Exam 2 REVIEW AMG LPN PDF

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Exam 2 REVIEW AMG LPN SCHOOL OF NURSING...

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Exam 2 Review: Mobility – 20 questions Wound care – 15 questions 3-4 SATAs Mobility: concept of the cane. Can is given to the strong side, should be the one to move forward first followed by weak leg and then strong leg a bit futher than the cane, then move cane again. How would you know if cane fits the pt? 15-30 degree angle. Cane or walker should not be above the waist bc angle will not be 15 to 30 degrees. Cane should be at the greater canter ___ Walker: lift it, forward the walker 6 inches, bring it down, weak and the strong, lift, forward, weak and the strong Crutches: crutch or tripod stance – same thing, created for stability. 6 inches on the sides and 6 inches in the front. 4 point gait: partial weight bearing 2 point: more stable than a 4 point. 3 point: one leg is injured, so non-bearing weight aka no pressure on the injured leg. What is a swing-through? Move crutches forward, then land both legs past the crutches. Swing-to? Small hops at the crutches. For pts with good upper arm strength How do I assist my pt? Stand on the weak side. Have a gait belt for stability, creates gravity at the center, and you have full control of your pt to move them. If pt is falling: extend your leg, bring your pt to the floor carefully and slowly. If pt is on the floor: how to document? Pt lying on the floor. Do not make up stories. What is isotonic exercise? Moving: walking, dancing Isometric: tightening/contracting and relaxing the muscle. Ex: kegel exercises to strengthen the pelvic floor of female pts who suffer from stress incontinence Kyphosis – abnormal curvature of the spine *read up on it. Scoliosis, lordosis** look up in the book Read about trochanter roll* – placed on both sides to prevent pt from moving Wedge adductor - Triangular foam in the middle of the leg so pt is in the A position – moment pt’s leg is adducted, hip can be dislocated again Foot board – to prevent plantar flexion Body mechanics – wide base apart. We tend to overreach and strain the muscles. Push is better than pull. Sliding is better than lifting. Cannot apply sliding to a pt bc of skin shear and wounds – lift the pt. Restraint: monitor and more on this All about transfer: bed to wheelchair, wheelchair to bed, bed to stretcher. Make sure room is not too dark and not too bright. Call bell within reach, nothing on the floor, no rug over wires. Non-skid socks, no water on the floor, lock the wheels, and lock the bed. Side rails How do you assess if pt is strong enough to ambulate? Assess vital signs - make sure VS are within range. What should the nurse do first? Assess. Always assess!! Evaluate, observe, check Further teaching questions – asking for the wrong answer. Priority: check for abc. If you see always/only, remove – distractor words. Wound care: Complications of wounds: dehiscence – popping sensation, hemorrhage, evisceration, __ ??

Laceration, surgical incision, contusion etc…, abrasion – scrape*** Different drainage – sanguineous – red blood, sero-sanguineous (pink; combo of clear and red blood), what is purulent drainage? Thick, yellow, pussy How do you assess the wound? Aroma, color, size (length, width, depth) Difference between tunneling (narrow and deep) and undermining (wider) how do we assess? Clock method 12 o’clock – head, 6 o’clock – butt, foot Irrigation – how do we clean? Top to bottom; how many inches from the wound?** Sterile irrigation When do you do wound culture? After irrigating the wound. What is levine technique? Sterile technique. Saturate the tip of the swab with drainage juice, gently press down against the wound bed. Z technique; How to collect drainage from a Jackson-Pratt? Drain into a calibrated container to measure output. How to close it? You squeeze it, then close it. Call the dr if: there’s no drainage, color changes, odor present, device not create suction How to collect drainage from a Hemovac? Drain out the contents of the hemovack container into a graduated cylinder. Cleanse the opening of hemovack with an alcohol pack. Press down until both sides of device are touching (it’s deflated) Stages of pressure injury: stage 1-4, unstageable. Make sure you can describe it well Braden scale Stages of healing – know well...