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nur 300 > knowledge assessment II > Flashcards

knowledge assessment II Flashcards

1
Q

body mechanics

A

coordinated efforts of the musculoskeletal and nervous systems

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2
Q

alignment and balance

A

also refers to posture

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3
Q

gravity

A

weight force exerted on the body

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4
Q

friction

A

force that occurs in a direction opposite to movement

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5
Q

decubitis

A

pressure ucler

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6
Q

decubitus

A

bed lying

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7
Q

shear

A

a gravity force pushing down on the patient’s body with resistance between the patient and the chair of bed

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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
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9
Q

muscule movement and posture

A

skeletal muscles are working elements of movement

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10
Q

nervous system and musculoskeletal system

A

regulates movement and posture

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11
Q

mobility refers to

A

a person’s ability to move about freely

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12
Q

immobility refers to

A

inability to move about freely

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13
Q

factors influencing mobility

A

immobility
bed rest

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14
Q

effects of muscular deconditioning

A

disuse atrophy
physiological
psychological
social

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15
Q

why bedrest?

A
  • reduces oxygen needs
  • decreases pain levels
  • helps regaining of strength
  • uninteruppted rest has psychological and emotional benefits
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16
Q

types of bed rest

A

bed rest
bed rest with bathroom privileges

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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
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18
Q

pathological influences on mobility

A
  • postural abnormalities
  • muscle abnormalities
  • damage to CNS
  • musculoskeletal trauma
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19
Q

metabolic effects of MSS

A

endocrine
calcium absoprtion
GI function

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20
Q

respiratory effects of bed rest

A

atelectasis and hypostatic pneumonia

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21
Q

CV effects of bed rest

A

orthostatic hypotension
thrombus

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22
Q

MS changes due to bed rset

A

loss of endurance
loss of muscle mass
decreased stability and balance

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23
Q

muscle effects from bed rest

A

loss of muscle mass
muscle atrophy

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24
Q

skeletal effects of bed rest

A

impaired calcium absorption
joint abnormalities

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25
Q

urinary effects of bed rest

A

urinary stasis
renal calculi
uti

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26
Q

integumentary effects of bed rest

A

pressure ulcer
ischemia (inadequate blood supply)

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27
Q

changes in mobility alter

A

endocrine metabolism
calcium reabsorption
functioning of GI system

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28
Q

endocrine system helps

A

maintain homeostasis

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29
Q

immobility disrupts normal metabolic functioning and causes

A
  • decreased metabolic rate
  • altered metabolism
  • GI distrubances
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30
Q

decrease in BMR due to immobility

A

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

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31
Q

anthropometric measurements

A

height
weight
skin folds

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32
Q

nutrition and metabolism assessment

A
  • 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
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33
Q

interventions for inadequate nutrition and metabolism

A
  • provide high calorie diet
  • provide high protein diet
  • supplemental vitamin B and C
  • monitor and evaluate I&Os
  • assess food intake
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34
Q

immobility and respiratory system

A
  • 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
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35
Q

respiratory assessment

A

observe chest movements
auscultate for pulmonary secretions
check O2
observe for respiratory difficulties

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36
Q

maintain pt airway

A

assess client ability to expectorate secretions
assess secretions for color, amount, and consistency
use suction if client is unable to expectorate secretions

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37
Q

interventions of immobility on respiratory system

A
  • 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
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38
Q

immobility on CV system

A
  • 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
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39
Q

most dangerous complication of immbolity

A

thrombus formation

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40
Q

assessment of CV

A

BP measurements w/ postural changes
pulse
edema
increase activity ASAP
“dangling” feet before standing

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41
Q

prevntion of venous stasis

A
  • 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
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42
Q

anti-embolic stocking

A

never massage extremities
observe S/S of DVT

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43
Q

nursing interventions for CV system

A
  • 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
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44
Q

musculoskeletal changes

A

lean body mass loss
muscle weakness/atrophy

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45
Q

skeletal effects

A

disuse osteoporosis
joint contracture

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46
Q

mobility assessment

A
  • gait (style of walking)
  • exercise (physical activity for conditioning the body, improving health, and maintaining fitness0
  • activity tolerance (physiological, emotional, developmental)
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47
Q

infants, toddlers, preschoolers and immobility

A

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

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48
Q

adolescents and immobility

A

delayed in gaining independence and in accomplishing skills

social isolation

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49
Q

adults and immobility

A

physiological systems at risk
changes in family and social structures

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50
Q

older adults and immobility

A

decreased physical activity
hormonal changes
bone reabsorption

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51
Q

body alignment is used for

A
  • 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
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52
Q

examples of body alignment

A

siting
standing
laying

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53
Q

contractures

A

develop in joints not moved periodically through their full ROM

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54
Q

ROM can be performed in

A

neck
shoulder
elbow
forearm
wrist
fingers and thumb
hip
knee
foot
toes

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55
Q

nursing interventions for MS

A
  • individalized progressive exercise program
  • active and passive ROM
  • continuous passive motion (CPM)
  • nutritional intake of calcim
  • use of assistive devices for ADLs
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56
Q

immobility on elimination

A
  • 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
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57
Q

elimination intervention

A
  • 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
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58
Q

immobility on GI

A

decreased peristalsis
constipation
fecal impaction

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59
Q

GI assessment

A

body measurements daily
observe for passage of liquid stools

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60
Q

GI interventions

A
  • 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
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61
Q

immobility on skin

A

pressure ulcers (inflammation + ischemia)

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62
Q

older adults at greater risk for

A

any break in skin which is difficult to heal causing further immobilization

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63
Q

break in skin is called a

A

bedsore, pressure sore, or decubitus ulcer

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64
Q

skin assessment

A
  • nutritional status
  • position and risk with each
  • ID client at risk
  • observe for skin breakdown
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65
Q

skin interventions

A
  • 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
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66
Q

provide client sitting in chair with a device to decrease pressure

A

limit sitting to less than 2 hrs

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67
Q

skin breakdown prevention

A
  • prevention
  • ID at risk clients
  • nutritional exam
  • daily skin exam
  • perineal care
  • skin care products
  • stimulate circulation
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68
Q

treating skin breakdown

A

keep area dry and clean
change dressings prn
increase protein, calories, and vitamins

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69
Q

effects of immobility on psychosocial issues

A
  • 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
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70
Q

psychosocial assessment

A
  • support by significant others, health care team
  • knowledge of exercise and activity
  • readiness to change behavior
  • program customized to personal needs
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71
Q

psychosocial issues

A

identity and self esteem
cultural and ethnic influence
family and social support

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72
Q

nursing interventions fro psychosocial responses

A
  • 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
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73
Q

maintain orientation to

A

time (clock and calendar)
person (call by name, introduce self)
place (talk about treatments and therapy and length of stay)

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74
Q

evaluation

A

have pt goals been met?

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75
Q

if pt goals haven’t been met…

A
  • 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?
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76
Q

safety guidelines

A
  • 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
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77
Q

process of kidneys

A

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

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78
Q

angiotensin II combines with ADH secretion to pituitary gland causing

A

reabsorption of H2O

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79
Q

angiotensin II causes

A

vasoconstriction to increase BP

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80
Q

angiotensin II combines with aldosterone causing

A

reabsorption of Na+ and Cl- causing body to hold onto water

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81
Q

increase in sympathetic activity from presence of angiotensin II causes

A

increase in BP

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82
Q

components of GU system

A

kidneys
ureters
bladder
urethra

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83
Q

function of kidneys

A
  • 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
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84
Q

once urinary system fails…

A

all organs will be affected

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85
Q

common urinary elimination problems

A
  • urinary retention
  • UTI
  • urinary incontinence
  • urinary diversions
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86
Q

uterostomy

A

creates different way to expel urine from body
“make bladder”

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87
Q

factors affecting urination

A
  • developmental considerations
  • food and fluid intake
  • sociocultural and psychological variables
  • activity and muscle tone
  • surgical procedurs
  • diagnostic procedures
  • pathologic conditions
  • pain
  • meds
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88
Q

infants GU

A
  • 15-60mL/kg/day
  • produce 8-10 wet diapers per day
  • no voluntary control
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89
Q

children GU

A
  • cannot control urination till18-24mo
  • toilet training: involves mature neuromuscular system and adequate communication skills
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90
Q

GU problems in children

A

enuresis
nocturnal enuresis

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91
Q

elderly GU

A
  • 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
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92
Q

frequency of urination

A
  • 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
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93
Q

when body is funcitoning well…

A

kidneys maintain the balance between fluid intake and output

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94
Q

when body is dehydrated…

A

kidneys reabsorb fluid

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95
Q

with fluid overload

A

kidneys excrete large amounts of fluid

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96
Q

foods/fluids affecting urine output

A
  • increased urine output: coffee, tea, cola, alcohol
  • decreased urine output: high Na+ foods
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97
Q

muscle tone GU

A
  • abdominal wall muscles
  • pelvic floor muscles (prolonged mobility, childbirth, menopausal muscle atrophy)
  • trama
  • long term catheterization
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98
Q

cultural norms of GU

A

privacy (urinary hesitancy)
facilities

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99
Q

gender GU

A

proper positioning

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100
Q

psychological factors of GU issues

A

anxiety
stress (urgency, frequency, muscle tension: difficulty to relax abdominal and perineal muscles can cause retention)

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101
Q

surgical procedures GU

A
  • 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
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102
Q

pathological conditions affecting urinary elimination

A
  • immobility problems and impaired communication
  • alteration in cognition
  • neurological conditions
  • CV and metabolic disorders
  • kidney/bladder infections
  • hypertrophy of prostate (male)
  • kidney stones
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103
Q

pain GU

A

suppression of urge to void with presence of pain in urinary tract
delayed micturition with painful musculoskeletal joints as with arthritis

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104
Q

diuretics

A

prevent reabsorption of water

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105
Q

anticholinergic meds

A

side effects urinary retention such as meds to reduce bladder spasms

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106
Q

nephrotoxic meds

A

can damage kidneys
ex. gentamycin or long term use of asprin or ibuprofen

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107
Q

analgesics and tranquilizers

A

suppress CNS, diminishing effectivness of neural reflex

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108
Q

diuretics make urine

A

pale yellow

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109
Q

rifampin (antibacterial for TB) make urine

A

orange

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110
Q

elavil (antidepressant) makes urine

A

green or blue-green

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111
Q

levodopa (parkinsons) makes urine

A

brown or black

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112
Q

risk factors for GU issues

A

being a women
individuals with indwelling urinary catheter
individuals with diabetes mellitus

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113
Q

being a women

A
  • viral infection anywhere else in body puts woman at risk for UTI
  • sexually active females
  • postmenopausal women
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114
Q

assessment of GU

A
  • through pt eyes
  • self care ability
  • cultural considerations
  • environmental factors
  • nursing history (pattern of urination, symptoms of urinary alterations)
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115
Q

regular urinalysis includes

A
  • color
  • specific gravity
  • glucose
  • clarity
  • pH
  • odor
  • protein
  • ketones
  • glucose
  • microscopic analysis: RBC, WBC, casts, crystals, pathogens
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116
Q

normal output

A

adult - 0.5mL - 1mL/kg/hr
less than 30mL may indicate kidney failure

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117
Q

bladder capacity

A

normal: 500-600mL
normal void: 300mL
urge to void: 150mL-250mL

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118
Q

pale straw to amber

A

normal
more concentrated in morning
straw - overhydration

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119
Q

dark red

A

bleeding from kidneys or ureters

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120
Q

bright red

A

bleeding from bladder or urethra
certain foods - beets, rhubarb, blackberries

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121
Q

dark amber

A

fever or dehydration
high levels of bilirubin (liver dysfunction)

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122
Q

clarity

A
  • 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
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123
Q

odor

A

aromatic; as it stands it develops an ammonia odor because of bacterial action
foul - infection (UTI)
strong sweet or fruity odor - diabetes, starvation

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124
Q

pH of urine

A
  • normal: 4.6-8.0
  • average 6.0
  • indicates acid base balance
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125
Q

< 7 = acid

A

acidosis, starvation, dehydration, diet high in meat or cranberries

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126
Q

> 7 = base

A

infection, UTI, vomitting, diet high in fruits and veggies

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127
Q

specific gravity

A

measure of concentration of dissolved solids in urine
normal: 1.005-1.030

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128
Q

high specific gravity

A

concentrated
dehydration (vomiting, diarrhea), reduced renal BF, increased ADH, glycosuria, proteinuria

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129
Q

low specific gravity

A

dilute urine
overhydration, early renal disease, decreased ADH (diabetes insipidus)

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130
Q

urinalysis

A

clean
first void is best
sent to lab within 2 hrs

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131
Q

clean-voided or midstream

A

relatively sterile

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132
Q

culture and sensitivity

A

sterile or clean voided
sensitivity to ID specific bacteria - change antibiotic to more specific

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133
Q

sterile urinary tests

A

catheterized
C&S

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134
Q

timed

A

test renal function and urine composition
2,12, or 24 hrs
creatinine clearnace, protein

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135
Q

nursing implications for urine testing

A
  • 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
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136
Q

blood urea nitrogen (BUN)

A

7-20mg/dL
end product of protein metabolism
elevated levels may indicate kidney damage or disease

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137
Q

creatinine

A

M - 0.8-1.4mg/dL; F - 0.6-1.2mg/dL
byproduct of muscle metabolism
elevated levels indicate kidney damage or disease

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138
Q

BUN/creatinine ratio

A

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
Q

KUB

A

kidneys ureters bladder
xray to determine size shape and position of kidneys

140
Q

CT scan

A

view renal BF and anatomy of kidney

141
Q

renal ultrasound

A

view gross renal structures

142
Q

endoscopy-cytoscopy

A

use an endoscope to visualize bladder and urethra

143
Q

intravenous pyelogram

A

used to view the ducts, renal pelvis, ureters, bladder, and urethra
iodine used - check for allergies

144
Q

urinary rention

A
  • urethral obstruction
  • surgical trauma
  • childbirth
  • bladder inflammation
  • decreased motor and sensory activity
  • neurogenic bladder
  • prostate enlargment
  • post-anesthesia effect
  • med side effects
  • anxiety
145
Q

retention with overflow

A

severe retention
2000-3000mL

146
Q

benign prostatic hyperplasia

A

enlarged prostate

147
Q

lower tract infections

A

cystits - bladder
urethritis - bladder and urethra

148
Q

upper tract infection

A

pyelonephritis ( kidneys and ureters)

149
Q

most common causes of UTI

A
  • instruments
  • poor hygeine
  • frequent sexual intercourse
  • residual urine
150
Q

symptoms of UTI

A
  • dysuria
  • hematuria
  • fever chills nausea, vomiting
  • with pyelonephritis - flank pain, tenderness, fever, chills
151
Q

infection control

A
  • urinary tract is sterile (sterile technique for all procedures)
  • wash hands
  • clean from front to back
  • plenty of fluids
152
Q

antimicrobial therapy

A

sulfonamides - sulfa drugs
primary use - UTI

  • gantisin (sulfisoxazole)
  • TMP-SMZ (trimethoprim/sulfamethoxazole)
  • bactrim, septra - combination of two sulfonamides used together
153
Q

involuntary loss of urine

A

types include
- stress
- urge
- mixed
- functional
- overflow
- temporary

154
Q

incontinence

A

should not be associated w/ aging
body image impairment
skin breakdown (acidic urine)

155
Q

treatment of urinary incontinence

A
  • lifestyle change
  • pelvic floor exercises
  • habit training - flexible toileting schedule based on clients pattern
156
Q

meds for incontinence

A
  • oxybutynin (ditropan)
  • tolterodine (detrtol)
  • darifenacin (enablex)
  • solifenacin (vesicare)
157
Q

incontinence devices

A

pessary
bladder neck support device
urethral insert or seal
surgical treatment

158
Q

nursing care for incontinence

A

maintain skin integrity
- wash with soap and water
- petroleum based on ointment for barrier
- if urinary diversion : good fit

159
Q

promote comfort for incontinence

A
  • clean dry clothes
  • urinary analgesics (pyridium)
  • urinary antibiotic (azo-gantrisin)
  • high fluid intake
160
Q

analysis and nursing diagnosis (urinary)

A
  • incontinence: functional, overflow, stress, urge
  • UTI
  • impaired self toileting
  • impaired skin integrity
  • urinary retention
161
Q

urinary interventions

A
  • pt education
  • promoting normal micturition (maintaining elimination habits, maintain adequate fluid intake)
  • promoting complete bladder emptying
  • preventing infections
  • medications
162
Q

evaluation of GU

A
  • 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
Q

tactile

A

touch

164
Q

olfactory

A

smell

165
Q

gustatory

A

taste

166
Q

kinesthetic

A

position and motion

167
Q

stereognosis

A

ability to recognize size, shape, and texture

168
Q

reception

A

stimulation of a single nerve cell or group of cells to create a nerve impulse that is sent to the brain

169
Q

perception

A

brain interprets the stimuli based on past experience or newness

170
Q

reaction/response

A

only the most important stimuli will elicit a reaction
intensity
contrast
adaptation
previous experience

171
Q

vision deficit can cause

A
  • falls
  • social isolation
  • injury
  • fear
172
Q

hearing deficit can cause

A
  • falls
  • social isolation
  • injury
  • impaired verbal communication
173
Q

tactile deficit can cause

A
  • deficit in self care
  • social isolation
  • injury
  • mobility
174
Q

olfactatory deficit can cause

A

-deficits in self care
- social isolation
- injury
- poor nutrition

175
Q

gustatory deficit can cause

A
  • injury
  • poor nutrition
  • social isolation
  • poor oral hygeine
176
Q

kinethetic deficit can cause

A
  • falls
  • injury
  • social isolation
  • impaired mobility
177
Q

stereognosis deficit can cause

A
  • falls
  • injury
  • social isolation
  • fear/anxiety
178
Q

too little stimulation

A

infants and young children need stimuli to grow including touch, sounds, odors, visual stimuli
adults have sensory decline with age

179
Q

stages of senses with age

A
  1. hearing
  2. vision
  3. smell/taste
  4. balance coorodination/decreased response to touch
180
Q

social interactions include

A

family and friends
nurse

181
Q

factors that influence sensory function

A
  • over or understimulation
  • social interactions
  • environment
  • culture
  • illness
  • medications
  • stress
  • personality
182
Q

environment

A

does occupation put person at risk?
exposure to loud sounds or lights
hospital: immobilized pt, isolation

183
Q

culture

A

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
Q

illness (sensory)

A
  • neuro disorders
  • circulatory issues
  • hypoxia
  • head injuries
185
Q

medications (sensory)

A

ASA and lasix - ototoxic
opioids
medical marijuana
OTCs/herbals

186
Q

sensory deficits

A

deficit in the normal function of sensory reception and perception
patient may change behaviors to adapt

187
Q

sensory deprivation

A

inadequate quality or quantity of stimulation
S/S confusion, increased anxiety, bizarre thoughts, visual and motor changes

188
Q

sensory overload

A

reception of multiple sensory stimuli
S/S scattered thoughts, restlessness, anxiety

189
Q

sensory overload is common in

A

ICUs due to lots of alarms, lack of windows, noise, pain

190
Q

sensory assessment

A
  • 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
Q

interventions for sensory issues

A
  • 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
Q

assessment - vision

A
  • 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
Q

glaucoma

A

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
Q

macular degeneration

A

associated with aging and results in severe central vision loss
leading cause of blindness and poor vision in adults over 65 in US

195
Q

diabetic retinopathy

A

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
Q

cataracts

A

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
Q

presbyopia

A

gradual decline in the ability of the lens to accommodate of focus on objects
unable to see objects close

198
Q

presbycusis

A

common progressive hearing disorder in older adutlts

199
Q

dizziness

A

common in older adulthood usually resulting from vestibular dysfunction
frequently change in the head precipitates vertigo or disequalibrium

200
Q

xerostomia

A

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
Q

cerumen accumulation

A

buildup of earwax in the external auditory canal

202
Q

peripheral neuropathy

A

disorder of the peripheral nervous system

203
Q

symptoms of peripheral neuropathy

A

numbness
tingling
stumbling gait

204
Q

stroke

A

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
Q

stroke affecting left hemisphere of brain results in

A

symptoms on right side such as difficulty with speech

206
Q

stroke affecting right hemisphere causes

A

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
Q

interventions for presbyopia, macular degeneration, diabetic retinopathy

A
  • 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
Q

what is the most dangerous thing for someone who cannot see to be doing

A

driving!

209
Q

tips for driving

A
  • 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
Q

computer/digital eye strain

A
  • 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
Q

assessment for hearing loss

A
  • 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
Q

interventions for hearing issues

A
  • 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
Q

dangerous situation for someone who cannot hear

A

driving!

214
Q

assessment of smell

A

increased body odor
cannot recognize noxious smells/decreased sensitivity

215
Q

assessment of taste

A

weight change
appetite change
excess use of seasoning or sugar
C/O taste of food

216
Q

interventions for olfactory and/or gustatory deficits

A

oral hygeine
good hydration
seasonings
removal of unpleasant odors
no blending or mixing of foods
different textures
check expiration dates

217
Q

what is dangerous situation for someone who can not smell

A

fire!

218
Q

assessment for tactile dysfunction

A
  • 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
Q

interventions for tactile dysfunction

A

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
Q

what are dangerous situation for someone who can not feel

A

hot, persons touching, riding bikes, cold, sharps

221
Q

special communication needs

A
  • artificial airways
  • aphasia
222
Q

artificial airways

A
  • 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
Q

aphasia

A

varied degrees of inability to speak, interpret or understand language

224
Q

expressive (Broca’s area) aphasia

A

motor type of aphasia
inability to name common objects or express simple ideas in words or writing

225
Q

sensory or receptive (wernicke) aphasia

A

inability to understand written or spoken language

226
Q

health promotion activites in community/home

A
  • screening; vision, hearing
  • safe environment- home risk assessment
  • alternative ways of communication
  • use of assistive devices
227
Q

home risk assessment

A
  • cracked walkways
  • scatter rugs
  • extension cords
  • clutter
  • labeled faucets
  • lighting
  • grab bars in BR
228
Q

delirium

A

confusion that can be reversed

229
Q

dementia

A

can not be reversed

230
Q

interventions for impaired cognition

A
  • 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
Q

general interventions in acute care setting for sensory issues

A
  • 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
Q

planning of care for those with sensory issues

A
  • 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
Q

evaluation of sensory interventions

A

patient is only person who can tell if sensory ability has improved

234
Q

homeostasis

A

maintenance/balance of body components
all fluid, electrolytes, acid, and bases all values will be off

235
Q

function of water in the body

A

medium for transport
controls temperature
promotes digestion
acts as a lubricant to tissues

236
Q

water as medium for transport

A

moves electrolytes, blood (RBCs, WBCs), hormones, nutrients, and wastes

237
Q

how does water control temp

A
  • need hydration
  • dehydration = higher temp
  • postop pt has slight elevated temp due to fluid loss
238
Q

fever

A

100.4

239
Q

elevated temp

A

99.9-100.3

240
Q

electrolytes

A

na+
k+
hco3-
cl-
mg+

241
Q

body weight and water

A
  • 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
Q

body systems that support homeostasis

A
  • thirst
  • kidneys
  • CV system
  • neuro
  • lymphatic system
243
Q

thirst

A

losing or gaining too much water, brain is triggered to either increase drinking or decrease drinking

244
Q

kidneys

A
  • help excrete water or retain water
  • antidiuretic hormone (ADH) retains water in body which prevents elimination of water
  • renin-angiotensin-aldosterone system (RAAS)
245
Q

ADH

A

helps retention of water restoring volume (blood volume) of water

246
Q

renin-angiotensin-aldosterone system (RAAS)

A

triggered by kidneys that regulates amount of water or Na+ that kidneys hold on to

247
Q

CV system

A
  • atrial natriuertic peptide (ANP): secreted from cardiac muscle which help regulate fluid volume by reducing plasma volume (volume in general)
248
Q

ANP is secreted to

A

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
Q

brain natriuretic pepetide (BNP)

A
  • 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
Q

lymphatic system

A
  • assists in removing excess protein and fluid within the body
  • edema, lymphatic system aids in removal of excess fluid
251
Q

daily fluid requirements

A
  • 35-45 mL/kg/day
  • BW measure
252
Q

factors affecting fluid needs

A
  • 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
Q

sources of fluid loss

A

sensible and nonsensible

254
Q

sensible loss

A

loss than CAN be measured
urine
diarrhea (not form of stool)
emesis/vomiting
wound drainage
gastric drainage

255
Q

urine output daily

A

1200-1500mL/day in normal adult

256
Q

nonsensible losses

A

loss that CANT be measured
- sweat (500-600mL/day)
- talking (perspiration)/respiratory tract (400mL/day)
- GI feces (100-200mL/day)

257
Q

sources of fluid intake

A

liquids
food
cell metabolism

258
Q

liquids

A

PO
1100-1400mL/day average

259
Q

food

A

800-1000 mL/day average

260
Q

cell metabolism

A

300mL/day average

261
Q

measuring I&Os

A

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
Q

daily weights

A
  • 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
Q

if person goes up 2.2kg/day

A

validate findings!

264
Q

calculate fluid req

A

35-45 mL/kg/day

265
Q

2.2 lbs

A

1 kg

266
Q

165 male requires

A

3000mL/day

267
Q

fluid volume deficit data cues

A
  • 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
Q

why does heart rate go up with FVD

A

heart tries to compensate and work harder to push blood throughout body

269
Q

FVD labs

A
  • 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
Q

nursing actions for FVD

A
  • monitor I&Os
  • monitor BP and VS
  • administer fluids
  • monitor daily weight
271
Q

fluid volume excess data cues

A
  • edema (lower extremities, fingers, periorbital edema)
  • high BP
  • bounding pulse
  • SOB
  • confusion related to % of electrolyte balance
272
Q

FVE labs

A
  • BUN decrease
  • hemoglobin decrease
  • hematocrit decrease
  • urine SG decrease
273
Q

nursing interventions for FVE

A
  • monitor I&Os
  • monitor BP and VS
  • potentially diuretics?
  • monitor daily weight
  • monitor respiratory status
274
Q

fluid imbalances may be from

A

vomiting
diarrhea
certain illness

275
Q

intracellular fluid (ICF)

A

about 40-60% BW
fluid found inside cells
K+ within the cells

276
Q

extracellular fluid (ECF)

A

about 20-60% BW
fluid fond outside cells
Na+ is outside the cell

277
Q

interstitial fluid (IF)

A

fluid between cells

278
Q

intravascular fluid (IVF)

A

fluid within blood vessels

279
Q

basic function of fluids and electrolytes

A
  • 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
Q

major electrolyte in ECF

A

sodium (Na+)

281
Q

sodium helps

A

transport wastes, O2, movements of electrolytes

282
Q

major electrolyte in ICF is

A

potassium (K+)

283
Q

potassium helps

A

internal fluids necessary for bodily function

284
Q

osmolarity

A

concentration of solutes in a solution
facilitates movement of electrolytes from one place to another

285
Q

osmolarity in ECF

A

almost solely due to Na+

286
Q

osmolarity in ICF

A

almost solely due to K+
very narrow range acceptable for K+

287
Q

Na+/K+ work together to

A

maintain homeostasis

288
Q

how are fluid and electrolytes transported

A

through osmosis or active transport

289
Q

osmosis

A
  • 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
Q

active transport

A

moves against concentration gradient

291
Q

isotonic fluids

A
  • 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
Q

typical isotonic fluids

A
  • normal saline 0.9%
  • lactated ringers
  • replacement of volume, no shifting fluids
293
Q

hypotonic fluids

A
  • have lower concentration of solutes in fluid
  • when infused it moves water into the cell
  • will increase size of cell
294
Q

typical hypotonic fluids

A

normal saline 0.45%
specific type of dehydration in which hydration is needed in cells

295
Q

hypertonic fluids

A

when infused it moves water out of cell
will shrink size of cell

296
Q

typical hypertonic fluids

A

normal salin 3%

297
Q

blood pH

A

7.35-7.45

298
Q

blood CO2

A

35-45

299
Q

blood HCO3

A

22-26

300
Q

blood paO2

A

80-100 mmHg

301
Q

pao2

A

pressure that o2 is exerting within vascular system so there can be uptake of hemoglobin

302
Q

blood sao2

A

> 93%
saturation of o2 on hemoglobin

303
Q

lines of defense to help maintain acid-base balance

A
  • chemical buffer system including food and fluids, respiratory system, renal control of plasma HCO3-
304
Q

respiratory system on acid base balance

A
  • 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
Q

renal control of plasma HCO3

A
  • 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
Q

pH (H+ ions)

A
  • begins with blood pH
  • high concentration of H+ ions is going to indicate acidity
307
Q

blood pH <7.35

A

acidotic state
indicates more H+ ions

308
Q

blood pH >7.45

A

alkalotic state
indicates fewer H+ ions

309
Q

paCO2> 45

A

indicates excessive CO2 retention indicating state of acidosis

310
Q

paCO2 <35

A

less CO2 retention indicating state of alkalosis

311
Q

increase in paco2 and decrease in pH indicates

A

Respiratory Acidosis

312
Q

HCO3 <22

A

acidosis

313
Q

HCO3 >26

A

alkalosis

314
Q

HCO3 indicates

A

renal control and metabolic disorders

315
Q

ROME

A
  • 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
Q

what do you look for to determine if acid-base imabalance is respiratory

A

PaCO2

317
Q

what do you look for to determine if acid-base imabalance is metabolic

A

HCO3

318
Q

causes of respiratory acidosis

A
  • acute problems such as airway obstruction, pneumonia, asthma, chest injuries, or pulmonary edema
  • COPD, such as emphazema
  • opiate use that depresses respiratory rate
319
Q

cues for respiratory acidosis

A
  • headache
  • drowsiness
  • disorientation
  • muscle weakness
  • pale to cyanotic
320
Q

blood gas values of respiratory acidosis

A

pH < 7.35
PaCO2 > 45 mmHg

321
Q

when the underlying cause of acid-base imablance is respiratory,

A

correction or improvement in ventilation is to lower PaCO2

322
Q

when underlying cause is nonrespiratory,

A

then correction or improvement of underlying cause must occr

323
Q

medical treatment of respiratory acidosis

A
  • 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
Q

nursing actions for respiratory acidosis

A
  • maintain airway
  • monitor ABGs
  • monitor vital signs
  • admin supp O2
  • assist with intubation
  • monitor K+ levels
  • administer sedatives cautiosly
325
Q

respiratory alkalosis causes

A
  • hyperventilation
  • anxiety
  • high fever
  • overdose of aspirin
  • infection
326
Q

respiratory alkalosis cues

A
  • anxiety
  • irritability
  • muscle cramping
  • numbness
  • tingling
327
Q

blood gas values of respiratory alkalosis

A

pH >7.45
PaCO2 < 35 mmHg

328
Q

medical treatment of respiratory alkalosis

A
  • ID and eliminate causative agent
  • reduce fever
  • eliminate source of sepsis
  • o2 therapy
  • sedative therapy
329
Q

nursing action of respiratory alkalaosis

A
  • encourage slow, deep breathing
  • monitor VS
  • provide emotional support and reassurance - reduce anxiety
  • assist with activites of daily living
  • patient education
330
Q

metabolic acidosis causes

A
  • diarrhea
  • renal failure
  • sepsis
  • starvation
  • overdose of asprin
331
Q

metabolic acidosis cues

A
  • muscule twitching
  • warm
  • flushed skin
  • n/v
  • decreased muscle tone
332
Q

blood gas values for metabolic acidosis

A

pH <7.35
HCO3 <22 mEq/L

333
Q

medical treatments of metabolic acidosis

A
  • sodium bicarb replacement
  • parenteral fluid replacement
  • antidiarrheals
  • dialysis
  • mechanical ventialation
334
Q

nursing actions of metabolic acidosis

A
  • monitor hemodynamic status - VS, telemetry
  • assess peripheral vascular status
  • admin sodium bicarb as order
  • provide reassurance and teaching
335
Q

metabolic alkalosis causes

A
  • vomiting
  • extensive GI suction
  • excessive use of antacids with bicarbonate
  • diuretics
336
Q

metabolic alkalosis cues

A
  • restlessness
  • lethargy
  • confusion
  • nausea
  • vomiting
  • tremors
  • tingling
337
Q

blood gas values of metabolic alkalosis

A

pH >7.45
HCO3 > 26 mEq/L

338
Q

medical treatment of metabolic acidosis

A
  • discontinuation of K+ wasting diuretics
  • discontinuation of nasogastric suctioning
  • antiemetics
339
Q

nursing actions of metabolic acidosis

A
  • hemodynamic monitoring (RR, pulse, telemetry)
  • asses LOC
  • IV fluid admin
  • electrolyte supplements
  • providing reassurance and teaching
340
Q

respiratory acidosis overview

A

body state - acidosis
CO2 - retain/increase
H+ ions - increase
pH state - decrease in pH level
Body response - increase depth and rate of respiration

341
Q

respiratory alkalosis overview

A

body state - alkalotic
CO2 - excreted/decrease
H+ ions - decrease
pH state - increase in pH level
body response - decrease depth and rate of respirations

342
Q

metabolic alkalosis overview

A

body state - alkalotic
HCO3 - excreted, decrease
H+ ions - reabsorbed
pH state - increase
body response - alkaline urine, decrease in blood HCO3, decrease in H+

343
Q

metabolic acidosis overview

A

body state - acidotic
HCO3 - absorb/increased
H+ ions - excreted
pH state - decrease
body response - urine acidic, decreased HCO3, decreased pH

nur 300 (3 decks)

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