Foundations II final

• External ventricular drain (EVD) is a tube that drains CSF from the brain
• When moving a patient with an EVD, it must be clamped, move the patient to a new position, then have nursing reset the device before unclamping
• Normal ICP: 5-15
• Restraints are used when a patient interferes with the treatment plan or are in danger to themselves or others. Used when all other methods have failed
• Locked restraints are for violent behavior
• Soft restraints are for non-self-destructive behavior
• List the four types of restraints

  1. Locked restraints
  2. Soft restraints
  3. four bed rails
  4. wedging bed against the wall
• CPR

  • Rate = 100-120 bpm
  • Adult 1 or 2 = 30:2, depth 2-2.4 inch
  • Child/infant 1 rescuer = 30:2, 1.5-2 inch
  • Child/infant 2 rescuers = 15:2, depth 1.5-2 inch
• Rescue breath

  • Adult = 1 breath every 5-6 sec
  • Child = 1 breath every 2-3 sec
• Choking

  • If patient is unresponsive = lower them to the ground and begin CPR (starting with chest compressions), check their mouth before rescue breaths to see if item is dislodged
  • If patient is responsive = abdominal thrusts until object is out or pt loses consciousness
• Seizures

  1. Pillow under head
  2. Keep onlookers away
  3. Do not forcibly hold the pt down - roll onto their side
  4. Do not put anything in their mouth
  5. Monitor respiratory status
  6. Time the seizure, if longer than 5 minutes call 911
• Infiltration = most common complication seen in children

  • area is tense to touch, cool, swollen
  • tx is elevation, cool compress, plus analgesics
• CVC complications

  • infection
  • phlebitis
  • Occlusion - kink in the line, notify RN
  • Air embolism - place pt on left side in trendelenberg, head down, notify RN/MD stat and do not move the patient
  • Sx: pallor, tachycardia, cyanosis, cough
  • Admin O2 and monitor pulse ox
• CVC complications

  • Malposition - neck/chest swelling, gurgling sound in ears
  • notify RN
  • Catheter breakage/dislodgment leakage
  • IMMEDIATELY clamp catheter above the breakage using a non-toothed clamp
  • Dislodgment = the length is longer than before, page RN, they will stop infusion, notify MD
• NWB = 0% of pts weight

  • Walker, crutches
• TDWB - limb only used for balance

  • Walker, crutches
• PWB - 50% of pts body weight

  • Walker, crutches
• WBAT - as much weight as comfortable

  • Walker, crutches, WBQC, cane
• FWB - full body weight

  • No device needed, may use cane for balance
• Glaucoma = losing peripheral vision first
• Cataracts = cloudiness, blurry vision
• Homonymous hemianopsia = visual field cut in the same field of vision

  
• Hemi-spatial visual neglect = not acknowledging a field of vision; only drawing one side of a clock

  
• When to not initiate PT:

  • Resting HR is <50 bpm or >120 bpm
  • Resting SBP <90 mmHg or >200
  • Resting glucose <70 or >200
• When to terminate PT:

  • RR > 40
  • HR decreases > 10 bpm with activity
  • SpO2 < 90%
  • SBP decreases >10 with activity
• Doning PPE

  1. Gown
  2. Mask
  3. Goggles
  4. Gloves
• Doffing PPE

  1. Gloves
  2. Goggles
  3. Gown
  4. Mask
• Contact Precautions:

  • Gloves and gown
  • Wash hands before and after wearing gloves
• Droplet Precautions:

  • Gloves, gown, facemark, goggles
• Airborne Precautions:

  • Private room with negative pressure
  • Respirator, gown, mask, goggles, gloves
• When to wash hands with hand sanitizer vs soap and water:

  • Before touching a patient
  • Before a procedure
  • After a procedure or bodily fluid exposure
  • After touching a patient
  • After touching a patient surroundings
  • every five uses of hand sanitizer, you need to wash hands
• Acute rehab:

  • 3 hours per day for 5-7 consecutive days (15 hours in 7 days)
  • Average length of stay 10-14 days
  • Physician care daily
• Subacute rehab:

  • 1 or 2 hours of therapy per day
  • Average length of stay 24-60 days
  • Physician care once a week
• ADA

  • Common door width = 32 inches
  • Max force to open doors = 5 lbs
  • Counter top heights = 36 inches
  • Elevator call button = no more than 54 inches
  • Ramp rise = 1 inch, 12 inch run ratio
  • if taller than 6", must have railings on both sides
• When to mobilize when a pt has a DVT

  • Mobility is contraindicated until intervention is initiated
  • Anticoagulation is the main intervention
  • Therapy may still be possible on unaffected limbs
  • Mobility to be restarted ASAP, immobility is a huge risk factor for another DVT
• ACSM Strengthening Guidelines

  • > 2 days/week
  • Intensity:
  • Light - 40-50% I RM
  • Moderate - 60-80% 1 RM, 5-6 on BORG
  • Vigorous - 60-80% 1 RM, 7-8 on BORG
  • 8-10 exercises of major muscle groups
  • >1 set of 10-15 reps, progress to 1-3 sets of 8-12 reps
• ACSM Aerobic Training Guidelines

  • Moderate >5 days/week
  • 5-6 RPE
  • 30-60 min/day, 150-300 min/week
  • Vigorous > 3 days/week
  • 7-8 RPE
  • 20-30 min/day, 75-100 min/week
• Neuromotor exercise = balance + agility + proprioceptive

  • effective for reducing and preventing falls
  • 2-3 days/week, 20-30 min
• Extravasation injury

  • Occurs when an irritant infuses under the skin and causes changes in color, swelling, blisters, and resembles a burn

  
• Phlebitis is vein inflammation, looks like a red streak above IV site

  • warm and tender
  • more common in adults