Med Sug Exam 2 Flashcards
What are the functions of the skin?
body temp regulation, vitamin D production, absorption, elimination
What is self care?
Capable of managing their personal health independently once oriented to the bathroom
What is partial care?
Receive morning care of bedside or seated near sink in the bathroom. Require assistance with body that are difficult to reach
What is complete care?
Require nursing assistance with all aspects of personal hygiene
At what angle do you brush dentures?
45 degree angle
What is the purpose of a Yankeur suction device
use on patients that need help with oral care to prevent infection
T/F wrap dentures in a napkin after cleaning
false; possible losing them
T/F you use hot water to clean dentures
false; room temp
Why don’t you want dentures to sit out after washing them?
it causes them to dry out which then causes them to easily break and remove the plastic in the dentures
How do you properly care for dentures after washing?
Put them in water at room temp over night in a cup
When performing normal perineal care, where do you start cleaning?
from least contaminated to most contaminated
For females, you wipe
front to back(top to bottom)
When performing perineal care, you want to use
non soap cleaners that are pH balanced as soap dries out the skin
When performing perineal care on a male, you want to
clean the head of the penis in a circular motion then move to shaft
Pressure ulcers
Compromised circulation related to pressure over bony prominences or combined with friction
Venous ulcers
Result in injury and poor venous return, incomplete valves or obstruction
In venous ulcers, you
have a pulse
Arterial Ulcers
Injury and underlying ischemia caused by underlying conditions of atherosclerosis or thrombus
In arterial ulcers, you
have no pulse
Neuropathic ulcers(diabetic ulcers)
Result of diabetic neuropathy, peripheral arterial disease which leads to poor sensation
-pts report numbness and tingling=check feet
Risk factors of skin breakdown
poor nutrition, immobility, neurological status, diabetes, incontinence
Stage 1 pressure ulcer
Non-blanchable erythema(redness ) of intact skin
-changes in sensation, temp, and firmness
Stage 1 ulcer may precede visual changes so you can check if its stage 1 if its
warm to touch(palpable) and painful to touch
“My ass hurts” is an example of
stage 1 pressure ulcer
In stage 1, color changes
do not include purple, maroon discoloration as these indicate deep tissue injuries
Stage 2 ulcer
Partial thickness(dermis), skin loss with expose dermis-blood exposed
-wound bed is viable; pink pr red, moist. May present as intact or ruptured serum filled blister
Stage III ulcer
Full thickness(dermis) skin loss, subq fat may be visible
-complete skin breakdown-yellowish border
-Bone, tendon, muscle are not exposed-does not involve underlying fascia
Stage IV ulcer
Full thickness skin and tissue loss with exposed bone, tendon and muscle
Unstageable ulcer
Area covered by slough and/or eschar in wound bed
-black and yellowish- cant see what stage it is because of the slough and eschar
-needs to be derided-cleaned out(not done by nurse)
Characteristics of venous(stasis) ulcers
-warm, a lot of swelling
-wound usually seeping/draining
-palpable pulse
-use compression socks to aid in circulation
When you have a venous ulcer, elevation causes
decreased pain
Arterial ulcer
-no palpable pulse
-skin shiny and hairless
-foot is pale and cool to touch
When you have a arterial ulcer, elevation causes
increased pain
Characteristics of ulcer prevention
-Protective footwear of socks and boots
-avoid massage over boney prominence
-apply emollient to keep skin pliable
-avoid most environments
-avoid cold, caffeine, nicotine and constrictive garments
-avoid use of thermal devices such as hot water during skincare
When a patient is bed bound, change their position every
2 hours
When a patient is chair bound, change their positions every
hour
Prevention of Neuropathic ulcers
-control blood glucose(controls sugar)
-daily check of feet
-avoid applying heat
The Braden pressure risk assessment is used to
identify patients at risk of ulcers
A high score indicates a person is at
low risk of developing ulcers
19-23
The assessment measures which 6 things?
sensory perception, moisture, activity, mobility, nutrition, and friction/shear
Interventions for preventable mild/low risk(15-18)
-regular turning schedule
-activity
-protect heels
-use pressure redistribution surfaces
Skin pallor can indicate
anemia
Skin cyanosis can indicate
hypoxemia
Preventing skin breakdown by
-assisting with feedings
-monitor albumin/pre-albumin levels
-check weights daily/weekly
The main factor of preventing skin breakdown is
avoiding use of more than one incontienent containment on bed such as brief chux or draw sheet as it causes more friction and skin breakdown
Asepsis
The practice of activities to prevent infection or stop spread of microorganisms
Medical asepsis(clean technique)
Involves procedures and practices that reduce the number and transfer of pathogens
Hand hygiene and wearing gloves is used in
medical asepsis
Examples of medical asepsis conditions
pressure wound, arterial and venous ulcers
Surgical asepsis(sterile technique)
Used to keep objects and areas free from microorganisms
Examples of surgical asepsis
Inserting an indwelling urinary catheter, central lines and post op surgical wounds
T/F compression therapy is not used with pressure ulcer injuries
true
Purpose of a wound vac
draws fluids out to allow wounds to heal
With large wounds you want to monitor
fluid and electrolytes
Pressure ulcer scale for healing(PUSH)
determines if wounds are healing or not
-evaluates: length/width, exudate amount, tissue types present in wounds
Serous fluid
clear liquid in which drainage is pale yellow and watery
RYB wound classification
Red=protect
Yellow=cleanse
Black=debride
Example of serous fluid
fluid from a blister
Serosanguineous fluid
drainage is pale pink and yellow and is thin and contains plasma and red cells
Sanguineous fluid
drainage is bloody such as acute laceration
Purulent
pus where drainage contains white cells and microorganisms and occurs when infection is present
Phases of wound healing consist of
hemostasis, inflammatory phase, proliferation phase, and maturation phase
Hemostasis phase
-Occurs immediately after initial injury
- involves blood cells constricting and blood clot begins
-exudate is formed such as swelling and pain
-increased perfusion which leads to heat and redness
-platelets and other cells migrate to injury and promote healing
Inflammatory phase
-follows hemostasis and last 4-6 days
- white blood cells move to the wound
-macrophages enter wound area and remain for an extended period and they digested debris and release growth factors that attract fiberblasts to fill in the wound
Proliferation phase
-Begins within 2 to 3 days of injury last up to 2 to 3 weeks
-new tissue is built to fill the wound space through action of fibroblasts -capillaries grow over wound and epithelial cells
-granulation forms foundation for scar
Maturation phase
-Begins after 3 weeks and last 6 months after injury
-collagen is remodeled and new is formed
-scar is flat thin and white line
Principles of wound healing
- Intact skin is the first type of defense
- Careful hand hygiene prevents spread
- Adequate blood supply is essential for normal body response to injury(homeostasis-local, adaption syndrome-inflammation response-local)
- Normal healing is prompted wound is free from foreign material
- Response to a wound is more effective if proper nutrition is maintained
A patient has a wound that is healing by secondary intention. To best support healing of
the wound, the nurse should expect the practitioner’s order to state, “Clean wound with:
1. Betadine and apply a dry sterile dressing.”
2. Normal saline and cover with a gauze dressing.”
3. Normal saline and apply a wet-to-damp dressing.”
4. Half peroxide and half normal saline and apply a wet to dry dressing.”
- Normal saline and apply a wet-to-damp dressing.
The nurse must collect the following specimens. Which specimen collection does not
require the use of surgical aseptic technique?
1. Stool for ova and parasites
2. Specimen for a throat culture
3. Urine from a retention catheter
4. Exudate from a wound for culture and sensitivity
- Stool for ova and parasites
To interrupt the transmission link in the chain of infection, the nurse should:
1. Wash the hands before and after providing care to a patient
2. Position a commode next to a patient’s bed
3. Provide education about a balanced diet
4. Change a dressing when it is soiled
- Wash the hands before and after providing care to a patient
The nurse must make the decision to give a patient a full or partial bed bath. This decision
depends on the:
1. Physician’s order for the patient’s activity
2. Immediate needs of the patient
3. Time of the patient’s last bath
4. Wishes of the patient
- Immediate needs of the patient
A patient is incontinent of urine and stool. For which patient response should the nurse
be most concerned?
1. Confusion
2. Dehydration
3. Altered sexuality
4. Impaired skin integrity
- Impaired skin integrity
Which condition identified by the nurse places a person at the greatest risk for self-care
toileting and elimination problems?
1. Amputation of a foot
2. Early dementia
3. Fractured hip
4. Pregnancy
- Fractured hip
The nurse identifies that additional teaching about skin care is necessary when an older
adult says, “I should:
1. Bathe twice a week.”
2. Rinse well after using soap.”
3. Humidify my home in the winter.”
4. Use a bubble-bath preparation when I take a bath.”
- Use a bubble-bath preparation when I take a bath.”
A patient is incontinent of loose stools and is mentally impaired. What should the nurse
do to help prevent skin breakdown?
1. Wash the buttocks with strong soap and water
2. Frequently check the rectal area for soiling
3. Gently put a pad under the buttocks
4. Place the call bell in easy reach
- Frequently check the rectal area for soiling
The nurse must bathe the feet of a patient with diabetes. What should the nurse do
before bathing this patient’s feet?
1. File the nails straight across with an emery board
2. Ensure a physician’s order for hygienic foot care is obtained
3. Teach the patient that daily foot care is essential to healthy feet
4. Assess for additional risk factors that may contribute to foot problems
- Assess for additional risk factors that may contribute to foot problems
The nurse identifies that a patient’s pressure ulcer has just partial-thickness skin loss
involving the epidermis and dermis. The nurse documents that the patient’s pressure
ulcer is:
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
- Stage II
An immobilized bed-bound patient is placed on a 2-hour turning and positioning
program. The nurse explains to the family members that this is done primarily to:
1. Support comfort
2. Promote elimination
3. Maintain skin integrity
4. Facilitate respiratory function
- Maintain skin integrity
The nurse is transferring a patient from a bed to a wheelchair. To quickly assess this
patient’s tolerance to the change in position, the nurse should:
1. Obtain a blood pressure
2. Monitor for bradycardia
3. Determine if the patient feels dizzy
4. Allow the patient time to adjust to the change in position
- Determine if the patient feels dizzy
Which stage pressure ulcer requires the nurse to measure the extent of undermining?
1. Stage 0
2. Stage I
3. Stage II
4. Stage III
- Stage III
A patient is diagnosed with a stage IV pressure ulcer with eschar. Which medical treatment
should the nurse anticipate the physician will order for this patient?
1. Heat lamp treatment three times a day
2. Application of a topical antibiotic
3. Cleansing irrigations twice daily
4. Débridement of the wound
- Débridement of the wound
Which is the earliest nursing assessment that indicates permanent damage to tissues
because of compression of soft tissue between a bony prominence and a mattress?
1. Nonblanchable erythema
2. Circumoral cyanosis
3. Tissue necrosis
4. Skin abrasion
- Nonblanchable erythema
A client who is confused and disoriented is wearing a restraint that was applied following the
manufacturer’s directions. The client struggles against the restraint. Which does the nurse conclude is the primary reason for this behavior?
1. A restraint should not cause discomfort if it is applied correctly and checked frequently.
2. Confused, disoriented clients who are restrained may become agitated and respond in a reflex-like way; attempts to gain control
require problem solving, which they usually are unable to perform.
3. A client usually struggles against a restraint to get free, not to manipulate staff.
4. Disoriented and confused clients do not always have the cognitive ability to understand what is happening to them
and often struggle against restraints.
- Disoriented and confused clients do not always have the cognitive ability to understand what is happening to them and often struggle against restraints.
A nurse on the evening shift in the hospital is caring for a slightly confused client. Which is the most effective nursing intervention to prevent disorientation at night?
1. Although checking on the client regularly is something the nurse should do, it will not prevent disorientation.
2. The client has to be oriented enough to be aware of the presence of the call bell before it can be used.
3. A small night-light in the room provides enough light for visual cues for a minimally confused client, which should help
prevent or limit disorientation when the client awakens at night.
4. The client may not remember the description of the environment on awakening and may become disoriented in the dark.
- A small night-light in the room provides enough light for visual cues for a minimally
confused client, which should help
prevent or limit disorientation when the client awakens at night.
A nurse is caring for an older adult on bedrest. Which should the nurse provide to best prevent a pressure
(decubitus) ulcer in this client?
1. An air mattress distributes body weight
over a larger surface and reduces pressure
over bony prominences.
2. Although bathing removes secretions and promotes clean skin, it can be drying, which can compromise skin integrity.
3. Protein does not prevent pressure (decubitus)
ulcers. Protein is the body’s only
source of nitrogen and is essential for building, repairing, or replacing bodytissue. It requires a primary health-care provider’s prescription.
4. An indwelling urinary catheter should never be used to prevent a pressure (decubitus) ulcer; however, a catheter may be
used to prevent contamination of a pressure(decubitus) ulcer after it is present in a client who is incontinent of urine. It requires a primary health-care provider’s prescription.
- An air mattress distributes body weight over a larger surface and reduces pressure over bony prominences.
Which are the reasons why restraints are used when caring for clients? Select all that apply.
1. ____ The purpose of restraints is not to limit movement.
2. ____ Restraints can increase agitation; if used when a client is severely agitated, they can cause injury.
3. ____ Immobilization is not the purpose of
restraints. Restraints should be snug, yet loose enough for some movement.
4. _ _ _ The primary reason for the use of restraints is to prevent client injury; restraints are used only as a last resort
to protect the client from self-injury
or from hurting others.
5. __ _ In an emergency a client may be placed in restraints when a client’s activity threatens the safety of others.
- _ _ _ The primary reason for the use of restraints is to prevent client injury; restraints are used only as a last resort
to protect the client from self-injury
or from hurting others. - __ _ In an emergency a client may be placed in restraints when a client’s activity threatens the safety of others.
How do you assess cognition?
through orientation, memory, spatial ability, attention, and reasoning
Levels of consciousness
alert, verbal stimuli, painful stimuli, and unresponsive
-assess with Glasgow Coma scale
Characteristics of Delirium
-acute
-fluctuating
-lasts days to weeks
-altered consciousness
-impaired attention
-Increased/decreased psychomotor changes
-usually reversible
Characteristics of Dementia(think Alzheimer’s)
-chronic
-progressive
-months to years
-clear consciousness
-normal attention, except in severe cases
-often normal psychomotor changes
-rarely reversible
Confusion
agitated and disoriented which causes altered awareness and easily distracted
Wong Baker FACES Pain Scale
rates pain from 0-10 based off pictures of faces-ask them to point to a photo they identify with
Mild:0-3
Moderate:4-6
Severe:7-10
The Wong Baker FACES Pain Scale is based for
early dementia patients that are alert/awake and have a good attention span
FLACC scale
assesses face, legs, activity, cry, consolably
0-2 rating
The FLACC scale is used when
a patient is unconscious and cant properly communicate
Interventions for patients that are awake
-Observe for at least 2 to 5 minutes -observe legs and body uncovered -reposition patient or observe activity; assess body for tenseness and tone
-initiate counseling intervention as needed
Interventions for patients who are asleep
-Observe for at least 3 minutes or longer
-observe body and legs uncovered -if possible reposition patient
-touch body and assess for tenseness and tone
When communicating with patients who are confused, use
-Frequent face-to-face contact to communicate
-speak calmly, simply and directly to the patient
-orient and re-orient patient to environment
-orient patient to time, place and person
-communicate that patient is expected to form self-care activities
-offer explanation for care
-reinforce reality if patient is delusional
What are the reporting obligations
Nurses are obligatory reporters for abuse, rape and communicable diseases
-abuse includes physical, verbal, sexual or emotional neglect which more than half of the reported cases are in elderly
When using restraints,
Keep bed in lowest position possible and have at least one side rail down
T/F all restraints need to be based off doctors orders
true
Factors of using restraints
-least restrictive
-discontinue as soon as possible
-assess every 15 minutes and assessment by RN with physician order renewal 2-4hrs
Restraint assessment: Physical status
Check vital signs, assess skin, nutrition status, hydration status, circulation in extremities with restraints, range of motion, hygiene, elimination, and physical comfort
Restraint Assessment: Psychological/emotional status
Physiological comfort in maintaining of dignity, safety and patient rights
Glaucoma: Open Angle
-Fluid moves out
-open
-decreased peripheral vision
-blurry vision
Glaucoma: Closed(Narrow) Angle
-Pain as fluid backs up into the eye
-decreased peripheral vision
-blurry vision
How do we determine a patients arousal?
Through Reticular Activating System(RAS)
Consciousness
Delirium, dementia, confusion, normal consciousness, somnolence, minimally conscious state, locked in syndrome
Unconscious
-Asleep, stupor, coma
-Veg state
Sensory Deprivation
-Environment with decreased or monotonous stimuli
-impaired ability to receive environmental stimuli
-inability to process environmental stimuli
Example of sensory deprivation
patients in the ICU
Sensory overload
-Patient experiences so much that the brain is unable to respond meaningfully or will ignore stimuli
-out of control and exhibit manifestations observed in sensory deprivation
-nurse works on decreasing stimuli and help patient gain control over the environment
How do you stimulate a patient senses?
Interact with them by playing games
When caring for a visually impaired patient, you should
-Acknowledge yourself when you enter the room
-speak in a normal tone of voice -explain reason for touching patient before doing it
-keep call light within reach
-orient patient to sounds in environment
-orient patient to room arrangement and furniture
-assist with ambulation by walking slightly ahead of person
-stay in vision field
-let them know when you’re leaving
How to communicate with an unconscious patient
-Be careful what is being said in their presence; hearing is the last sensory lost
-speak in normal tone voice
-speak to patient before touching
-keep environmental noise at low levels
Polypharmacy
when a patient, particularly elders, have too many meds that might interact with one another
To handle polypharmacy, you must
-Coordinate patient care by educating them the best way and provide them with simple terms
-organize pillboxes
-contact primary care provider about if the patient still needs certain meds while reviewing the med list with them as some may react with one another
It is not the nurses job to
tell the patient to stop taking certain meds; clarify with provider
Stereognosis
Perception of solidity of objects by using only tactile stimulus
Which measure is appropriate when caring for a patient who is hearing impaired?
A. Speak to the patient before making your presence known
B. Increase noises in the background to stimulate senses
C. Position yourself so that light is in your face
D. Dont use pantomime to express messages to avoid embarrassment
C. Position yourself so that light is in your face
Which of the following interventions would be appropriate to stimulate the sense of stereognosis in long-term care residents?
A. Tape pictures of loved ones on the wall
B. Play soft music in the recreation room
C.Prepare a fragrant cup of tea
D. Provide a soft textured blanket on the bed
D. Provide a soft textured blanket on the bed
Poor sleep makes us
More sensitive to pain, more stress, and poor judgment
Sleep
State during which an individual lacks conscious awareness of environmental surroundings but can be easily aroused
Sleep includes
Memory, mood, hormone secretion, glucose metabolism, immune function, and body temperature
How many hours of sleep do we require
7-8 hours in a 24 hour period
Adequate sleep
Amount of sleep one needs to be fully awake and alert the next day
Insufficient sleep
Obtaining less than recommended amount of sleep
Fragmented sleep
Frequent arousals or actual awakening that interrupted sleep continuity
Dyssomnias
Term used to describe problems associated with initiating and maintaining sleep characterized by insomnia
Parasomnias
Patterns of waking behavior that appear during sleep
-unusual/often undesirable behaviors that occur while falling asleep, transitioning between sleep stages or during arousal from sleep due to CNS activation
Examples of NREM sleep experiences
Sleepwalking, sleep terrors, nightmares and somnambulism
Somnambulism
performing complex tasks when you are asleep
Sleep is controlled by
hypothalamus, brainstem, and thalamus
Wake behavior
RAS/ neurotransmitters play a role in maintaining arousal and consciousness
Bulbar synchronizing region(BSR)
area of brain causing sleep
Orexin(hypocretin)
Nero peptide and lateral hypothalamus that regulates arousal and wakefulness
Melatonin
Produced by pineal gland that is linked to environmental light and dark cycle and released an evening as it gets dark
NREM sleep
Restores the body, power cleans the brain and helps with memory
-75-80% of sleep
Glympathic system(gilia cells)
Removes waste and metabolic contaminants from the brain activity
-works during the day but most effective during NREM
Stage 1 of NREM
Easily awakened and may have involuntary jerking movement
Stage 2 of NREM
Majority of sleep that helps maintain sleep aroused with relative ease
Stage 3 of NREM
Deep sleep
-arousal is difficult
When stage during NREM do older adults lose?
Stage 3
REM sleep
-20-25%
-occurs 3-4x a night
-most vivid dreams occur
-brain wakes slow wakefulness and postural muscles inhibited which decrease skeletal muscle tone
-cognitive restoration
-body goes into paralysis
Prefrontal cortex shuts downiest is activated
What sleep is your body free of stress
REM sleep
If you have less than 6 hours of sleep, then you are at a high risk of developing
obesity and a high BMI
Its important that you sleep after
learning new material to save new memories stored in the hippocampus
What cells slow down when we are sleep deprived?
T cells
-less than 4 hours of sleep=70% drop of natural killer cells
Insomnia
Difficulty staying asleep, falling asleep, waking up too early, or complaints of waking up feeling unrefreshed
Chronic insomnia
Daytime symptoms that last for 1 month or longer and causes fatigue and poor concentration
Who is at most risk for chronic insomnia
women who are divorced, separated or widowed
Acute insomnia
Difficulty falling asleep or staying asleep for at least 3 nights a week for less than a month
Factors of inadequate sleep hygiene
-caffeine
-nicotine
-alcohol
-irregular sleep schedules
-nightmares
-exercising near bed
-jet leg
Cognitive behavioral therapy
Works on progressive muscle relaxation measures and stimulus control
Nursing interventions to promote sleep
-keep room cool and dark
-go to bed same time each night
-promote bedtime rituals
Narcolepsy
Caused by brains inability to regulate sleep wake cycles normally
-causes uncontrollable urges to sleep and often go directly into REM sleep
-cause unknown
Symptoms of narcolepsy
-sleep paralysis
-hallucinations
-fragmented nighttime sleep
Nursing interventions for narcolepsy
-avoid alcohol and heavy meals
-advise patient to take 3 or more short 15 min naps throughout the day
Obstructive sleep apnea
Partial or complete upper airway obstruction during sleep caused by your tongue or overweight of obesity
Apnea
cessation of spontaneous respirations lasting longer than 10 seconds that may cause hypoxemia or hypercapnia
Symptoms of sleep apnea
-Smoking
-morning headaches
-chronic daytime sleepiness
- fatigue
-irritability
- impaired concentration
- snoring
Complications of sleep apnea
-Hypertension
-cardiac changes
-poor concentration and memory -impotence
-depression
Periodic Limb Movement Disorder
-different than restless limb syndrome
-Involuntary continuous movements of legs and arms that cause poor sleep
- it can also include jaw and abdominal muscle
-treat with meds
Gerontologic Considerations for sleep: Older adults are associated with
-Overall shorter sleep time
-decreased amount of deep sleep
- increased arousal and awakenings
-signs of depression
-heart disease, pain, and cognitive problems
-avoid long term use of benzodiazepines
For the older adults, risk for falls increases
at night; encourage night lights
When trying to ambulate a patient, make sure
head of bed is all the way up and side rails are at waist level for the nurse
Body mechanics
The use of one’s body to produce a motion that is safe, energy conserving and anatomically and physiologically efficient and with maintenance of a persons body balance and control
When pushing, pulling, and lifting, make sure
Spine is in neutral position; bend at the ankles and not at the back causing isometric contraction of abdominal
When crouching to push or pull,
Promote good posture, keep head in neutral position and make sure ankles, knees, hips and shoulders are aligned
When enforcing body mechanics, you want to
- Position close to person/object
-pelvis of patient-pelvis of nurse (center of gravity) - widen base of support
-vertical gravity line - use major muscle groups
ex)legs-strongest part of body - don’t twist shoulders on pelvis
- maintain lumbar curve(lumbar lordosis)
Actions to perform when transferring a patient
-prepare patient and area-communicate
-consider best method and direction to move-transfer to strong side
-place chair/wheelchair to where patient will move
-unplug ant unnecessary wires
-place lines and tubes on same side of bed as chair
What is the first step when enforcing patient safety or performing any body mechanic steps?
communicate-explain what you’re doing and review plan of care
-assess their level of assistance prior
Transfer types
-sit-stand
-stand pivot-use for a patient that can bear their own way, just need extra support
-squat pivot-partial weight bearing position patient from a chair to another chair
-transfer board
Levels of assistance: independent
No physical assistance and no verbal assistance
Levels of assistance: supervision
Within arms reach and in line of sight
Level of assistance:contact guard
Hands-on but not assisting or doing the activity
ex) weight lifting help
Levels of assistance:minimal assist
Patient does more than 75% of the activity
ex) patient who uses a cane
Levels of assistance: moderate assist
Patient who performs 25- 75% of activity
ex) patient who uses a walker
Level of assistance:maximal assist
Patient does less than 25% of activity but does participate; may need a 2 person assist
Levels of assistance:dependent
Patient is unable to assist with activity and are complelty bed bound-need transfer board
Contractures
Shortening or tightening of skin, muscle, fascia, and or joint capsule that prevents normal movement or flexibility of structure
Nursing interventions to prevent contractures
Passive range of motion every 1-2 hours
T/F you can still log roll a patient if they had any lower back issues or surgery
false
When providing assistance, you want to
provide at hip level and avoid under arms
Which is the primary source for assessing how a client slept?
1. Nursing-care assistant
2. Client’s roommate
3. Nurse
4. Client
- client
A school nurse is teaching a group of high school students about health promotion and
sleep. Which age group should the nurse explain requires the least amount of sleep?
1. Adolescents
2. Older adults
3. Young adults
4. Middle-age adults
- Older adults
Which is the most important nursing intervention that supports a patient’s ability to
sleep in the hospital setting?
1. Providing an extra blanket
2. Limiting unnecessary noise on the unit
3. Shutting off lights in the patient’s room
4. Pulling curtains around the patient’s bed at night
- Limiting unnecessary noise on the unit
A nurse is caring for a patient who is diagnosed with narcolepsy. Which is the most
serious consequence of this disorder?
1. Inability to provide self-care
2. Impaired thought processes
3. Potential for injury
4. Excessive fatigue
- Potential for injury
A nurse is planning a teaching program for a patient with a diagnosis of
obstructive sleep apnea. Which should the nurse plan to discuss with this patient?
1. Using the ordered device that supports airway potency
2. Placing two pillows under the head when sleeping
3. Requesting a sedative to promote sleep
4. Sleeping in the supine position
- Using the ordered device that supports airway potency
A patient is being admitted to the hospital and the nurse is performing a complete
assessment. Which is the most therapeutic question the nurse can ask about the
quality of the patient’s sleep?
1. “How would you describe your sleep?”
2. “Do you consider your sleep to be restless or restful?”
3. “Is the number of hours you sleep at night good for you?”
4. “Does your bed partner complain about your sleep behaviors?”
- “How would you describe your sleep?”
While walking, a client becomes weak and the client’s knees begin to buckle. Which
should the nurse do?
1. Hold up the client.
2. Walk the client to the closest chair.
3. Call for assistance to help the client.
4. Lower the client to the floor carefully.
- Lower the client to the floor carefully.
Which is the most therapeutic exercise that can be done by a client confined to bed?
1. Isometric exercises
2. Active-assistive exercises
3. Active range-of-motion exercises
4. Passive range-of-motion exercises
- Active range-of-motion exercises
A nurse is transferring a client from the bed to a chair using a mechanical lift. As the
nurse begins to raise the lift off the bed, the client begins to panic and scream.
Which should the nurse do?
1. Immediately lower the client back onto the bed.
2. Say, “Relax” and slowly continue the procedure.
3. Quickly continue and say, “Be calm, it’s almost over.”
4. Stop the lift from rising until the client regains control.
- Immediately lower the client back onto the bed.
Which nursing intervention enhances an older adult’s sensory perception and
thereby helps prevent injury when walking from the bed to the bathroom?
1. Providing adequate lighting
2. Raising the pitch of the voice
3. Holding onto the patient’s arm
4. Removing environmental hazards
- Providing adequate lighting
A nurse is performing passive range-of-motion exercises for a patient who is in the
supine position. Which motion occurs when the nurse bends the patient’s ankle so
that the toes are pointed toward the ceiling?
1. Adduction
2. Supination
3. Dorsal flexion
4. Plantar extension
- Dorsal flexion
Which nursing action should be implemented when assisting a patient to move from
a bed to a wheelchair?
1. Lowering the bed to 2 inches below the height of the patient’s wheelchair
2. Applying pressure under the patient’s axillae areas when standing up
3. Letting the patient help as much as possible when permitted
4. Keeping the patient’s feet within 6 inches of each other
- Letting the patient help as much as possible when permitted
Which do nurses sometimes do that increase their risk for injury when moving
patients?
1. Use longer, rather than shorter, muscles when moving patients
2. Place their feet wide apart when transferring patients
3. Pull rather than push when turning patients
4. Rotate their backs when moving patients
- Rotate their backs when moving patients
Tell whether the following statement is true or false.
Molecules in the body’s chemical compounds that remain intact are called electrolytes.
false; non electrolytes
Tell whether the following statement is true or false.
A hypertonic solution has a greater osmolarity, causing water to move out of
the cells and to be drawn into the intravascular compartment, causing the cell to shrink.
true
Which one of the following chemical buffer systems is the most important
buffer system of the body in that it buffers as much as 90% of the hydrogen of ECF?
A. Phosphate buffer system
B. Protein buffer system
C. Carbonic acid–sodium bicarbonate buffer system
D. Hydrogen buffer system
Carbonic acid–sodium bicarbonate buffer system
Which one of the following electrolyte imbalances occurs due to a sodium deficit in ECF caused by a loss of sodium or gain of water?
A. Hyponatremia
B. Hypernatremia
C. Hypokalemia
D. Hyperkalemia
A. Hyponatremia
Tell whether the following statement is true or false.
Central venous access devices provide access for a variety of IV fluids, medications, blood products, and TPN solutions and allow a means for
hemodynamic monitoring and blood sampling.
true
Osmolarity
number of solute particles per 1L of solvent
Osmolality
number of solute particles in 1kg of solvent
Providing fluids can be determined/given by
-volume
-maintenance
-Free water for hydration, rehydration conservative management
Providing fluids through volume
depends on low bp, high HR
ex) positive tilt, shock, dehydration
-given through lactated ringer
Anything greater than 2L of NSS should be monitored for
hyperchloremia which can induce metabolic acidosis and hyperkalemia
Do not given NSS to a patient. who is
bleeding(likely acidotic) as this can exacerbate and worsen coagulopathy
Providing fluids through Maintenance is for
pre op surgical patients
Providing fluids for free water for hydration, rehydration conservative management
-do less invasive technique first-oral then move to NG tube(250ml/6hrs)
-montior sodium correction-increase about 0.25mEq/hr or about 2mEq every 4 hours
There is caution with administering free water as IV because
you never want to give too many bags, use only one or it will cause cerebral edema
What route is the most preferred route
enteral feeding-maintains gut integrity
Fluid imbalance
Involved volume or distribution of water and electrolytes
Hypovelemia
deficiency in amount of water and electrolytes in ECF with near normal water and electrolyte proportions
Dehydration
decrease volume of water and electrolyte change
Third space fluid shift
distributional shift of body fluids into potential body spaces
Hypervolemia
Excess retention of water and sodium in ECF
Overhydration
above normal amount of water in intracellular spaces
Edema
excessive ECF accumulate in tissue space
Interstitial to plasma shift
Movement of fluid from space surrounding cells to blood
Expected outcomes
-maintain approximate fluid intake to output balance (2500mL intake and outtake over 3 days)
-maintain urine specific gravity within normal range (1010 to 1025)
Fluid and electrolyte imbalance
The process of regulating extracellular fluid volume, body fluid osmolality, and plasma concentrations of electrolytes.
-When they are out of balance together or separate NOTHING in our body works
ECV deficit=(too diluted) values
Deficit in sodium or potassium
Na+ = < 135 mEq/ L
Osmolarity: <280 mosmol/kg
K+ = <3.5 mEq/ L
Optimal osmolarity values
Na+ = 135-145 mEq/L
Osmolarity = 280-300 mosmol/kg
K+ = 3.5-5.0
ECV excess-(too concentrated) values
Too much in the fluid
Na+ = >145 mEq/L
Osmolarity >300 mosmol/kg
K+ = >5.0 mEq/L
Intervention to augment intake
Infusion -Iv or into rectum, gi tract, subq, or bone marrow
-Input matches output (normally)
Nursing intervention input and output documentation
-If input is greater than output start looking for edema or excess fluid
-If output is greater than input start looking for dehydration
Normal serum osmolarity for adults
270-300
Increased osmolarity=
increased stimulus to drink
SEVERE hypovolemia causes stimulation of…
Dry mucous membranes, angie 2, angie 3, arterial baroreceptor stimulation during
How to calc osmolality at bedside:
Na+ x 2 = Glucose/18 + BUN/3
Filtration
Opposing forces at the capillary level distributes fluid between vascular and interstitial compartments (extracellular)
Hydrostatic pressure
Pushes fluid OUT of compartments
Colloid osmotic pressure (caused by large protein particles)
Pulls fluid into compartment
During output stage,
Aldosterone regulated excretion of sodium and water(isotonic) and potassium
-Magnesium indirectly
-Antidiuretic regulates excretion of water
Normal output vs abnormal output
Normal output
Renal -urine
Gi- stool
Skin - sweat and perspiration
Lung- vapor
Abnormal output
Emesis - vomit
Hemorrhage- bleeding
Drainage from tubes
Why are very young adults at greatest risk for fluid imbalance?
more body fluid causing excess fluid which leads to loss of fluids more easily=dehydration
Why are older adults at greatest risk of fluid imbalance
have decreased thirst mechanism which increases their osmolarity and have decreased nephrons
Women and obese people are at risk because
they have less body water
Sodium and its expected lab value
Controls and regulates volume of body fluids;135-145 mEq/L
food sources for sodium
-Dill Pickles
-Tomato juice
-Sauce
-Soup
-Table salt
Symptoms of sodium loss
Muscle cramps, Loss of appetite , Dizziness
Potassium and its expected lab value
Chief regulator of cellular enzyme activity and water content; 3.5-5 mEq/L
Food sources for potassium
Potato with skin, Plain yogurt, Banana, LEAFY GREEN VEGGIES
Symptoms of potassium loss
Muscle weakness,Muscle paralysis, Mental confusion
Calcium and its expected lab value
Nerve impulses, blood clotting, muscle contraction and b12 absorption; 8.6-10.2 mg/dL
Food sources for calcium
Dairy,Collard greens , Spinach, Kale, Sardines , LEAFY GREEN VEGGIES
Symptoms of calcium loss
Osteoporosis, Osteopenia, Muscle spasm
Magnesium and its expected lab value
Metabolism of carbs and proteins, vital actions involving enzymes; 1.3-2.3 mEq/L
Food sources for magnesium
Halibut, Pumpkin seeds, Spinach
LEAFY GREEN VEGGIES
Symptoms for magnesium
Muscle cramps,Nausea, confusion
Chloride and its expected lab values
Maintains osmotic pressure in blood, produces hydrochloric acid; 97-107 mEq/L
Food sources for chloride
Table salt and Fruits and veggies
Symptoms of chloride loss
Changes in ph and Irregular heart beat
Bicarbonate
Body’s primary buffer system
Phosphate and its expected lab value
Involved in important chemical reactions in the body, hereditary and cell division;2.5-4.5 MG/dL
Primary prevention of electrolyte imbalance
-Patient teaching
-Dietary measures
-Fluid management =Adequate intake with vomit and diarrhea
-Limiting intake when prone to edema
Secondary prevention
Monitor blood serum levels
Collaborative interventions consist of
Water replacement therapy:
-Oral fluids
-Iv fluids
Electrolyte supplements and replacement:
-Potassium
-Sodium
-Magnesium
-Calcium
Pharmacotherapy:
-Diuretics
-Insulin
-Vasopressin
How do you detect jugular vein dissension
Assessed @ 45 degree angle
-If present check for peripheral edema
Skin turgor assessment:ECF volume deficit
Skin turgor diminished with lag and pinch skin fold return and mucous membranes are dry and tongue furrowed with fluid volume deficit
Less predictive of fluid deficit in older adults because of
loss of tissue elasticity
Isotonic solution
Same concentration of particles as plasma
Hypotonic solution
Lesser concentration of particles than plasma
Hypertonic solution
Greater concentration of particles than plasma
When giving a transfusions, you must
do a full head to toe assessment before and after and get a full set of vitals before and after
Acid Base balance
Process of regulating the pH, bicarbonate concentration, and partial pressure of co2 of body fluids.
Carbonic acid is excreted through the
lungs
Metabolic acid is excreted through the
kidneys
If you are acidotic, your ph is
< 7.35
Optimal ph
7.25-7.45
If you are alkalosis, your ph is
> 7.45
Alkalosis
Caused by the loss of too much acid or the retention of too much base
-Respiratory alkalosis= CO2 loss
-Metabolic alkalosis= Hco3 excess
Acidosis
Retention of too much acid or loss of too much base
-Respiratory acidosis= Co2 retention
-Metabolic acidosis=HCO3 loss or h+ retention
First response to imbalance in ph
Respiratory change (RATE and DEPTH)
The renal system has the slowest response to imbalance because
-Kidneys cannot excrete carbonic acid
-Renal fluid contain H and phosphate buffers to neutralize metabolic acids
Impaired cellular and organ function
-Altered cell function especially in the brain=Co2 cross the blood brain barrier which alters mental status
-Change in intracellular enzyme activity resulting in cell dysfunction
-Acidosis:
decreases the level of consciousness (LOC)
-Alkalosis:
Decreases the LOC
other neurological manifestations
Dysrhythmias
CO2 values
Acidosis: >45 mm hg
Normal: 25-45 mm hg
Alkalosis: < 35 mm hg
HCO3 values
Acidosis: <22 meq/L
Normal: 22-26 meq/L
Alkalosis : >26 meq/L
PaCO2 value
35-45 mm Hg
-influenced by respiratory system
HCO3 value
22-26 mEq/L
-monitor kidney function
BUN value
10-22 mg/100 mL
-Increase occurs with impaired renal function
creatinine value
0.7-1.4 mg/100 mL
-Can be found with impaired renal function, heart failure, shock and dehydration
Hemoglobin value
13-18 g/dL = male
12-16 g/dL = female
-Decreased levels = anemia
Hematocrit value
42-50 % = males
40-48% = females
-Increased hematocrit means severe dehydration and shock
-Decreased hematocrit are seen with massive blood loss
Platelet value
100,000-400,000/mm3
-Prevents or treats bleeding
What two systems control ph
respiratory and metabolic
kidneys hold onto
bicarb
respiratory holds onto
CO2
who gets respiratory acidosis
COPD patients
