NURSING 110 Foundations

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NURSING 110 Foundations
2013-01-06 19:15:55

first semester nursing school
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  1. What is diabetic neuropathy?
    damaged BV's lose sensation
  2. 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
  3. 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
  4. How often should a pt do ROM exercises on bed rest?

    What is the alternative?
    bid or turn q 2 h
  5. What is the purpose of doing ROM exercises?
    to prevent contractures
  6. What are contractures?
    permanent shortening of muscle, ligments, and tendons
  7. What is the only way to relieve contractures?
    cutting contracted areas
  8. 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
  9. What is perfusion and how is it affected by regular exercise?
    • blood flow with oxygen
    • increased
  10. 2 nursing interventions to decrease risks of orthostatic hypotension?
    • change positions slowly
    • get baseline vitals
  11. Use _____ & ______ devices to prevent DVT's.
    TED's and Kendal's
  12. What is it important to monitor when a pt is using TED's?  How?

    check toes for warm, pink, and able to wiggle
  13. What should you do if you cannot feel a pulse?
    listen for it
  14. How often should TED's be taken off and for how long?
    q 12 h for 30 min  / once per shift
  15. What is congruent therapy?
    using TED's and Kendal's together
  16. 2 other names for Kendal's?
    • pneumatic compression
    • sequential compression device
  17. 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
  18. What is adelectasis? 
    What indicates adelectasis?
    • collapse of alveoli at cellular level
    • cannot hear breath sounds over the area
  19. Intervention to prevent adelectasis?
    incentive spirometer
  20. ISQ1WA?
    incentive spirometer q 1 h while awake
  21. What must be documented with incentive spirometer?
    that the nurse encourage its use
  22. What can occur is a pt does not use incentive spirometer?
    secretions build up and cause pneumonia
  23. TCDBQ2H?
    turn, cough, deep breathe q 2 h
  24. CPM?
    continuous passive motion - machine bends legs
  25. 3 reasons ppl are ambulatory soon after surgery/injury?
    skin breakdown, DVT, pneumonia
  26. Every time you assess a pt on bed rest you should assess for _______.
    homan's sign
  27. When is checking homan's sign contraindicated?
    ankle surgery
  28. When should dietary be consulted on albumin level of a pt?
  29. ______ meds slow the GI system.
    pain meds
  30. 3 affects of bed rest on the GU system?
    • increased risk for urinary calculi
    • urinary stasis
    • bladder muscle tone decreased
  31. Intake and output should be _____.
  32. 5 characteristics of uring that should be documented?
    amount, color, clear, cloudy, and sediment
  33. What causes increased BUN?
    poorly perfused kidneys
  34. What causes increased creatinine?
    renal calculi & renal failure
  35. What causes decreased albumin?
    malabsorbtion or malnutrition
  36. 3 pt who are at risk for skin breakdown?
    • immobile
    • respiratory care because have to sit up
    • incontinent
  37. What is the best defense against skin breakdown?
    skin care
  38. A pt on bed rest must be turned q ___ h.
  39. Shearing?
    dragging skin across surfaces
  40. 2 parts of nursing assessment?
    • nursing history
    • physical assessment
  41. What is the nursing intervention plan based on?
    the assessment
  42. 6 considerations in making nursing diagnoses?
    pain, risk for falls, impaired walking, impaired transfer ability, impaired home maintenance, self-care defecit
  43. 3 safety measures for all pt?
    • bed in lowest locked position
    • side rails up X 2
    • call light within reach
  44. HOB?
    head of bed
  45. Degree of Fowler's, semi-Fowler's, and high Fowler's positions?
    • Fowler's - 45 - 60
    • semi- Fowler's 30
    • high- Fowler's 90
  46. What parts of the body bear the main part of the weight in all Fowler's positions?
    buttocks, sacrum, and scapulae
  47. Supine?  AKA?
    • on back with head and shoulders slightly elevated
    • dorsal recumbent
  48. Prone?
    on tummy with head to the side
  49. If a person is a prone position they need a pillow under their _____.
  50. Where should a pillow be placed when a pt is in the side-lying position?
    between the knees and ankles
  51. What is the trendelenberg position and its use?
    • head down
    • uses gravity to move up in bed
  52. When transferring from bed to chair should always lead with the healthy/weak side.
  53. Pt should be ambulated next to ______.
    the wall
  54. Most important first step when transferring a pt to a wheelchair or other chair/bed?
    lock wheels
  55. What type of damage can result from improper use of crutches?
    damage to nerves and BV's of the axillary areas
  56. When using restraints pt should be assessed q ___ h and released q ____ h.
    assess q 2 h and release q 4 h
  57. What should be done before getting a pt out of bed?
    nonskid footwear
  58. 5 functions of the skeletal system?
    support, protect, muscle attachment, mineral storage, blood cell production
  59. 3 functions of muscle?
    movement, posture, production of heat
  60. Arthritis?
    inflammation, pain, damage to joint , cartilage, and or stiffness
  61. Osteoarthritis?
    noninflammatory, progressive disorder of movable joints
  62. Sprain?
    partial tear or rupture of a joint from its attachment
  63. Dislocation?
    displacement of bone from joint with tearing of ligaments, tendons, and capsules
  64. Fractures?
    break in the continuity of a bone or cartilage
  65. Strain?
    stretching of a muscle
  66. Any illness that lowers O2 intake will alter _______.
    activity level
  67. Negetive nitrogen balance?
    diseases characterized by a larger breakdown of protein than that which is manufactured
  68. 3 types of exercise?
    isotonic, isometric, isokinetic
  69. Isotonic exercise?
    muscle shortening and active movement
  70. Isometric exercise?
    flexing muscle but not moving it
  71. Isokenetic exercise?
    muscle contractions with resistance
  72. 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