NURSING 110 Foundations
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What is diabetic neuropathy?
damaged BV's lose sensation
What are the risks associated with diabetic neuropathy?
decreased circulation causes decreased healing of wounds and more likely to be injured because can't feel harm being done
What are the 3 types of ROM? Describe them
- Active: pt does alone
- Passive: nurse moves pt without pt help
- Active-assistive: the nurse assists the pt in movements
How often should a pt do ROM exercises on bed rest?
What is the alternative?
bid or turn q 2 h
What is the purpose of doing ROM exercises?
to prevent contractures
What are contractures?
permanent shortening of muscle, ligments, and tendons
What is the only way to relieve contractures?
cutting contracted areas
What are the effects of exercise on the cardiovascular system? (cardiac output, hear work, heart rate, and BP)?
cardiac output increased, heart work decreased, heart rate decreased and BP decreased
What is perfusion and how is it affected by regular exercise?
- blood flow with oxygen
2 nursing interventions to decrease risks of orthostatic hypotension?
- change positions slowly
- get baseline vitals
Use _____ & ______ devices to prevent DVT's.
TED's and Kendal's
What is it important to monitor when a pt is using TED's? How?
check toes for warm, pink, and able to wiggle
What should you do if you cannot feel a pulse?
listen for it
How often should TED's be taken off and for how long?
q 12 h for 30 min / once per shift
What is congruent therapy?
using TED's and Kendal's together
2 other names for Kendal's?
- pneumatic compression
- sequential compression device
What happens to the respiratory system of a pt on bed rest? Why? What is the pt at risk for because of this?
- depth and rate decrease
- because body needs less O2
What is adelectasis?
What indicates adelectasis?
- collapse of alveoli at cellular level
- cannot hear breath sounds over the area
Intervention to prevent adelectasis?
incentive spirometer q 1 h while awake
What must be documented with incentive spirometer?
that the nurse encourage its use
What can occur is a pt does not use incentive spirometer?
secretions build up and cause pneumonia
turn, cough, deep breathe q 2 h
continuous passive motion - machine bends legs
3 reasons ppl are ambulatory soon after surgery/injury?
skin breakdown, DVT, pneumonia
Every time you assess a pt on bed rest you should assess for _______.
When is checking homan's sign contraindicated?
When should dietary be consulted on albumin level of a pt?
______ meds slow the GI system.
3 affects of bed rest on the GU system?
- increased risk for urinary calculi
- urinary stasis
- bladder muscle tone decreased
Intake and output should be _____.
5 characteristics of uring that should be documented?
amount, color, clear, cloudy, and sediment
What causes increased BUN?
poorly perfused kidneys
What causes increased creatinine?
renal calculi & renal failure
What causes decreased albumin?
malabsorbtion or malnutrition
3 pt who are at risk for skin breakdown?
- respiratory care because have to sit up
What is the best defense against skin breakdown?
A pt on bed rest must be turned q ___ h.
dragging skin across surfaces
2 parts of nursing assessment?
- nursing history
- physical assessment
What is the nursing intervention plan based on?
6 considerations in making nursing diagnoses?
pain, risk for falls, impaired walking, impaired transfer ability, impaired home maintenance, self-care defecit
3 safety measures for all pt?
- bed in lowest locked position
- side rails up X 2
- call light within reach
Degree of Fowler's, semi-Fowler's, and high Fowler's positions?
- Fowler's - 45 - 60
- semi- Fowler's 30
- high- Fowler's 90
What parts of the body bear the main part of the weight in all Fowler's positions?
buttocks, sacrum, and scapulae
- on back with head and shoulders slightly elevated
- dorsal recumbent
on tummy with head to the side
If a person is a prone position they need a pillow under their _____.
Where should a pillow be placed when a pt is in the side-lying position?
between the knees and ankles
What is the trendelenberg position and its use?
- head down
- uses gravity to move up in bed
When transferring from bed to chair should always lead with the healthy/weak side.
Pt should be ambulated next to ______.
Most important first step when transferring a pt to a wheelchair or other chair/bed?
What type of damage can result from improper use of crutches?
damage to nerves and BV's of the axillary areas
When using restraints pt should be assessed q ___ h and released q ____ h.
assess q 2 h and release q 4 h
What should be done before getting a pt out of bed?
5 functions of the skeletal system?
support, protect, muscle attachment, mineral storage, blood cell production
3 functions of muscle?
movement, posture, production of heat
inflammation, pain, damage to joint , cartilage, and or stiffness
noninflammatory, progressive disorder of movable joints
partial tear or rupture of a joint from its attachment
displacement of bone from joint with tearing of ligaments, tendons, and capsules
break in the continuity of a bone or cartilage
stretching of a muscle
Any illness that lowers O2 intake will alter _______.
Negetive nitrogen balance?
diseases characterized by a larger breakdown of protein than that which is manufactured
3 types of exercise?
isotonic, isometric, isokinetic
muscle shortening and active movement
flexing muscle but not moving it
muscle contractions with resistance
4 benefits of exercise on the cardiovascular system?
- increased efficiency of the heart
- decreased heart rate and blood pressure
- increased blood flow to all body parts
- increased circulating fibrinolysis
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