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56 Cards in this Set
- Front
- Back
How should you use a cane?
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-maintain 2 points of support on the ground at all times
-keep the cane on the stronger side of the body -support body weight on both legs, move the cane forward 6-10in, then move the weaker leg forward toward the cane, lastly advance the stronger leg |
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Dentures:
-what type of strength should you use with brushing & flossing? -how should you removing dentures? |
-Clts c fragile oral mucosa require gentle brushing & flossing
-provide denture care if clt is unable to do so -remove dentures c a gloved hand, pulling down & out at the front of the upper denture, & lifting up & out at the front of the lower denture |
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-How do you brush dentures?
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1. place dentures in a denture cup or emesis basin
2. brush them c a soft brush n denture cleaner 3. rinse them c water 4. store the dentures, or assist the clt c reinserting the dentures |
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How does music therapy work as a type of pain management?
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-decreases physiological pain, stress & anxiety by diverting the person's attention away from the pain & creating a relaxation response
-music produces an altered state of consciousness through sound, silence, space, & time -highly effective in reducing post-op pain |
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How should music therapy be implemented?
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-let clt select the type of music
-must be listened to for 15-30 mins to be therapeutic -earphones help clt concentrate on music while avoiding other clts or staff -if pain is acute, increase the vol of music |
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Why is it important to have continuous bladder irrigations after having prostate surgeries?
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-to maintain the patency of indwelling urinary catheters (b/c blood, pus, sediment can collect c/in tubing resulting in bladder distention & build up of stagnant urine)
-after prostate surgery, irrigation is done to remove clotted blood from the bladder & ensure the drainage of urine |
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If bladder is going to be manually irrigated after prostate surgery, how much solution should be instilled?
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-50 ml
--> 50 ml of irrigating solution is instilled & then withdrawn c a syringe to remove clots that may be in bladder & catheter |
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What should the nurse assess when a clt has continuous bladder irrigation (CBI)?
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-rate of infusion: rate of infusion is based on the color of drainage
-->ideally drainage should be light pink c/out clots -continously monitor the inflow and outflow -patency of catheter -->of outflow<inflow: assess catheter patency for clots/kinks. If outflow is blocked & patency cannot be reestablished by manual irrigation, the CBI is stopped& physician is notified immediately -record I&Os: q8hr OR per orders |
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How does the nurse obtain urine output when the clt is on continous bladder irrigation (CBI)?
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-to obtain urine output, subtract amount of fluid instilled into bladder from total output
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What are the steps when implementing intermittent irrigation?
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1. place clt in dorsal recumbent or supine position
2. avoid cold solution b/c bladder may spasm 3. clamp cath just below soft injection port 4. clean injection port c antiseptic swab (specimen collection port) 5. insert needle through port @ 30* angle 6. slowly inject fluid into cath & bladder 7. withdraw syringe remove clamp & allow solution to drain into drainage bag --> if ordered by MD, keep clamp closed to allow solution to remain in bladder for short time (20-30 min) |
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What should the nurse document in regards to closed continous irrigation?
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-doc type & amount of irrigation solution used
-doc amount returned as drainage & character of drainage -doc (& report) any findings: complaints of bladder spasms, inability to instill fluid into bladder &/presesnce of blood clots |
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What should be documented/report when the nurse is providing continuous irrigation?
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-document type and amount of irrigation solution used, amount returned as drainage, & the character of drainage
-doc & report any abnormal findings (c/o of bladder spasms, inability to instill fluid into bladder &/or blood clots) |
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Kegel exercises are advised for....
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-clts c urinary incontience
-->menopause, after child birth |
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How do you teach a clt to preform kegel exercises?
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1. sit on toliet c knees far apart & tighten muscle to stop the flow of urine (to learn the muscle)
2. Practice tightening this muscle at non-voiding times 3. instruct clt to contract muscle for a count of 3, hold then release for a count of 3, & repeat 10x 4. repeat cycles for 25-30x, 3x/day for 6 months |
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What color should a normal stoma be?
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-pink
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When a stoma is dusky blue in color, this indicates...
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-ischemia
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A black-brown stoma color, indicates...
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Necrocsis
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T/F: it is normal after creating a stoma to see mild to moderate swelling in the first 2-3wks after surgery.
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True
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How long can skin barriers around a stoma stay in place for?
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-3 to 5 days
--> intact barries c no evidence of leakage |
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What preparation around the stoma area should the nurse teach the clt to do before appling a skin barrier?
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-skin should be washed c mild soap, warm water, & dried thoroughly before the skin barrier is applied
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When applying a pouch around a stoma, how much larger should the opening be in regards to the stoma?
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the opening around the appliance should be no more than 1-16in larger than the stoma
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T/F do stoma's shrink?
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True; stoma's shrink & they do not reach usual size for 6-8wks
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How full should the colostomy bag be before it is appropriate to empty the pouch?
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-1/3 full; to prevent leaking
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What interventions can the clt take to prevent skin breakdown & malodor?
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-cleanse the skin
-use skin barriers -use deodorizers |
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If using barrier paste to fill in the creases next to the stoma, how long should you wait before you apply the pouch?
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1-2 mins to allow the paste to dry
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In what way should the clt/nurse apply non-allergic paper tape around the skin barrier?
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-in a picture frame method
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What techniques can the nurse use as distraction methods before the burn clt has dressing changes?
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-Relaxation tapes
-visualization -guided imagery -biofeedback -meditation -->used as ajuncts to traditional pharmacologic tx of pain |
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What questions can the nurse ask the clt when attempting guided imagery?
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-nurse can ask the clt about a favorite hobby/recent vacation
-nurse can explore these areas further by asking questions that make the clts visualize & describe a favorite hobby or recent vacation |
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What type of relaxation technique would be benefical to use when assisting a clt to go to sleep?
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-relaxation tapes
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What do cold and heat applications help relieve?
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-cold & heat applications relieve pain & promote healing
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Moist heat can help relieve pain from...
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-tension HA
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Cold heat can reduce the acute pain from...
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-inflamed joints
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How can the nurse avoid skin injury when applying heat and cold therapy?
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-avoid injury to skin by checking the temp & avoiding direct application of the cold or hot surface to the skin
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What population is esspecially at risk for skin injury when using heat & cold therapy?
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-spinal cord
-other neuro injury -older adults -confused clts |
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T/F: Ice massage/cold therapy are particularly effective for pain relief.
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-True
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How should the nurse perform ice massage?
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-apply the ice c firm pressure followed by slow, steady, circular massage
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T/F: cold may be applied to pain site on the opposite side of the body corresponding to the pain site or on a site located btwn the brain & the pain site
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-True
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What is more effective: application of cold near the actual site of pain or farther away?
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-application near the actual site of pain tends to work best
-->each clt responds differently to the site of application |
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How long is it appropriate to apply cold therapy?
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-5-10 minutes
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What sensations can a clt experience when experiencing cold therapy?
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-clt feels cold, burning & aching sensations & numbness
--> when numbness occurs, the ice should be removed |
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Cold is particularly effective for tooth/mouth pain when the ice is placed...
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-on the web of the hand between the thumb & index finger
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T/F: Cold applications are effected before invasive needle punctures
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-True
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Is it appropriate for clts to lay on heating applications?
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-No because burning can occur
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Before applying heat or cold applications what should the nurse should assess?
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-clts physical condition for ssx of potential intolerance to heat & cold
-observe the area to be tx |
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What types of issues can increase the risk of clts injury in regards to hot/cold therapy?
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-alterations in skin integration
-open wounds -edema -bruising -bleeding -localized areas of inflammation |
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Why is it important to have a baseline skin assessment before starting cold & heat therapy?
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-provides a guide for evaluating skin changes that might occur during therapu
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If an area of the body is actively bleeding, would it be appropriate to cover the area with a warm application?
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-No. An active area should not be covered by a warm application b/c bleeding will continue
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If a clt has a localized inflammation, is a warm application around the area appropriate?
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-No. Warm applications are contraindicated when clts have an acute, localized inflammation such as appendicitis b/c the heat could cause the appendix to rupture
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T/F: if a clt has cardio vascular problems, it is ok to apply heat to lrg portions of the body.
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-False: it is unwise to apply heat to lrg portions of the body to a clt c CV prob b/c the resulting mass vasodilation may disrupt blood supply to vital organs
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If the site of injury is edematous, is application of cold appropriate?
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-No. Cold is contraindicated if the site of injury is already edematous.
-Cold further slows circulation to the area & prevents absorption of the interstitial fuild. -if a clt has impaired circulation (arteriosclerosis), cold further reduces blood supply to affected area |
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T/F: cold is contraindicated in presence of neuropathy?
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-True. Neuropathy: clt unable to preceive temp changes
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T/F: cold is contraindicated in shivering.
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-True. Cold intensifies shivering & dangerously increase body temp
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What should the nurse ***** when applying cold therapy to the lower extremities?
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-assess for cap refill
-observe skin color -palpating skin temp -assess distal pulses -observe for any edematous areas --> if ssx of circulatory inadequacy, question order |
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If cold/heat therapy was ordered & the clt is confused or unresponsive, should the nurse question the order or continue c the tx plan?
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-the nurse should continue c the tx plan.
-if a clt is confused or unresponsive, make freq observations of skin integrity after therapy begins |
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Is it in the nurse scope of practice to ***** the condition of the equipment being used on a clt in regards to cold/heat therapy?
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-yes it is. The nurse should always assess the condition of equipment being used.
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What knowledge base should the RN know before starting heat/cold therapy?
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-understanding normal body responses to local temp variations
-assess the integrity of the body part -determine the clts ability to sense temp variations -ensure proper operation of the equipment |