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What is diabetic neuropathy?
damaged BV's lose sensation
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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
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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
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How often should a pt do ROM exercises on bed rest?
What is the alternative?
bid or turn q 2 h
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What is the purpose of doing ROM exercises?
to prevent contractures
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What are contractures?
permanent shortening of muscle, ligments, and tendons
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What is the only way to relieve contractures?
cutting contracted areas
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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
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What is perfusion and how is it affected by regular exercise?
- blood flow with oxygen
- increased
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2 nursing interventions to decrease risks of orthostatic hypotension?
- change positions slowly
- get baseline vitals
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Use _____ & ______ devices to prevent DVT's.
TED's and Kendal's
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What is it important to monitor when a pt is using TED's? How?
neurovascular
check toes for warm, pink, and able to wiggle
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What should you do if you cannot feel a pulse?
listen for it
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How often should TED's be taken off and for how long?
q 12 h for 30 min / once per shift
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What is congruent therapy?
using TED's and Kendal's together
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2 other names for Kendal's?
- pneumatic compression
- sequential compression device
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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
- adelectasis
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What is adelectasis?
What indicates adelectasis?
- collapse of alveoli at cellular level
- cannot hear breath sounds over the area
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Intervention to prevent adelectasis?
incentive spirometer
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ISQ1WA?
incentive spirometer q 1 h while awake
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What must be documented with incentive spirometer?
that the nurse encourage its use
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What can occur is a pt does not use incentive spirometer?
secretions build up and cause pneumonia
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TCDBQ2H?
turn, cough, deep breathe q 2 h
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CPM?
continuous passive motion - machine bends legs
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3 reasons ppl are ambulatory soon after surgery/injury?
skin breakdown, DVT, pneumonia
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Every time you assess a pt on bed rest you should assess for _______.
homan's sign
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When is checking homan's sign contraindicated?
ankle surgery
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When should dietary be consulted on albumin level of a pt?
<3.5
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______ meds slow the GI system.
pain meds
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3 affects of bed rest on the GU system?
- increased risk for urinary calculi
- urinary stasis
- bladder muscle tone decreased
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Intake and output should be _____.
equal
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5 characteristics of uring that should be documented?
amount, color, clear, cloudy, and sediment
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What causes increased BUN?
poorly perfused kidneys
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What causes increased creatinine?
renal calculi & renal failure
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What causes decreased albumin?
malabsorbtion or malnutrition
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3 pt who are at risk for skin breakdown?
- immobile
- respiratory care because have to sit up
- incontinent
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What is the best defense against skin breakdown?
skin care
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A pt on bed rest must be turned q ___ h.
2
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Shearing?
dragging skin across surfaces
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2 parts of nursing assessment?
- nursing history
- physical assessment
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What is the nursing intervention plan based on?
the assessment
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6 considerations in making nursing diagnoses?
pain, risk for falls, impaired walking, impaired transfer ability, impaired home maintenance, self-care defecit
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3 safety measures for all pt?
- bed in lowest locked position
- side rails up X 2
- call light within reach
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Degree of Fowler's, semi-Fowler's, and high Fowler's positions?
- Fowler's - 45 - 60
- semi- Fowler's 30
- high- Fowler's 90
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What parts of the body bear the main part of the weight in all Fowler's positions?
buttocks, sacrum, and scapulae
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Supine? AKA?
- on back with head and shoulders slightly elevated
- dorsal recumbent
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Prone?
on tummy with head to the side
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If a person is a prone position they need a pillow under their _____.
ankles
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Where should a pillow be placed when a pt is in the side-lying position?
between the knees and ankles
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What is the trendelenberg position and its use?
- head down
- uses gravity to move up in bed
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When transferring from bed to chair should always lead with the healthy/weak side.
healthy
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Pt should be ambulated next to ______.
the wall
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Most important first step when transferring a pt to a wheelchair or other chair/bed?
lock wheels
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What type of damage can result from improper use of crutches?
damage to nerves and BV's of the axillary areas
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When using restraints pt should be assessed q ___ h and released q ____ h.
assess q 2 h and release q 4 h
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What should be done before getting a pt out of bed?
nonskid footwear
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5 functions of the skeletal system?
support, protect, muscle attachment, mineral storage, blood cell production
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3 functions of muscle?
movement, posture, production of heat
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Arthritis?
inflammation, pain, damage to joint , cartilage, and or stiffness
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Osteoarthritis?
noninflammatory, progressive disorder of movable joints
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Sprain?
partial tear or rupture of a joint from its attachment
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Dislocation?
displacement of bone from joint with tearing of ligaments, tendons, and capsules
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Fractures?
break in the continuity of a bone or cartilage
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Strain?
stretching of a muscle
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Any illness that lowers O2 intake will alter _______.
activity level
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Negetive nitrogen balance?
diseases characterized by a larger breakdown of protein than that which is manufactured
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3 types of exercise?
isotonic, isometric, isokinetic
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Isotonic exercise?
muscle shortening and active movement
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Isometric exercise?
flexing muscle but not moving it
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Isokenetic exercise?
muscle contractions with resistance
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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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