Nursing Procedures Palmas

-safe and efficient use of appropriate muscle groups to do the job

• Keep your back straight

• Ensure a wide base of support: keep feet separated

• Bend from the hips and knees; not the waist • Use the major muscle groups (strongest) • Use body weight to help push or pull • Avoid twisting. Pivot the whole body

• Hold heavy objects close to your body • Push or pull instead of lifting • Ask for help as needed • Synchronize efforts with client & other staff • Use mechanical devices, turning or lifting sheets as needed

From bed to chair or wheelchair

• Identify client’s strongest side

• Lower bed, lock wheels, elevate HOB • Place chair beside bed • on same side as client’s strongest side • Wheelchair faces FOB

If assistance in transfer is needed: • Place one arm under client’s shoulders • Other arm should be placed over and around the knees

• Bring legs over the side of bed while raising the client’s shoulder off the bed

• • • • •

Dangle client Watch for signs of fainting or dizziness Stand in front of client Place client’s feet flat on the floor Brace client’s weak foot and knee

Log rolling • When spinal column must be kept straight (post-injury or surgery) • 2 or more persons are needed: Both staff move to side of bed to which the client is being turned staff 1: keep client’s shoulders & hips straight staff 2: keep thighs & lower legs straight

• Draw client toward the both of you in a single unified motion • Client’s head, spine, and legs are kept in a straight position • Position with pillows for support and raise side rails

• Accurate measure for crutches vital to prevent brachial plexus injury • Distance between axillas and arm pieces: 2-3 fingerwidths or 2.5 – 5 inches • Elbows slightly flexed 20-30 degrees when walking • Stand on client’s unaffected side • Never rest axilla on axillary bars!

• Weight supported on hand piece; on the palm • Place crutches 6 – 10 inches diagonally in front of the foot • Instruct client to stop ambulation if numbness or tingling in the hands or arms occur

Four-point gait 1. 2. 3. 4.

Advance Advance Advance Advance

left crutch right foot right crutch left foot

-

Most stable crutch gait

-

Partial weight bearing on both legs

Three-point gait 1. Advance both crutches forward with the affected leg and shift weight to crutches 2. Advance unaffected leg and shift weight onto it -

Allows affected leg to be partially or completely free of weight bearing

-

Full weight bearing on one leg,

Two-point gait 1. Advance left crutch and right foot 2. Advance right crutch and left foot -

Faster version of the four-point gait More normal walking pattern Partial weight bearing on both legs, balance

Swing-to & swing-through gait 1. Advance both crutches 2. Advance both legs (or one leg is held up) -

Faster gait

-

Partial weight bearing on both legs, strength, and balance

Using Crutches: Sitting and Standing Sitting down 1. Back up to the chair or bed until it is felt behind the knees. Take crutches and hold them together with one hand.

25

Using Crutches: Sitting and Standing 2. Reach back for the chair or bed with your free hand.

26

Using Crutches: Sitting and Standing

3. Slowly lower yourself onto the chair or bed. 27

Using Crutches: Sitting and Standing Standing Up 2.Hold the hand grips of both crutches in one hand 3.Push off from the chair with the other hand 4.Stand and check your 28

UP WITH GOOD DOWN WITH BAD

Cane Types:

Straight cane

Quad cane

30

Cane Flex elbow 20-30 degrees angle and hold handle

Tips should have concentric rings as shock absorber and to provide optimal stability Tip of cane should be 6 inches lateral to the base of the fifth toe 31

Cane good side

e n a c Hold

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v d A

L

n o n a e

eg l d

f a d

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w e

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When going up the stairs follow: “up with the good, 32

Walker • Lift and move walker forward 8-10 inches • With partial or non-weight bearing, put weight on wrists and arms and step forward with affected leg, supporting self on arms, and follow with good leg. • Nurse should stand behind patient, hold onto gait belt at waist, as needed, for balance. 33

• Also known as – – – –

Mantoux screening test Tuberculin sensitivity test Pirquet test PPD test

• Purpose – To check if client was exposed to tuberculosis bacilli

• Equipment – Tuberculin syringe – Tuberculin/PPD tuberculin

What is tuberculin? A glycerine extract of the tubercle bacilli

What is PPD? Purified Protein derivative

• Procedure – Intradermal injection of 0.1 ml (5 tuberculin U) – Read 48 to 72 hours later

5 mm + •(Positive) HIV positive person

•Recent contact of TB case •Persons with nodular or fibrotic changes on chest X-ray consistent with old healed TB •Patients with organ transplants •Immunosuppresed patients

10 mm +  Recent arrivals (less Positive

than 5 years) from high-prevalence countries Injection drug users Residents and employees of highcongregate settings (e.g. prisons, nursing homes) Mycobacteriology lab personnel Persons with clinical conditions that place them at high-risk (e.g. diabetes, leukemia) Children less than 4 years of age, or children and adolescents exposed to adults in high-risk

15 mm +  Positive Persons with no known risk factors for TB

• False-positive results – Nontuberculosis mycobacteria – Previous BCG vaccination

Part 1 Test Result Normal

Part 2 Test Result

Diagnosis

---

Normal

Low

Normal

Low

Low

Pernicious Anemia Malabsorption

URINE COLLECTION • To obtain aseptic or sterile urine sample for microbiological analysis

Normal Urine Characteristic –Normal urine volume: 500-1,500 ml/day; Average: 1,200 ml –Urine Color: clear, light yellow –pH: 4.6-8.0 (average 6.0) –Specific gravity: 1.010 – 1.030 –Protein, blood, and glucose  should not be present in urine. –Ketones- present in clients who are alcoholic, fasting, starving, on highprotein diet, and in DKA

Specimen Collection Methods –Clean-catch midstream specimen –Specimen from an indwelling catheter •Closed-system method •Open-system method

–24-hour urine collection

Collecting Urine Specimens Clean-Catch (Midstream) Specimen • Initial urinary flow is allowed to escape • 3-10 ml of midstream urine is collected in a sterile container • avoid collecting last few drops of urine • send specimen immediately to the laboratory or within 2 hours after collection

Collecting Urine Specimens Sterile Specimen from Indwelling Catheter a. From a closed system Method – clamp drainage tubing about 4”below junction of drainage tubing and catheter for 10-30 minutes – Clean specimen collection port with alcohol or antiseptic solution – Collect 3-10 ml of urine with a sterile syringe – If no collection port is visible, check if the catheter is selfsealing – For self-sealing catheter, insert needle slowly at 450 angle taking care not to puncture the other

b. Open-System Method -Place line saver under tubing at junction of catheter and drainage tubing -Disinfect the junction before and after the collection -Hold the disconnected tube (catheter and drainage tubing) 1.5-2 inches from each other -Do not allow the catheter tip to touch container

Collecting Urine Specimens 24-Hour Urine Collection • Discard the first voided urine • Collect all the subsequent urine passed • At the 24th hour, collect the last sample • Urine should be kept cool, refrigerated or with preservative during the 24-hour collection period • Specimen sent to the laboratory within 2 hours after collection

• Sterile gloves • Percutaneous introducer kit • IV pole • Premix flush solution • IV tubing • Clean gloves • Sterile towels • Skin antiseptic

• Pressure transducer system with – – – –

• • • •

Pressure bag Tubing Flush device Transducer

Pressure monitor Razor Sterile 4x4 sponges Stethoscope

• Lidocaine 1-2% • 3 ml syringe with 18-G and 25-G needle for topical anesthesia • Antimicrobial wipes • Occlusive dressing or tape • Suture with attached needle

• Sterile needle holder or clamp • Cutdown tray • Sterile gown • Cap • Mask • Emergency cart • Sterile syringes filled with 5 or 10ml D5W

•Signed consent •Enema tube and bag •Ordered solution for enema •Laxative •Wheelchair

•Low residue diet 1-2 days before test •Clear liquid diet before test; no dairy products •One glass of water every hour for 8-10 hours •Administer one full bottle of magnesium citrate at 2pm day before test •3 5-mg Dulcolax tablets at 7PM, evening before test •Keep NPO after Dulcolax •Administer suppository or cleansing enema early morning before test

Barium studies should follow IVPs, UTZ, and arteriograms. Ba interferes with visualization. Barium enema before barium swallow!!!

•Sterile specimen container, with tightfitting cap •Gloves, if necessary •Label •Laboratory request forms

•#12 to 14 French sterile suction catheter •Lab request form •Sterile gloves •Mask •Sterile in-line specimen trap (Lukens trap) •NSS •Portable suction machine •O2 therapy •Label •Optional: Nasal airway

Oxygen Therapy • Indication: Hypoxemia/Hypoxia • Review: Normal ABG – PaO2= 80-100 mmHg – PaCO2= 35-45 mmHg – PaHCO3= 22-26 mmHg – pH= 7.35-7.45 – O2 Saturation= 95%-100% 120

Methods of Delivery Nasal Cannula • a low-flow oxygen delivery system • Approximate O2 conc. – – – – – –

1 Liter = 24%-25% 2 Liter = 27%-29% 3 Liter = 30%-33% 4 Liter = 33%-37% 5 Liter = 36%-41% 6 Liter = 39%-45%

• Cannula prongs should be well placed in the client’s nares • Tubing is slipped around client’s ears and under chin • Secure cannula by tightening the tubing but assure client’s comfort 121

Methods of Delivery Transtracheal Catheter • Fr 8 catheter inserted bet. 2nd & 3rd tracheal cartilage • Does not interfere with talking, eating, drinking • Expect a stent post-op 122

Methods of Delivery

• Venturi Mask

• High airflow oxygen entrainment system • For patients requiring low but constant O2 conc. (e.g. COPD) • Can deliver 24-50% O2 @ 4 to 10L/min • Does not allow CO2 rebreathing 123

Methods of Delivery Simple Face Mask • Low-flow system40to60% at 5-8 L/min • Can be used for aerosolization 124

Methods of Delivery Partial Rebreathing Mask • Has an inflatable bag that stores 100% O2 • Indicated for patients needing high O2 conc. • On inspiration, patient inhales from mask • On expiration, bag refills with oxygen • Allows mixing of inspired and expired air

125

Methods of Delivery Non-Rebreathing Mask • Has an inflatable bag that stores 100% O2 • Indicated for patients needing high O2 conc. • Does not allow mixing of inspired and expired air

126

Methods of Delivery CPAP Mask • Provides expiratory and inspiratory positive airway pressure • Mask provides tight seal • Used when patient have not responded to attempts to increase O2 with other types of mask • Keeps airway open (e.g OSA patients)

127

Methods of Delivery ET and tracheostomy tube with T-piece (Briggs adapter) • For patients who cannot protect airway, mechanically ventilated or not. • Attached to T-piece usually when weaning from ventilator • O2 concentrations of 21100% may be used.

128

Methods of Delivery Manual resuscitation bag • Can be used in unintubated client needing high O2 concentration • Usually used in CP arrest situation • For hyperoxygenating patient prior to suctioning among ventilated patients 129

Standard Intervention •Check for adequate oxygen source/supply and other appropriate equipment for function •Humidifier should be filled with sterile distilled water to indicated level •Determine current vital signs, level of consciousness, and most recent ABGs before starting therapy - Low Concentration (24%-28) - High Concentration (greater than 30) 130

Standard Intervention

• Post “NO SMOKING” signs on the patient’s door • Be sure that electric devices are in good working order • Asses risk for CO2 retention especially for COPD client • Monitor response to therapy by oximetry. • Gerontological Considerations – Ciliary action decreases with age. – Elder client’s are prone to dehydration for procedures causing mucous membranes to dry. – Muscular structures of the pharynx and larynx atrophy with age 131

Suctioning General Principles • Make sure suction equipment is functional • Monitor for signs and symptoms to note needing suctioning

Suctioning Special considerations • Clients sensitive to decreased oxygen levels should be suctioned for shorter durations, but more frequently • For pediatric clients: Two people required • Perform any procedure which loosens secretions before suctioning

• Suction catheter sizes – Pediatric: 8-12 French – Adult: 14-16 French • Position patient appropriately • Suction pressure – Infants: 60-100 mmHg – Adult: 100-120 mmHg

Suctioning • Hyperoxygenate the client before and after suctioning • Suction is applied only upon withdrawal of the catheter • Suction only for 10-15 seconds • Allow 1-3 minutes of rest between suctioning periods • Let the client cough in between suction periods • After procedure, position client with head of bed elevated at 450, side rails up, and

Oral Airway Suctioning • Also used to decreased halitosis and anorexia due to excess oral secretions • Insert catheter into the mouth along jaw line and slide to oropharynx • Ask client to take 3-4 breaths in between suction period • After suctioning, irrigate mouth with 510 ml of mouth wash • Apply petroleum jelly to lips, and mouth moisturizer to inner lips and

Nasopharyngeal/Nasotracheal Suctioning

• Determine patency of nasal passage • Have client blow nose with both nares open • Clean mucous and dried secretions from nares • For nasotracheal: once catheter is visible in back of throat or resistance is felt, ask client to pant or cough  attempt to insert the

Endotracheal Tube Suctioning • Special Considerations • Clients sensitive to decrease oxygen levels • must be well ventilated and oxygenated prior to beginning suctioning to • prevent CO2 build up. • Confused or pediatric clients may need to be restrained. • For elderly, skin is often thin and sensitive to • pressure. Special care should be taken to prevent skin breakdown • For pediatric clients,

Set oxygen on Ambu breathing bag to 100% Have assistant deliver ventilations If secretions are thick, place 2-3 ml saline into ET tube, and administer deep ventilations with Ambu bag Suction oral airway and perform oral care

Hyperoxygenate before suctioning. Depth of suction: 6 inches

Suctioning

Complications  Infection  Cardiac arrhythmias  Hypoxia  Mucosal trauma  Death

• Women with moderate to high risk of developing deep vein thrombosis postoperatively

• Morbid obesity with no correct fit • Inflammatory conditions of the lower leg • Severe arteriosclerosis • Edema of the legs • Pulmonary edema • Severe lower limb deformity

•Disposable sitz baths with tubing and bag •Warm water, but cool water may be indicated •Towels for drying •Thermometer •Clean gloves, if needed

1. Verify physician’s order 2. Raise toilet seat and place sitz bath with “front” facing the front of the bowl 3. Fill basin with warm water up to ½ to 2/3 full 4. Close flow clamping tube 5. Open top of plastic bag and fill with hot water 6. Hang bag at level higher than sitz baths 7. Insert tubing at the front or rear of sitz baths 8. Wash hands

1. Identify client 2. Explain procedure 3. Assist client into tx area; provide call bell 4. Check the temperature 5. Provide privacy 6. Assist client to sit in sitz bath Duration: 15-20 minutes 8. Maintain water temperature by continually adding appropriate temperature to bag 9. Assist client to dry area and allow client to sit---prevent hPN 10.Empty and clean sitz bath basin (don clean gloves) 11.Discard soiled linen

1. Explain purpose and procedure 2. Obtain informed consent 3. Ensure that x-ray film has been taken 4. Assess if client has allergies to topical anesthetics 5. Explain that movement and coughing will be done during the

1. Wash hands 2. Take V/S and respiratory movement assessment 3. Administer sedative as ordered 1. Provide adequate 4. Positioning warmth and covering 2. Place unwrapped sterile tray in bedside table 3. Open sterile gloves; keep sterility 4. Assist with skin prep 5. Don clean gloves. Instruct client not to move, cough during needle insertion 6. Observe for pallor, dyspnea, tachycardia, chest pain or vertigo.

1. Apply pressure dressing 2. Observe client every 5 mins. For the next half hour for possible pulmonary edema, crepitus, cardiac distress, or shift in 1. Monitor V/S and breath mediastinum sounds 3. Place client on 2. Observe dressing, unaffected side change as needed 3. Obtain chest x-ray 4. Record color, amount, and consistency of fluid 5. Complete lab slips and send to lab

•Chair •Drape •Sterile tray •Sterile gloves •Bucket •Dressing---elastic adhesive patch •BP equipment •Clean gloves

1. Explain purpose and procedure 2. Obtain informed consent 3. Assess for allergies to topical anesthetics 4. Assess for coagulation abnormalities or bleeding tendencies 5. Handwashing 6. Assess client’s abdominal girth and bowel sounds 7. Weigh client 8. Have client empty bladder

• Insertion of trocar needle in small incision • Observe total amount of fluid aspirated • Apply pressure dressing • Discard gloves and wash hands • Observe for leakage @ puncture site and for scrotal 1. Positioning: Fowler’s edema 2. Drape client: blanket • V/S and hPN; UO; bowel 3. V/S; check for pallor sounds and abdominal girth and vertigo • Weigh clients once V/S 4. Prepare tray; open stable sterile gloves • Reinforce/change dressings PRN 5. Skin prep • Monitor serum electrolytes 6. Don clean gloves • Document: color, consistency, and amount; and send to lab!!!

Chest tube drainage system • Returns negative pressure to the intrapleural space • Removes abnormal accumulations of air and fluids from the pleural space

Interventions • Monitor drainage: 100 ml/hour • Mark drainage in collection chamber at 1 to 4 hour interval • Water-seal chamber – flucutuates with client’s breathing – Pneumothorax: intermittent bubbling expected

• Suction control chamber – Normal: gentle bubbling – Vigorous bubbling >> leak

• Occlusive sterile dressing at insertion site • Chest radiograph: position & lung expansion • Assess respiratory status

• Encourage coughing and deep breathing • Turn client regularly >> drainage & ventilation • Do not strip or milk chest tube • Bedside: clamp and sterile occlusive dressing • Never clamp a chest tube without written order from doctor

• If drainage system cracks or breaks: – insert chest tube into a bottle of sterile water

• If chest tube pulled out accidentally: – Pinch skin opening together – Apply occlusive sterile dressing – Cover dressing with overlapping pieces of 2-inch tape

• Removal: client asked to take a deep breath and hold it, doctor removes tube

• 2 nurses to identify patient and blood products • Jehovah’s Witness: special written permission • You need an in-line filtration system! • Use a blood warmer • Ideal temperature: no more than 42 degrees C

1. 2. 3. 4.

Explain procedure V/S Prepare IV line- 20G Obtain blood from blood bank 30 mins. before transfusion 5. Compare with another nurse 6. Put on protective equipment and prepare blood recipient set 7. Remember to prime the tubing!

• Blood recipient set • IV pole • Gloves • Gown • Face Shield • Multiple-lead tubing • Blood components • 250 ml of NSS • Venipuncture equipment • Optional: warm compress; ice pack

1) If administering RBCs, you can dilute it with NSS 2) If administering whole blood, invert bag several times to mix cells 3) Attach blood preparation to the venipuncture device 4) Adjust the flow rate to no greater than 5 ml/min for first 15 mins. 5) Stay with patient and observe for any immediate reaction 6) Must infuse only for 4 hours!!! 7) Discard equipment (wear gloves) 8) Return empty bag to blood bank and discard tubing and filter 9) Record V/S

• filter can take up to 10 units of blood • you may use a pressure bag to hurry up transfusion • if it stops, open flow clamp; gently rock the bag back and forth; flush line with NSS

• Hepatitis C • HIV • Cytomegalovirus • Circulatory overload • Hemolytic reaction • Allergic • Febrile • Pyogenic • Coagulation disturbances

Provision of oxygen to the brain, heart & other vital organs until help arrives

• • • •

A - airway B - breathing C - circulation D– defibrillation or definitive treatment

• Each step begins with

Adult BLS: airway • Assessment • Gently shake victim’s shoulders and ask “are you okay?” • Activate EMS: “phone first” (8 yrs. Old over) “phone last” (below 8 yrs old) • Supine position on firm flat surface • 1-person rescue: on his knees, perpendicular to victim’s sternum and facing victim • 2-person rescue: perpendicular to head perpendicular to sternum

• • • •

Open airway Head tilt – chin lift Jaw-thrust maneuver Look for any foreign material, liquids, or solids in victim’s mouth • Wipe out any foreign material with a hooked index or middle finger

Adult BLS: breathing • Assess breathing and maintain an open AW • Place ear over victim’s nose and mouth while looking for the chest to rise and fall • Listen for air moving in and out of lungs • Feel for the flow of air • Breathing victim: logroll onto side as a

Non-breathing victim • Maintain head tilt – chin lift • Pinch nostrils closed • Give 2 slow full ventilations of 2 seconds per breath (allow victim to exhale in between) • Give 10 – 12 ventilations per minute • If unsuccessful, check victim’s head position and reposition if appropriate • If unsuccessful still, check mouth for foreign body, clear AW, and ventilate again • Be alert to gastric distention when giving ventilations • Mouth to nose • Mouth to stoma

Adult BLS: circulation • • • •

Assess circulation Always check for absence of pulse first Maintain an open AW Palpate for a carotid pulse for 5 – 10 secs • If there is pulse, continue giving 10 – 12 ventilations per minute • Recheck the pulse after 1 minute; if no pulse, start chest compressions

Adult BLS: chest compressions • Correct hand placement: lower half of sternum • With the hand closest to the victim’s feet, locate lower margin of rib cage • Mover fingertips along the margin to the notch where the ribs meet the sternum • Place middle finger on the notch and the index finger next to the middle finger • Place heel of opposite hand next to the

Ventilations

Circulation

Depth

adult

10 – 12/min

child

20/min

adult

Carotid pulse

child

Carotid pulse

infant

Brachial pulse

adult

1.5 – 2 inches

child

1 – 1.5 inches

infant

0.5 – 1 inch

15: 2 ratio for both one-man and 2-men rescue

• Complications of chest compression: – Laceration of internal organs – Punctured lungs – Fractured ribs or sternum

Foreign body airway obstruction

• Heimlich maneuver - stand behind the victim - place arms around the victim’s waist - make a fist - place the thumb side of the fist just above the umbilicus and well below the xiphoid process - use chest thrusts for the obese or for the advanced pregnancy victim

• measures the heart’s electrical activity as waveforms • can detect MI and infarctions • can detect rhythm and conduction disturbances • can detect chamber enlargement • can detect electrolyte imbalances • can detect drug toxicities

• ECG machine • Recording Paper • Disposable pregelled electrodes • 4” x 4” gauze pads • Optional: shaving supplies and marking pen

I. Set up equipment at bedside II. Explain procedure during setup III. Position: supine or low Fowler’s; arms @ side; make sure client is relaxed to prevent electrical

I. To prevent muscle tension, place pt’s hands under buttocks; do not let feet touch bed board II. Select flat, fleshy areas to place the electrodes III. If excessively hairy, shave; clean excess oil from skin IV. Apply electrodes to prepared site as recommended by manufacturer

I.

To guarantee best connection with leadwire, position electrodes on legs pointing superiorly II. Do not use alcohol or acetone pads…they will disrupt transmission of electrical impulses III. Connect limb leadwires to the electrodes

•White or RA= right arm •Green or RL= right arm •Red or LL= left leg •Black or LA= left arm •Brown or V1 to V6= chest I. Expose chest; position electrodes on chest II. If a woman, place electrodes below breast tissue; if large-breasted, displace breast tissue laterally III. Paper speed: 25 mm/second IV. If any waveform extends beyond paper size, adjust V. Ask patient to relax and breath normally and not to talk VI. Remove electrodes and clean patient’s skin

3 basic components: b)P wave c)QRS complex d)T wave

5 further divisions: ii.PR interval iii.J point iv.ST segment v.U wave vi.QT interval

P wave

-Represents atrial depolarization (electrical activation)

PR interval

- Time it takes for impulse to travel from atria to AV node and bundle of His

QRS complex

-Ventricular depolarization -Time it takes for impulse to travel through bundle

J point - Marks the end of QRS complex and beginning of the ST segment ST segment - Represents part of ventricular repolarization (restoration of electrical potential) T wave - Ventricular U wave repolarization - Follows the T wave, but is usually not seen

QT Interval - Ventricular depolarization and repolarization

• Nurse • Physical therapist • Caregiver

• Septic joints • Acute thrombophlebitis • Severe arthritic joint inflammation • Recent trauma with possible hidden fractures or internal injuries

• Determine joints that need exercise • Consult physician/PT for any limitations or precautions • The exercises need not be done in any order or all at once • Schedule exercises over the course of the day • Do exercises slowly, gently, to the end of normal ROM, or to the point of pain

• support pt’s head with hands • extend neck • flex chin to chest • tilt head laterally to the shoulder • rotate head from right to left

• support pt’s arm in extended, neutral position •Extend forearm and flex it backward • abduct arm outward from the side of body; adduct back to side • rotate shoulder • bend elbow to touch shoulder • touch the mattress on the other side of the bed for complete internal rotation • push arm backward for complete external rotation

• place pt’s arms at his side with his palm facing up • flex and extend his arm at the elbow • stabilize pt’s elbow, then twist hand to bring his palm up (supination) • twist it back again to bring his palm down (pronation)

• stabilize pt’s forearm; flex and extend wrist • rock his hand sideways for lateral flexion; rotate hand for circular motion • extend pt’s fingers, then flex hand into a fist; repeat extension & flexion with each finger • spread two adjoining fingers apart, then bring them together

• fully extend pt’s legs, then bend hips and knees toward chest allowing full joint flexion • move straight leg sideways, out and away from other leg; then back, over and across it • rotate his straight leg internally toward midline,

• bend the pt’s foot forward so that toes push upward (dorsiflexion); then bend foot so toes push downward (plantar flexion) • rotate ankle in a circular motion • invert ankle so that sole is in midline; then evert ankle so that sole faces away from midline

• flex the pt’s toes toward the sole, then extend them toward the top of the foot • spread two adjoining toes apart, then bring them back together

• which joints were exercised • patient’s tolerance of exercises • any edema or pressure areas • pain from the exercises • range-of-motion limitation • start passive ROM ASAP; joint disuse starts after 24 hours • use proper body mechanics • if pt needs long-term rehabilitation, consult physician/PT and teach family/caregiver • pts on prolonged bed rest or limited activity with no profound weakness can be taught how to do active ROM