Exam 2 Flashcards
What is mobility vs immobility?
mobility: person ability to move about freely
Immobility: inability to move freely
Bed Rest (3% loss of muscle a day)
What are factors that influence mobility?
developmental considerations
physical health
—> Muscular, skeletal, Nervous system problems
——> problems involving other body system
Mental Health
Lifestyle
Attitude and values
Fatigue + stress
external factors
Benefits of exercise?
controls weight
reduced risk of cardiovascular disease
reduced risk of type 2 diabetes and metabolic syndrome
reduced risk of some cancers (colon, breast, endometrial, lung)
strengthens bones and muscles (lower hip fx, improves arthritis)
improves mental health and mood
improves ability to do daily activities and prevents falls in older adults
increases chance of living longer
How does immobility affect the cardiovascular system?
orthostatic hypotension (drop of BP <20mmHg systolic or 10mmHg diastolic)
less fluid volume in circulatory system
increased cardiac workload
stasis of blood in legs
thrombus formation
How does immobility affect the respiratory system?
decreased respiratory movement resulting in decreased oxygenation and carbon dioxide exchange
stasis of secretions and decreased respiratory muscle
decreased ability to deep breath and cough
immobile patients are at high risk for developing pulmonary complications
—-> atelectasis: incomplete expansion or collapse of lung tissue
—–> hypostatic pneumonia
How does immobility affect Musculoskeletal system?
Muscle:
Lean body mass loss
muscle weakness/atrophy
decreased stability and balance
Skeletal:
disuse osteoporosis
pathological fractures
joint contracture
foot drop
How does immobility affect metabolic?
altered endocrine metabolism
decreased metabolic rate
negative nitrogen balance: weight loss, decreased muscle mass, and weakness
calcium reabsorption from bones
decreased urinary elimination of calcium resulting in hypercalcemia
alters protein, carbohydrate, fat metabolism
decreased protein resulting in loss of muscle
decreased appetite with altered nutritional intake
How does immobility affect the GI system?
decreased peristalsis
decreased fluid intake
constipation, then fecal impaction, then pseudodiarrhea
How does immobility affect urinary elimination?
urinary stasis
renal calculi from hypercalcemia
urinary tract infections from decreased fluid intake, poor perineal hygiene and indwelling urinary catheters
How does immobility affect the integumentary system?
pressure injury
—> caused by increased pressure on skin, aggravated by metabolic changes
—> inflammation
—-> decreased circulation to tissue causing ischemia
older adults at greater risk
What effects does immobility have on psychsocial?
emotional and behavioral responses
—–> hostility, giddiness, fear, anxiety, passivity
sensory alterations:
—> altered sleep patterns
changes in coping:
—> depression, sadness, dejection
What are complications of immobility?
Thrombophlebitis, Deep Vein thrombosis:
—> inflammation of the vein (usually in lower extremities) that result in clot formation
Manifestations: pain, edema, warmth, and erythema at site
Assess: measure calf and thighs daily
Nursing actions: notify MD, elevate leg, avoid pressure, do not massage, anticipate giving anticogaulents
Pulmonary Embolism:
occlusion of blood flow to one or more pulmonary arteries by clot: often orgininates in venous system of lower leg
Manifestations: SOB, chest pain, hemopysis, decreased BP and rapid pulse
Nursing Action: notify MD, position pt in high fowlers, obtain SpO2, prepare to obtain blood gases, monitor frequent VS, prepare to give thrombolytic or anticogulants
How to Assess Pressure Injury?
Skin: breakdown, warmth, change in color, skin turgor, observe bony prominences, bradden scale, observe for incontience
PAY ATTENTION TO:
skin beneath and around devices or compression stocking
bony prominences (heel, sacrum, occiput)
skin to skin areas ( penis, back of knee, inner thigh, butt)
all areas where patients lack sensations to feel pain/ had breakdown previously
if patient is getting epidural/spinal cord medication
How to access respiratory system?
chest wall movement +rate,
ausculatate (crackles, wheeze, diminished sounds)
assess cough
How to assess Cardiovascular system?
orthostatic blood pressure (lying, sitting to standing 1 + 3 minutes)
pulse
s/s dizziness
palpate apical and peripheral pulses
auscultate heart sounds
assess edema
check skin for s/s DVT
measure calf and thigh
How to assess elimination?
assess intake and output
bladder for distention
urine color + amount
clarity
frequency
auscultate bowel sounds
observe feces for color, amount, frequency and consistency
How to assess metabolic?
height + weight + skinfolds
intake and output
food intake
urinary + bowel elimination
wound healing
ausculutate bowel sounds
skin turgor
review labs (electrolytes, serum total protein, and BUN)
How to assess musculoskeletal system?
ROM capability
muscle tone + mass
observe for contractures
gait
alignment
endurance
monitor nutritional status of calcium
monitor use of assistive devices to assist ADLs
How to assess pyschosocial?
emotional status
mental status
behavior + decision making
mobility
sleep-wake pattern
coping skill
ADL
family support
social activites
What are variable that lead to back injury in health care workers?
uncoordinated lift
manual lifting and transferring of patients without assistive device
lifting when fatigued or after recent back injury recovery
repetitive movements such as lifting, transferring, and repositioning patient
standing for long period of time
tranferring patient
repetative task
transferring/repositioning uncooperative or confused patient
What are proper body mechanics?
use of proper body movement in daily activites
prevention and correction of problems associated with posture
enhancement of coordination and endurance
Good principles of body mechanics:
maintain a wide, stable base with feet
put bed at correct height (waist level when providing care; hip level when moving patient)
try to keep patient as close to you body as possible to minimize reaching
use big muscles rather than small muscles (legs not back)
know limits and seek assistance
Walkers:
WWAL: walker with affected leg
patient holds the handgrips on the upper bars takes a step moves walker forward and take another step
nurse on weak side
Canes:
COAL: cane opposite affected leg
keep cane on stronger side of body
support body weight on both legs
place cane forward 6-10 inches
move weaker leg forward with cane
advance stronger leg past cane
nurse on weak side
Crutches:
measuring for crutches
—> 2-3 fingers width- prevents nerve damage b/w axillae + rest pad
hand grips should be even with hip line
elbows flexed 30 degrees
Crutch Gait:
two point gait: partial wt. bearing both feet, move crutches while moving opposite leg (move RC and LF move together, then LC and RF together)
three point gait: bear wt. on one foot, using both crutches, move both crutch and injured leg together, then move injured leg
four point gait: bear wt. both legs (move RC then LF then LC then RF)
swing to gait: swing to crutch
swing through gait: swing past crutches
Health promotion:
prevention of work related musculoskeletal injury
promote activites and exercise
improve bone health in patients with osteoporosis
Implementation in acute care: metabolic
provide high-protein, high calories diet with vitamin B and C supplement
Implementation in acute care: Respiratory
repostion every 1-2 hours
cough and deep breaths every 1-2 hours
incentive spirometer while awake
yawn
provide chest physiotherapy
suction if unable to expectorate secretions
Implementation: cardiovascular
progress from bed to chair to ambulate
change postion as often as possible
reducing orthostatic hypotension (move pt gradually)
reducing cardiac workload: avoid valsalva maneuver)
give stool softner
preventing thrombus formation
sequential compression devices (anti-embolism hose stocking, leg exercise)
isometric exercise to increase activity tolerance
Safety Guidelines for Nursing Skill:
comunicate clearly with members of health care system
assess and incorporate the patient priorites of care and preferences
use best evidence when making decisions about pt care
Implementation: psychosocial
orient to time, person, place
develop schedule of therapies
alert roommate
involve in daily care, provide stimuli
hygiene
refer to psych, spiritual, social worker if not coping well
Implementation: integumentary
repositon every 1-2 hours; if mobile have them turn every 15 minutes
use corrective devices and therpeutic bed
provide skin care
monitor nutritonal intake
Implmentation: Elimination
provide adequate hydration
serve diet rich in fiber, fruit, veggie, fluid
stool softener, laxative, enema
perineal care
assess for paralytic ileus
Implemenation: Musculoskeletal
prevent muscle atrophy and joint contractures
change patient position every 2 hours
passive ROM
CPM (continuous passive motion)
Active ROM
cluster care to promote a proper sleep- wake cycle
physical therapy
assist with ambulation
Equipment and assistive devices:
gait belt
stand-assist and repositioning aid
lateral assist devices
friction- reducing sheets
mechanical lateral assist device
transfer chair
powered stand assist and repositoning lift
powered full body lift
Moving patients:
safety is first priority
ask pt to help as much as possible
determine if pt comprehends what is expected
determine patient comfort level
determine if you need assistance in moving patient
Positioning patient:
pillows
mattresses
adjustable bed
bed side rails
trapeze bar
additional equipment
Gait belt:
helps prevent falls
use when unsteady or poor balance
helps move patient with walking, moving from bed to chair or from sitting to standing
Polyuria
greater than 2000 mL/ day
Oliguria
less than 400 mL/day
Anuria:
total suppression of urine less than 150 mL/per day
Dysuria
painful urination
Nocturia
needing to use bathroom during the night
Postvoid retention:
holding urine after voiding
What Urine Volume is a cause of concern?
less than 30 mL/hr for more than 2 hours
What are developmental concerns with urination?
Children: voluntary control 18-24 months; toilet training 2-3 years, enuresis
Prostate enlargement: 40 years old urinary frequency, hesitation, retention, incontience, and UTI
Pregnancy: less space with growing fetus, increase circulatory volume, increase renal output, relaxation of sphinctor, greater risk of UTI
Childbirth: gravity weakens pelvic floor, risk of prolapse of bladder, stress incontience: kegel exercise
post menopausel: decreased tone due to low estrogen levels, urgency, stress incontience, UTI
Older adults: loss of muscle tone in bladder: frequency, ineffective emptying, residual urine, nocturia, neuromuscular problem
Other factors in urinary eliminination:
conditions: acute and chronic disorders: poor abdominal and pelvic muscle tone, spinal cord issue, pregnancy (kidney disease)
Immobility: incontience can occur as result of impaired mobility due to difficult transferring to bathroom
surgical procedure:
anesthesia + opioid analgesics result in decreased urine output
abdominal surgery creating obstructive edema and inflammation
pain:
suppresion of urge to urinate
obstruction in ureter
arthritis or painful joints lead to immbility and delayed urination
Psychofactors:
emotional stress and anxiety
having to use public toilets or bedpans
lack of privacy during hospital stay
not having enough time to urinate
Fluid intake and output:
Medication:
diuretic: prevent reabsorption of water + certain electrolytes
antihistamine + anticholinergic: urinary retention
analesics + tranqulilzers: suppress CNS, dimish effectiveness of reflex
medcation can cause change in urine color
Nephrotoxic meds ( chemo)
What are disease associated with renal problems:
congential urinary tract abnormalites
polycystic kidney disease
urinary tract infection
urinary calculi
hypertension
diabetes
gout
connective tissue disorders
What is urinary rentention?
an accumulation of urine due to inability of bladder to empty
Safety Guideline for urinary elimination:
Follow principles of surgical and medical asepsis as indicted
identify patient at risk for latex allergies
Incontinence prevention and treatment:
frequent check for incontience episodes
turning and repositoning schedule
no rinse skin cleansers are preferable to soap and water
avoid excessive fricition or scrubbing
low air loss/pressure distrubution mattress
change cloth pads frequently
limit disposable brief
moisture barrier creams
skin protectant spray
continuing + restorative care: urinary elimination
behavioral therapy
pelvic floor muscle training (kegals)
bladder retraining: increase uriniation intervals till no incontinence episodes
toileting schedule (q-2-3 hours or before and after meals)
intermittent catherterization (drain 300-400 mL of urine on schedule)
skin care
foods and fluids: avoid artifitcal sweetner, spicy foods, citrus products, caffeine)
increase fluid intake during daytime and decrease fluid intake prior to bedtime
types of urinary incontinence;
Overflow: bladder is full and urine leaks, drippling of urine, due to blockage of urethra
Urge/urgency: overactive bladder urgency (“gotta go”) brain telling bladder is full, overactive detrusor muscle with increased bladder pressure
Stress: weak pelvic muscles let urine escape with increased abdominal pressure associated with effort or exertion, sneezing, or coughing, pregnancy, bending, walking
Urinary Tract Infections: Risk factors
Risk factors:
sexually active women
women who use diaphragm for contraception
postmenopausal women,
individuals with diabetes,
uncircumcised patients,
use of indwelling catheters,
older adults
Urinary Tract Infections: Signs + symptoms
frequency,
urgency,
nocturia,
burning and pain (dysuria)
irritation of the bladder (cysitis)
hematuria
flank pain
suprapubic tenderness
fever
foul smelling cloudy urine
Urinary tract infections: Older adults
increased confusion
recent falls
new onset incontience
anorexia
fever
tacycardia
hypotension
Urinary diversions:
are created to reroute urine
can be temporary or permanent
continent or incontinent
Types:
ureterostomy (ileal conduit)
nephrostomy
indiana pouch
neobladder
Assessment: Nursing history: urinary elimination
fluid intake amount
pattern of urination (frequency and times of day, normal volume with voiding, history of recent change)
symptoms of urinary alterations
factors affecting ability to urinate normally: medical conditions, medications
past history of problem
adequacy of self care behaviors
urinary diversion
Physical examination: Urinary elimination
bladder if indicted + urethral meatus: assessment of skin integrity and hydration; exam of urine
Kidney: tenderness, auscultate to detect renal artery bruit
bladder: palpate, percussion, bedside scanner
—> external genitalia, urethral meatus: identify infection, inflammation, discharge, lesion
catheter insertion: for inflammation or breakdown
perineal skin
skin exposed to moisture
Assessment of Urine:
intake and output
characteristic of urine:
color
clarity
odor
pH
specific gravity
constituents
UTI: + nitrates, leukocyte esterase (WBC) bacteria
Urine specimen:
urinalysis: random nonsterile specimen
clean catch midstream for culture and sensitivity (C&S)
catheter: sterile urine specimen for C&S
timed urine specimen
point of care testing
Promoting Normal Micturition:
maintaining normal voiding habits
strengthening muscle tone (kegel exercise)
assisting with toileting
privacy important
close door and bedside curtain
mask sounds with running water
ask family to leave room
respond quickly to assistance
maintaining adequate fluid intake: helps flush solutes or particles that collect in urinary system and decrease bladder irritability
promoting complete bladder emptying: sitting for women and standing for me
preventing infection: increase fluid intake, perineal hygiene and voiding at regular intervals
Measure Urine Output:
ask patient to void into bedpan, urinal, specimen container in bed or bathroom
put on gloves: pour urine into appropraite measuring device
place calibrated container on flat surface and read at eye level
note amount of urine voided and record on appropriate form
discard urine in toilet unless specimen is needed, if specimen is required pour urine into appropriate specimen container
Types of catheters:
Foley ( baloon) catheter: indwelling catheter
Straight catheter: without ballon are used for clean intermittent catheterization
triple lumen (three-way): used to instill medications or continous bladder irrigation
coude (curved) catheter: semirigid curved tip for prostate enlargement
Urinary diversions: care
changing pouch:
gently cleanse the skin surrounding the stoma
measure stoma and cut opening in pouch
remove the adhesive backing and apply pouch
press firmly into place over stoma
observe appearance of stoma and surrounding skin
change every 4-6 days
continent diversion: catheretize 4-6 times a day
Routine catheter care:
use soap and water at insertion site
routine perineal care with soap and water at least q 8 hours and after defectation
empty drainage bag when half full or depending on orders
Catheter drainage system:
always hang bag below bladder on bedframe
bag should never touch floor
assess for cloting or kinks in tube
Variables that influence bowel elimination:
developmental considerations (Age)
food and fluid
psychological factors
pathologic conditions
surgery + anesthesia
diagnostic test: colonoscopy, endoscopy
lifestyle
physical activity
personal habits
pain
pregnancy
medications
Constipation:
a symptom, not disease
infrequent stool and/or hard, dry small stools that are difficult to eliminate
Diarrhea
increase in number of stools and passage of liquid, unformed feces
Flatulence
accumulation of gas in intestines causing walls to stretch
Impaction
results from unrelieved constipation; a collection of hardened feces wedged in rectum that person cannot expel
incontinence
inability to control passage of feces and gas into anus
Hemorrhoids
dilated, engorged veins in lining of rectum
Nursing History: Bowel Elimination
What patient describes as normal vs abnormal is often different and conditions that tend to promote normal elimination
identifying normal and abnormal patterns, habits, and that patient perception of normal and abnormal with regard to bowel eliminiation allows you to accurately determine a patient problem
recent changes in type, color, smell of stool: black tarry stool could be a sign of internal bleeding in GI tract or just from iron supplement
Bowel elimination assessment:
elimination pattern
stool characteristic
routines
bowel diversion
appetite changes
diet history
daily fluid intake
surgery/illness
medications
emotional state
exercise
pain/discomfort
social history
mobility and dexterity
Physical assessment of anus + rectum
Inspection + palpation:
lesion, ulcers, fissure (linear break on margin of anus), inflammation, external hemorrhoids
ask the patient to bear down as though having a bowel movement: assess for appearance of internal hemorrhoids or fissures and fecal masses
inspect perineal area for skin irritation secondary to diarrhea or fecal incontinence
Physical Assessment of abdomen:
sequence for abdominal assessment proceeds from inspection, auscultation, percussion to palpate
Inspection: observe contour, any masses, scars, or distention
Auscultation: listen for bowel sounds in all quadrants
—-> note frequency, character, audible clicks, flatus
—–> describe bowel sounds as hypoactive, hyperactive, absent or infrequent
percussion + palpation: performed by advanced practice professionals
Laboratory Test: Bowel elimination
H/H (hemoglobin + hematocrit) for anemia
LFTs (liver function test) serum amylase and serum lipase used to assess for hepatobiliary disease and pancreatitis
fecal specimens
Diagnostic examinations: Bowel elimination
Direct Visualization: endoscopy, colonoscopy, esophagogastroduodenoscopy
wireless capsule endoscopy
indirect visualization:
upper gastrointestinal (UGI)
small bowel series
barium enema
admominal ultrasound
magnetic resonance imaging (MRI)
abdominal CT scan
bowel preparation
patient teaching: report abdominal pain, fever, chills or bleeding
Fecal occult blood test:
guaiac fecal occult blood test (gFOBT) or fecal immunochemical test (FIT) vit c can affect results
Stool collection:
Medical aseptic technique is imperative
hand hygiene before + after glove use, is essential
wear disposable gloves
do not contaminate outside of container with stool
obtain stool and package, label, transport according to agency policy
Patient Guidelines:
void first so that urine is not in stool sample
defecate into container rather than toilet bowl
do not place toilet tissue in bed pan or specimen container
avoid contact with soaps, detergents, disinfectants as these may affect test results
notify nurse when specimen is avaiable
Digital removal of stool:
use if enemas fail to remove impaction
last resort in managing severe constipation
can cause stimulation of vagus nerve
Restorative Bowel Care:
promotion of regular exercise (150 minutes of exercise each week, if immoble promote ambulation as soon as possible)
management of patient with fecal incontinence or diarrhea
—> fecal collector for short term use
—> maintenance of skin integrity
—-> liquid stool contains digestive enzymes that can cause rapid skin breakdown. Irritation for repeat wiping or frequent ostomy pouch changes can irritate skin
—>good skin care: cleansing with a no rinse cleanser: apply a barrier ointment
—rehydration
management of patient with constipation:
increase fiber diet, hydration, exercise, avoid opioids
Bed Pan positioning:
prevent muscle strain and discomfort
elevate head of bed 30-45 degrees
sitting positon increases downward pressure to rectum
wear gloves when handling bedpans
when patient are immobile or it is unsafe to allow them to raise hip, they remain flat and roll onto bedpan
Enemas:
cleansing enemas:
- normal saline: safest (isotonic)
- warm tap water: hypotonic and exerts osmotic pressure lower than fluid in intersitital spaces: cause water intoxication
- hypertonic: (fleets) pulls fluid out of interstitial spaces: used for patient who cant tolerate large volumes of fluids
- soapsuds: intestinal irritation stimulates peristalsis (caution with pregnant + elderly)
oil retention: lubricate and soften stool
other types of enema:
- carminative (relieve gas distention) kayexalate (treat high serum K+ levels)
Administration of enema:
sterile technique is unnecessary
wear gloves
explain procedure, positioning, precautions to avoid discomfort, length of time necessary to retain solution before defecation
unsafe to give enema on toilet
Bowel training:
Goal: eliminate a soft, formed stool at regular intervals without laxative
when achieved continue to offer assistance with toileting at successful time
Factors within patient control:
- timing ( 1 hour after meal)
- positioning (upright, use toilet or bedside commode over bedpan)
- privacy
- nutrition (fluid + fiber)
-exercise (2 1/2 hours per week)
Nasogastric tube: (NG)
categories of nasogastric (NG) tube:
- fine or small bore medication administration and enteral feeding
- large bore (12 french and above) for gastric decompression or removal of gastric secretions
Maintaining Patency of NG Tube:
- flush with normal saline or warm water
- if an NG tube does not drain properly after flushing, reposition it by advancing or withdrawing it slightly (any change in tube postion requires you to verify its placement in patient GI tract)
Colostomy Care:
Care for ostomies:
- use mild soap and water to cleanse skin, then dry it gently and completely
- custom cut to stoma size, 1/8 larger than stoma
- empty pouch when 1/3-1/2 full
- change pouch 3-7 days
- apply paste if necessary
Assess:
stoma (pink or red) skin ( no breakdown)
- note size, which should stabilize within 6-8 weeks
- keep skin around stoma site clean and dry
measure patient fluid intake + output (ileostomies higher risk for dehydration)
Psychological consideration:
self esteem, body image, sexuality
emotional support
promote self care
- encourage patient to care for and look at ostomy
Ileostomy vs colostomy: location, effluent
Colostomy: end of colon (depending on where in the colon)
should be more formed
Ileostomy: end of ileum
will be liquid (watch for undigested foods/ medications
Communicating with unconscious patient:
be careful what is said in patient presence; hearing is last sense that is lost
assume that patient can hear you and talk in normal tone of voice
speak to patient before touching
keep enviromental noise at a low level
Communicating with patient that is confused:
maintain patient safety
use frequent face to face contact to communicate the social process
speak calmly, simply, directly to patient
orient and reorient the patient to environment
orient the patient to time, place, person
offer explanations for care
reinforce reality if patient is delusional
Caring for hearing - impaired patient:
teach measures to prevent hearing problems
orient patient to presence before speaking
decrease background noises before speaking
check patient hearing aid
postion yourself so that light is on your face
talk directly to patient while facing him/her
use pantomime or sign language as appropriate
write any ideas you cannot convey in another manner
Caring for visually impaired patient:
orient patient to room arrangement and furnishing
assist with ambulation by walking slightly ahead of patient
stay in patient field of vision if he or she has partial vision
provide diversion using other sense
indicate conversation has ended when leaving room
teach patient self care behaviors to maintain vision and prevent blindness
acknowledge your presence in patient room
speak in normal tone of voice
explain the reason for touching the patient before doing so
keep call light within reach
orient the patient to sound in enviroment
Sensory Deprivation:
environment with decreased or monotonous stimuli
- nursing home
- patient living alone at home
impaired ability to recieve enviromental stimuli
inability to process environmental stimuli
Preventing sensory alterations:
control patient discomfort whenever possible
offer care that provides rest and comfort
be aware of need for sensory aids and prostheses
use social activities to stimulate sense and mind
enlist aid of family member to participate in or encourage activites
encourage physical activity and exercise
provide stimulation for as many sense as possible
Assessment of sensory experience:
through patient eye…
sensory alteration history
physical assessment
health promotion habit
communciation methods
use of assistive device
person at risk
mental status
ability to perform self care
enviromental hazards
social support
other factors affecting perception
Factors affecting sensory stimulation:
Developmental consideration
culture
personality and lifestyle
stress and illness
medications
social interaction
enviromental
illness
Effect of sensory deprivation:
Perceptual Disturbance:
inaccurate perceptions in sights, sounds taste, smell, body positon, coordination, equilibrium
cognitive disturbance:
problems with concentration, attention span, memory, problem solving, task performance
emotional disturbance:
manifested in apathy, anxiety, fear, anger, belliegerence, panic, depression
Sensory Overload:
The patient experiences so much sensory stimuli that the brain is unable to respond meaningfully or ignore stimuli.
The patient feels out of control and exhibits manifestations observed in sensory deprivation.
Nursing care focuses on reducing distressing stimuli and helping the patient gain control over the environment.
Noise above 80 dB can cause damage if exposed too long
Sources of noise into categories: Staff conversation (65%), roommates (54%), alarms (42%), intercoms (39%), and pagers (38%) were the most common sources of noise disruption reported by patients
