Unit 2 Flashcards
What is body mechanics?
The way people move.
What is the benefit of good posture?
less fatigue and stress on the spine.
What is considered proper body mechanics?
proper alignment, wide base support, avoid bending and twisting, squat to lift, keep objects close, raise beds, push vs lift, get help.
What is Range of Motion?
The full movement potential of a joint without causing pain.
What is AROM?
active range of motion - does on their own
What is PROM?
passive range of motion - you do for them
What are factors affecting mobility/activity?
- lifespan- young and old have unsteady gait, decreased mobility
- nutrition- poor nutrition = decreased mobility, weak, fall risk, break bones easily
- lifestyle- over weight = decreased mobility
- stress- lack of motivation to move around, be active
- external environment- what you do for a living, strain on body
- disease- weak, in pain
What is exercise?
contraction/relaxation of muscle
How much (at a minimum) should you exercise per day?
30 min.
What are some effects of immobility?
muscle atrophy, joint dysfunction, pneumonia, venous stasis, increased coaguability, orthostatic hypotension, glucose intolerance, pressure ulcers, constipation, paralytic ileus, urinary tract infection, psychological effects.
What is abduction?
the movement of a limb away from the midline
What is adduction?
the movement of a limb toward the midline
What is extension?
increasing the angle of the joint
What is flexion?
decreasing the angle of the joint
What is hyperextension?
increasing the angle of the joint passed 180 degrees
What is dorsiflexion?
flexion of the foot upward, toes pointed toward the head.
What is rotation?
rotating (or turning) a joint on its axis.
What is internal rotation?
rotating toward the axis of the body
What is external rotation?
rotating away from the axis of the body
What is plantar flexion?
pointing your toes downward
What is pronation?
to be turned backward, assume “prone position”
What is supination?
to be in anatomical position.
What is Fowler’s position?
sitting with legs straight at a 45-60 degree angle
What makes it high Fowlers?
angle greater than 60 degrees
What makes it semi Fowlers?
angle of 35 degrees
What makes it low Fowlers?
angle of 15 degrees
What is a lateral position?
a person on their side, whether it be left or right. arms forward, legs usually bent for comfort. pillow below head and between legs.
What is a prone position?
laying on their stomach
What is Sims’ position?
usually left, can be right. sideways. lower arm behind body, higher arm bent in front. top leg bent 90 degrees, foot touching lower leg knee.
What is supine position?
laying on back, in anatomical position.
What is Trendelenburg position?
supine with head lower than feet.
What are some key things to remember when moving patients in bed?
slide down by gravity, patient may assist, 2 staff to move, prevent friction and sheering.
What are some key things to remember for assisting/transferring safety?
non skid foot wear, lower bed, lock wheels, stay with patient, sit on side of bed with feet dangling prior to getting out of bed, ask for assistance when needed.
What are some tools to assist a patient out of bed?
transfer board, transfer belt, and mechanical life.
What are key things to know with using a cane?
hold cane with stronger side. avoid leaning over, distribute weight evenly, and advance cane with weaker leg.
What are key things to know with using a walker?
stand erect, elbows bent 30 degrees. move weaker leg with walker. slide, step, slide, step -> pick up, put down.
What are key things to know when using crutches?
not too long or not too short. keep crutches about 4-6 inches to the side of heels. advance crutches, step with good leg, swing bad leg. when using stairs, move good leg up a stair before crutches.
What are the steps in applying anti-embolism stockings?
measure- correct size
inspect- look for adema
elevate- 15 min prior to application
turn- inside out to the level of heal, then advance up leg
What are sequential compression devices?
cuffs surrounding lower leg, promotes venous return. same function as stockings.
What are the fasting glucose parameters?
70-110 mg/dL
What are the random result glucose parameters?
less than 126 mg/dL
What is hypoglycemia?
low blood sugar, <70 mg/dL
What are signs/symptoms of hypoglycemia?
skin-cold, clammy. weakness to coma
What are causes of hypoglycemia?
insufficient calories, excessive exertion, too much hypoglycemic meds.
What is hyperglycemia?
high blood sugar, >110 mg/dL
What are signs/symptoms of hyperglycemia?
polydipsia, polyphagia, polyuria
What are causes of hyperglycemia?
excess carbs, too little hypoglycemia meds
What are ADL’s?
activities of daily living. examples: bed making, personal hygiene, and self-care.
What are the role of nurses in ADL’s?
assess self-care ability, provide assistance with ADLs, promote self-care.
What are some influencing factors of persons performing ADL’s?
financial factors, personal preferences, culture and religion, economic status, developmental levels, and physical factors including, pain, limited mobility, sensory deficits, cognitive impairments, emotional disturbances, and disease/medication.
What are the types of schedule care?
routine hygiene care in in-patient facility can be - Early morning care, A.M. care, and P.M. (or H.S.) care.
What are the steps in making an unoccupied bed?
prepare environment place blue bag near bed don gloves remove dirty sheets place dirty linen in blue bag discard dirty gloves and wash hands make one side of bed, then move to the other side miter corners
What are the steps in making an occupied bed?
Same procedure as unoccupied.
easier with two staff, keep patient safe.
roll patient,
partially remove dirty sheets,
replace with new sheets, starting at head then feet
roll patient to other side,
fully remove dirty linen, place in blue bag
finish placing new sheets on bed
lay patient back down.
What are the Do’s and Don’ts of making a bed?
DO-
assess what linens are already in the room, place pillows and clean linens on clean area, practice proper body mechanics.
DONT-
shake linens, place solid linens on floor, hold soiled linens close to body.
What is bathing an opportunity for?
opportunity for therapeutic communication and facilitates assessment of skin, hair, & nails, physical functioning, cognitive ability, sensory disturbances, and pain.
What does bathing promote?
circulation and therapeutic communication
What do you do for foot care?
document abnormal findings.
wash, rinse, dry well
shoes that fit
do not cut or file nails or calloused areas
if diabetic, have professional provide care
What do you do for nail care?
inspect nails for cleanliness
look for redness or swelling
diabetics must have professional provide care
What do you do for perineal care?
cleanse area, front to back. outside to in. cleanest to dirtiest. uncircumsized- you must pull back, skin, clean, dry, and replace skin.
What devices are used to stay dry with incontinent patients?
briefs and condom catheters
What are some things to remember when caring for dentures?
store in wet container. slippery, breaks easily. place wash cloth in sink during cleaning.
What are common types of baths?
shower or tub bath
bed bath
disposable bag or packaged bath
What are risks for impaired skin integrity?
poor nutrition, skin dampness, dehydration, insufficient circulation, skin diseases, immobility, systemic diseases, and age.
What are some nursing interventions for impaired skin integrity?
follow repositioning schedule (every 2 hours)
frequent skin assessment
prevent friction or shearing with moving patient
provide good skin care
keep linens dry and wrinkle free
use protective devices
What is defecation?
the process of eliminating waste products.
What is feces?
semisolid mass of water, fiber, undigested food, and inorganic material.
What are factors affecting bowel elimination?
diet, fluid intake, activity, defecation habits, medications, diagnostic/surgical procedures, bowel diversions, and pain.
What are common diagnostic testing for bowel elimination?
direct visualization, radiography, laboratory. guaiac test - blood in stool.
What is a guaiac test?
hemacult - blood in stool. blue means positive for blood.
What should you do to promote regular defecation?
encourage fluids, proper diet, exercise, provide privacy, correct position- squatting, timing.
What are common alterations in defecation?
flatulence, diarrhea, constipation, fecal impaction, and bowel diversions.
Ways to manage flatulence
insertion of a rectal tube and medication- simethicone (gas-x, mylicon)
What are reasons for insertion of rectal tube?
decompression of distended colon for immediate relief. not for management of diarrhea. temporary <20 minutes
What are things to monitor with diarrhea?
monitor stool. assess and monitor for fluid imbalance, monitor skin integrity.
What are ways to manage diarrhea?
proper diet teaching- clear liquids, BRAT diet, foods to avoid greasy, spicy,
antidiarrheal meds- not recommended for acute diarrhea, teach about OTC aids, bismuth salts (Pepto-Bismol), loperabmide (Imodium)
Ways to manage constipation.
increase fiber intake, increase fluid intake, increase activity, laxative only when lifestyle changes are ineffective, teaching positioning, and regular toileting`
What are signs and symptoms of fecal impaction?
feelings of fullness, bloating, constipation, watery stool or diarrhea, detection via digital exam.
What are parts of the bowel training program?
train to get on a regular schedule. plan program with client.
increase fiber in diet gradually and increase fluid intake to 8 glasses of water per day.
What digital removal?
using 1 or 2 fingers inserted into the rectum to break up feces.
What is the temperature of the water for a cleansing enema?
105-110 degrees F
What is the amount of water used for a cleansing enema?
500-1000 mL of saline water
What is a retention enema?
using oil, hold for 30-60 minutes to soften stool.
What is return flow enema used for?
relieve gas
How much water is used for a return flow enema?
100-200 mL of tap water or saline water
What are reasons for enemas?
promotes defecation for stimulating peristalsis, breaks up fecal mass, stretches rectal wall, stimulates defecation reflex.
Types of cleansing enemas
tap water, soap suds, or saline
Types of retention enemas
fleets and fleets oil, medicated enema, and nutritive enema.
What is a ostomy?
stoma, surgical creation of opening of intestines to outside of body. due to ischemic intestines.
What is the effluent of an ostomy look like?
ileum- most liquid
sigmoid- most solid
What is an ileostomy?
ostomy in the ileum.
What is a colostomy?
ostomy of the colon.
Managing a bowel diversion.
be attentive to client’s psychosocial needs, be professional, show acceptance. attend to odor control. address client participation in ostomy care, client teaching for home. stoma assessment and care, strict attention to skin care/peristomal skin assessment, monitor amount and type of effluent.
How do you care for a colostomy?
change entire appliance every 3-5 days, empty pouch before removing, assess stoma and skin, cut wafer 2-3 cm larger than the stoma.
What is a sitz bath?
cleansing bath to provide comfort and promote healing.
What are foods that increase stool odor?
asparagus, beans, cabbage, eggs, fish, garlic, onions, some spices.
What are foods that increase intestinal gas?
beer, broccoli, Brussel sprouts, cabbage, carbonated beverages, cauliflower, corn, cucumbers, dairy products, dried beans, peas, radishes, spinach.
What are foods that thicken stools?
applesauce, bananas, bread, cheese, yogurt, pasta, pretzels, creamy peanut butter, tapioca, rice.
What are foods that loosen stools?
chocolate, dried beans, fried foods, greasy foods, highly spiced foods, leafy green vegetables, raw fruits and juices, and raw vegetables.
What are the 6 rights in medication administration?
right patient right dose right route right time right medication right documentation
What are important things to do for med administration?
standard precautions, identify patient, check MD order, check allergies, prepare one patient at a time. 3 label checks- on MAR, when preparing, at bedside. preform assessment, stay at bedside until meds are taken.
What are enteral drugs?
drugs that enter blood stream via intestines.
ex. oral, sublingual, buccal, and liquid meds.
What is to be remembered with enteric coated tablets and long-acting meds?
may not be crushed, broken, or chewed.
What are sublingual or buccal meds?
absorbed through mucous membranes. dissolve quickly. no PO fluids.
What are rectal meds?
meds delivered by insertion into rectum. assess for bleeding and diarrhea. positon in left sims. use lubricant. do not insert into stool. remain on left side for 5-10 min.
Types of topical meds?
eye, ear, inhaled, nasal, to the skin.
