Unit 4 Flashcards by Mja Towner

What is an example of damage to the central nervous system

Spina Bifida

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What are the 8 systemic effects

Metabolic
Cardiovascular
Muscle effects
Elimination
Respiratory
Musculoskeletal changes
Skeletal effects
Integumentary

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What are metabolic systemic effects

Endocrine
Calcium absorption

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What are cardiovascular systemic effects

Orthostatic hypotension
Thrombus

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What are muscle systemic effects

Loss of muscle mass
Muscle atrophy

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What are elimination systemic effects

Urinary stasis—leading to UTI
Renal calculi (kidney stones)
GI function—constipation parastalsis slows down

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What are Respiratory systemic effects

Atelectasis (Collapsed lung)
Hypostatic pneumonia (lack of movement infection in the lung)

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What are musculoskeletal changes systemic effects

Loss of endurance and muscle mass and decreased stability and balance.
Contractures—involuntary shortening of ligaments

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What are skeletal effects systemic effects

Impaired calcium absorption
Joint abnormalities

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What is integumentary systemic effects

Pressure ulcer
Ischemia

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Immobile patients are at high risk for developing pulmonary complications such as….

Atelectasis
Hypostatic pneumonia

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What can we do to prevent immobile patients from developing pulmonary complications

Insentive spirometer
Cough and deep breathe

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How does immobility increase cardiac overload

No muscles moving, heart works harder to get blood to move

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What are the cardiovascular changes due to immobility

Orthostatic hypotension
Increased cardiac workload
Thrombus formation—DVT

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What do you do to prevent urinary elimination complications with immobile patients

Monitor I and Os
Proper pericare
Hydrate
Toileting schedule

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Emotional and behavioral responses, sensory alterations, and changes in coping are all examples of what immobility effect

Psychosocial effects—-
Emotional and behavior—hostility, fear, anxiety
Sensory-altered sleep patterns
Changes in coping—depression, sadness,

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What are some developmental changes in immobile infants, toddlers

Prolonged immobility delays gross motor skills, intellectual development, or musculoskeletal development

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What are the developmental changes in immobile adolescents

Delayed in gaining independence and in accomplishing skills
Social isolation can occur

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What are the developmental changes in immobile adults

Physiological systems are at risk
Changes in family and social structures

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What are the developmental changes in immobile older adults

Decreased physical activity
Hormonal changes
Bone reabsorption

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What is a smart goal

Specific
Measureable
Achievable
Realistic
Timely

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What are the three pressure related factors contributing to development of pressure injuries ?

Pressure intensity
Pressure duration
Tissue tolerance

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What are risk factors for pressure ulcer development?

Impaired sensory
Impaired mobility
Alteration in LOC
Shear
Friction
Moisture
Dietary intake

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What is the classification of pressure injuries

Stage 1- non blanchable erythema of intact skin
Stage 2-partial-thickness skin loss with exposed dermis
Stage 3-full-thickness skin loss
Stage 4- Full thickness skin and tissue loss (down to bone)

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What is the definition of Unstageable pressure injury

Full-thickness skin and tissue loss obscured by slough or Escher

Define a deep-tissue pressure injury

Localized area of non-blanchable dark discoloration, or epidermal separation with dark wound bed or blood filled blister

How do you document wound classification

Describe onset, duration of healing process

What are some economic consequences of pressure injuries

-billions of dollars -Medicare and Medicaid no longer reimburses for care related to stage 3 and stage 4 pressure injuries occurring in hospitalization

What are some factors influencing pressure injury formation and wound healing?

Nutrition Tissue perfusion Infection Age Psychosocial impact of wounds

Your client is an 80 year old male who is visiting the clinic today for a routine physical examination. The client’s skin turgor is fair, but the client reports fatigue and weakness. The skin is warm and dry, pulse is 116 beats/min, and urine is concentrated. which instructions should the nurse provide

Drink more water to prevent further dehydration

How often do you turn patients to prevent pressure injuries

1 to 2 hours

What are dressings to treat pressure injuries

Gauze sponges Transparent adhesive film Hyrocolloid dressings

What are some reasons for ostomies

Cancer, IBD, diverticulitis, Trauma, congenital abnormalities

What is the definition of a food desert?

Grocery stores 1 mile away

T/F decreased food security can lead to poor patient outcomes, longer hospital admissions due to delayed healing

What does BMR mean

Basic metabolic rate is the energy needed at rest to maintain life-sustaining activities Breathing Circulation Heart rate Temperature

What is REE

Resting energy expenditure is the amount of energy you need to consume over 24 hour period for your body to maintain all of its internal working activities while at rest

What are some factors that would affect REE

Illness, pregnancy, activity level and lactation

What are the 6 nutrients

Carbohydrates Protein Fats Water Vitamins Minerals

What are proteins essential for

Essential for growth, maintenance, and repair of body tissue

What are complete protein?

High quality protein, contains all amino acids in sufficient quantity to support growth and maintain nitrogen balance

What is the most calorie-dense nutrient

Fats

What are fats comprised of?

Composed of triglycerides and fatty acids

What percentage of water takes up the weight of the body?

60%-70% of total body weight

T/F vitamins are inorganic substances present in small amount in foods that are essential to normal metabolism

False Vitamins are organic substances present in small amounts in foods that are esssential to normal metabolism

What are the fat soluble vitamins What are the water soluble vitamins

Fat soluble — (ADEK) Water— C AND B

What are minerals by definition

Minerals are inorganic elements essential to the body as catalysts in biochemical reactions

What is the ideal time for breastfeeding

6 months is ideal

How much calories does the mother need more a day

500 KCal more a day

When does you wait to introduce to the infant

Cow milk should wait until the infant is 12 months or older

T/F do women who use oral contraceptives need extra vitamins

What is the recommended amount of protein when pregnant

60 grams

What is the amount of folic acid needed during pregnancy

600 MCG

T/F Vitmains and mineral need decreases with 65+ adults

False, Vitamins and Mineral needs stay the same

What are the developmental needs to older adults?

Changes in appetite, taste, smell Income is fixed—amount of money available Lack of transportation to the store Oral health—missing teeth—malnutrition and dehydration Thirst sensation diminishes, leading to inadequate fluid intake

How often do we increase the hourly rate of enteral tube feeding

Increase the hourly rate very 8-12 hours per doctors orders if tolerating

T/F feeding enteral route reduces sepsis, minimizes hypem etabolic response to trauma

What are some restrictions of enteral tube feeding

NG tubes are used for less than 4 weeks Surgically placed tubes are preferred long term X-rays is the most accurate way to check placement

What are diagnoses to place an enteral feeding tube

Risk for aspiration Impaired self-feeding Impaired swallowing Nutrition imbalance

What do we need to consider for an enteral feeding tub

Budget Culture Food safety Interest in change

What are food examples of clear liquid diet?

Coffee, tea, carbonated beverages, clear fruit juices, gelatin, popsicles

What are food examples of full liquid diet

Ice cream, blended cream soups, custards, refined cooked cereals, vegetable juice, puréed vegetables, all fruit juices

What are food examples of thickened liquid diet

Puréed meats, vegetables, and fruits, mashed potatoes and gravy

What is the food examples of mechanical soft

All cream soups, ground or diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs

What are food examples of High fiber diets

Fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits

What is a diabetic diet

Focuses on total energy, nutrient and food distribution, include a balances intake of carbohydrates, fats, and proteins, varied caloric recommendations

What is a gluten free diet

Eliminates wheats, oats, rye, barley, and their derivatives

Differentiate type 1 and types 2 diabetes

Type 1-requires both insulin and dietary management Type 2 - controlled by diet and exercise therapy

How can stress cause urinary elongation problems

Cough/sneeze you pee

What are the common urinary elimination problems

Stress Urgency Reflex

What are the characteristics of urine

Color Clarity Odor Manifestations

Day 1, what is the frequency and color of the urine

Once in 24 hours Reddish-orange

What color is the urine of day 5 and after

Pale yellow

What is the normal pH of urine

4.6-8.0

Are glucose and ketones present in urine?

No they should not be present

What is the normal protein in urine

8mg/100mL

What is the normal range of WBC in urine

0-4

What are the normal lab values of specific gravity of urine

1.005-1.030

What are the common bowel elongation problems

Constipation Impaction Diarrhea Incontinence

What are the 6 assessments of stool

Color Odor Consistency Frequency Shape Constituents

What are the 6 assessments of stool

Color Odor Consistency Frequency Shape Contituents

What is encopresis

This occurs when a child who is old enough to have bowel control (4 years old and older does not have control)

When do children have voluntary control of voiding urine

18-24 months of age

What is enuresis?

This occurs when a child who is old enough to have bladder control (3 years and older) does not have control

What are the bowel stimulants

Psyllium, docusate, magnesium hydroxide

What does loperamide do to stool?

Solidify stool

What is bisacodyl

Bowel stimulant

What interventions promote healthful elimination

Hydration Adequate dietary fiber Regular toileting practices Regular exercise Avoidance of environmental contamination Put patient in voiding position