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Nursing Fundamentals > Exam 4 > Flashcards

Exam 4 Flashcards

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1
Q

Isometric Exercise

A

Muscle contraction without motion
(Hand against the wall)

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2
Q

Isotonic Exercise

A

Movement of the joint during muscle contraction
(Weight training, push ups)

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3
Q

Aerobic Exercise

A

Uses large muscle groups, continuously
(Jogging, brisk walking, cycling)
Increases ♥️ rate and respiratory

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4
Q

Adults should get _______ min per week of moderate-intensity exercise

A

150 - 300 min

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5
Q

Factors affecting mobility

A

Developmental stage
Nutrition
Chronic disease
Lifestyle
Environmental
Diseases & abnormalities (trauma)
Diseases of other bone systems (respiratory, bedrest, fatigue)

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6
Q

Prolonged immobilization causes ________ changes in almost every body system- as well as ________ changes

A

Physiological

Psychological

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7
Q

Common complications of prolonged immobility

A

Skin breakdown
Pressure injury
Constipation
Atrophy
DVT
Orthostatic hypotension
Pooling in lower lungs
Atelectasis
UTI
Balance
Depression

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8
Q

Prolonged immobility interventions

A

Support…..
Oxygenation
Nutrition
Skin Integrity
Cardiovascular function
Musculoskeletal system

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9
Q

Factors affecting skin integrity

A

Age (elasticity)
Nutrition (dehydration)
Mobility (friction & shearing)
Sensation level (-sensation = +pressure)
Impaired Circulation
Medications
Infection
Moisture
Fever
Lifestyle (obesity)

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10
Q

Classification of wounds

A

-Skin integrity (open/close)
-Healing time (acute/chronic)
-Contamination (clean/clean-contam/contaminated/infected)
-Depth (superficial/partial/thickness)

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11
Q

Types of wounds

A

Abrasions, abscess, contusion, crushing, incision, laceration, penetrating, puncture, tunnel

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12
Q

Signs of an infected wound

A

Redness & swelling
Worsening pain
Pus or discharge
Warmth

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13
Q

Phases of wound healing

A
  1. Hemostasis (clotting)
  2. Inflammatory (WBC)
  3. Proliferative (granulation/collagen)
  4. Maturation/ Remodeling
    (collagen cont/4-5wks)
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14
Q

Granulation Tissue

A

Beefy red
3rd of 4 stages

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15
Q

Serous exudate

A

Straw colored

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16
Q

Sanguineous

A

Bloody drainage

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17
Q

Serosanguineous

A

Mix of bloody and straw colored fluid

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18
Q

Purosanguineous exudate

A

Contains blood and pus

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19
Q

Complications of wound healing

A

Hemorrhage (internal/external)
Infection (trauma2-3d or surf 4-5d)
Dehiscence (opens)
Evisceration (coming out)
Fistula (extra tunnel)

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20
Q

Blanchable erythema good or bad?

A

There’s still blood supply to area…
However, at risk for skin breakdown

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21
Q

Definition of Shear

A

Friction + the force of gravity
(sliding in bed)
Not visible

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22
Q

Moisture does what with wounds

A

Increased moisture reduces resistance of the skin

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23
Q

What scale is used for Ulcer risk factors

A

Braden scale-
Sensory
Moisture
Activity
Mobility
Nutrition
Friction and shear
Lower # the higher the risk

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24
Q

Focused skin assessment

A

Color, temp, texture, turgor, moisture
Medical device in area
Obesity (pannus)
Bony prominences

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25
Q

Wound assessment

A

Location, type, size
Periwound (around)
Undermining (open under wound/side)
Epiboly (edge)
Tunneling
Drainage
Pain
Nutritional status

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26
Q

Pressure injuries are caused by unrelieved pressure to an area, resulting in ________

A

Ischemia

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27
Q

Stage 1 pressure injury

A

No blanching
Damaged tissue
No adequate blood flow to area
Not open

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28
Q

Stage 2 pressure injury

A

Partial thickness loss with exposed dermis (open)
Can have a blister
Pink, red, moist

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29
Q

Stage 3 Pressure injury

A

Full thickness skin loss
Adipose tissue
Granulation can be present
Slough and eschar (yellow/black)

30
Q

Stage 4 pressure injury

A

Full thickness skin loss
Muscle, tendon, ligament, bone
(Deeper)
Slough/eschar

31
Q

Deep Tissue Injury DTI

A

Necrosis in underlying tissue
Non-blanchable
Purple “boggy” feel
Intact skin

32
Q

Unstageable Pressure Injury

A

Obscured full thickness skin and tissue loss
(Open)
slough/eschar

33
Q

Extrinsic factor for pressure injury

A

Friction
Pressure
Shearing
Moisture

34
Q

Intrinsic factor for pressure injury

A

Immobility
Impaired sensation
Poor nutrition
Dehydration
Aging
Fever, infection
Edema

35
Q

How often should you reposition a patient who is immobile

A

Every two hours

36
Q

Nutritional Intervention for ulcers

A

1.2 to 1.5 g of protein per kg/day

37
Q

What is the main regulator of fluids and electrolytes

A

Kidneys

(1500ml/day)

38
Q

Third Space

A

Blood is in a 3rd compartment
Peritoneal
Pericardial
Vesicles (blisters)

39
Q

How much should fluid intake be?

A

1500-2000 ml
Non-caffeinated
No sugar drinks

40
Q

1st symptom of dehydration?

A

Thirst

41
Q

Signs of Hypovolemia

A

-cap refill
-low BP
-Orthostatic
-Tachycardia, weak pulse
-Confused, HA (neuro)
-dry skin, pale
-clear lungs
-S.G of 1.030

42
Q

Signs of Hypervolemia

A

weight gain
Edema
skin- no hair, shiny
Tachycardia- bounding
Elevated BP
Pulmonary edema
Lungs- adventitious (moist)
JVD (jugular)

43
Q

What do you assess with Edema?

A

Visual
Measure
Finger pressure
Daily weights
I&O

44
Q

Responsible for bone health

A

Calcium

45
Q

What is low, mostly in alcoholics?

A

Magnesium

46
Q

Key electrolyte in cellular metabolism
(arrhythmias)

A

Potassium

47
Q

Grade edema

A

0= no edema
1= slight 2 mm, rebound’s immed.
2= pitting 4mm, 15 sec rebound
3= 6mm deep, 30 sec rebound
4= 8mm, +30 sec to rebound

48
Q

It is impossible to know about every culture, but….

A

….It is important to learn about those you will encounter most often

49
Q

Ethnicity key point

A

Reference ethnicity vs Hispanic
(Mexican American, Puerto Rican, Cuban)

50
Q

Race key point

A

You can’t determine a persons race by appearance. Ask them!
(White, African American)

51
Q

Take a trip to BALI

A

-Be aware of cultural heritage
-Appreciate uniqueness
-Learn about cultural group
-Incorporate cultural values in care plan

52
Q

Cultural intervention

A

Ask pt what matters the most to them in their illness treatment

53
Q

Physical changes hours/days before death

A

Surge of energy
Weakness & fatigue
Sleeping a lot
Restlessness, confusion, agitation
Dysphasia low gag reflex
Vision blurs- hallucinations
Mottling (webbing)
Hot/cold temp
Decreased urine output
-BP, +HR
Death rattle
Cheyne-stokes breathing

54
Q

Actively dying occurs over a period of…

A

10-14 days

55
Q

Palliative Care

A

Care treatment that reduces symptoms
Doesn’t have to be dying
Slow/progressive disease

56
Q

Hospice

A

-Must have Dr determine less than 6m
-Must chose comfort care
-Quality of life is as important as length of life

57
Q

Euthanasia

A

Active/passive
Cocktail

58
Q

Physician assisted suicide/death

A

6m to live
3 requests in 15 days
Self administer

59
Q

Rigor mortis

A

2-4 hours after death
Disappears 96 hours after death

60
Q

Livor mortis

A

Bluish and mottled

61
Q

SBAR

A

Situation (symptoms, change, observations, evaluation)
Background (Med hx)
Assessment (vitals, pain, focused)
Recommendations

62
Q

Adaptive (effective) coping

A

Making healthy choices

63
Q

Maladaptive (ineffective) coping

A

Unhealthy style, temporary fix
Other harmful
Substance abuse

64
Q

Outcome of stress

A

Heart disease, IBS, HAs, +BS, Alzheimers, cold, obesity, pain, depression

65
Q

Self concept consists of

A

Physical appearance
Sexual performance
Intellectual abilities
Success in the workplace
Friendships
Problem solving
Unique talents

66
Q

Factors affecting self concept

A

Gender
Developmental level
Socioeconomic status
Family
Peer relationships
Illnesses and hospitalizations
Out of control

67
Q

Severe anxiety

A

Person only focuses on self & need to relieve anxiety

Difficulty doing tasks
HA, tachycardia, insomnia, dizziness, urinary frequency, diarrhea

68
Q

Panic

A

Person becomes irrational, hallucinations

Screaming, dilated pupils, trembling, palpitations

69
Q

Displacement

A

Transferring feelings from one target to another

70
Q

What percentage of RNS have EtOH or drug dependence

A

14-20%

71
Q

A persons well being depends on a balance of

A

Physical
Psychological
Sociological
Cultural
Developmental
Spiritual

Nursing Fundamentals (4 decks)

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