Exam 4 Flashcards
Isometric Exercise
Muscle contraction without motion
(Hand against the wall)
Isotonic Exercise
Movement of the joint during muscle contraction
(Weight training, push ups)
Aerobic Exercise
Uses large muscle groups, continuously
(Jogging, brisk walking, cycling)
Increases ♥️ rate and respiratory
Adults should get _______ min per week of moderate-intensity exercise
150 - 300 min
Factors affecting mobility
Developmental stage
Nutrition
Chronic disease
Lifestyle
Environmental
Diseases & abnormalities (trauma)
Diseases of other bone systems (respiratory, bedrest, fatigue)
Prolonged immobilization causes ________ changes in almost every body system- as well as ________ changes
Physiological
Psychological
Common complications of prolonged immobility
Skin breakdown
Pressure injury
Constipation
Atrophy
DVT
Orthostatic hypotension
Pooling in lower lungs
Atelectasis
UTI
Balance
Depression
Prolonged immobility interventions
Support…..
Oxygenation
Nutrition
Skin Integrity
Cardiovascular function
Musculoskeletal system
Factors affecting skin integrity
Age (elasticity)
Nutrition (dehydration)
Mobility (friction & shearing)
Sensation level (-sensation = +pressure)
Impaired Circulation
Medications
Infection
Moisture
Fever
Lifestyle (obesity)
Classification of wounds
-Skin integrity (open/close)
-Healing time (acute/chronic)
-Contamination (clean/clean-contam/contaminated/infected)
-Depth (superficial/partial/thickness)
Types of wounds
Abrasions, abscess, contusion, crushing, incision, laceration, penetrating, puncture, tunnel
Signs of an infected wound
Redness & swelling
Worsening pain
Pus or discharge
Warmth
Phases of wound healing
- Hemostasis (clotting)
- Inflammatory (WBC)
- Proliferative (granulation/collagen)
- Maturation/ Remodeling
(collagen cont/4-5wks)
Granulation Tissue
Beefy red
3rd of 4 stages
Serous exudate
Straw colored
Sanguineous
Bloody drainage
Serosanguineous
Mix of bloody and straw colored fluid
Purosanguineous exudate
Contains blood and pus
Complications of wound healing
Hemorrhage (internal/external)
Infection (trauma2-3d or surf 4-5d)
Dehiscence (opens)
Evisceration (coming out)
Fistula (extra tunnel)
Blanchable erythema good or bad?
There’s still blood supply to area…
However, at risk for skin breakdown
Definition of Shear
Friction + the force of gravity
(sliding in bed)
Not visible
Moisture does what with wounds
Increased moisture reduces resistance of the skin
What scale is used for Ulcer risk factors
Braden scale-
Sensory
Moisture
Activity
Mobility
Nutrition
Friction and shear
Lower # the higher the risk
Focused skin assessment
Color, temp, texture, turgor, moisture
Medical device in area
Obesity (pannus)
Bony prominences
Wound assessment
Location, type, size
Periwound (around)
Undermining (open under wound/side)
Epiboly (edge)
Tunneling
Drainage
Pain
Nutritional status
Pressure injuries are caused by unrelieved pressure to an area, resulting in ________
Ischemia
Stage 1 pressure injury
No blanching
Damaged tissue
No adequate blood flow to area
Not open
Stage 2 pressure injury
Partial thickness loss with exposed dermis (open)
Can have a blister
Pink, red, moist
Stage 3 Pressure injury
Full thickness skin loss
Adipose tissue
Granulation can be present
Slough and eschar (yellow/black)
Stage 4 pressure injury
Full thickness skin loss
Muscle, tendon, ligament, bone
(Deeper)
Slough/eschar
Deep Tissue Injury DTI
Necrosis in underlying tissue
Non-blanchable
Purple “boggy” feel
Intact skin
Unstageable Pressure Injury
Obscured full thickness skin and tissue loss
(Open)
slough/eschar
Extrinsic factor for pressure injury
Friction
Pressure
Shearing
Moisture
Intrinsic factor for pressure injury
Immobility
Impaired sensation
Poor nutrition
Dehydration
Aging
Fever, infection
Edema
How often should you reposition a patient who is immobile
Every two hours
Nutritional Intervention for ulcers
1.2 to 1.5 g of protein per kg/day
What is the main regulator of fluids and electrolytes
Kidneys
(1500ml/day)
Third Space
Blood is in a 3rd compartment
Peritoneal
Pericardial
Vesicles (blisters)
How much should fluid intake be?
1500-2000 ml
Non-caffeinated
No sugar drinks
1st symptom of dehydration?
Thirst
Signs of Hypovolemia
-cap refill
-low BP
-Orthostatic
-Tachycardia, weak pulse
-Confused, HA (neuro)
-dry skin, pale
-clear lungs
-S.G of 1.030
Signs of Hypervolemia
weight gain
Edema
skin- no hair, shiny
Tachycardia- bounding
Elevated BP
Pulmonary edema
Lungs- adventitious (moist)
JVD (jugular)
What do you assess with Edema?
Visual
Measure
Finger pressure
Daily weights
I&O
Responsible for bone health
Calcium
What is low, mostly in alcoholics?
Magnesium
Key electrolyte in cellular metabolism
(arrhythmias)
Potassium
Grade edema
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
It is impossible to know about every culture, but….
….It is important to learn about those you will encounter most often
Ethnicity key point
Reference ethnicity vs Hispanic
(Mexican American, Puerto Rican, Cuban)
Race key point
You can’t determine a persons race by appearance. Ask them!
(White, African American)
Take a trip to BALI
-Be aware of cultural heritage
-Appreciate uniqueness
-Learn about cultural group
-Incorporate cultural values in care plan
Cultural intervention
Ask pt what matters the most to them in their illness treatment
Physical changes hours/days before death
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
Actively dying occurs over a period of…
10-14 days
Palliative Care
Care treatment that reduces symptoms
Doesn’t have to be dying
Slow/progressive disease
Hospice
-Must have Dr determine less than 6m
-Must chose comfort care
-Quality of life is as important as length of life
Euthanasia
Active/passive
Cocktail
Physician assisted suicide/death
6m to live
3 requests in 15 days
Self administer
Rigor mortis
2-4 hours after death
Disappears 96 hours after death
Livor mortis
Bluish and mottled
SBAR
Situation (symptoms, change, observations, evaluation)
Background (Med hx)
Assessment (vitals, pain, focused)
Recommendations
Adaptive (effective) coping
Making healthy choices
Maladaptive (ineffective) coping
Unhealthy style, temporary fix
Other harmful
Substance abuse
Outcome of stress
Heart disease, IBS, HAs, +BS, Alzheimers, cold, obesity, pain, depression
Self concept consists of
Physical appearance
Sexual performance
Intellectual abilities
Success in the workplace
Friendships
Problem solving
Unique talents
Factors affecting self concept
Gender
Developmental level
Socioeconomic status
Family
Peer relationships
Illnesses and hospitalizations
Out of control
Severe anxiety
Person only focuses on self & need to relieve anxiety
Difficulty doing tasks
HA, tachycardia, insomnia, dizziness, urinary frequency, diarrhea
Panic
Person becomes irrational, hallucinations
Screaming, dilated pupils, trembling, palpitations
Displacement
Transferring feelings from one target to another
What percentage of RNS have EtOH or drug dependence
14-20%
A persons well being depends on a balance of
Physical
Psychological
Sociological
Cultural
Developmental
Spiritual
