of cane should be even with

greater trochanter or even w/ the

pt’s wrist crease

• (^) Elbow flexed @ 15-30 degree angle
• (^) Hold cane on the STRONG SIDE!
  • (^) Helping them :
    • (^) Nurse on the weak side
    • Position tip 4 inches from side of foot
    • (^) Hold cane on strong side
    • (^) Move cane on the weak side together, then the strong side
    • (^) Using stairs
      • (^) Good = UP
      • (^) Bad = DOWN

Walkers

Proper Fit:

• (^) Elbows bent @ 15-30 degree

angle

• (^) Hand grips even w/ the wrist

crease

Proper use (in order):

• (^) Lift walker, move it forward
• (^) Move weak side
• (^) Put weight on hand grips
• (^) Move strong side
• (^) When getting up – hold onto

chair, stand, grab walker

To walk with this method:

1. Lift the walker (roll forward if using a wheeled walker).
2. Move the walker one step or a few inches ahead 3.Support your weight with your hands by gripping the top of the walker.
3. Step forward to the center or middle of the walker with your injured leg, new joint, or weaker side first. When taking a step, don't step all the way to the front of the walker.
4. Use the walker to help you keep your balance as you take the step.
5. Bring your other foot forward to the center of the walker.
6. Repeat the process. Weight Bearing Gait

Cataracts

• (^) Description : lens opacity causes vision changes
  • (^) Decreased/blurred vision
  • (^) Night driving glare
  • (^) Diplopia (double vision)
• (^) Dx : slit lamp exam, visual acuity test
• (^) Improvement w/ surgery :
  • (^) Eye patch must cover eye – sunglasses to prevent photophobia
  • HOB 30-40 degrees
  • (^) Prevent increased intraocular pressure

Glaucoma Primary Open Angle Glaucoma

• (^) Most common
• (^) Peripheral vision loss
• (^) Meds focus on decreasing aqueous humor & cholinergic agents - (^) Brimonidine - (^) Timolol

Primary Angle Closure Glaucoma

• Acute
• (^) Sudden, severe eye pain
• (^) N&V
• (^) Blurred vision & colored halos