Basic Care And Comfort Flashcards
Proper crutch measurement and position
- 2 fingers below axilla
- crutches 8-10 inches out to side
- flex elbows 20-30 degrees
Type of exercise in which the client alternates contraction and relaxation of a muscle to maintain strength of muscle when joint is immobilized
Isometric exercise
Which position avoids hip flexion?
Supine
Which position is supine with the knees flexed?
Dorsal recumbent
Which position promotes extension of the hip joint?
Prone
Which position promotes drainage of oral secretions?
Side lateral
Which position promotes visualization of the rectal area?
Knee-chest
Which position decreases abdominal tension?
Sim’s
Position that increases venous return and promote lung expansion
Fowler’s
High Fowler’s
60-90 degrees
Fowler’s
45-60 degrees
Semi-Fowler’s
30-45 degrees
Low Fowler’s
15-30 degrees
Position used for shock
Modified trendelenburg (feet elevated 20 degrees, head slightly elevated)
Position used for a vaginal exam
Lithotomy
Myasthenia gravis results from a deficiency in
Acetylcholine
NOTE: key manifestation is ptosis
Parkison’s disease results from a deficiency in
Dopamine
When is joint and muscle stiffness at its worst in a client with rheumatoid arthritis?
In the morning and after periods of inactivity
Heberden’s and Bouchard’s nodules are manifestations of which disease process?
Osteoarthritis
Inflammation of the fluid filled sac between the muscles, tendons, and bones affecting larger joints such as the knees, elbows, and shoulders
Bursitis
Heat/cold therapy for bursitis
Apply heat for movement and cold to reduce inflammation
Assessment of developmental dysplasia of the hip (DDH)
- uneven gluteal folds and thigh creases
- limited abduction of hip
- ortalin’s sign (seen in infants < 4 years old; clicking sound when hip is moved to abduction)
- limb on affected side is shorter than limb on unaffected side
DDH interventions for the newborn to 6 months
Pavlik harness for 3-6 months
DDH interventions for infant 6-18 months
Bilateral Bryant’s traction, hip spica cast for immobilization
DDH interventions for the older child
Open reduction, hip spica cast
Scoliosis assessment
- uneven hips or scapula
- kyphosis lump on back
- instruct client to bend at waist to visualize deformity
Assessment of spinal bifida occulta
Dimpling at the site
Nursing interventions for meningocele/myelomeningocele
- Cover lesion with moist sterile dressing
- Position infant on abdomen or semi-prone
- Monitor for S/S of meningitis and increased ICP
How frequently should a client who is to undergo a delayed prosthesis fitting be positioned prone?
30 minutes three times/day to prevent hip contracture
Injury to the soft tissue characterized by ecchymosis and hematoma formation
Contusion
Interventions for contusion
Application of cold for 24 hrs followed by moist heat, elastic bandage
Complication of fracture to long bone, such as the femur
Fat embolism
NOTE: S/S similar to PE + petechiae
Most common and early symptom of compartment syndrome
Severe pain unrelieved by analgesics
The nurse cares for the school-age child diagnosed with a fracture of the tibia located in the epiphyseal plate. What is a major complication associated with this type of fracture
Bone growth of the fractured leg may be affected
Assessment of a hip fracture
Shortened leg that is adducted and externally rotated
Parathyroid hormone helps to maintain the balance of _________ and _________ in the body
Calcium; phosphorus
Hypoparathyroidism will present with symptoms of _________
Hypocalcemia
NOTE: hyperparathyroidism will present with signs of Hypercalcemia
Clients with hyperparathyroidism are at risk for
Renal calculi
NOTE: increase fluid intake and follow acid-ash diet for prevent of stones
A goiter is enlargement of the thyroid gland most often caused by lack of _________ in the diet
Iodine
Foods that promote growth of a goiter
Cabbage, turnips, spinach, and seafood
The client’s diet during lactation should be increased by ___ calories/day
500
Why would the nurse’s administration of tube feedings (enteral nutrition) be more appropriate than total parenteral nutrition (TPN) for the client diagnosed with a stroke?
The client’s gastrointestinal tract can still digest feedings
Parenteral nutrition nursing interventions
- change IV tubing every 24 hrs
- keep solutions refrigerated, and warm to room temperature prior to administration
- if new solution unavailable, used D10W temporarily to avoid rebound hypoglycemia
Vitamin A is necessary for
Visual acuity
Vitamin D is necessary for
Calcification of bones and absorption of calcium and phosphorus
Vitamin E is an antioxidant. Without vitamin E, the client will experience
Hemolytic anemia
Vitamin K is necessary for
Blood clotting
NOTE: vitamin K deficiency can result in bleeding and bruising
Vitamin B1 (thiamine) is essential for
Carbohydrate metabolism
Vitamin B2 (riboflavin) is needed for
Protein metabolism
B6 (Pyridoxine) is needed for
Amino acid metabolism
NOTE: B6 deficiencies can result in anemia, seizures, and peripheral neuropathy
Folic acid is necessary for
RBC formation
NOTE: deficiency may result in anemia
Vitamin B12 (Cyanocobalamin) is necessary for
Nerve function and RBC formation
NOTE: B12 deficiency may result in pernicious anemia
Niacin is need for
Normal growth
Vitamin C (ascorbic acid) is needed for
Collagen synthesis
NOTE: Vitamin C deficiency can result in scurvy
Primary sources of calcium
Milk products, green leafy vegetables, eggs
Primary sources of phosphorus
Milk, eggs, nuts
Primary sources of iodine
Seafood, iodine salt
Primary sources of sodium
Table salt, canned vegetables, milk, cured meats, processed foods
Primary sources of potassium
Grains, meats, vegetables
Primary sources of iron
Liver, oysters, leafy vegetables, apricots
At what age can a bland diet of rice cereal and strained fruit be introduced?
4-5 months
At what age can strained vegetables and meat be introduced?
5-6 months
At what age can chopped meat and finger foods be introduced?
7-9 months
Toddlers begin to eat solid food when they have ___ to ___ teeth
6-8 (12-36 months)
Recommended amount of vegetables per day
2.5-3 cups
Recommended amount of fruits per day
1.5-2 cups
Recommended amount of grains per day
6-7 oz. Equivalents
Recommended amount of milk per day
3 cups
Recommended amount of meat and beans per day
5-6 oz. Equivalents
Recommended amount of oils per day
5-6 teaspoons
What does the client following a vegan diet eat?
Fruits, vegetables, nuts, seeds
What does the client following a lactovegetarian diet eat?
Vegan diet + milk, cheese, yogurt, and milk products
What does the client following the ovovegetarian diet eat?
Vegan diet + eggs
What does the client following the lactoovovegetarian diet eat?
Vegan diet + dairy products and eggs
Caloric requirement for normal, healthy adult
1,500-3,000 kcal/day
Fluid requirement for the average adult
1,800-2,500 mL/day
Kidney diet
Low protein, potassium, and sodium
Normal urine pH
4.5-8.0
Normal urine specific gravity
1.010-1.030
NOTE: this is a measurement of urine concentration
Toilet training is initiated after ___ months of age
18
Examples of foods high in oxalates
Spinach, wheat germ, and peanuts
