Multidimensional Care 1 - Final Exam Study Guide PDF

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Multidimensional Care 1 - Final Exam Review Sheet Exam 12/14/20 @ 9am 1.) Musculoskeletal a.) Terminology Movement of the Muscles  Abduction – movement of drawing away from the center of the body (such as fingers spread apart).  Adduction – movement of drawing toward the middle of the body (for example, fingers held together).  Eversion – turning outward.  Inversion – turning inward.  Extension – movement in which a limb is place in a straight position.  Flexion – movement in which a limb is bent.  Rotation – turning around on its own axis.  Pronation – movement that turn the palm the hand downward.  Supination – movement that turns the palm of the hand upward. Common Muscular Conditions  Bursitis – inflammation of the bursa sac, which lines the joint and provides smooth joint movement.  Fibromyalgia – pain in fibrous tissues of muscles, tendons, or ligaments.  Myoparalysis – paralysis of a muscle.  Myotonia – muscles react slowly after contraction or stimulation.  Polymyositis – inflammation of “many muscles.”  Tendinitis or tendonitis – inflammation of a tendon.  Tendinopathy – any disease involving a tendon.  Tennis elbow – the tendon that connect the arm muscle to elbow becomes inflamed due to the repetitive use of the arm.  Tenosynovitis – inflammation of the tendon and the sheath around it, often in a finger or a wrist. b.) Flexibility Training  Exercise at least 30 minutes every day. The amount of activity depends on age, physical condition, and the intensity of the exercise. Any activity is better than none. Tai Chi, Yoga, exercise classes, and weight training are helpful ways to improve balance, coordination, flexibility and strength.  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. c.) Risk for Falls  Interventions/Prevention - Assess all older patients for risk for falls.

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Use assessment tolls such as the Morse Fall Scale, STRATIFY, and the Hendrich II Fall Risk Model (HIIFRM) to help the nurse focus on factors that Increase an older person’s risk for falling. Monitor the patient’s activities and behavior as often as possible, preferably every 30 to 60 minutes. Teach the patient and family about the fall prevention program to become safety partners. Remind the patient to call for help before getting out of bed or a chair Help the patient get out of bed or a chair if needed; lock all equipment such as beds and wheelchairs before transferring patients Teach patients to use the grab bars when walking in the hall without assistive devices or when using the bathroom. Provide or remind the patient to use a walker or cane for ambulating if needed; teach him or her how to use these devices Remind the patient to wear eyeglasses or a hearing aid if needed Help the incontinent patient to toilet every 1 to 2 hours Clean up spills immediately Arrange the furniture in the patient’s room or hallway to eliminate clutter or obstacles that could contribute to a fall. Provide adequate lighting at all times, especially at night. Observe for side effects and toxic effects of drug therapy Orient the patient to the environment Keep the call light and patient care articles within reach; ensure that the patient can use the call light Place the bed in the lowest position with the brakes locked Place objects that the patient needs within reach Ensure that adequate handrails are present in the patient’s room, bathroom and hall. Have the physical therapist assess the patient for mobility and safety.

d.) Musculoskeletal Trauma – an injury to a muscle, bone, or soft tissue resulting from excessive external force. Injuries include blunt tissue trauma, alterations in tendons and ligaments and fractures.  Assessment o Inspection (discoloration, swelling or deformity). o Palpation (looking for tenderness or deformity) o Assess ROM (both active and passive) with consideration to the joint above and below the injured part. o Neurovascular examination

o 6 P’s – pain, pallor, paralysis, paresthesia, pulselessness, pressure.  Risks of? o Forceful exertion o Awkward postures (stooping, bending over, kneeling, reaching overhead). o Repetitive movements  Priorities/Interventions o Assess skin color, temperature, sensation, mobility, pain, and pulses distal to the fracture site. o Check capillary refill by applying pressure to the nail and observing for the speed of blood return. o Reposition patient every 2 hours. o Position the patient with head of the bed elevated 30 to 45 degrees unless medically contraindicated. o Assess the 6 P’s.  Complications o Pain o Infection/ disorder such as those listed below o Swelling o Redness and heat at the site of infection and /or in the surrounding area. o Loss of function of the area affected, particularly if pain and/or swelling affect joints and other musculoskeletal structures. o Tissue exudate which or may not contain pus. e.) Disorders  Osteomyelitis o An infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue. Infections can also begin in the bone itself if an injury exposes the bone to germs. o Smoker and people with chronic health conditions are more at risk for developing. o People who have diabetes may develop osteomyelitis in their feet if they have foot ulcers. o Can be curable, most people need surgery to remove areas of the bone that have died. After surgery, strong intravenous antibiotics are typically needed. o Symptoms: Fever, swelling, warmth and redness over the specific area, fatigue, loss of ROM, nausea, irritability. o Can enter the bone via: bloodstream, injuries & surgery. o Diagnosed: physical exam, blood test, imaging, bone biopsy. o Treatment: Surgery, antibiotics, lifestyle changes. o Interventions:  Assess the patient’s vital signs at least every 4 hours.  Remove excessive clothing, blankets, and linens. Adjust the room temperature.

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 Administer the prescribed medicine, and anti-pyretic medications.  Offer a tepid sponge bath.  Elevate the head of the bed. Osteoarthritis o A degenerative joint disease, most common. o Over diagnosed and trivialized. o Two- classifications:  Primary or idiopathic OA – has no prior event or disease related to it.  Secondary OA – results from previous joint injury or inflammatory disease. o Causes: increased age, obesity, previous joint damage, repetitive use. o Symptoms: pain, stiffness, functional impairment. o Prevention: weight reduction, prevention of injuries, perinatal screening for congenital hip disease. o Interventions: weight loss, assistive devices, exercise, analgesic, physical therapy. Rheumatoid Arthritis o Chronic inflammatory disorder that can affect more than just your joints. o Condition can damage a wide variety of body systems, including the skin, lungs, heart and blood vessels. o Autoimmune, chronic, diffuse connective tissue disease o Affects the lining of the joints, causing a painful swelling that can eventually result in bon erosion and joint deformity. o Symptoms: tender, warm, swollen joints, erythema, lack of function, deformities, and rheumatoid nodules. o Risk factors: your sex, age, family history, smoking, environmental exposures and obesity. o Interventions: Relieve pain and discomfort, reduce fatigue, increase mobility, facilitate self-care, improve boy-image and coping skills, educate the patient on the disease. Osteoporosis o A bone disease that occurs when the body loses too much bone, makes too little bone, or both. As a result, bones become weak and may break from a fall or, in serious cases, from sneezing or minor bumps. o “Porous bone” o Symptoms: back pain, loss of height over time, a stooped posture, a bone that breaks much more easily than expected. o Risk factors: Your sex (women more likely), age (older you get), race (white or Asian most likely), family history, body frame size (men and women who have small body frames have higher risk). o Dietary Factors: low calcium intake, eating disorders, gastrointestinal surgery.

o Prevention: More protein, maintain a healthy body weight, 1000mg calcium per day, 600IU vitamin D per day, plenty of exercise. f.) Traction  Nursing Care o Application of a pulling force to a part of the body to provide reduction, alignment, and rest. o Used as a last resort to decrease muscle spasms and prevent or correct deformity and tissue damage. o Mechanical traction can be continuous or intermittent. o Two most common types of traction are skin and skeletal traction.  Skin traction – involves use of a Velcro boot (buck’s traction), belt, or halter, which is usually secured around the affected leg.  Primary purpose is to decrease painful muscle spasms that accompany hip fractures.  The weight is used as a pulling force and is limited to 5 to 10 pounds to prevent injury to the skin. o Ensure that that the traction weight bag is hanging freely, the bag must not rest on the bed or the floor. o If the rope becomes frayed replace them. o The rope must be in the pulley tracts. o Ensure the bandages are free from wrinkles. o Tilt the bed to maintain counter traction. o Inspect the skin traction for signs of skin breakdown. o Inspect the skeletal traction sites for signs of irritation or infection. g.) Immobility  Complications of? o Skin Breakdown/pressure ulcers o Contractures o Muscular weakness/muscular atrophy o Disuse osteoporosis o Renal calculi o Urinary stasis/urinary retention/urinary incontinence o Urinary tract infections o Atelectasis/Pneumonia o Decreased respiratory vital capacity o Venous stasis/venous insufficiency o Orthostatic hypotension o Decreased cardiac reserve o Edema o Emboli o Thrombophlebitis o Constipation and the loss of calcium from the bones

2.) Safety a.) Transfer and Ambulation Safety  Evaluate each situation and use an algorithm to determine the safest method to transfer or move the client. Answer these questions: can the client bear weight? Can they assist? Are they cooperative?  Determine the client’s ability to help with transfers (balance, muscle strength, endurance, and use of a trapeze bar.  Evaluate the need for additional staff or assistive devices (transfer belt, hydraulic lift, sliding board).  Assess and monitor the use of mobility aids (canes, walkers, crutches).  Include assistance or mobility aids in the plan of care for safe transfers and ambulation. Body Mechanics o Understand location of center of gravity and base of support. o Keep feet shoulder width apart. o Plan work carefully to do it safely. o Elevate work to a comfortable level. o Avoid twisting. o Bend knees when lifting heavy objects. o Carry objects close to body with elbows bent. o Push, pull, or slide heavy objects instead of lifting them. o Get help when you need to move a patient. b.) Fire Safety  Smoking is prohibited in healthcare facilities (think about home fires 75% are related to oxygen). Oxygen is highly used in every healthcare facility.  Our role is to ensure the patients and family follow these policies.  If a fire occurs call a “code red” or “code yellow” depending on the institution process. Stay safe and evacuate if needed. Use RACE or PASS RACE  Rescue – remove clients from the general area  Alarm – sound alarm  Contain – contain fire (close doors and windows, make sure fire doors close).  Extinguish PASS  Pull  Aim  Squeeze  Sweep Classes of Extinguishers  Class A – is for combustibles (paper, woods, upholstery, rags, other types of trash fires).  Class B – for flammable liquids and gas fires.

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Class C – for electrical fires.

c.) Infant Safety  Drowning is the leading cause of death for children ages 1-4, followed by motor vehicle accidents.  Falls, choking, sudden infant death syndrome (SIDS), and ingesting poisons are other critical safety concerns. Injury Prevention (ATI)  Aspiration o Avoid small objects (grapes, coins, and candy), which can be lodged in their throat. o Provide age-appropriate toys o Check clothing for safety hazards (loose buttons)  Bodily Harm o Keep sharp objects out of reach o Keep infants away from heavy objects they can pull down. o Do not leave infants alone with animals. o Monitor for shaken baby syndrome  Burns o Check the temperature of bath water o Turn down the thermostat on the hot water heater to 49 degrees Celsius (120 degrees Fahrenheit) or below.  Drowning  Falls o Keep crib mattress in lowest position with the rails all the way up.  Poisoning  Motor Vehicle Injuries  Suffocation d.) Bleeding Precautions  Use an electric shaver  Use a soft-bristled toothbrush  Do not have dental work performed without consulting your health care provider  Do not take aspirin or any aspirin-containing products. Read the label to be sure that the product does not contain aspirin or salicylates.  Do not participate in contact sports or any activity likely to result in your being bumped, scratched, or scraped.  Use sensitive tape.  Limit needlesticks as much as possible. e.) Handwashing CDC

1.) Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. 2.) Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. 3.) Scrub your hands for at least 20 seconds. “Hum happy birthday” from beginning to end twice. 4.) Dry your hands using a clean towel or air dry them. Nursing Standard 1.) Wet your hands 2.) Apply soap 3.) Rub palms together 4.) Rub backs of hands 5.) Interlace finger 6.) Scrub thumbs 7.) Rub palms with fingertips 8.) Rinse 9.) Dry f.) Sterile Technique  Sterile Field o An area created by placing sterile surgical drapes around the patient’s surgical site and on the stand that will hold sterile instruments and other items needed during surgery. o Donning a hair cover, protective eyewear, shoe covers, performing a hand scrub, donning a sterile gown and sterile gloves. o Every member of the healthcare team is responsible in maintaining the aseptic environment. o Must be kept in view at all times. o When changing position within a sterile field, staff must turn face-to-face or back-to-back to avoid cross-contamination. o Team members not implementing aseptic measures must stay at least 1 foot back from the sterile area and must face the sterile field when passing it. o Always check for latex allergies. Steps:  Should be prepared on a clean, dry, flat work surface.  Inspect the integrity of the sterile item. Look for any punctures, tears, discoloration, moisture, or any other signs indicating the package may be contaminated.  Check the expiration date.  Place the item on the work surface. Opening a sterile drape:

After removing the plastic outer wrapping of the sterile drape, place the drape on the work surface.  Carefully reaching around the sterile area, open the flap farthest from the body, first.  Open the side flaps and then flap closest to the body. Gently pull each flap so it lays flat on the surface.  With fingertips of one hand, grasp the folded top edge and gently lift away from the wrapper, being careful not to touch the other surfaces or items.  Let the drape unfold and grasp the adjacent corner with the other hand and lay the drape onto the work surface.  Position the crape with the bottom half of the drape over the top half of the work surface and the top half of the drape over the bottom half of the work surface. Sterile items can now be placed on the sterile drape. Pouring a sterile solution:  Before opening a sterile solution, examine the container at verify contents and to check for the expiration date.  Loosen he cap on the sterile solution being careful not to touch the lip of the bottle.  Glove the nondominant hand. This hand is used to manage the items on the sterile field.  Hold the container away from the field and 1-2 inches above the inside of the container. Be careful not to splash the fluid onto the sterile field. Adding items to a sterile field:  Open the sterile item holding the wrapped item in the nondominant hand.  Use the dominant hand to carefully peel the wrapper over the nondominant hand.  Gently drop the sterile item onto the sterile field being careful not to hold the arms over the sterile field.  Dispose of the outer wrapper.  Add additional sterile supplies to the sterile field in the same manner. 

3.) Physiological Response a.) Prioritization  Maslow’s Hierarchy o 1-4th levels are the “Basic Physiological Needs” or “Deficiency needs.”  Enables anxiety if it is not met but does not provide self-growth.  Essential for maintenance of life.  Level 1: Physiological needs (Food, Water, Rest)  Level 2: Safety (Security)

Level 3: Love/Belonging (Intimate relationships, friendships)  Level 4: Esteem (Feeling of Accomplishment) o 5th level if the “growth need”  Enables self-actualization and reach of full potential.  Level 5: Self-actualization (Achieving one’s full potential) 

b.) Oxygenation and Perfusion  Interventions to Promote Adequate Oxygenation - Position the client to allow for maximal chest expansion - Encourage or assist client with frequent changes in position, every 2 hours. - Encourage deep breathing and coughing. - Encourage ambulation. - Promote comfort so client can tolerate the above activities. - Incentive Spirometry - Chest Physical Therapy - Nasal Cannula - Mechanical Ventilation - Endotracheal tube - Tracheostomy - Closed chest drainage - Extubation - Continuous positive airway pressure - Positive end-expiratory pressure c.) Pain Pain Assessment: plays a role in the client’s rest and comfort needs and in the area of anxiety related to illness recovery. It’s considered the fifth (5th) vital sign.  Types of Pain - Cutaneous Pain: arises from burning your skin. Example – on a hot iron or from touching a hot pan on the stove. - Visceral Pain: caused from deep internal disorders such as menstrual cramps, labor pains, or gastrointestinal infections. - Deep Somatic Pain: originates from the ligaments, tendons, nerves, blood vessels and bones. Example – fractures or sprains - Radiating Pain: starts at an origin but extends to other locations. Example – pain from a sore throat might extend to ears and head. - Referred Pain: occurs in an area distant from the site or origin. Example – pain from a heart attack might be felt in the left arm or jaw. - Phantom Pain: pain that is perceived from an area that has been surgically or traumatically removed. Example – pain from an amputated limb. - Neuropathic Pain: results from an injury of one or more nerves.

Acute Pain: Short-duration, rapid onset, and associated with some kind of injury. - Chronic Pain: lasts 6 months or longer and interferes with ADL’s. Assessment Step 1. o “This is a pain rating scale that many of our patients use to help us understand their pain and set goals for pain relief. We will ask you regularly about pain, but any time you have pain you must let us know so we can help control it. We don’t always know when you hurt” Step 2. o “On this pain rating scale 0 means no pain, and 10 means the worst pain -

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possible pain. The middle of the scale, around 5, means moderate pain. A 2 or 3 would be mild pain, but 7 or higher means severe pain” 

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Step 3. o “Pain refers to any kind of discomfort anywhere in your body. Pain also means aching and hurting. Pain can include pulling, tightness, burning, knifelike feelings, and other sensations” Step 4. o “I want to be sure that I’ve explained this clearly; so, would you give me two examples of pain you’ve had recently?”. If the patient's examples include various parts of the body and various pain characteristics, it indicates that he or she understands as a fairly broad concept. An example of what a patient might say is “I have a mild, sort of throbbing headache now, and yesterday my back was aching”. Step 5. o “Using the scale, what is your pain right now? What i...