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What are seizure precautions?
- Padding on every surface the client could hit
- Suction and O2 hooked up and ready
- 4 rails up
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what are the types of seizures
- partial/focal- 1 part of the brain
- Generalized- more than 1 part of the brain
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What are the different categories of restraints?
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different types of restraints
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when do nurses use behavioral restraints?
danger to themselves or others
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what are the guidelines for behavioral restraints?
- Physician must assess the patient within 1 hour of application
- Restraint usually does not exceed 4 hrs
- must have continuous visual and auditory monitoring
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what are the guidelines for medical restraints?
- must have order within 12 hrs of applying restraints
- physician must see pt every day
- order must be renewed every day
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why do nurses use medical restraints
- if a patient is trying to pull out tubes, IVs..
- pt is confused
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Behavioral Restraint Documentation Guidelines
- Document every 15 minutes
- Continues visual and auditory monitoring
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Medical Restraint Documentation Guidelines
- Document previous interventions (what you tried)
- Document every 2 hours
- Visually Assess every 30 min
- Release restraint and provide ROM, assessment, personal needs every 2 hrs
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what kind of know is used for tying restraints
- Quick Release
- 1 pull to release client
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what are the different kinds of restraints
- mitt/hand
- limb
- vest
- seat belts
- geri chair/ lap trays
- mummy
- elbow
- cribnets
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when is seat belt considered restraint
when it is tied out of the reach of the client
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when are side rails considered a restraint
- when all four are up
- Unless it is for a seizure precaution client
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when should you reevaluate a client in restraints
- continually
- every time you look at them you can assess to see if the restraint is still needed
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active ROM
client does the ROM themselves
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passive ROM
Nurse does ROM exercise for the client
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if restraints are taken off when family is present, what must the nurse do?
- check on the client every 30 mins
- make sure family understands the reason client had restraints
- family cannot leave client alone without restraints
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What are the different ambulation techniques?
- walking with client
- instructing how to use assistive devices
- walker, cane, crutches
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if client is walking independently, what should you do?
walk on clients weak side
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if client is slightly weak and unstable, what should nurse do?
- grasp the back of the gait belt ad walk behind them and slightly to the side
- have wheel chair behind
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client is moderately weak and unstable, what should the nurse do
- walk on the weaker side
- interlock your forearm with clients forearm
- always use walking belt
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client is very weak and unstable, what should the nurse do
- walk on the client's stronger side
- with your arm around their waist and other arm holding clients elbow
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what are the different assistance devices
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how should cane be used for max support
- cane on the stronger side
- 6" from side and 6"from foot
- move cane 1"forward
- weak foot
- strong foot ahead of cane
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cane instructions for client gaining strength
- cane 6" from foot and 6"from side
- move cane and week leg together
- strong leg ahead of cane
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method for using walker max support
- elbows should be slightly bent
- move walker 6" ahead
- right foot up
- left foot up
- then walker again
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walker method one leg weaker
- move walker and weak leg at the same time 6"
- then stronger leg
- repeat
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what are the different methods for using crutches
- 4 point gait
- 3 point gait
- 2 point gait swing to
- swing thru
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what is 4 point gait crutches
- right crutch
- left foot
- left crutch
- right foot
- safest gait
- must be weight bearing on both legs
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what is 3 point gait
- crutches and bad leg
- good leg
- need to be able to bear weight od affected leg
- point gait
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what is swing to gait
- crutches forward
- then swing legs the crutches
- used with paralysis of legs/hips
- prolonged use caused atrophy of leg muscles
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2 point gait
- left crutch and right foot
- right crutch and left foot
- need partial weight bearing on each foot
- simulates walking
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what is swing thorough gait
- crutches forward
- legs swing past crutches
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what is goniometer
a tool that is used to measure the angle of a joint
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muscle assessment includes
- inspection - size, symmetry, contractures, tremors (intention or resting)
- palpation - flaccidity (uncooked chicken) unused muscle
- spasticity (very hard muscle/Charlie horse)
- smoothness of movement
- muscle strength
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joint assessment
- inspection - swelling, symmetry
- auscultation - popping or cracking
- Palpation - tenderness, smoothness of movement, crepitation, nodules, ROM
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assessment bone
- inspection - skeletal deformities
- Palpation- Edema, tenderness
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