exam 3 Milligan College
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| 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
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| Special Factors r/t Environment | *Home
*Workplace
*Community
*Health care setting
*Bioterrorism
*Disaster planning
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| Hygiene care separated into | *Early morning care
*Morning Care
*Hour of Sleep or PM care
*As needed PRN care
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| Factors Influencing Personal Hygiene | Culture
Religion
Environment
Developmental level
Health and energy
Personal preference
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| 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
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| Sweat is made up of | water, sodium, potassium, chloride, glucose, urea, and lactate
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| 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
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| 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
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| Hygiene Pearls of Nursing Care | *Gather info on client preference
*Maintain healthy, moist skin
*Cleanse don’t cover up
*Cornstarch can be used
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| 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
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| 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
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| 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
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| 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
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| Nose care | *Clients can typically clean and clear most nasal secretions by blowing gently into a soft tissue
*If encrusted, client may need assistance
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| Environmental Issues with Bathing | *Room temperature
*Ventilation
*Noise
*Beds
*Mattresses
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| RACE | Rescue patients
set the Alarm off
Confine the fire
Extinguish it
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| PASS | Pull pin
Aim
Squeeze
Sweep
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| all 4 side rails up is considered: | a restraint
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| goal during seizure | is to keep client free from harm
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| Seizure Precautions | *pad bed
*put oral suction in place
*children with freq wearing helmet
*put on side during seizure
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| Minimize noise: | *Acoustic tile on ceilings, walls, and floors
*Drapes and carpeting absorb
*Background music
*Noise cancelling headphones
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| 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
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| Protecting Against Radiation | *Limit time near source
*Provide as much distance as possible from source
*Use shielding devices
*Be familiar with agency protocols
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| Disaster planning 4 phases | *Mitigation
*Preparedness
*Response
*Recovery
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| 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
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| 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
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| goals for nurses on restraints | is to have a restraint-free environment
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| 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
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| Center of Gravity | the point at which all of the body’s mass is centered
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| Base of Support | the foundation on which the body rests
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| 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
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| Physical activity | bodily movement that enhances health
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| 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
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| Functional Strength | ability of body to perform work
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| Activity tolerance | type and amount of exercise or ADLs an individual is able to perform without experiencing adverse effects
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| Center of Gravity | the point at which all of the body’s mass is centered
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| 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
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| Base of Support | the foundation on which the body rests
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| 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
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| 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
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| Physical activity | bodily movement that enhances health
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| 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
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| Functional Strength | ability of body to perform work
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| Activity tolerance | type and amount of exercise or ADLs an individual is able to perform without experiencing adverse effects
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| Balance Result of proper functioning of: | *Cerebral cortex-Initiates voluntary movement
*Cerebellum-Coordinates motor activity
*Basal ganglia-Maintains posture
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| Coordinated Movement | Complex mechanisms
Proprioception
*Awareness of posture, movement, changes in equilibrium
*Knowledge of position, weight, resistance of objects in relation to body
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| 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
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| 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
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| 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
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| 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
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| 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
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| Glomerular filtrate is made up of | water, electrolytes, glucose, amino acids, and metabolic waste
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| Proximal convoluted tubule | is where most of the water and electrolytes are reabsorbed
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| Loop of Henle is | where solutes (like glucose) are reabsorbed and other substances are secreted – resulting in concentrated urine
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| Distal convoluted tubule is where | ADH and aldosterone control the reabsorbtion of additional water and sodium
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| reabsorbtion | process that allows fine regulation of fluid and electrolyte balance
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| Ureters | adults are 25-3cm long
lower end enters bladder @ bladder floor & there is a flap to prevent reflux
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| normal capacity of bladder is | 300-600 mL of urine
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| urethra | female 3-4 cm & male 20 cm
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| 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
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| oliguria | 30cc below norm & should be reported
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| normal output of urine | 60cc, 1500mL per day
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| T/F clients & family can help record I&O | T
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| when measuring urine output in calibrated container where do you check level @? | eye level
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| 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
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| Coude’ catheters | males with prostate problems curve tip
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| check urine flow when? | every 2-3hrs
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| when should you catheterize, change, or remove? | only when necessary
removal asap
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| Behavioral-oriented continence training program | Bladder training
Habit training
Prompted voiding
Pelvic muscle exercises (Kegels)
Positive reinforcement
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| T/F? UI is a normal part of aging and often is treatable | F NOT normal
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| Vesicostomy | opening of bladder onto skin
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| Functions of the Colon | -Absorb water and nutrients
-Mucosal protection of the intestinal wall
*Protects from acids
*Protects from bacterial activity
-Fecal Elimination
-Movement
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| normal adults produce ___ amts of flatus | 7-10 L
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| Haustra | pouches formed in the large intestine
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| If propelled quickly through the large intestine what happens? | more watery stool up to 95%
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| Causes of constipation | Insufficient fiber and fluid intake
Insufficient activity
Irregular habits
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| normal stool | Normally 75% water and 25% solid materials
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| fecal impaction | Passage of liquid fecal seepage and no normal stool
caused by poor defecation habits & constipation
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| Diarrhea major causes | Stress, medications, allergies, intolerance of food or fluids, disease of colon
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| bowel incontinence generally associated with | Impaired functioning of anal sphincter or nerve supply
Neuromuscular diseases
Spinal trauma
Tumor
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| Flatulence causes & physical problem | Foods
Abdominal surgery
Narcotics
leads to stretching & inflation of intestines
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| Gastrostomies and jejunostomies are typically performed for | alternate feeding routes
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| constipation | excessive dry or hard or less than 3x week
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| Cleansing enema | Prevents escape of feces during surgery
Prepare intestines for certain diagnostic tests
Removes feces in instances of constipation or impaction
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| Carminative and return-flow enema | Used primarily to expel flatus
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| Retention enema | Introduces oil or medication into the rectum and sigmoid colon
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| Hypertonic (Fleet phosphate)enema solution | draws water into colon
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| hypotonic (tap water) enema solution | Distends the colon
Stimulates peristalsis
Softens feces
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| Isotonic (physiologic or normal saline) enema solution | Distends the colon
Stimulates peristalsis
Softens feces
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| soapsuds (pure soap) enema | irritate mucosa
distends the colon
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| oil enema solution | lubricates feces & colonic mucosa
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| Normal stoma should appear | red and may bleed slightly when touched
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| stoma wafer doesn't fit | stoma paste or powder
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| average adult has how much blood pass through kidney each min? | 1200mL of blood
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| kidneys are | the primary regulators of acid-base balance & contain nephrons (functional unit)
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| each kidney contains how many nephrons? | 1 million approx
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| 6 parts of a nephron: | Glomerulus
Bowman’s capsule
Proximal convoluted tubule
Loop of Henle
Distal convoluted tubule
Collecting Duct
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