Study Guide Test 4

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  1. what are the 2 most common illnesses to happen at a nursing home because of immobility
    • pneumonia
    • UTI
  2. to effect of immobility on Psychosocial Outlook (psychoneurologic)
    • self esteem, body image, self concept
    • Exaggerated emotional responses
    • coping mechanisms (old ones are gone, or haven't been developed new ones yet)
  3. Effects of immobility on Integumentary System
    • Reduced Turgor
    • Pressure, shearing forces
    • skin tears easy, pressure causes skin to breakdown
  4. Immobility effects onUrinary System
    • Person must be upright for urinary flow
    • Urinary Stasis, Retention
    • Calculi (kidney or bladder stones
    • UTI
  5. Immobility effects on Metabolic System
    • Decreased Metabolic Rate
    • Negative Nitrogen balance (catabolism greater than anabolism
    • Anorexia
    • Negative calcium balance
  6. Immobility Effects On Respiratory System
    • ⇩resp. movement (⇩ventilation & O2/carbon dioxide exchange)
    • pooling of resp. secretions
    • Atelectasis (collapse of lobe or entire lung)
    • Hypostatic pneumonia
  7. what should nurses do to reduce the effects of immobility on the respiratory system.

    turn, cough, deep, breath
  8. what are the effects of immobility on the cardiovascular system?
    • ↑ in cardiac workload (venous vlaves, muscle contractions, gravity)
    • Orthostatic Hypotension
    • Venous Vasodilation
    • Thrombus Form(impaired venous return,hypercoaguability)
    • dependent edema
    • diminished cardiac reserve (↑HR,↓ coronary flow)
    • ↑use of Valsalve Maneuver
  9. effects of immobility on Musculoskeletal
    • Muscle changes develop rapidly
    • bones bear weight or will demineralize
    • disuse osteoporosis
    • hypercalcemia
    • contractures form
  10. what is the purpose of bedrest
    • to promote healing
    • reduce metabolic and o2 needs
    • promote tissue repair
    • decrease pain
    • relieve edema
  11. normal developementa variations
    • newborn - reflective and random
    • gross & fine motor skills are refined as people age and after they get older they start to decrease
  12. what are the principles of good body mechanics
    • wide base of support-feet wide apart
    • lower the center of gravity, bring it closer to the base of support- bend knees and hips
  13. hen the venous what does flaccid mean
    decreased muscle tone
  14. what is dependent edema
    • when venous pressure is sufficiently great, some of the serous part of the blood is forced out of the blood vessel into the interstitial spaces surrounding the blood vessels.
    • (swelling)
  15. when are sequential compression devices used?
    SCDs are used for clients who are undergoing surgery or immobilized because of illness or injury
  16. what are SCDs used for?
    • to promote venous return from the legs
    • prevent thrombi and venous stasis
  17. steps to applying SCDs
    • measure
    • place sleeve under leg
    • wrap securely around leg
    • secure with Velcro straps
    • allow 2 fingers space
    • connect to unit adjust pressure and turn on.
  18. where is dependent edema commonly located on the body?
    • sacrum and heels- pt that is in bed
    • lower legs and feet- pt sitting in chair
  19. what 3 conditions predispose a client to thrombus formation?
    • impaired venous return to the heart
    • hypercoagulability
    • injury to the vessel wall
  20. what is Virchow's Triangle?
    • 3 broad categories of factors that contribute to thrombosis
    • 1. alterations in normal blood flow
    • 2. injuries to the vascular endothelium
    • 3. hypercoaguability
  21. what are the most useful measure in predicting activity tolerance?
    • HR - strength & rhythm
    • RR -depth, rhythm
    • BP
  22. when should Heart Rate, Resp Rate, and Blood Pressure be taken if you are trying to determine activity tolerance?
    • Before (baseline)
    • During
    • Immediately After
    • 3 mins after
  23. what observations would tell nurse that pt was not tolerating the activity well?
    • sudden facial pallor
    • feelings of dizziness or weakness
    • change in level of consciousness
    • HR & RR significantly exceed baseline
    • weakening of pulse
    • Dyspnea, SOB, CP
    • Diastolic BP change of 10mmHg or more
  24. NANDA Dx:
    Activity Intolerance
    • Insufficient physiological or psychological energy to endure or complete required or desired daily activities
    • there are 4 labels that can be used after Dx label
  25. what would the plan be if the client was not tolerating activity?
    • stop immediately
    • make a plan to work patient up to the activity
  26. what assessments need to be made during ROM?
    • if the ROM is more or less than the previous day
    • does pt have any contractures
    • deformities
  27. What assessment data would the nurse use to help the nurse know when to stop ROM to a joint?
    • go to the point of slight resistance
    • never to the point of discomfort
  28. move head from upright midline position forward, so that the chin rests on the chest
    • neck - pivot joint
    • Flexion
  29. move the head from the flexed (chin to chest )
    to the upright position
    neck - pivot joint

  30. Flexion
    neck-pivot joint
    chin to chest
  31. extension

    neck-pivot joint
    • opposite of flexion
    • move head from chin to chest back upright
  32. neck - pivot joint

    move head from upright position as far back as possible
  33. lateral flexion
    neck pivot joint
    move head laterally to the right and left shoulders
  34. move head laterally left or right to shoulders
    lateral flexion

    neck- pivot joint
  35. move head from upright position as far back as possible

    neck pivot joint
  36. shoulder - ball and socket'
    raise arm forward and upward to a position beside the head

    move arm from vertical position forward and down to rest by side
  37. move arm from resting position at side back behind the body

  38. shoulder
    move arm laterally from the sides up to a position by the head
  39. shoulder

    • move arm laterally from side across the front of the body as far as possible
    •  arm may be bent or straight
  40. shoulder  ball and joint

    move each arm forward, up, back and down to make full circle
  41. shoulder
    external and internal rotation
    • arm out at a right angle
    • external- move arm so fingers point upward
    • internal- move arm so fingers point down
  42. elbow - hinge joint
    rotation of supination
    • elbow bent move arm so that forearm and palm are facing up
    • opposite or pronation where the forearm and palm face down
  43. proprioception
    awareness of posture, movement, and changes in equilibrium
  44. what assessment needs to be made during ROM
    goniometric measurements
  45. semi fowlers
    • head and trunk are raised  degrees
    • degrees of elevation
  46. Fowler's position
    45 - 60 degree angle of elevation of the upper body,
  47. high Fowler's Position
    upper body is raised 90 degrees
  48. Sim's Position
    halfway between lateral and prone, arm is behind the body
  49. Lateral Position
    Side lying, with top leg bent
  50. prone
    lay on stomach with head to one side
  51. orthopneic
    client sits in bed or on the side of the bed
  52. dorsal recumbent position
    lying on back with head and shoulders slightly elevated with a pillow
  53. What is level 1 of the 4 levels of activity intolerance
    • Walks regular pace on level ground indefinitely, climbs one flight of stairs or more but is more out of breath than normal
    • walks 1 block/500ft lvl ground, climbs 1 flight stair slowly w/o stopping
    • walks no more than 50 ft lvl ground, unable to climb stairs w/o stopping
    • Dyspnea & fatigue at rest
  54. sedentary lifestyle
    reports habit of life that is characterized by low physical activity level
  55. risk for disuse syndrome
    at risk for deterioration of body systems as a result of prescribed or unavoidable musculoskeletal inactivity
  56. impaired physical Mobility
    Limitation in independent, purposeful physical movement of the body or one of the extremities
  57. risk for Activity Intolerance
    at risk of experiencing insufficient physiological or psychological energy to endure or complete required or desired daily activities
Card Set:
Study Guide Test 4
2013-09-16 02:56:36
Nur 101Fundamentals Study Guide test

Nursing 101 Test 4
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