knowledge assessment II Flashcards
1
Q
body mechanics
A
coordinated efforts of the musculoskeletal and nervous systems
2
Q
alignment and balance
A
also refers to posture
3
Q
gravity
A
weight force exerted on the body
4
Q
friction
A
force that occurs in a direction opposite to movement
5
Q
decubitis
A
pressure ucler
6
Q
decubitus
A
bed lying
7
Q
shear
A
a gravity force pushing down on the patient’s body with resistance between the patient and the chair of bed
8
Q
skeletal system
A
- provides attachments for muscles and ligaments, protects vital organs, aids in calcium regulation
- provides leverage for mobility
- bones are long, short, flat, or irregular
- joints, ligaments, tendons, cartilage
9
Q
muscule movement and posture
A
skeletal muscles are working elements of movement
10
Q
nervous system and musculoskeletal system
A
regulates movement and posture
11
Q
mobility refers to
A
a person’s ability to move about freely
12
Q
immobility refers to
A
inability to move about freely
13
Q
factors influencing mobility
A
immobility
bed rest
14
Q
effects of muscular deconditioning
A
disuse atrophy
physiological
psychological
social
15
Q
why bedrest?
A
- reduces oxygen needs
- decreases pain levels
- helps regaining of strength
- uninteruppted rest has psychological and emotional benefits
16
Q
types of bed rest
A
bed rest
bed rest with bathroom privileges
17
Q
immobility may be
A
- temporary, such as following surgery of total knee replacement
- permanent, such as parplegia
- sudden onset, such as fractured arm and leg following MV accident
- slow onset, such as mutliple sclerosis
18
Q
pathological influences on mobility
A
- postural abnormalities
- muscle abnormalities
- damage to CNS
- musculoskeletal trauma
19
Q
metabolic effects of MSS
A
endocrine
calcium absoprtion
GI function
20
Q
respiratory effects of bed rest
A
atelectasis and hypostatic pneumonia
21
Q
CV effects of bed rest
A
orthostatic hypotension
thrombus
22
Q
MS changes due to bed rset
A
loss of endurance
loss of muscle mass
decreased stability and balance
23
Q
muscle effects from bed rest
A
loss of muscle mass
muscle atrophy
24
Q
skeletal effects of bed rest
A
impaired calcium absorption
joint abnormalities
25
urinary effects of bed rest
urinary stasis
renal calculi
uti
26
integumentary effects of bed rest
pressure ulcer
ischemia (inadequate blood supply)
27
changes in mobility alter
endocrine metabolism
calcium reabsorption
functioning of GI system
28
endocrine system helps
maintain homeostasis
29
immobility disrupts normal metabolic functioning and causes
- decreased metabolic rate
- altered metabolism
- GI distrubances
30
decrease in BMR due to immobility
altered metabolism of carbs, fats, and proteins causing:
- fluid electrolute and calcium imablances which causes:
- GI disturbances which causes:
- decrease in appetitie and decrease in peristalsis
31
anthropometric measurements
height
weight
skin folds
32
nutrition and metabolism assessment
- anthropometric measurements
- fluid intake and outpt
- lab tests for electrolyte imbalances/nutritional status
- assess ability to fight and heal infection
- assess urinary and bowel elimination status
- auscultate bowels
33
interventions for inadequate nutrition and metabolism
- provide high calorie diet
- provide high protein diet
- supplemental vitamin B and C
- monitor and evaluate I&Os
- assess food intake
34
immobility and respiratory system
- decreased respiratory movement (lung expansion) resulting in decreased oxygenation and carbon dioxide exchange
- pooling (stasis) of secretions
- decreased and weakened respiratory muscles resulting in atelectasis and hypostatic pnemonia
- decreased cough response
35
respiratory assessment
observe chest movements
auscultate for pulmonary secretions
check O2
observe for respiratory difficulties
36
maintain pt airway
assess client ability to expectorate secretions
assess secretions for color, amount, and consistency
use suction if client is unable to expectorate secretions
37
interventions of immobility on respiratory system
- reposition client q1-2hrs
- teach client to turn, cough, and deep breathe (TCDB) q1-2hrs
- teach client to yawn every hour while awake
- teach client to use incentive spirometer 10x/hr while awake
- implement chest physiotherapy (CPT): auscultate lungs for effectiveness of chest or respiratory therapy
- teach client to consume a minimum of 2000 mL of fluid unless on restricted intake
38
immobility on CV system
- orthostatic hypotension
- increased cardiac workload BUT decreased cardiac output leading to poor cardiac effectiveness causing...
- increased oxygenation requirements
- less fluid volume
- stasis of blood in legs
- thrombus formation
39
most dangerous complication of immbolity
thrombus formation
40
assessment of CV
BP measurements w/ postural changes
pulse
edema
increase activity ASAP
"dangling" feet before standing
41
prevntion of venous stasis
- anti-embolic stockings (TED hose)
- sequential compression devices (SCD)
- avoid placing pillows under knees or lower extremities, crossing legs, wearing tight clothes around waist or on legs, sitting for long periods of time
42
anti-embolic stocking
never massage extremities
observe S/S of DVT
43
nursing interventions for CV system
- increase activity ASAP
- change position as often as possible
- perform isometric exercises to increase tolerance for activity
- perform ROM (ankle pumps or knee flexion)
- increase fluid intake
- give low dose heparin (5,000 units q8-12hr)
- contact PCP if assessment data indicates venous thrombosis
44
musculoskeletal changes
lean body mass loss
muscle weakness/atrophy
45
skeletal effects
disuse osteoporosis
joint contracture
46
mobility assessment
- gait (style of walking)
- exercise (physical activity for conditioning the body, improving health, and maintaining fitness0
- activity tolerance (physiological, emotional, developmental)
47
infants, toddlers, preschoolers and immobility
prolonged immobility delays gross motor skills, intellectual development, or musculoskeletal development
48
adolescents and immobility
delayed in gaining independence and in accomplishing skills
social isolation
49
adults and immobility
physiological systems at risk
changes in family and social structures
50
older adults and immobility
decreased physical activity
hormonal changes
bone reabsorption
51
body alignment is used for
- determining normal physical cahnges
- ID deviations in body alignment
- pt awareness of posture
- ID postural learning needs
- ID trauma, muscle damage, or nerve dysfunction
- obtaining info on incorrect alignment (ie: fatigue, malnutrition, psychological problems
52
examples of body alignment
siting
standing
laying
53
contractures
develop in joints not moved periodically through their full ROM
54
ROM can be performed in
neck
shoulder
elbow
forearm
wrist
fingers and thumb
hip
knee
foot
toes
55
nursing interventions for MS
- individalized progressive exercise program
- active and passive ROM
- continuous passive motion (CPM)
- nutritional intake of calcim
- use of assistive devices for ADLs
56
immobility on elimination
- urinary stasis
- UTI (decreased fluid intake, poor perineal care, and indwelling Foley catheters resulting in UTI
- renal calculi (change in calcium metabolism with hypercalcemia resulting in renal calculi
57
elimination intervention
- force fluids
- record I&Os
- perineal care
- promote urination by pouring warm water over perineal area if client has difficulty
- insert straight or foley catherter is bladder is distended
- strain urine if there are stones
58
immobility on GI
decreased peristalsis
constipation
fecal impaction
59
GI assessment
body measurements daily
observe for passage of liquid stools
60
GI interventions
- assess bowel sounds
- record BM
- maintain hydration (at least 2,000 mL)
- teach client to consume diet including fruits, veggies, and high fibers
- give stool softner, use laxatives, cathartics, or enemas as last resort
- digital removal of fecal impactions
61
immobility on skin
pressure ulcers (inflammation + ischemia)
62
older adults at greater risk for
any break in skin which is difficult to heal causing further immobilization
63
break in skin is called a
bedsore, pressure sore, or decubitus ulcer
64
skin assessment
- nutritional status
- position and risk with each
- ID client at risk
- observe for skin breakdown
65
skin interventions
- pressure support devices (position client using corrective devices such as pillows, foot boots, trochanter rolls, and wedge pillows)
- turn client every 1-2 hrs
- use therapuetic beds if client is in a bed for an extended time
- teach client who can move independently to shift weight at least every 15 minutes
66
provide client sitting in chair with a device to decrease pressure
limit sitting to less than 2 hrs
67
skin breakdown prevention
- prevention
- ID at risk clients
- nutritional exam
- daily skin exam
- perineal care
- skin care products
- stimulate circulation
68
treating skin breakdown
keep area dry and clean
change dressings prn
increase protein, calories, and vitamins
69
effects of immobility on psychosocial issues
- emotional and behavioral responses: hostility, giddiness, fear, anxiety
- sensory alterations: altered sleep patterns, frequent dozing disrupts nighttime sleep, sleep in unfamiliar noisy place can be stressful
- cognition and perception: preoccupation with somatic complaints, difficlty with time perception, difficulty understand and following directions, crying and other outbursts, confusion, visual and auditory hallucinations
- changes in coping: depression, dejection
70
psychosocial assessment
- support by significant others, health care team
- knowledge of exercise and activity
- readiness to change behavior
- program customized to personal needs
71
psychosocial issues
identity and self esteem
cultural and ethnic influence
family and social support
72
nursing interventions fro psychosocial responses
- socialization
- meaningful stimuli
- maintenance of body image
- avoid sleep interruptions
- utilize resources ie, pastoral care, social services
- involve pt in daily care
- have nurses and staff interact
73
maintain orientation to
time (clock and calendar)
person (call by name, introduce self)
place (talk about treatments and therapy and length of stay)
74
evaluation
have pt goals been met?
75
if pt goals haven't been met...
- are there ways to assist increasing acitvity?
- which activities are you having trouble completing?
- how do you feel about not being able to dress yourself and make own meals?
- which exercises do you find most helpful?
- what goals for activity would you like to set now?
76
safety guidelines
- communicate clearly
- mentally review transfer steps
- assess patient mobility and strength
- determine assistance if needed
- raise side rail on opposite side of bed
- arrange equipment
- evaluate body alligment
- understand use of equipment
- educate patient
77
process of kidneys
kidneys secrete renin which combines with liver production of angiotensinogen
converts into angiotensin and then th elungs produce angiotensinogen coverting enzyme to create angiotensin II
78
angiotensin II combines with ADH secretion to pituitary gland causing
reabsorption of H2O
79
angiotensin II causes
vasoconstriction to increase BP
80
angiotensin II combines with aldosterone causing
reabsorption of Na+ and Cl- causing body to hold onto water
81
increase in sympathetic activity from presence of angiotensin II causes
increase in BP
82
components of GU system
kidneys
ureters
bladder
urethra
83
function of kidneys
- filter waste products
- fluid and electrolyte balance (Na+, K+, Cl-, HCO3-)
- red blood cell formation (erythropoiesis)
- BP regulation (renin-angiotensin system)
- maintains calcium and phosphate regulation
84
once urinary system fails...
all organs will be affected
85
common urinary elimination problems
- urinary retention
- UTI
- urinary incontinence
- urinary diversions
86
uterostomy
creates different way to expel urine from body
"make bladder"
87
factors affecting urination
- developmental considerations
- food and fluid intake
- sociocultural and psychological variables
- activity and muscle tone
- surgical procedurs
- diagnostic procedures
- pathologic conditions
- pain
- meds
88
infants GU
- 15-60mL/kg/day
- produce 8-10 wet diapers per day
- no voluntary control
89
children GU
- cannot control urination till18-24mo
- toilet training: involves mature neuromuscular system and adequate communication skills
90
GU problems in children
enuresis
nocturnal enuresis
91
elderly GU
- changes in kidney and bladder function
- urgency and frequency are common
- loss of bladder elasticity and muscle tone leads to nocturia and incomplete emptying of bladder
- mobility, cognition, and manual dexterity problems
92
frequency of urination
- depends on amount of urine produced
- most healthy people do not void during sleeping hours
- first urine is good for UA
- stagnation of urine in bladder serves as good medium for bacterial growth
93
when body is funcitoning well...
kidneys maintain the balance between fluid intake and output
94
when body is dehydrated...
kidneys reabsorb fluid
95
with fluid overload
kidneys excrete large amounts of fluid
96
foods/fluids affecting urine output
- increased urine output: coffee, tea, cola, alcohol
- decreased urine output: high Na+ foods
97
muscle tone GU
- abdominal wall muscles
- pelvic floor muscles (prolonged mobility, childbirth, menopausal muscle atrophy)
- trama
- long term catheterization
98
cultural norms of GU
privacy (urinary hesitancy)
facilities
99
gender GU
proper positioning
100
psychological factors of GU issues
anxiety
stress (urgency, frequency, muscle tension: difficulty to relax abdominal and perineal muscles can cause retention)
101
surgical procedures GU
- NPO status
- anesthetic and narcotic analgesics slow GFR and impairs sensory and motor impulses
- lower abdominal and pelvic area with local trauma causes edema and inflammation
- urinary retention
102
pathological conditions affecting urinary elimination
- immobility problems and impaired communication
- alteration in cognition
- neurological conditions
- CV and metabolic disorders
- kidney/bladder infections
- hypertrophy of prostate (male)
- kidney stones
103
pain GU
suppression of urge to void with presence of pain in urinary tract
delayed micturition with painful musculoskeletal joints as with arthritis
104
diuretics
prevent reabsorption of water
105
anticholinergic meds
side effects urinary retention such as meds to reduce bladder spasms
106
nephrotoxic meds
can damage kidneys
ex. gentamycin or long term use of asprin or ibuprofen
107
analgesics and tranquilizers
suppress CNS, diminishing effectivness of neural reflex
108
diuretics make urine
pale yellow
109
rifampin (antibacterial for TB) make urine
orange
110
elavil (antidepressant) makes urine
green or blue-green
111
levodopa (parkinsons) makes urine
brown or black
112
risk factors for GU issues
being a women
individuals with indwelling urinary catheter
individuals with diabetes mellitus
113
being a women
- viral infection anywhere else in body puts woman at risk for UTI
- sexually active females
- postmenopausal women
114
assessment of GU
- through pt eyes
- self care ability
- cultural considerations
- environmental factors
- nursing history (pattern of urination, symptoms of urinary alterations)
115
regular urinalysis includes
- color
- specific gravity
- glucose
- clarity
- pH
- odor
- protein
- ketones
- glucose
- microscopic analysis: RBC, WBC, casts, crystals, pathogens
116
normal output
adult - 0.5mL - 1mL/kg/hr
less than 30mL may indicate kidney failure
117
bladder capacity
normal: 500-600mL
normal void: 300mL
urge to void: 150mL-250mL
118
pale straw to amber
normal
more concentrated in morning
straw - overhydration
119
dark red
bleeding from kidneys or ureters
120
bright red
bleeding from bladder or urethra
certain foods - beets, rhubarb, blackberries
121
dark amber
fever or dehydration
high levels of bilirubin (liver dysfunction)
122
clarity
- translucent or clear when fresh
- as urine stands and cools, becomes cloudy
- cloudy or foamy in freshly voided urine may indicate RBCs WBCs bacteria vaginal discharge sperm or prostatic fluid
- kidney disease
- infection
123
odor
aromatic; as it stands it develops an ammonia odor because of bacterial action
foul - infection (UTI)
strong sweet or fruity odor - diabetes, starvation
124
pH of urine
- normal: 4.6-8.0
- average 6.0
- indicates acid base balance
125
< 7 = acid
acidosis, starvation, dehydration, diet high in meat or cranberries
126
> 7 = base
infection, UTI, vomitting, diet high in fruits and veggies
127
specific gravity
measure of concentration of dissolved solids in urine
normal: 1.005-1.030
128
high specific gravity
concentrated
dehydration (vomiting, diarrhea), reduced renal BF, increased ADH, glycosuria, proteinuria
129
low specific gravity
dilute urine
overhydration, early renal disease, decreased ADH (diabetes insipidus)
130
urinalysis
clean
first void is best
sent to lab within 2 hrs
131
clean-voided or midstream
relatively sterile
132
culture and sensitivity
sterile or clean voided
sensitivity to ID specific bacteria - change antibiotic to more specific
133
sterile urinary tests
catheterized
C&S
134
timed
test renal function and urine composition
2,12, or 24 hrs
creatinine clearnace, protein
135
nursing implications for urine testing
- provide pt teaching
- all specimens must be labeled with name, date, and time
- transport in timely fashion if unable, refrigerate
- wear gloves
- plastic bag as per facility
136
blood urea nitrogen (BUN)
7-20mg/dL
end product of protein metabolism
elevated levels may indicate kidney damage or disease
137
creatinine
M - 0.8-1.4mg/dL; F - 0.6-1.2mg/dL
byproduct of muscle metabolism
elevated levels indicate kidney damage or disease
138
BUN/creatinine ratio
10:1 or 20:1
sudden occurrence of high ratios indicate kidney failure
low ratios occur with low protein diets, muscle injuries, liver damage
139
KUB
kidneys ureters bladder
xray to determine size shape and position of kidneys
140
CT scan
view renal BF and anatomy of kidney
141
renal ultrasound
view gross renal structures
142
endoscopy-cytoscopy
use an endoscope to visualize bladder and urethra
143
intravenous pyelogram
used to view the ducts, renal pelvis, ureters, bladder, and urethra
iodine used - check for allergies
144
urinary rention
- urethral obstruction
- surgical trauma
- childbirth
- bladder inflammation
- decreased motor and sensory activity
- neurogenic bladder
- prostate enlargment
- post-anesthesia effect
- med side effects
- anxiety
145
retention with overflow
severe retention
2000-3000mL
146
benign prostatic hyperplasia
enlarged prostate
147
lower tract infections
cystits - bladder
urethritis - bladder and urethra
148
upper tract infection
pyelonephritis ( kidneys and ureters)
149
most common causes of UTI
- instruments
- poor hygeine
- frequent sexual intercourse
- residual urine
150
symptoms of UTI
- dysuria
- hematuria
- fever chills nausea, vomiting
- with pyelonephritis - flank pain, tenderness, fever, chills
151
infection control
- urinary tract is sterile (sterile technique for all procedures)
- wash hands
- clean from front to back
- plenty of fluids
152
antimicrobial therapy
sulfonamides - sulfa drugs
primary use - UTI
- gantisin (sulfisoxazole)
- TMP-SMZ (trimethoprim/sulfamethoxazole)
- bactrim, septra - combination of two sulfonamides used together
153
involuntary loss of urine
types include
- stress
- urge
- mixed
- functional
- overflow
- temporary
154
incontinence
should not be associated w/ aging
body image impairment
skin breakdown (acidic urine)
155
treatment of urinary incontinence
- lifestyle change
- pelvic floor exercises
- habit training - flexible toileting schedule based on clients pattern
156
meds for incontinence
- oxybutynin (ditropan)
- tolterodine (detrtol)
- darifenacin (enablex)
- solifenacin (vesicare)
157
incontinence devices
pessary
bladder neck support device
urethral insert or seal
surgical treatment
158
nursing care for incontinence
maintain skin integrity
- wash with soap and water
- petroleum based on ointment for barrier
- if urinary diversion : good fit
159
promote comfort for incontinence
- clean dry clothes
- urinary analgesics (pyridium)
- urinary antibiotic (azo-gantrisin)
- high fluid intake
160
analysis and nursing diagnosis (urinary)
- incontinence: functional, overflow, stress, urge
- UTI
- impaired self toileting
- impaired skin integrity
- urinary retention
161
urinary interventions
- pt education
- promoting normal micturition (maintaining elimination habits, maintain adequate fluid intake)
- promoting complete bladder emptying
- preventing infections
- medications
162
evaluation of GU
- through pt eyes (assess pt self image, social interactions, sexuality, emotins
- pt outcomes (use expected outcomes developed during planning to determine effectiveness, evaluate for changes in patient voiding pattern and/or prescence of symptoms, evaluate pt/caregiver compliance w/ plan)
163
tactile
touch
164
olfactory
smell
165
gustatory
taste
166
kinesthetic
position and motion
167
stereognosis
ability to recognize size, shape, and texture
168
reception
stimulation of a single nerve cell or group of cells to create a nerve impulse that is sent to the brain
169
perception
brain interprets the stimuli based on past experience or newness
170
reaction/response
only the most important stimuli will elicit a reaction
intensity
contrast
adaptation
previous experience
171
vision deficit can cause
- falls
- social isolation
- injury
- fear
172
hearing deficit can cause
- falls
- social isolation
- injury
- impaired verbal communication
173
tactile deficit can cause
- deficit in self care
- social isolation
- injury
- mobility
174
olfactatory deficit can cause
-deficits in self care
- social isolation
- injury
- poor nutrition
175
gustatory deficit can cause
- injury
- poor nutrition
- social isolation
- poor oral hygeine
176
kinethetic deficit can cause
- falls
- injury
- social isolation
- impaired mobility
177
stereognosis deficit can cause
- falls
- injury
- social isolation
- fear/anxiety
178
too little stimulation
infants and young children need stimuli to grow including touch, sounds, odors, visual stimuli
adults have sensory decline with age
179
stages of senses with age
1. hearing
2. vision
3. smell/taste
4. balance coorodination/decreased response to touch
180
social interactions include
family and friends
nurse
181
factors that influence sensory function
- over or understimulation
- social interactions
- environment
- culture
- illness
- medications
- stress
- personality
182
environment
does occupation put person at risk?
exposure to loud sounds or lights
hospital: immobilized pt, isolation
183
culture
differing amounts of eye contact
family presence - may prefer having family instead of being alone
vision and hearing deficits can impact health literacy and understanding ADLs
184
illness (sensory)
- neuro disorders
- circulatory issues
- hypoxia
- head injuries
185
medications (sensory)
ASA and lasix - ototoxic
opioids
medical marijuana
OTCs/herbals
186
sensory deficits
deficit in the normal function of sensory reception and perception
patient may change behaviors to adapt
187
sensory deprivation
inadequate quality or quantity of stimulation
S/S confusion, increased anxiety, bizarre thoughts, visual and motor changes
188
sensory overload
reception of multiple sensory stimuli
S/S scattered thoughts, restlessness, anxiety
189
sensory overload is common in
ICUs due to lots of alarms, lack of windows, noise, pain
190
sensory assessment
- person at risk
- sensory alteration history
- mental status
- physical assessment
- ability to perform self-care
- health promotion habits
- environmental hazards
- communication methods
- social support
- use of assistive devices
- other factors affecting perception
191
interventions for sensory issues
- frequent orientation
- encourage visitors if appropriate
- organize care
- quiet times
- dim lights at night
- avoid excessive conversation outside the room
- can NOT turn off alarms
192
assessment - vision
- squinting
- bringing things close to them to read
- note if colorblind
- wears glasses
- difficulty reading
- difficulty grabbing or finding objects
- using magnifier glass
- decreased ADLs
- decreased socialization
- falls
193
glaucoma
intraocular structural damage resulting from elevated intraocular pressure
obstruction of the aqueaous humor can cause this
potentially can lead to blindness
pts see black surrounding what they're looking at
194
macular degeneration
associated with aging and results in severe central vision loss
leading cause of blindness and poor vision in adults over 65 in US
195
diabetic retinopathy
pathological changes occur in blood vessels of the retina resulting in decreased vision or vision loss caused by hemorrhage and macular edema
black dots
196
cataracts
increased opacity in the lens which blocks light rays from entering the eyes
sometimes develop slowly and progressively after age 35 or from trauma
blurry vision
197
presbyopia
gradual decline in the ability of the lens to accommodate of focus on objects
unable to see objects close
198
presbycusis
common progressive hearing disorder in older adutlts
199
dizziness
common in older adulthood usually resulting from vestibular dysfunction
frequently change in the head precipitates vertigo or disequalibrium
200
xerostomia
decrease in salivary production that leads to thicker mucus and a dry mouth
often interferes with ability to eat and leads to appetite and nutritional problems
201
cerumen accumulation
buildup of earwax in the external auditory canal
202
peripheral neuropathy
disorder of the peripheral nervous system
203
symptoms of peripheral neuropathy
numbness
tingling
stumbling gait
204
stroke
cerebrovascular accident caused by clot, hemorrhage, or emboli disrupting blood flow to the brain
creates altered proprioception (body positoin) with marked incoordination and imbalance
loss of sensation and motor function in extremities controlled by the affected area of the brain
205
stroke affecting left hemisphere of brain results in
symptoms on right side such as difficulty with speech
206
stroke affecting right hemisphere causes
symptoms on left side
including visual spatial alterations, sch as loss of half of visual field or inattention and neglect especially to left side
207
interventions for presbyopia, macular degeneration, diabetic retinopathy
- items within reach, clutter free
- glasses
- good lighting: warm incadescent versus bright
- good eye contract
- large print or magnifier; braile
- decrease glare: amber or yellow lenses, blinds, shades
- sunglasses
- color distinction/contrast (red, orange, and yellow easier to distinguish
208
what is the most dangerous thing for someone who cannot see to be doing
driving!
209
tips for driving
- drive in familiar areas
- no night driving
- avoid highways
- have phone with you
- drive slowly but not so slow
- keep car in good condition
210
computer/digital eye strain
- screen 4-5 inches below eye level
- screen 20-28 inches from your eyes
- use document holder
- avoid glare from window or light
- how you sit- feet on floor and no wrist on keyboard
- rest eyes every 2hrs for 15 min
- look away every 20 minutes from screen for 20 seconds
211
assessment for hearing loss
- asks for repetition of words
- has hearing aid
- inattentive
- respond inappropriately
- speak too loud or too soft
- have trouble following directions
- turn their head in one direction
- smiling and nodding
- lip reading
- C/O tinnitis
- do not hear you enter the room - may be frightened
212
interventions for hearing issues
- asks about hearing aids/eyeglasses
- get pt attention
- talk slowly and clearly - no shouting
- speak to good ear
- sign language, lip reading, pad and pencil
- confirm communication
- recorded music - can hear low-frequency sounds
- quiet environment
- personal space
- amplified phone; written instructions; interpreters
- speak with hands, face, and eyes
- check for cerumen
- let phone ring a few times before hanging up
213
dangerous situation for someone who cannot hear
driving!
214
assessment of smell
increased body odor
cannot recognize noxious smells/decreased sensitivity
215
assessment of taste
weight change
appetite change
excess use of seasoning or sugar
C/O taste of food
216
interventions for olfactory and/or gustatory deficits
oral hygeine
good hydration
seasonings
removal of unpleasant odors
no blending or mixing of foods
different textures
check expiration dates
217
what is dangerous situation for someone who can not smell
fire!
218
assessment for tactile dysfunction
- clumsiness
- failure to respond to touch
- C/O numbness/tingling/burning in hands/fingers
- decreased grip strength
- over or under reaction to pain
- possible injuries to hands; burns
219
interventions for tactile dysfunction
massage
check temperature
firm touch
label faucets
caution with hot or cold items
signs for pain
no heating pads
touch activities - hair, combing, back rub - ask
loosen linens on bed
check skin
220
what are dangerous situation for someone who can not feel
hot, persons touching, riding bikes, cold, sharps
221
special communication needs
- artificial airways
- aphasia
222
artificial airways
- use pictures
- pad and pencil/laptop/communication board
- no shouting or loud voice
- be patient with responses
- vibrator voice box for laryngectomy patients - passy muir valve
223
aphasia
varied degrees of inability to speak, interpret or understand language
224
expressive (Broca's area) aphasia
motor type of aphasia
inability to name common objects or express simple ideas in words or writing
225
sensory or receptive (wernicke) aphasia
inability to understand written or spoken language
226
health promotion activites in community/home
- screening; vision, hearing
- safe environment- home risk assessment
- alternative ways of communication
- use of assistive devices
227
home risk assessment
- cracked walkways
- scatter rugs
- extension cords
- clutter
- labeled faucets
- lighting
- grab bars in BR
228
delirium
confusion that can be reversed
229
dementia
can not be reversed
230
interventions for impaired cognition
- promote orientation (introductions, calendars, personal objects, open shades in daytime)
- simple sentences
- do not offer too many choices
- face pt when speaking
- relieve anxiety (handholding, continuity of care, respect feelings, help w/ words, music)
231
general interventions in acute care setting for sensory issues
- orient to environment
- be sure patient has assistive devices (glasses, hearing aids)
- good lighting
- clutter free
- call bell
- control stimuli (combine activities in one vist, control noise)
- address by name
- anticipate pt needs (toileting)
- ambulate safely
232
planning of care for those with sensory issues
- include family
- use standards as guides
- partner with the patient to set realistic goals and achievable outcomes
- make safety top priority
- value other professionals' contributions
- consider community-based resources
233
evaluation of sensory interventions
patient is only person who can tell if sensory ability has improved
234
homeostasis
maintenance/balance of body components
all fluid, electrolytes, acid, and bases all values will be off
235
function of water in the body
medium for transport
controls temperature
promotes digestion
acts as a lubricant to tissues
236
water as medium for transport
moves electrolytes, blood (RBCs, WBCs), hormones, nutrients, and wastes
237
how does water control temp
- need hydration
- dehydration = higher temp
- postop pt has slight elevated temp due to fluid loss
238
fever
100.4
239
elevated temp
99.9-100.3
240
electrolytes
na+
k+
hco3-
cl-
mg+
241
body weight and water
- premature babies have 85% water making up body weight (fluid loss in infants occur rapidly decreasing BW)
- elderly BW is 50%
- adults BW is 60%
242
body systems that support homeostasis
- thirst
- kidneys
- CV system
- neuro
- lymphatic system
243
thirst
losing or gaining too much water, brain is triggered to either increase drinking or decrease drinking
244
kidneys
- help excrete water or retain water
- antidiuretic hormone (ADH) retains water in body which prevents elimination of water
- renin-angiotensin-aldosterone system (RAAS)
245
ADH
helps retention of water restoring volume (blood volume) of water
246
renin-angiotensin-aldosterone system (RAAS)
triggered by kidneys that regulates amount of water or Na+ that kidneys hold on to
247
CV system
- atrial natriuertic peptide (ANP): secreted from cardiac muscle which help regulate fluid volume by reducing plasma volume (volume in general)
248
ANP is secreted to
stimulate vasoDILATION
in cases of FVO, heart is overwhelmed with fluid so opening of veins and arteries it allows for more fluid to reach kidneys to excrete fluid
249
brain natriuretic pepetide (BNP)
- produced by cardiac cells but released by brain
- when heart cant pump the way it should, BNP will be released to reduce that load
- elevated BNP indicative of heart failure
250
lymphatic system
- assists in removing excess protein and fluid within the body
- edema, lymphatic system aids in removal of excess fluid
251
daily fluid requirements
- 35-45 mL/kg/day
- BW measure
252
factors affecting fluid needs
- sweating/diaphoresis
- activity level
- environment (hotter temp, winter air is dryer so fluid loss is present, altitude)
- food consumption (high intake Na+, body needs to burn calories, so fluid is necessary)
- any illness (Cough---HF)
- functional factors of cardiac, respiratory, renal, integumentary, hepatic system (any alteration will impose threat to water)
253
sources of fluid loss
sensible and nonsensible
254
sensible loss
loss than CAN be measured
urine
diarrhea (not form of stool)
emesis/vomiting
wound drainage
gastric drainage
255
urine output daily
1200-1500mL/day in normal adult
256
nonsensible losses
loss that CANT be measured
- sweat (500-600mL/day)
- talking (perspiration)/respiratory tract (400mL/day)
- GI feces (100-200mL/day)
257
sources of fluid intake
liquids
food
cell metabolism
258
liquids
PO
1100-1400mL/day average
259
food
800-1000 mL/day average
260
cell metabolism
300mL/day average
261
measuring I&Os
measure urinary output
very important for certain conditions and if daily requirement is not being met or too much fluid is being lost, problem occurs
daily weights are best measure to assess fluid intake or loss
262
daily weights
- best measure to assess fluid loss and intake
- baseline necessary
- establish accurate weight by time of day, what person is wearing, if it on bed, using same scale at same time of day
263
if person goes up 2.2kg/day
validate findings!
264
calculate fluid req
35-45 mL/kg/day
265
2.2 lbs
1 kg
266
165 male requires
3000mL/day
267
fluid volume deficit data cues
- dizziness
- hypotension
- weight decrease
- imbalance in I&Os
- more concentrated urine measured by specific gravity (1.001-1.030) - 1.030 implies greater concentration indicative of decreased fluid
- dry skin and mucous membranes
- poor skin turgor
- HR increased
- weak thready pulse
268
why does heart rate go up with FVD
heart tries to compensate and work harder to push blood throughout body
269
FVD labs
- BUN increase (measure of kidney function)
- creatinine can be low or high (measure of kidney function)
- hemoglobin increase (allows RBCs to transport oxygen)
- hematocrit increase (shows volume or RBCs and WBCs)
- urine SG increase
270
nursing actions for FVD
- monitor I&Os
- monitor BP and VS
- administer fluids
- monitor daily weight
271
fluid volume excess data cues
- edema (lower extremities, fingers, periorbital edema)
- high BP
- bounding pulse
- SOB
- confusion related to % of electrolyte balance
272
FVE labs
- BUN decrease
- hemoglobin decrease
- hematocrit decrease
- urine SG decrease
273
nursing interventions for FVE
- monitor I&Os
- monitor BP and VS
- potentially diuretics?
- monitor daily weight
- monitor respiratory status
274
fluid imbalances may be from
vomiting
diarrhea
certain illness
275
intracellular fluid (ICF)
about 40-60% BW
fluid found inside cells
K+ within the cells
276
extracellular fluid (ECF)
about 20-60% BW
fluid fond outside cells
Na+ is outside the cell
277
interstitial fluid (IF)
fluid between cells
278
intravascular fluid (IVF)
fluid within blood vessels
279
basic function of fluids and electrolytes
- essential for basic life functioning
- help by way of charges to maintain balance of water
- ensures acid-base balance
- ensures proper functioning of nerves, muscles, heart, brain, etc.
280
major electrolyte in ECF
sodium (Na+)
281
sodium helps
transport wastes, O2, movements of electrolytes
282
major electrolyte in ICF is
potassium (K+)
283
potassium helps
internal fluids necessary for bodily function
284
osmolarity
concentration of solutes in a solution
facilitates movement of electrolytes from one place to another
285
osmolarity in ECF
almost solely due to Na+
286
osmolarity in ICF
almost solely due to K+
very narrow range acceptable for K+
287
Na+/K+ work together to
maintain homeostasis
288
how are fluid and electrolytes transported
through osmosis or active transport
289
osmosis
- flow between semi-permeable membrane of fluid going from one place to another
- will dilute without a lot of energy
- from areas of high concentration to low concentration
290
active transport
moves against concentration gradient
291
isotonic fluids
- pressure gradients are relatively equal
- concentration of particles is like blood
- fluid moves between compartments and mostly isotonic fluids are used to control for volume deficits
can be used to raise BP and expand ECF
292
typical isotonic fluids
- normal saline 0.9%
- lactated ringers
- replacement of volume, no shifting fluids
293
hypotonic fluids
- have lower concentration of solutes in fluid
- when infused it moves water into the cell
- will increase size of cell
294
typical hypotonic fluids
normal saline 0.45%
specific type of dehydration in which hydration is needed in cells
295
hypertonic fluids
when infused it moves water out of cell
will shrink size of cell
296
typical hypertonic fluids
normal salin 3%
297
blood pH
7.35-7.45
298
blood CO2
35-45
299
blood HCO3
22-26
300
blood paO2
80-100 mmHg
301
pao2
pressure that o2 is exerting within vascular system so there can be uptake of hemoglobin
302
blood sao2
>93%
saturation of o2 on hemoglobin
303
lines of defense to help maintain acid-base balance
- chemical buffer system including food and fluids, respiratory system, renal control of plasma HCO3-
304
respiratory system on acid base balance
- one system that tries to help us control acid-base balance
- second line of defnese
- hyperventilation causes output of CO2 which causes you to become alkalotic causing respiratory alkalosis (if this happens, provide paper bag to slow breathing and absorb some CO2 that they are blowing off)
- always associated with CO2 and 2nd line of defnese
305
renal control of plasma HCO3
- kidneys secrete and absorb hydrogen ions in order to control amount of bicarb in the body
- metabolic is always associated with renal control and other kinds of disease processes
306
pH (H+ ions)
- begins with blood pH
- high concentration of H+ ions is going to indicate acidity
307
blood pH <7.35
acidotic state
indicates more H+ ions
308
blood pH >7.45
alkalotic state
indicates fewer H+ ions
309
paCO2> 45
indicates excessive CO2 retention indicating state of acidosis
310
paCO2 <35
less CO2 retention indicating state of alkalosis
311
increase in paco2 and decrease in pH indicates
Respiratory Acidosis
312
HCO3 <22
acidosis
313
HCO3 >26
alkalosis
314
HCO3 indicates
renal control and metabolic disorders
315
ROME
- respiratory
- opposite (alkalosis: high pH, low PaCO2, acidosis: low pH, high PaCO2
- metabolic
- equal (alkalosis: high pH, high HCO3, acidosis: low pH, low HCO3)
316
what do you look for to determine if acid-base imabalance is respiratory
PaCO2
317
what do you look for to determine if acid-base imabalance is metabolic
HCO3
318
causes of respiratory acidosis
- acute problems such as airway obstruction, pneumonia, asthma, chest injuries, or pulmonary edema
- COPD, such as emphazema
- opiate use that depresses respiratory rate
319
cues for respiratory acidosis
- headache
- drowsiness
- disorientation
- muscle weakness
- pale to cyanotic
320
blood gas values of respiratory acidosis
pH < 7.35
PaCO2 > 45 mmHg
321
when the underlying cause of acid-base imablance is respiratory,
correction or improvement in ventilation is to lower PaCO2
322
when underlying cause is nonrespiratory,
then correction or improvement of underlying cause must occr
323
medical treatment of respiratory acidosis
- bronchodilators to open constricted ariways
- supp. O2
- meds to treat hyperkalemia
- antibiotics to treat infection
- chest physiotherapy
- removal of foreign body from airway
- chest tube insertion
- intubation for mechanical ventilation
324
nursing actions for respiratory acidosis
- maintain airway
- monitor ABGs
- monitor vital signs
- admin supp O2
- assist with intubation
- monitor K+ levels
- administer sedatives cautiosly
325
respiratory alkalosis causes
- hyperventilation
- anxiety
- high fever
- overdose of aspirin
- infection
326
respiratory alkalosis cues
- anxiety
- irritability
- muscle cramping
- numbness
- tingling
327
blood gas values of respiratory alkalosis
pH >7.45
PaCO2 < 35 mmHg
328
medical treatment of respiratory alkalosis
- ID and eliminate causative agent
- reduce fever
- eliminate source of sepsis
- o2 therapy
- sedative therapy
329
nursing action of respiratory alkalaosis
- encourage slow, deep breathing
- monitor VS
- provide emotional support and reassurance - reduce anxiety
- assist with activites of daily living
- patient education
330
metabolic acidosis causes
- diarrhea
- renal failure
- sepsis
- starvation
- overdose of asprin
331
metabolic acidosis cues
- muscule twitching
- warm
- flushed skin
- n/v
- decreased muscle tone
332
blood gas values for metabolic acidosis
pH <7.35
HCO3 <22 mEq/L
333
medical treatments of metabolic acidosis
- sodium bicarb replacement
- parenteral fluid replacement
- antidiarrheals
- dialysis
- mechanical ventialation
334
nursing actions of metabolic acidosis
- monitor hemodynamic status - VS, telemetry
- assess peripheral vascular status
- admin sodium bicarb as order
- provide reassurance and teaching
335
metabolic alkalosis causes
- vomiting
- extensive GI suction
- excessive use of antacids with bicarbonate
- diuretics
336
metabolic alkalosis cues
- restlessness
- lethargy
- confusion
- nausea
- vomiting
- tremors
- tingling
337
blood gas values of metabolic alkalosis
pH >7.45
HCO3 > 26 mEq/L
338
medical treatment of metabolic acidosis
- discontinuation of K+ wasting diuretics
- discontinuation of nasogastric suctioning
- antiemetics
339
nursing actions of metabolic acidosis
- hemodynamic monitoring (RR, pulse, telemetry)
- asses LOC
- IV fluid admin
- electrolyte supplements
- providing reassurance and teaching
340
respiratory acidosis overview
body state - acidosis
CO2 - retain/increase
H+ ions - increase
pH state - decrease in pH level
Body response - increase depth and rate of respiration
341
respiratory alkalosis overview
body state - alkalotic
CO2 - excreted/decrease
H+ ions - decrease
pH state - increase in pH level
body response - decrease depth and rate of respirations
342
metabolic alkalosis overview
body state - alkalotic
HCO3 - excreted, decrease
H+ ions - reabsorbed
pH state - increase
body response - alkaline urine, decrease in blood HCO3, decrease in H+
343
metabolic acidosis overview
body state - acidotic
HCO3 - absorb/increased
H+ ions - excreted
pH state - decrease
body response - urine acidic, decreased HCO3, decreased pH
