Exam 2 Flashcards
1
Q
what unit do you measure urine in?
A
mL
2
Q
what characteristics should you document in relation to urine?
A
color, clarity, smell,
3
Q
what is included in intake?
A
oral fluids, IV fluids, ice
4
Q
how much intake is required everyday?
A
6-8 8OZ CUPS
2L
5
Q
how many mL is 1 fluid oz
A
30mL
6
Q
what is the ratio of volume for ice to wate?
A
Ice is half the volume of water
7
Q
what is considered output?
A
blood, urine, bowel, emesis, drainage
8
Q
how many grams is one mL
A
1 gram to 1mL
9
Q
What is included in a urine history assesment?
A
pattern changes, weight changes
10
Q
what is included in a urine assessment under problems?
A
frequency, urgency, difficulty starting, nocturia
11
Q
what existing problems should be considered under a urine assessment?
A
medications and comorbidities
12
Q
what characteristics should you document under assessment for urine?
A
color…should be straw to clear
odor
floaters
13
Q
what do muscles do?
A
create movement, maintain posture, stabilization
14
Q
do muscles support soft tissues like organs?
A
yes through the abdominals
15
Q
what do muscles do in terms of thermoregulation?
A
create heat
16
Q
what does the nervous system do?
A
causes purposeful movement
17
Q
what is anatomical position?
A
facing forward, palms forward,
18
Q
what is abduction?
A
moving part away from the midline
19
Q
what is adduction?
A
moving towards midline
20
Q
what happens to the angle when going into extension?
A
angle increases
21
Q
what happens to the angle in flexion?
A
angle decreases
22
Q
what is rotation?
A
moving a body part 360 degrees without creating a circle
23
Q
what is circumduction?
A
moving something in a circular motion
24
Q
what is internal rotation?
A
spinning inward
25
what is external rotation?
spinning outward
26
what two body parts can rotate and circumduct?
xx
27
what is plantar flexion?
pointing toes down
28
what is dorsiflexion?
pointing feet up
29
what is hyperextension?
extended something and extended beyon that
30
what is pronation?
palms facing behind
31
what is supination?
palms facing forward
32
oppostion?
all fingers touching thumb
33
what is inversion?
arch goes up....sole towards body midline
34
what is eversion?
arch goes down....sole away from body of midline
35
what does development do as a factor affecting movement?
age and a musclular development......baby....teen...adult....elderly
36
what does physical healthy do as a factor affecting movement?
muscles.....disorders..... arthritis....CHF
37
what does mental health do as a factor affecting movement?
depression....less energy
38
what does lifestyle do as a factor affecting movement?
what you do in your free time....sedentary vs active
39
what does attitude and values do as a factor affecting movement?
someone who goes to the gym or exercises
40
what does fatigue/stress do as a factor affecting movement?
this effects energy levels
41
what does external factors do as a factor affecting movement?
weather...finances....unsafe neighborhood
42
what are the effects of exercise on cardiovascular?
increased heart efficieny....decrease heart rate and BP....increased blood flow and oxygenation
43
what are the effects of exercise on respiratory?
increased depth of respiration....increased rate...improved gas exchange....improved rate of CO2 excretion
44
what are the effects of exercise on GI?
increased appetite and intestinal tone
45
what are the effects of exercise on skin?
increased circulation
46
what are the effects of immobility on cardiovascular?
increased cardiac workload...increased risk for orthostatic hypotension
47
what are the effects of immobility on respiratory?
decresed depth and rate of respiration.....pooling of secretion...impaired gas exchange
48
what are the effects of immobility on GI?
disturbance in appetite.....decreased food intake...alterations in protien metabolism....poor digestion...constipation
49
what are the effects of immobility on skin?
impaired circulation....skin breakdown
50
what does immobility do to peristalsis
decreased peristalsis
51
how often should you reposition patient?
2 hours
52
what is part of the patient history in regards to movement?
daily activity level....endurance.....exerciise....external factors affecting mobility
53
what is the physical assessment in regards to movement?
ease of movement...gait...posture...alignment... joint structure.... strength...muscle mass...tone...endurance
54
how do you implement in adults?
fintess counseling....clarify misconceptions....desing and moninter safe exercises....
55
how do you implement in older audlts
teach and counsel about
need for regular exercise......need for high protein, calcium, and vitamin D....pacing activities....use assistive devices....safety proof home
56
when do you need two people to transfer?
when you patient is more than 35lbs
57
what does the ability to assist mean in regard to transfer?
can they help
58
what does tools mean in regard to transfer?
using lifts...gait belt....
59
what does area mean in regard to transfer?
clutter and things around
60
what does the ability to understand mean in regard to transfer?
can the patient understand what you are going to do
61
what should you do when performing a safe transfer?
plan...communiate...treat pain...elevate workspace...lock wheels...body alignment...body support...avoid friction...smooth movements....appropriate equipment....document
62
what are some patient transfer assistive devices
gait belt....standing assist....lateral assist/slide... friction-reducing sheets....mechanical lateral assist...transfer chair....powered stand assist chair...powered full-body lifts
63
what are transfer techniques for nurses
draw sheets...log rolling...bed to char
64
what is fowlers position?
45 to 90 degrees
65
what is supine?
flat on back
66
what is prone?
flat on stomach
67
what is sims position?
on the side with top leg in front and top shoulder forward
68
what is side lying or lateral?
on side with knees stacked and shoulder stacked
69
what are some positioning devices?
the foam wedge... mattresses...adjustable bed... trapeze bar...foot support....hip and leg support...hand and wrist support...side rails
70
what are mobility aids for waling
walker.....cane...crutches...braces
71
what side should your cane be on?
crutch should be on strong side
72
what are the steps to walking with a cane?
move cane forward and then move weak side and then move strong side
73
what are the steps to use a walker
move the walker forward....then the weak foot...then the strong foot
74
how far should top of crutch be from armpit
1 to 2 inches
75
how far should foot be from the foot of the crutch?
12 inches
76
how far should cane be from foot?
4 inches
77
what angle should your elbow be for walker
15 degrees
78
what is isotonic exercise?
shortening and moving of a muscles with no resistance
79
what is isometric exercise?
contraction with no relaxation
80
what is isokenetic?
muscles contraction with resistance
81
what is aerobic exercise
improves heart rate and blood flow
82
what is stretching?
moving muscles through the range of motion
83
what is strength and endurance
building muscle mass and strength
84
ADLs
things done in the home
85
what is active range of motion?
when you move your own joint
86
what is passive range of motion?
when you have someone help in range of motion
87
where should you support joint?
above and below the join
88
how often should ROM be done?
ROM exercise twice a day
89
what do the kidney do?
remove waste products from blood and produce urine
90
what does the ureter do?
takes urine from the kidney and stores in the bladder
91
what does the bladder do?
stores urine
92
what is urine incontinence?
the inability to control the release of urine...different levels
93
what are complicatins of incontinence?
UTI....skin breakdown....mental health
94
what education should be provided to incontinent patients?
drink only beyween 0600 and 1800
limit alcohol, caffeine, and citrus
take diuretics in the morning
kegal exercises
95
what nursing care should be done for incontinent patients?
peri care and clean linens
96
what is urine retention?
holding onto urin
97
what are the complications of retention?
UTI....distened bladder...kidney infection...overstretching of bladder`
98
what education should be provided to those holding urine?
stay hydrated....go when you have to
99
what nursing care should be provided to patients with urine retention?
sit patients up pee......privacy...give them time....schedule
100
what is a in and out catheter?
a cath that is used for acute retention...sterile collection...or spinal chord injuries
101
what is a foley cath?
a catheter that stays in place for a extended period of time
102
how often should foley be changed????
xxx
103
what is a coude?
a catheter that has a curved rigid tip...used for males with enlarged prostate
104
what is a suprapubic catheter?
catheter that inserts directly into the bladder from the pubic region
105
what is a condom catheter?
for males....less invasive....change every 24 hours...leave 1-2 inches from tip of penis to the tip of condom cath
106
what is a pure wick
for females...less invasive...change every 24 hours....top 1/3 needs to be over urethral opening...suction needs to be no more than 40....can be used during menstration
107
what is a urinnalysis?
can come from bedpan, hat, or urinal.....not sterile...looks at lab levels
108
what is a urine culture?
sterile....shows infections in urine
109
what does the esophagus do?
takes food from mouth to stomach
110
what does the stomach do?
mixes food and liquid with digestive juices
111
what does the duodenum of the small intestine do?
It absorbs nutrients like vitamins, minerals, carbohydrates, fats, proteins and water from food to be used by the boddy
112
what does the jejunum of the small intestine do?
absorb sugars, amino acids, and fatty acids
113
what does the ileum of the small intestine do?
major absorptive products being vitamin B12 and bile acids.
114
what does the large intestine do?
turns the liquid digested food into solid stool
115
what does the ascending colon do?
absorbs water from stool
116
what does the transverse colon do?
absorbs water from stool
117
what does the desceding colon do?
stores stool
118
what should the abdomen look like during an assessment?
should be flat, soft, and not tender
Also should be bowel sounds
119
what history should you gather in regards to fecal?
patterns, color, form, diet, stress, GI bleed
120
do meds change your bowle habbits?
yes
121
is bleeding a concern in bowel?
yes
122
what problems are involved in bowel movement?
constipation and diarrhea
123
what is diarrhea?
3 or more loose stools a day
124
what complications arise from diarrhea?
dehydration, nausea, vomiting
125
what education should be provided those who have diarrhea?
drink water, avoid caffeine and alcohol
126
what should nurses do for those who have diarrhea?
administer fluids/electrolytes, look for symptoms of dehydration
127
what is constipation?
hard to pass stool.....dry....hard
128
what is the complication with constipation?
impaction....neausea and vomitting
129
what education needs to be provided to those who are experiencing constipation
need to drink fluids....2L of water
Eat 25-30g of fiber per day
Exercise
130
what nursing care needs to be provided to those who have constipation?
oral fluids and IV fluids....walking....balanced diet
131
what are the two kinds of enemas?
saline enema or oil enema
132
what position muse a patient be in to do an enema?
left lateral
133
how long should someone hold a saline enema?
15 minutes
134
how long should someone hold a oil enema?
30-60 minutes
135
how many mL is a oil enema?
150 to 200
136
how many mL is a saline enema?
500 - 1000
137
how does a saline enema work?
distends intesines, lubricates stool, and irritates bowel
138
how does a oil based enema work?
lubricates everything
139
what position should a patient be in when getting an enema?
left lateral
140
what does a stool culture show?
sterile procedure that shows infection present
141
what does a fecal occult blood test show?
if blood is present
142
what is a colostomy?
diversion of intestines through skin
143
why do people have colostomy?
when lifestyle changes dont fix bowel habbits....cancer...surgery
144
what should a stoma look like?
red, moist, and painless
145
when should you be worried about stoma?
dry, wrong color, painful
146
when should a colo bag be emptied?
1/3 to 1/2 full
147
what education can be provided to those with colostomy bags?
support groups and how to take care of it
148
what is a healthy weight?
a weight that can be maintaned with the number of calories burned
149
fat in the abdomen makes you susceptible to what kind of disease?
hypertension, diabetes, stroke, and cardiovascular problems
150
what are the three nutrient food groups?
carbs....fats...protien
151
what does the body use carbs for?
converted to glucose and used for energy
152
what are proteins used for?
form genes and enzymes.....good for muscles, skin, blood.....essential for the body
153
what are fats used for?
used to store energy, absorb nutrients, and used in hormones
154
are fats soluble in blood and water?
no
155
what are examples of vitamins?
Vitamin D, C, B
156
where are vitamins found?
from fresh foods
157
what is the ranking for vitamin content?
Fresh, Frozen, canned
158
what do vitamins do?
vitamins help you resist infections and keep your nerves healthy, while others may help your body get energy from food or help your blood clot properly
159
what are examples of minerals?
copper, zinc, sodium
160
what do minerals do?
building strong bones and teeth. controlling body fluids inside and outside cells. turning the food you eat into energy
161
what percentage of bod weight is water?
50-60
162
what is more important water or food?
water
163
what is a good split between carbs, proteins, and fats
carbohydrates 45–65%
fat 25–35%
protein 10–30%
