Term
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Definition
| A person's ability to move about freely |
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Term
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Definition
| A person's inability to move about freely. |
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Term
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Definition
| Mobility or partial immobility--immobility; may be resolve or be permanent |
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Term
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Definition
| The client is restricted to bed for therapeutic reasons; based on state of health and injury/condition. Does not get out of bed period. DO NOT DANGLE!! |
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Term
| What are some benefits of bedrest |
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Definition
*Reduces phys. activity and oxygen demands
*Reduces pain and amt/freq of pain meds. (does not replace pain meds)
*Allows rest and opportunity to regain strength
*Provides uninterrupted rest for the exhausted client. |
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Term
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Definition
*Lost of strength D/T bed rest (inactivity)--loss of 3% of muscle strength per day
*Loss of bone density (Ca) and joint mobility. |
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Term
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Definition
| Lost of muscle strength D/T prolong inactivity from bed rest trauma, casting, or local nerve damage |
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Term
| Name some physiological effects from immobility and or bed rest. (5) |
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Definition
| metabolic changes, resp. changes, cardiovascular changes, musculoskeletal changes, integumentary changes, urinary elimination changes |
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Term
| Reagrding respiratory changes what can bed rest cause and what do you do to prevent it? |
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Definition
| Can cause atelectasis (aveoli collapse) and hypostatic pneumonia (inflamm of the lung from statis of secretions)**Prevent it by TCDB q 2hrs/this moves secreations around |
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Term
| How is orthostatic hypotension defined as? |
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Definition
| A drop of 25mm Hg systolic and of 10 mm Hg diastolic in BP when the client rises from a lying or sitting position to a standing position. |
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Term
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Definition
| Is an ATTACHED clot to the interior wall of a vessel. It is a accumulation of platelets, fibrin and clotting factors. |
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Term
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Definition
| Is al or part of a thrombus that is FREELY MOVING in a vessel. |
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Term
| What is a positive Holman'ssign? How do you test for it? |
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Definition
| Could mean the client has a DVT. Take clients foot and sharply planter flex it, look for edema and if pt. has pain then it is a positive sign for a DVT. |
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Term
| How are pressure ulcers (decubitus ulcers) caused? |
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Definition
| Caused by continual pressure on the tissue causing decreased blood and oxygen to the cells. |
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Term
| What is ichemia and what can it lead to? |
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Definition
| Ichemia is decreased blood flow that can lead to necrosis which is dead cells. |
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Term
| What is the normal fluid intake amount for a healthy adult? |
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Definition
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Term
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Definition
| Maximum amt of movement possible at a joint...is limited by ligaments, muscles, and construction of the joint and the clients joint mobility and comfort level. |
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Term
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Definition
| Active range of motion: The CLIENT exercises or uses his/her limbs/joints |
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Term
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Definition
| Passive range of motion: The NURSE/PT moves the client's extremities |
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Term
| Do you need a MD order to do ROM? and how many times do you repeat the movement? |
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Definition
| Yes you need a MD order and repeat each movement 3 times |
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Term
| True/False You should not craddle the patients joint when performing PROM |
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Definition
| False- you should craddle (support above and below the joint when doing PROM |
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Term
| When you have a clean wound what kind of dressing are you going to apply? |
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Definition
| A moist dressing to keep it moist so it does not dry out. |
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Term
| What kind of dressing do you use for a dirty wound? |
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Definition
| Debriding dressing (Wet--dry) or (Moist--damp) you want to allow the moisture to evaporate as to get the "gunk" out of the wound to get it clean. |
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Term
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Definition
| A reduction in blood flow. Use pad of finger to assess |
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Term
What is normal reactive hyperemia?
Would this be considered an pressure ulcer? |
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Definition
| Redness-Localized vasodilation; blanching w/ fingertip pressure; lasts less than 1 hour. NOT considered a pressure ulcer. |
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Term
Define abnormal reactive hyperemia.
Is is a pressure ulcer? |
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Definition
| Excessive vasodilation adn induration; skin is bright pink to red; NO blanching with fingertip pressure; can last 1 HR to 2 WEEKS; Stage I pressure ulcer |
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Term
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Definition
| Abnormal firmness of tissue with margins as a result of edema or inflammation |
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Term
| What is shearing force defined as? When can it occur? |
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Definition
| PRESSURE exerted against the skin in a direction parallel to the body's surface. Can occur when the client "slides" down in bed or is pulled across the bed to be repositioned. Client skins adheres to bed while the muscles and bones slide in the direction of the movement. Deep tissue damage can occur and vessel damage. |
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Term
| Define friction. What does it affect? |
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Definition
| The MECHANICAL FORCE exerted when the skin is dragged across a course surface such as bed linens. Affects the epidermis (elbows, heels) |
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Term
| How do you prevent friction? |
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Definition
| Proper lifiting/repositioning using a drawsheet, sheepskin protectors (elbows/heels) skin sealants, maintaining skin hydration (moisturizers, adequate fluid intake) |
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Term
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Definition
| Presence and duration of excess moisture on the skin (maceration) skin look like prunes. Reduces skin resistance to pressure and trauma. |
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Term
| Does edema increase the risk of pressure ulcers? If so, why? |
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Definition
| Yes, because circulation is decreased (thus decreasing the oxygen and increasing the waste products) |
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Term
| Name contributing factors to pressure ulcer formation. (12) |
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Definition
| Pressure, shearing force, friction, moisture, Poor nutrition, edema, anemia, cachexia (abnormally thin), obestiy, infection, imparied peripheral circulation, older adults. |
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Term
| Why is obesity a contributing factor to pressure ulcers? |
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Definition
| Adipose tissue is POORLY VASCULARIZED and an excess amount can increase the risk of ischemic damage. |
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Term
| Why is an infection bad regarding pressure ulcers? |
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Definition
| A presence of pathogens and a fever can increase the metabolic needs of the body; at greater rish for ischemic damage, diaphoresis which increases the amt of moisture on the skin |
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Term
| Define Stage I pressure ulcer |
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Definition
| Nonblanchable erythema of INTACT skin, warmth, hardness |
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Term
| Define Stage II pressure ulcer |
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Definition
| Partial-thickness skin loss involving the epidermis and dermis, ulcer is superficial and look like and abrasion, blister or shallow crater. |
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Term
| Define Stage III pressure ulcer |
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Definition
| Full-thickness skin loss involving damage or necrosis of sub q tissue down to the fascia; ulcer looks like a deep crater w/ or wo/ undermining of adjacent tissue |
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Term
| Define Stage IV pressure ulcer |
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Definition
| Full-thickness skin loss w/ extensive tissue destruction/necrosis; or damage to muscle, bone or supporting structures. |
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Term
| What do you look for if skin changes are noted? What do you do? |
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Definition
| Assess location, size, color, temperature, induration. Reposition client off the area, make sure skin is clean and dry, and reassess in 1 hour. Document. |
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Term
| The HOB should be at what degress or less to decrease shearing force. How often should a patient be turned. |
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Definition
| 30 degrees or less. At least q 2 hrs. |
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Term
| What is a Cintron bed used for and what does it do? |
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Definition
| Decreases pressure and reduces shearing, friction, and maceratin by distributing the client's weight thru gentle flow of temperature-controlled air forced upward thru a mass of fine ceramic microshperes. |
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Term
| What is the normal urine output for an healthy adult? |
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Definition
| 1500ml - 1600ml/24 hrs; 60ms/hr |
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Term
| Urine output less than _______ for how many hours consecutivly. Does this need attention? |
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Definition
| Less than 30ml/hr for 2 hrs consecutivly may indicate renal alteratins and requires ATTENTION NOW! |
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Term
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Definition
| Nothing to do with the kidneys. Decreased blood flow to and thru kidneys (ie. dehydration, hemmorage, shock) |
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Term
| What is renal or intrarenal? |
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Definition
| Damage that affects the function of the kidneys (ie. renal neoplasms (cancer tumor) and infections) |
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Term
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Definition
| Obstructions in teh collection system, from the calyces within the kidney to the urethral meatus (ie. caculi, kidney stones) |
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Term
| Name some characteristics of urine |
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Definition
| Color (pale, straw color to amber), transparent initially; cloudy w/ standing, Odor: Stronger when more concentrated--amminia order w/ standing, sweet or fruity w/ DM. |
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Term
| What is a sterile specimen? What is it used for? |
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Definition
Clean-voided or mid-stream specimen.
Used for C&S=Culture and Sensitivity |
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Term
| What is the specific gravity range? What is the range with normal fluid intake? |
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Definition
Range 1.010 - 1.030////
Range with normal fluid intake 1.016 - 1.022 |
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Term
| You should have the urge to void every......? |
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Definition
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Term
| What is IVP? What do you have to watch for? |
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Definition
| Intravenous pyelogram: IV injection of dye; visualizes the urinary system during the production of urine, intestines need to be empty, NPO or clear liquids after midnight.***Watch ofr possible delayed reaction to the dye*** |
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Term
| Can the valsalva maneuver increase or decrease HR? |
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Definition
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Term
| What is paralytic ileus and how long does it last? What causes it? |
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Definition
| Peristalsis stops, lasts 24-48 hrs, cam be caused by bowel surgery, trauma to abd. and anticholinergic drugs. Need to listen to all 4 abd. quadrents for 2 mins for bowel sounds. NPO until bowel sounds return. |
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Term
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Definition
| Liquids, gases, or solids move from higher to lower concentration. Example, |
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Term
| What is insensible loss and where does it happen? |
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Definition
| The fluid loss you CANNOT SEE from the skin. |
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Term
| What is sensible loss and where does it happen? |
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Definition
| Fluid loss you CAN SEE from the skin. Example, sweat from running |
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Term
| What is ADH and when is it released? Will your specific gravity be high or low? |
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Definition
| Antidiuretic hormone- Released in response to increased osmolarity. Specific gravity will be high. |
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Term
| What is the fluid output for the kidneys for an average adult per day and per hour? |
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Definition
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Term
| When a person is dehydrated what will the specific gravity be high or low and give a number and how will the urine be? |
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Definition
| Specific gravity will be greater than 1.030 urine will be concentrated. |
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Term
| When a patient is overhydrated what will the hematocrit and hemoglobin values and RBC count look like? High or low? |
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Definition
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Term
| What is the single most important assesment in fluid status? |
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Definition
| Daily weight. Need about 3 days to notice a trend. |
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Term
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Definition
| Blood Urea Nitorgen test=Creatinine level ratio. Normal is 10:1 change in ratio is better indicator of kidney dysfunction. |
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Term
| What is Hematocrit (Hct)? |
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Definition
| volume % of whole blood that is composed of RBCs. |
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Term
| What is a positive airflow room? |
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Definition
| Air is purified. Air comes thru and air vent and does out the door. Used when patient has no immune system. |
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Term
| What is a negative air flow room? |
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Definition
| Air come thru the door and up thru the ven then cleaned with filters. Prevents air flow out of the room. |
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Term
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Definition
| Inamiate object that has a pathogen still ALIVE on it and you can catch it. |
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Term
| What are the cardinal signs? (5) |
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Definition
| redness (erythema), heat, pain, swelling (edema), decreased mobility (if over a joint) |
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Term
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Definition
| Maintain balance and body alignment to reduce risk of injury, facilitate body movement, reduce use of energy. |
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Term
| What is a return demostration? What do you tell them after. |
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Definition
| Make sure the patient knows how to do what is asked (ie. dressing change) before leaving the hospital. You tell them what they did right and what to improve on. |
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Term
| Name the five parts to the nursing process. |
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Definition
| Assessment, nursing diagnosis, planning, implementation and evaluation |
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Term
| What is NANDA and the purpose? |
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Definition
| North American Nursing Diagnosis Association. It is so that all health care peoples are speaking the same language. |
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Term
| What is an dependent intervention? |
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Definition
| Need a MD order (ie. pain meds, regular diet or level of activity) |
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Term
| What is an independent intervention? |
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Definition
| Nursing actions that do not require an MD order (ie. V.S. back rub) |
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Term
| What are collaborative interventions? |
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Definition
| Involve multidisciplinary actions (ie. PT) |
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Term
| Is teaching a nursing intervention? |
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Definition
| Yes it is a major intervention. |
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Term
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Definition
| A systematic approach to client care; outcone-oriented; to determine appropriate nursing diagnoses and treatment of actual (or potential) health problems. |
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Term
| What is the first nursing intervention? |
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Definition
| Assess degree and etiology of (nursing diagnosis) |
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