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Nurs 210 exam 3

exam 3 Milligan College

QuestionAnswer
Factors Affecting Ability to Protect Self from Injury *Age and development *Lifestyle *Mobility and health status *Sensory-perceptual alterations *Cognitive awareness *Emotional state *Ability to communicate *Safety awareness *Environmental factors
Special Factors r/t Environment *Home *Workplace *Community *Health care setting *Bioterrorism *Disaster planning
Hygiene care separated into *Early morning care *Morning Care *Hour of Sleep or PM care *As needed PRN care
Factors Influencing Personal Hygiene Culture Religion Environment Developmental level Health and energy Personal preference
Skin -Largest organ of the body -5 major functions: 1. protects 2. regulates body temp 3. secretes sebum 4. transmits sensations 5. produces and absorbs Vitamin D
Sweat is made up of water, sodium, potassium, chloride, glucose, urea, and lactate
National Patient Safety Goals (NPSGs) *Established after release of the 2000 IOM report To Err is Human *Increase awareness of the need to improve client safety *focus of NPSGs on system wide solutions *To create an environment of learning & improvement NOT fear & scape-goating
6 General Guidelines for Skin Care *Intact * skin protects depends on general health of the cells, amt of subQ, & dryness of skin *Moisture in contact w/ skin increased bacterial growth & irritation *Body odor caused by skin bacteria acting on secretions *Skin sensitivity &injury var
Hygiene Pearls of Nursing Care *Gather info on client preference *Maintain healthy, moist skin *Cleanse don’t cover up *Cornstarch can be used
Purposes of Bathing Remove transient microorganisms, body secretions and accumulated oil, and dead skin cells Stimulate circulation Produce a sense of well-being Promote relaxation and comfort Prevent or eliminate unpleasant body odors
Mouth Care Assessment and interventions should be completed each shift and mouth care provided at least: *TID for those eating and drinking *q4h for those NPO at low-risk *q2h for ventilated pts, pts on BiPAP, and NPO & considered high-risk Offered at least TI
Eye Care *Typically, eyes require no special hygiene *Lacrimal fluid continually washes the eyes *Eyelashes and eyelids prevent the entrance of foreign substances or particles *Clean from inner canthus to outer canthus
ear care Most normal ears require minimal hygiene Clients with excessive cerumen and clients with hearing aids may require additional assistance from the nurse Hearing aids are removed for surgery and some tests
Nose care *Clients can typically clean and clear most nasal secretions by blowing gently into a soft tissue *If encrusted, client may need assistance
Environmental Issues with Bathing *Room temperature *Ventilation *Noise *Beds *Mattresses
RACE Rescue patients set the Alarm off Confine the fire Extinguish it
PASS Pull pin Aim Squeeze Sweep
all 4 side rails up is considered: a restraint
goal during seizure is to keep client free from harm
Seizure Precautions *pad bed *put oral suction in place *children with freq wearing helmet *put on side during seizure
Minimize noise: *Acoustic tile on ceilings, walls, and floors *Drapes and carpeting absorb *Background music *Noise cancelling headphones
Reducing Electrical Hazards *Properly grounded electrical equipment *Using machines in good repair *Wearing shoes with rubber shoes *Standing on a nonconductive floor *Using nonconductive gloves
Protecting Against Radiation *Limit time near source *Provide as much distance as possible from source *Use shielding devices *Be familiar with agency protocols
Disaster planning 4 phases *Mitigation *Preparedness *Response *Recovery
CMS gives only 2 reasons to restrain a client: *Prevent purposeful or accidental harm *To do work is required to medically treat a pt that cannot be accomplished by other means
Alternatives to Restraints: *Assign nurses in 2 *Place unstable clients in an area closely supervised *Prepare clients before a move to limit relocation shock *Stay w/a client using a bedside commode or bathroom if confused *monitor meds *rocking chair *removable lap tray *pi
goals for nurses on restraints is to have a restraint-free environment
Behavior Management Standard (Violent) Nurse may apply restraints but physician practitioner must see client w/in 1hr 4 eval Written restraint order 4 adult, following eval, valid 4 only 4 hours. MD must see client q8h Must b continual visual & audio monitoring if client restrained & seclude
Center of Gravity the point at which all of the body’s mass is centered
Base of Support the foundation on which the body rests
Medical Surgical Care Standard (Nonviolent) Restraints *Up to 12 hours for obtaining the physician’s written order *Orders renewed daily *Order must state the reason and time period *PRN order prohibited *restraints used only after every possible means of safety unsuccessful & documented *document need
Physical activity bodily movement that enhances health
Exercise a type of physical activity defined as planned, structured, bodily movement performed to improve health and maintain fitness to achieve an optimal state of health
Functional Strength ability of body to perform work
Activity tolerance type and amount of exercise or ADLs an individual is able to perform without experiencing adverse effects
Center of Gravity the point at which all of the body’s mass is centered
Isometric (Static or Setting) Exercise Muscle contraction without moving the joint (muscle length does not change) Involve exerting pressure against a solid object Produce a mild increase in HR and CO No apparent increase in blood flow to other parts of the body
Base of Support the foundation on which the body rests
Isokinetic (Resistive) Exercise Muscle contraction or tension against resistance Can either be isotonic or isometric Person moves (isotonic) or tenses (isometric) against resistance An increase in blood pressure and blood flow to muscles occurs
Medical Surgical Care Standard (Nonviolent) Restraints *Up to 12 hours for obtaining the physician’s written order *Orders renewed daily *Order must state the reason and time period *PRN order prohibited *restraints used only after every possible means of safety unsuccessful & documented *document need
Physical activity bodily movement that enhances health
Exercise a type of physical activity defined as planned, structured, bodily movement performed to improve health and maintain fitness to achieve an optimal state of health
Functional Strength ability of body to perform work
Activity tolerance type and amount of exercise or ADLs an individual is able to perform without experiencing adverse effects
Isotonic (Dynamic) Exercise *Muscle shortens to produce muscle contraction and active movement *Increase muscle tone, mass, and strength *Maintain joint flexibility and circulation *HR and CO quicken to increase blood flow to all parts of the body
Isometric (Static or Setting) Exercise Muscle contraction without moving the joint (muscle length does not change) Involve exerting pressure against a solid object Produce a mild increase in HR and CO No apparent increase in blood flow to other parts of the body
Isokinetic (Resistive) Exercise Muscle contraction or tension against resistance Can either be isotonic or isometric Person moves (isotonic) or tenses (isometric) against resistance An increase in blood pressure and blood flow to muscles occurs
Aerobic Exercise Activity during which the amount of oxygen taken in the body is greater than that used to perform the activity Improve cardiovascular conditioning and physical fitness
Anaerobic Exercise *Activity in which the muscles cannot draw enough oxygen from the bloodstream *Anaerobic pathways are used to provide additional energy for a short time *Used in endurance training for athletes
Joint Mobility ROM is maximum movement possible for joint ROM varies and determined by: *Genetic makeup *Developmental patterns *Presence or absence of disease *Physical activity
Balance Result of proper functioning of: *Cerebral cortex-Initiates voluntary movement *Cerebellum-Coordinates motor activity *Basal ganglia-Maintains posture
Coordinated Movement Complex mechanisms Proprioception *Awareness of posture, movement, changes in equilibrium *Knowledge of position, weight, resistance of objects in relation to body
Overall Goals for Problems Related to Mobility or Activity Increased tolerance 4 physical activity Restored/improved capability to ambulate &/or participate in ADLs Absence of injury from falling/improper use of body mechanics Enhanced fitness Absence complications assoc. w/ immobility Improved well-being
To Help with Moving Pts… Broad base of support Lower center of gravity Flex knees & hips Avoid twisting motions Keep objects close 2 ur body & center of gravity Lift w/large muscle groups Get assistance w/heavy objects Work @waist level Avoid working against gravity (lowe
General Guidelines for Moving and Lifting Clients *B4 moving, assess *If indicated, use pain relief modalities *Prepare any needed assistive devices *Plan around encumbrances *Be alert to the effects of any medications *Obtain required assistance *Explain the procedure to the client
General Guidelines for Transferring a Client Plan Obtain essential equipment b4 starting Remove obstacles Explain transfer 2 client & assistive personnel Support or hold client rather than equipment Explain what client should do Make written plan, including client’s tolerance
General Guidelines for Ambulating Assess amnt of assistance client will require Assess 4 S&S of orthostatic hypotension Prepare client 4 ambulation Apply transfer/walking belt Physically support client Obtain assistance 2 follow w/ wheelchair or assist w/ physical support Teach use
Glomerular filtrate is made up of water, electrolytes, glucose, amino acids, and metabolic waste
Proximal convoluted tubule is where most of the water and electrolytes are reabsorbed
Loop of Henle is where solutes (like glucose) are reabsorbed and other substances are secreted – resulting in concentrated urine
Distal convoluted tubule is where ADH and aldosterone control the reabsorbtion of additional water and sodium
reabsorbtion process that allows fine regulation of fluid and electrolyte balance
Ureters adults are 25-3cm long lower end enters bladder @ bladder floor & there is a flap to prevent reflux
normal capacity of bladder is 300-600 mL of urine
urethra female 3-4 cm & male 20 cm
process of Micturition Urine collects in the bladder Pressure stimulates special stretch receptors in the bladder wall Stretch receptors transmit impulses to the spinal cord voiding reflex center Internal sphincter relaxes stimulating the urge to void urine eliminated
oliguria 30cc below norm & should be reported
normal output of urine 60cc, 1500mL per day
T/F clients & family can help record I&O T
when measuring urine output in calibrated container where do you check level @? eye level
Preventing Urinary Tract Infections (UTI) Drink 8 cups H2O daily Practice frequent voiding (every 2-4hrs) Avoid use of harsh soaps, bubble bath, powder, or sprays in perineal area Avoid tight-fitting clothing Wear cotton underclothes wipe from front-back Take showers rather than baths
Coude’ catheters males with prostate problems curve tip
check urine flow when? every 2-3hrs
when should you catheterize, change, or remove? only when necessary removal asap
Behavioral-oriented continence training program Bladder training Habit training Prompted voiding Pelvic muscle exercises (Kegels) Positive reinforcement
T/F? UI is a normal part of aging and often is treatable F NOT normal
Vesicostomy opening of bladder onto skin
Functions of the Colon -Absorb water and nutrients -Mucosal protection of the intestinal wall *Protects from acids *Protects from bacterial activity -Fecal Elimination -Movement
normal adults produce ___ amts of flatus 7-10 L
Haustra pouches formed in the large intestine
If propelled quickly through the large intestine what happens? more watery stool up to 95%
Causes of constipation Insufficient fiber and fluid intake Insufficient activity Irregular habits
normal stool Normally 75% water and 25% solid materials
fecal impaction Passage of liquid fecal seepage and no normal stool caused by poor defecation habits & constipation
Diarrhea major causes Stress, medications, allergies, intolerance of food or fluids, disease of colon
bowel incontinence generally associated with Impaired functioning of anal sphincter or nerve supply Neuromuscular diseases Spinal trauma Tumor
Flatulence causes & physical problem Foods Abdominal surgery Narcotics leads to stretching & inflation of intestines
Gastrostomies and jejunostomies are typically performed for alternate feeding routes
constipation excessive dry or hard or less than 3x week
Cleansing enema Prevents escape of feces during surgery Prepare intestines for certain diagnostic tests Removes feces in instances of constipation or impaction
Carminative and return-flow enema Used primarily to expel flatus
Retention enema Introduces oil or medication into the rectum and sigmoid colon
Hypertonic (Fleet phosphate)enema solution draws water into colon
hypotonic (tap water) enema solution Distends the colon Stimulates peristalsis Softens feces
Isotonic (physiologic or normal saline) enema solution Distends the colon Stimulates peristalsis Softens feces
soapsuds (pure soap) enema irritate mucosa distends the colon
oil enema solution lubricates feces & colonic mucosa
Normal stoma should appear red and may bleed slightly when touched
stoma wafer doesn't fit stoma paste or powder
average adult has how much blood pass through kidney each min? 1200mL of blood
kidneys are the primary regulators of acid-base balance & contain nephrons (functional unit)
each kidney contains how many nephrons? 1 million approx
6 parts of a nephron: Glomerulus Bowman’s capsule Proximal convoluted tubule Loop of Henle Distal convoluted tubule Collecting Duct
Created by: midnight1854