Unit 4 Flashcards
What is an example of damage to the central nervous system
Spina Bifida
What are the 8 systemic effects
Metabolic
Cardiovascular
Muscle effects
Elimination
Respiratory
Musculoskeletal changes
Skeletal effects
Integumentary
What are metabolic systemic effects
Endocrine
Calcium absorption
What are cardiovascular systemic effects
Orthostatic hypotension
Thrombus
What are muscle systemic effects
Loss of muscle mass
Muscle atrophy
What are elimination systemic effects
Urinary stasis—leading to UTI
Renal calculi (kidney stones)
GI function—constipation parastalsis slows down
What are Respiratory systemic effects
Atelectasis (Collapsed lung)
Hypostatic pneumonia (lack of movement infection in the lung)
What are musculoskeletal changes systemic effects
Loss of endurance and muscle mass and decreased stability and balance.
Contractures—involuntary shortening of ligaments
What are skeletal effects systemic effects
Impaired calcium absorption
Joint abnormalities
What is integumentary systemic effects
Pressure ulcer
Ischemia
Immobile patients are at high risk for developing pulmonary complications such as….
Atelectasis
Hypostatic pneumonia
What can we do to prevent immobile patients from developing pulmonary complications
Insentive spirometer
Cough and deep breathe
How does immobility increase cardiac overload
No muscles moving, heart works harder to get blood to move
What are the cardiovascular changes due to immobility
Orthostatic hypotension
Increased cardiac workload
Thrombus formation—DVT
What do you do to prevent urinary elimination complications with immobile patients
Monitor I and Os
Proper pericare
Hydrate
Toileting schedule
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,
What are some developmental changes in immobile infants, toddlers
Prolonged immobility delays gross motor skills, intellectual development, or musculoskeletal development
What are the developmental changes in immobile adolescents
Delayed in gaining independence and in accomplishing skills
Social isolation can occur
What are the developmental changes in immobile adults
Physiological systems are at risk
Changes in family and social structures
What are the developmental changes in immobile older adults
Decreased physical activity
Hormonal changes
Bone reabsorption
What is a smart goal
Specific
Measureable
Achievable
Realistic
Timely
What are the three pressure related factors contributing to development of pressure injuries ?
Pressure intensity
Pressure duration
Tissue tolerance
What are risk factors for pressure ulcer development?
Impaired sensory
Impaired mobility
Alteration in LOC
Shear
Friction
Moisture
Dietary intake
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)
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
T
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
T
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
T
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
