STNA Test 2

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Atrophy

Weakness and muscle wasting from lack of use.

Contractures

Disfigurements cause by muscle shortening.

Active Range of Motion (ROM)

Patient during activities of daily living.

Passive Range of Motion (PROM)

Performed for patients when independent movement is impossible.

When doing Range of Motion exercises:

Apply gentle, steady pressure until the muscle relaxes. Do Not: jerking movements, stretch joints too far, and not do it too fast!

Patients with osteoporosis:

Cause sustain fractures with little or no trauma.

Abduction

Movement away from the midline or center.
Use this stretch in ROM of the: shoulder and the hip.

Adduction

Movement toward the midline or center.
Use this stretch in ROM of the: shoulder and the hip.

Extension

Movement by which the two ends of any jointed part are drawn away from each other.
Use this stretch in ROM of the: shoulder and hip+knee.

Flexion

Decreasing the angle between two bones.
Use this stretch in ROM of the: shoulder and hip+knee.

Order of stretches:

Shoulder
1. Flexion & Extension 3x
2. Abduction & Adduction 3x
Hip (+Knee on #2)
1. Abduction & Adduction 3x
2. Flexion & Extension 3x

Medical Asepsis

Procedure followed to keep germs from being spread to one person to another.

Standing Transfer

Patient stands during the transfer with the help of one or two nursing assistants.

Sitting (Lateral) Transfer

Patient sits throughout the transfer like when a sliding board is used.

Non-Weight Bearing

Unable to stand or walk on one or both.

Partial Weight Bearing

Unable to bear full weight on one or both legs.

Full Weight Bearing

Able to stand on both legs.

Gait Belt

Belt place around the patient's waist to assist in ambulation.

Patient on Stretchers...

Are not left alone.

Ambulate

To walk.

Shearing

Force on skin over bone when the skin remains at the point of contact while the bone moves; causes damage to the skin.

Dangling

Sitting up with legs hanging over the edge of the bed.

Gatch Bed

Stationary bad about 26 inches high.

Electric Bed

Bed similar to gatch bed but can be raised or lowered and the head and knee areas can be adjusted due to its operation of this electrically.

Low Bed

Used for patients that are at risk of falls and side rails is not desirable.

Mitered Corner

One type of corner used in making a facility bed.

Toe Pleat

An extra space made by folding the top linen over 2 to 3 inches at the end of the bed to keep the linen from pulling the feet downward. This is more comfortable for the patient and reduces the risk of contractures, such as foot droop.

Box (Square) Corner

One type of corner used in the making of a hospital bed.

Infection Control

Preventing infections such as viruses, protozoa, etc.

Microorganism

Tiny organism that can be seen only with a microscope, particularly bacteria.

Pathogen

Microbes that cause diseases in humans are this and can be grown well by: body temperature, light is limited, moisture, food supply, and oxygen needs can be met.

Nonpathogens

Do not produce disease, but help in: processing of cheese, beer, and yogurt; curing of leather, and baking of bread.

Nosocomial Infection

Infection acquired by a patient while being cared for in a health care facility.

Handwashing

The most single important health procedure any individual can perform to prevent the spread of microbes.

Personal Protective Equipment (PPE)

Gloves, gown, mask, and goggles or face shield.

Chain of Infection

Conditions that include: causative agent, reservoir, portal of exit, portal of entry, mode of transmission, and susceptible host.

Causative Agent

Microorganism that can produce the disease in humans. Common biological agents of infectious disease are: bacteria, viruses, fungi, and protozoa.

Reservoir

Pathogens can survive at. Examples include: Human active cases and carriers, insects and animals, environment, and formates (objects that become contaminated with infectious material that contains the microbe (ex. bedpans to instruments)).

Portal of Entry

Enter through the body by: breaks in the skin or mucous membranes, respiratory tract, urinary tract, circulatory system, etc.

Portal of Exit

Infectious organisms leave the reservoir of the host through body secretions by: Excretions of the respiratory or genital tract, draining wounds, urine, feces, etc.

Transmission

Spread of infectious organisms may happen in one of the three ways: airborne transmission, droplet transmission, and contact transmission.

Host

Person who harbors infectious organisms.

Bacteria

One-celled microbes with shaped as:
Coccus-round or spherical
Bacillus-straight rod
Spirillum- spiral, corkscrew, or slightly curved.

Contact Precautions

Used when the infectious pathogen is spread by direct or indirect contact.

Draw Sheet

May be placed under a heavy or helpless patient to make moving easier.

90-90-90 Position

Feet should be 90° angle to lower legs, lower legs should be at 90° angle to the thighs, and thighs should be 90° angle to the torso.

Positioning

helping residents into positions that will be comfortable and healthy for them

Supine

position in which the resident lies flat on his back

Lateral/Side

a resident is lying on either side

Prone

a resident is lying on the abdomen

Fowler's

a resident is in a semi- sitting position. head and knees are elevated

Sim's

a resident is in a left side-lying position. Lower arm is behind the back, upper knee is flexed and raised toward the chest, using a pillow as support.

Body Alignment

Position in which the body can properly function.

Gait

Refers to the way in which a person walks.

Wheelchair

Mobility device, not a transportation device.

Closed Bed

Following discharge of a patient and after the unit is cleaned (terminal cleaning) and it remains closed until a new patient is admitted.

Unoccupied Bed

Beds are often made while patients are up in a shower or chair.

Open Bed

Like a sign saying "welcome" and it shows that the unit has been prepared.

Occupied Bed

Usually follows the bed bath, while the patient is covered with a bath blanket; it can be done any time it would add to the comfort of the patient and when the patient is in bed.

Bathing can be performed as:

Tub, shower, complete, or partial bath.

Perineum

Area between the legs.

Female Perineal Care

1. Identifies that hands should be washed.
2. Explains procedure to the resident. (Mannequin)
3. Pulls curtain; provides privacy.
4. Raises side rail opposite working side of bed or asks test observer to stand on the opposite side of the bed
5. Fills basin with comfortably warm water.
6. Raises the bed between mid-thigh and waist level.
7. Places bath blanket on resident/mannequin.
8. Turns resident to side and places waterproof pad under resident's buttocks then returns resident to his/her back OR raises
hips and places waterproof pad under buttocks.
9. Puts on gloves.
10. Exposes perineum only.
11.Verbalizes separating labia.
12.Using water and soapy washcloth, cleans both sides and middle of labia from top to bottom using a clean portion
of a washcloth with each stroke.
13.Rinses and dries both sides and middle from top to bottom with a clean portion with each stroke.
14. Covers the exposed area with the bath blanket.
15. Assists resident (mannequin) to turn onto side away from the Candidate.
16. With a new washcloth, cleans the rectal area.
17. Using water, washcloth and soap cleans area from vagina to rectal area with single strokes.
18.Rinses and dries area from vagina to rectal area. 19.Removes waterproof pad from under buttocks.
20. Position resident (mannequin) on their back.
21. Disposes of soiled linen and bath blanket in an appropriate container.
22.Empties, rinses and dries equipment and returns to storage.
23.Turns gloves inside out as they are removed. Disposes of gloves in the appropriate container.
24. Lowers bed if it was raised.
25.Lowers side rail if side rail was used.
26. Places call light or signaling device within reach of resident.
27. Identifies that hands should be washed.

Denture Care

1. Identifies that hands should be washed.
2. Explains procedure to resident.
3. Lines sink with a protective lining that would help prevent damage to the dentures. (Towel, paper towel or washcloth)
4. Puts on gloves and removes dentures from cup.
5. Handles dentures carefully to avoid damage.
6. Applies toothpaste and thoroughly brushes dentures including the inner, outer, and chewing surfaces of upper and/or lower
dentures. Toothettes may be utilized instead of a toothbrush as long as all of the surfaces listed above are cleaned.
7. Rinses dentures using clean cool water.
8. Places dentures in rinsed cup.
9. Adds cool clean water to denture cup.
10. Cleans and dries equipment and returns to storage.
11. Discards protective lining in an appropriate container.
12. Turns gloves inside out as they are removed and disposes of gloves in an appropriate container.
13. Maintains respectful, courteous interpersonal interactions at all times.
14.Leaves call light or signaling device within easy reach of the resident.
15. Identifies that hands should be washed.

Mouth Care

1. Identifies that hands should be washed.
2. Explains procedure to the resident.
3. Gathers equipment and supplies.
4. Provides for resident's privacy pulls privacy curtain.
5. Candidate puts on gloves AFTER ALL SUPPLIES HAVE BEEN GATHERED.
6. Drapes the chest with towel (Paper or cloth) to prevent soiling.
7. Wets tooth brush and applies toothpaste to toothbrush.
8. Brushes resident's teeth, including the inner, outer, and chewing surfaces of all upper and lower teeth. If available, toothettes may be utilized instead of the toothbrush as long as all of the surfaces listed above are cleaned.
(Candidate must verbalize as they perform the step)
9. Cleans tongue.
10. Assists resident in rinsing mouth.
11.Wipes resident's mouth, removes soiled towel and places in appropriate container.
12.Empties, rinses and dries emesis basin. Rinses toothbrush. Returns emesis basin and toothbrush to storage.
13. Turns gloves inside out as they are removed. Disposes of gloves in the appropriate container
14. Leaves resident in position of comfort.
15. Leaves call light or signaling device within easy reach of the resident.
16. Maintains respectful, courteous interpersonal interactions at all times.
17. Identifies that hands should be washed.

Hair Care

1. Identifies that hands should be washed.
2. Explains procedure to the resident.
3. Places towel on shoulders.
4. Asks resident how they would like their hair combed.
5. Combs/brushes hair gently and completely.
6. Discards linen in appropriate container.
7. Leaves hair neatly brushed, combed or styled.
8. Maintains respectful, courteous interpersonal interactions at all times.
9. Leaves call light or signaling device within easy reach of the resident.
10. Identifies that hands should be washed.

Nail Care

1. Identifies that hands should be washed.
2. Explains procedure to the resident.
3. Immerses nails in comfortably warm water and soaks for at least five (5) minutes. (The five minutes may be verbalized.)
4. Dries hand thoroughly, being careful to dry between fingers.
5. Gently cleans under nails with orange stick.
6. Gently pushes cuticle back with wash cloth.
7. Files each fingernail.
8. Cleans equipment and returns to storage. Discards linen in linen hamper.
9. Identifies that hands should be washed.
10. Maintains respectful, courteous interpersonal interactions at all times.
11. Leaves call light or signaling device within easy reach of the resident.

Partial Bed Bath

1. Identifies that hands should be washed.
2. Explains procedure to the resident.
3. Pulls privacy curtain.
4. Fills basin with comfortably warm water
5. Raises the bed between mid thigh and waist level.
6. Covers resident with a bath blanket.
7. Fanfolds bed linens at least down to waist or moves linens to opposite side.
8. Removes resident's gown without exposing resident and disposes in linen hamper.
9. Washes and dries face WITHOUT SOAP.
10. Places towel under arm, exposing one arm.
11. Washes arm, hand and underarm using soap and water.
12. Rinses arm, hand, underarm, and dries entire area.
13.Assists resident to put on a clean gown.
14.Empties, rinses and dries basin/s and returns equipment to storage.
15. Disposes of soiled linen in appropriate container.
16. Lowers bed if it was raised.
17. Maintains respectful, courteous interpersonal interactions at all times.
18. Leaves call light or signaling device within reach of the resident.
19. Identifies that hands should be washed.

Unoccupied Bed

1. Identifies that hands should be washed.
2. Gathers linen and transports correctly.
3. Places clean linen top of bedside stand, on over-bed table, over back of chair or drapes over foot of bed.
4. Raises the bed between mid thigh and waist level.
5. Removes soiled linen from bed without shaking or contaminating uniform.
6. Places removed linen in linen hamper.
7. Applies bottom fitted sheet, keeping it straight and centered.
8. Makes bottom linen smooth and/or tight, free of wrinkles.
9. Places clean top linen and blanket or bed spread on the bed.
10. Tucks in top linen and blanket or bedspread at the foot of the bed.
11. Makes mitered corners at the foot of the bed.
12. Applies clean pillowcase with zippers and/or tags to inside of pillowcase.
13. Leaves bed completely and neatly made.
14. Returns bed to lowest position if it was raised.
15. Identifies that hands should be washed.

Occupied Bed

1. Identifies that hands should be washed.
2. Gathers linen and transports correctly.
3. Places clean linen on top of bedside stand, on over-bed table, over back of chair or drapes over foot of bed.
4. Explains procedure to resident.
5. Provides privacy pulls privacy curtain.
6. Raises side rail opposite working side of the bed or asks test observer to stand on the opposite side of the bed.
7. Raises the bed between mid-thigh and waist level.
8. Resident is to remain covered at all times.
9. Assists resident to roll onto side toward raised side rail or test observer. Side rail remains up or test observer is directed to
remain on side opposite candidate at all times during the task.
10. Rolls or fan folds soiled linen, soiled side inside, to the center of the bed.
11. Places clean bottom sheet along the center of the bed and rolls or fan folds linen against resident's back and unfolds
remaining half.
12. Secures two fitted corners.
13.Raises second siderail or asks test observer to stand opposite working side of the bed and assists the resident to roll over the bottom linen, preventing trauma and avoidable pain to resident.
14. Removes soiled linen without shaking, and places in hamper.
15. Avoids touching linen to uniform.
16. Pulls through and smoothes out the clean bottom linen.
17. Secures other two fitted corners.
18. Places clean top linen and blanket or bedspread over covered resident. Removes used linen making sure the resident is unexposed at all times.
19. Tucks in top linen and blanket or bedspread at foot of the bed.
20. Makes mitered corners at the foot of the bed.
21. Applies clean pillowcase, with zippers and/or tags to inside.
22. Gently lifts resident's head when replacing the pillow.
23. Lowers bed if it was raised.
24.Returns side rails to lowered position if side rails were used.
25. Maintains respectful, courteous interpersonal interactions at all times.
26. Leaves call light or signaling device within easy reach of the resident.
27. Identifies that hands should be washed.

Backrubs

This can be helpful for the patients from stimulating to the patient's circulation to major aid in preventing skin breakdown (pressure ulcers).

Shaving

Very important for self-care for most men. When you are done afterwards of shaving: discard the razor in a puncture-resistant (sharps) container. If any nicks while shaving: report the incident to the nurse.

Water should be in the basin:

105°F- normal
95°F- diabetics

Decubitus Ulcers

Older term for a pressure ulcer; open area that develops on the skin over a bony prominence as a result of pressure. Preventing this includes from: keep the skin well-lubricated with lotion to monitor the skin on the feet and ankles daily and report abnormalities promptly. (pg. 658)

Empty a Drainage Bag

1. Identifies that hands should be washed.
2. Explains procedure to resident
3. Provides for privacy pulls privacy curtain
4. Puts on gloves
5. Places a barrier on the floor under the drainage bag.
6. Places the graduate on the previous placed barrier. Opens the drain to allow the urine to flow into the graduate.
7. Avoids touching the graduate with the tip of the tubing. Closes the drain.
8. Wipes the drain with antiseptic wipe.
9. Replaces drain in holder. Candidate places graduate on flat surface at eye level to measure output.
10. Empties graduate into toilet. Rinses and dries equipment. Returns equipment to storage.
11. Turns gloves inside out as they are removed. Disposes of gloves in the appropriate container.
12. Leaves resident in a position of safety and comfort.
13. Records the output in cc/ml on signed recording sheet.
14. Candidate's measurement is within 25cc/mls of Observer's measurement.
15. Places call light within reach of resident.
16. Maintains respectful, courteous interpersonal interactions.
17. Identifies that hands should be washed.

Bedpan and Fracture Pan Output

1. Identifies that hands should be washed.
2. Explains the procedure to resident.
3. Provides privacy for resident pulls curtain.
4. Candidate puts on gloves.
5. Positions resident on bedpan/fracture pan correctly using correct body mechanics
6. Positions resident on bedpan/fracture pan with pan in correct orientation,
7. Raises head of bed to comfortable level.
8. Leaves tissue within reach of resident and candidate steps away from the resident until RN Observer identifies resident is
finished.
9. Candidate returns and gently removes bedpan/fracture pan and holds while Observer adds a known quantity of fluid.
10.Candidate places graduate on flat surface at eye level to measure output.
11.Empties graduate, rinses and dries bedpan/fracture pan and graduate and returns to storage. Flushes toilet if used.
12. Washes/assists resident to wash and dry hands with wet wash cloth and towel.
13. Turns gloves inside out as they are removed and disposes of gloves in an appropriate container
14. Records the output in cc/ml on signed recording sheet.
15.Candidate's measurement reading is within 25cc/mL of RN Observer's reading.
16. Maintains respectful, courteous interpersonal interactions at all times.
17. Leaves call light or signaling device within easy reach of the resident.
18. Identifies that hands should be washed.

Applying Antiembolic Stocking to One Leg

1. Identifies that hands should be washed.
2. Explains procedure to resident.
3. Provides for resident's privacy by only exposing one leg and pulling privacy curtain.
4. Rolls, gathers, or turns stocking down inside out to the heel.
5. Places stocking over the toes, foot, and heel and rolls OR pulls up the leg.
6. Checks toes for possible pressure from stocking and adjusts as needed.
7. Leaves resident with stockings that are smooth and wrinkle free.
8. Maintains respectful, courteous interpersonal interactions at all times.
9. Leaves call light or signaling device within easy reach of the resident.
10. Identifies that hands should be washed.

Ambulation with Gait Belt

1. Identifies that hands should be washed.
2. Explains procedure to be performed and obtains gait belt.
3. Locks bed brakes to ensure resident's safety.
4. Locks wheelchair brakes to ensure resident's safety.
5. Lowers bed to a position so the resident's feet will rest comfortably flat on the floor when sitting on the bed.
6. Brings resident to sitting position with feet flat on the floor and places gait belt around waist to stabilize trunk.
7. Tightens gait belt. Checks gait belt for tightness by slipping fingers between gait belt and resident.
8. Assists resident to put on non-skid slippers.
9. Brings resident to standing position, using proper body mechanics.
10. With one hand grasping gait belt and the other stabilizing resident by holding forearm,
shoulder, or using other appropriate method to stabilize, ambulates resident at least 10 steps.
11. Assists resident to pivot and sit in a controlled manner that ensures safety. Removes gait belt.
12. Maintains respectful, courteous interpersonal interactions at all times.
13. Leaves call light or signaling device within easy reach of the resident.
14. Identifies that hands should be washed.

Hand Washing

1. Introduces self to the resident.
2. Turns on water.
3. Wets hands.
4. Applies liquid soap to hands.
5. Rubs hands together using friction.
6. Interlaces fingers pointing downward.
7. Washes all surfaces of hands and wrist with liquid soap.
8. Rinses hands thoroughly under running water with fingers pointed downward.
9. Dries hands on clean paper towel(s) and immediately discards.
10. Turns off faucet with a SECOND (last) clean dry paper towel.
11. Discards paper towels to trash container as used.
12. Does not re-contaminate hands at any point during the procedure.

Exposure Incident

Mean that your eyes, nose, mouth, mucous membranes, or nonintact skin had contact with blood or other potentially infectious material.

Prosthesis

Artificial Limb

Gait Training

Teaching the patient to walk.

AM Care

Early morning care that help set the tone for the entire day.

PM Care

Bedtime care.

Bridging

Elevates an area of the body off the surface of the bed.

Integumentary Physical Changes

Hair loses color and becomes thinner, skin dries become less elastic with wrinkles develop, skin is fragile and tears easily, bruises easily, reduced blood flow in vessels that nourish the skin results in delayed hearing, fingernails and toenails thicken, to blood supply to the feet and legs is reduced, increasing the risk of injury and ulcers and sensation of cold.

Use Signal to Call for Help

When you move the patient to the wheelchair, you saw the patient is pale, what do you do?

Wide base support

Used for moving a patient.

3-5 Minutes

How long does it take to do a back rub?

Affected Side

When dressing a stroke patient, what side do you put on first?

Shoulders

When moving a patient away from you, what part do you move first?

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