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148 Cards in this Set
- Front
- Back
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Immobility & bed rest on CVS |
Increased cardiac workload, increased risk for orthostatic hypotension, increased risk for venous stasis and venous thrombosis |
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Immobility & bed rest on respiratory |
Decreased rate & depth of respirations, pooling of lung secretions, hypostatic, atelectas, decreased gas exchange |
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Immobility & bed rest on GI |
Appetite disturbance, decreased fluid intake, poor digestion, decreased peristalsis, constipation, weight gain |
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Immobility & bed rest on urinary |
Increased UTI, increased urinary retention & incontinence |
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Abduction |
Lateral movement of body part away from midline of body |
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Active |
The amount of joint motion produced by voluntary muscle contraction |
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Bedrest |
The confining of a patient to bed for rest |
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Contracture |
Permenantly contracted state of a muscle |
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Flexion |
Action of bending or condition of being bent (limb or joint) |
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Foot drop |
Complication resulting from extended plantar flexion |
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Gait |
A manner of walking |
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Passive |
Manual or mechanical means of moving the joints |
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Supination |
The turning of the palm or hand anteriorly or the foot inward and upward |
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Commode |
A receptacle suitable for use as toilet |
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Dangle |
Position in which the person sits on the edge of the bed with legs & feet |
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Fowler position |
Head of the bed adjusted 40 to 60 degrees |
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Orthostatic hypotension |
Temporary fall in blood pressure associated with assuming an upright position |
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CVA |
Cerebrovascular accident |
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Hemiplegia |
Paralysis of one side of body usually resulting from damage to the corticospinal tracts of CNS |
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Paraplegia |
Paralysis of lower portion of body and both legs |
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Quadriplegia |
Paralysis of all four extremities |
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PWB |
Partial weight bearing |
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FWB |
Full weight bearing |
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Immobility & bed rest on musculoskeletal |
Tone size, strength, mobility, flexibility, demineralization, endurance, stability, contractures |
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Immobility & bed rest on psychosocial well being |
Depression, lack of socialization, sleep, role changes in life, everyone will cope differently, increased sensory, lack of stimulation |
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Immobility & bed rest risks |
Contractures, osteoperosis, muscle atrophy, pressure ulcers, lack of socialization, stimulation, infection, constipation, atelectasas, impaired cognitive function, orthostatic hypotension, nutritional deficits, sleep cycle altered |
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What to assess before transferring client |
Check ADLs/ care plan, client assessment/pre handling client, environment assessment |
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Client assessment |
Ability to weight bear, strength in both legs & arms, balance |
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Work area check |
Space available, equipment, arrangement of furniture, lighting, floor surface, breaks & height on bed/chair, ability of transfer belt/ lift |
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Rules for walker/cane |
Should be lined up with crease of wrist, elbows should be flexed 30 degrees, when rising from seated position use bed or chair for support |
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Dysuria |
Pain or discomfort when urinating |
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Urgency |
An immediate unstoppable urge to urinate due to a sudden involuntary contraction of the bladder |
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Frequency |
Urinating at too often at too frequent intervals |
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Hesitancy |
An involuntary delay or inability in starting the urinary stream |
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Nocturia |
Excessive urination at night |
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Polyuria |
Excessive passage of urine- sign of diabetes mellitus |
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Health care record |
Chart (online or in binder) |
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kardex |
Care plan |
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Personal information protection and electronic documents act (PIPEDA) |
Canadian law related to data privacy |
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Referrals |
Referring patient to another health care provider |
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Confidentiality |
Maintenance of privacy by not sharing or divulging to a third party |
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Consultations |
Diagnosis & proposed treatment by 2 or more health care workers at one time |
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Reports |
The account usually verbal and often tape recorded that nursing staff going off duty gives to the oncoming staff , to provide continuity of care despite the change in staff |
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Exudate |
Plasma and blood that can leak |
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Erythema |
Reddening of the skin caused by dilation of superficial blood vessels in the skin |
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Ecchymosis |
Bruising |
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Blanching |
To lose colour esp of the face |
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Ischemia |
A temporary deficiency of blood flow to an organ or tissue |
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Hyperemia |
Rapid blood flow to area |
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Reactive hyperemia |
Rapid blood flow to area after pressure |
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Slough |
Moist, yellow stringy tissue |
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Eschar |
Black leathery tissue |
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Serous |
Clear to light yellow |
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Sanguineous |
Blood bright red |
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Serosanguineous |
Pink |
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Charting by exception |
Charting any exceptions that you found |
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Abrasion |
Scraping away of skin or mucous membrane as a result of injury |
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Contusion |
Bruise |
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Laceration |
A wound or irregular tear of the flesh |
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Pressure ulcer |
Damage to skin or underlying structures from compression of tissue and inadequate perfusion |
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Penetrating wound |
A wound in which the skin is broken and agent causing the wound enters subcutaneous tissue |
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Puncture wound |
Wound made by sharp pointed instrument |
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Granulation tissue |
Fleshy projections formed on surface of a gaping wound that is not healing by first intention |
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Necrotic tissue |
Dead tissue |
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Debridement |
The removal of foreign material and dead or damaged tissue |
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Contaminated |
The introduction of pathogens or infectious material into or on normally clean or sterile objects spaces or surfaces |
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Macerated |
The softening of a solid by steeping in a fluid |
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Indurated |
Hardening |
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Hematoma |
A swelling comprising a mass of extravasated blood confined to an organ, tissue or space and caused by break in blood vessel |
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Purulent |
Forming or containing pus |
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Name and describe the phases of wound healing |
Hemostasis, inflammatory, reconstruction, maturation |
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Dysphagia |
Difficulty swallowing |
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What are common diseases associated with dysphagia |
CVA, head injury, MS, parkinson's disease, cerebral palsy, spinal cord injury, alzheimer's, huntington's disease, head/neck cancer |
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Anorexia |
Loss in appetite |
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Dysphasia |
Difficulty with speech |
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Malnutrition |
Deficiency and excess(or imbalance) of energy protein and other nutrients |
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How do you use crutches on stairs and curbs |
Up with good leg down with bad |
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Micturation |
Pass urine from the bladder |
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Diuresis |
The secretion and passage of large amounts of urine |
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What does the urethra do? |
Conveys urine from the bladder to the exterior |
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Immobility & bed rest on integumentary |
Can lead to pressure ulcers |
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What factors do you assess before transferring or mobilizing a client |
1.check ADL/ care plan (kardex) 2.client assessment/prehandling check 3.environment assessment 4. Ready |
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Client assessment before transferring or mobilizing a client |
1.physical ability (pre handling check) 2.ability to weight bear 3.strength in both legs and arms 4.balance |
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Cognitive abilities in patient before transferring or mobilizing |
Do they follow instructions? Are they hostile? Disoriented or withdrawn? Tired or fatigued? Visual, hearing or language problems? Sedated from medication? Pain? |
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When do you use an overhead or mechanical lift? |
Cannot or will not bear weight, cannot or will not follow instructions, unable to assist in getting up off floor, unpredictable in behavior or physical ability, greater risk in manual lift, staff do not feel comfortable, does not pass pre handling check |
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Safety using canes walkers and crutches |
Rubber soles, well fitting shoes, check rubber tips/ connections, well lit clear path, avoid water, powder, loose floor rugs, stand erect, look straight ahead, use transfer belt, walk behind and slightly to one side of pt |
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Safety for walker |
Should be lined up with crease of wrist, elbows should be flexed 30 degrees, when rising from seated position use bed or chair for support, always step into walker |
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Safety using cane |
Cane is held on pts strong side and advanced 4 to 12 inches, pt with poor balance should use canes with 3 or 4 feet to provide base, stand erect |
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Safety using crutches |
Should be able to fit width of 4 fingers between top of crutcu and axilla, weight of body is taken through hands & arms never axilla (can lead to chaffing and nerve damage) |
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Homeostasis |
State of equilibrium inside of the body, naturally maintained by adaptive responses that promote healthy survival |
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What will nurses do regarding fluid imbalances |
Anticipate potential for alterations, recognizes s&s of imbalances, intervene with appropriate actions |
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Disorders that cause fluid imbalance |
Heart failure, respiratory failure, excessive GI loss, renal failure, burns, dehydration, diabetic ketoacidosis |
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Water function in body |
Constant motion, maintains blood volume, transports nutrients, transports electrolytes, transports oxygen to cells, transports waste away from cells, regulates body temp, lubricates joints & membranes, medium for food digestion |
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Causes of dehydration |
Diarrhea, vomiting, fevers, heat related illness, diabetes mellitus, diuretics |
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Patients at risk for dehydration |
Impaired LOC, inability to take oral fluids, older adults, patients with watery diarrhea, ADH deficiency,excessive fever, excessive sweating with no fluid replacement |
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What do electrolytes do |
Help regulate water distribution, govern acid base balance, transmit nerve impulses, contribute to energy generation, contribute to blood clotting, molecules split into ions when placed into a solution, |
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What does the urethra do? |
Conveys urine from bladder to exterior |
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What are characteristics of urine |
Colour- pale yellow straw coloured or amber Odor-aromatic Turbidity- clear or translucent pH- about 6.0 with range of 4.6 to 8 specific gravity, constituents |
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Anuria |
24 hour urine output is less than 50 ml. Kidney shutdown or renal failure. |
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Glucosuria |
Presence of sugar in urine |
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Proteinuria |
Protein in urine |
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Pyuria |
Pus in urine- appears cloudy |
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Oliguria |
Scanty or greatly diminished amount of urine voided in a given time; 24 hour urine output is less than 400 mL |
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What are factors affecting micturition? |
Developmental considerations, food and fluid intake (2000-2400 is normal), psychological variables, activity and muscle tone, pathologic conditions, medications |
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Disease associated with renal problems |
Congenital urinary tract abormalities, polycystic kidney disease, UTI, urinary calculi, hypertension, diabetes mellitus, gout |
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Effects of DIURETICS on urine production & elimination |
Prevent reabsorption of water and certain electrolytes in tubules |
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Effects of cholinergic medications on urine production & elimination |
Stimulate contraction of detrusor muscle, producing urination |
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Effect of analgesics and tranquilizers on urine production and elimination |
Suppress CNS, diminish effectiveness of neutral reflex |
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Colour of urine from anticoagulants |
Red..may cause hematuria |
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Colour of urine from diuretics |
Pale yellow |
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Colour of urine from Pyridium |
Orange to orange red urine. Used to relieve symptoms caused by UTI |
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Colour of urine from Elavil |
Green or blue green urine |
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Colour of urine from Levodopa |
Brown or black urine (iron) |
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Nursing process for urinary elimination |
Assess data about voiding patterns, habits, past history of problems, physical examination of bladder, if indicated and urethral meatus, assessment of skin integrity amd hydration, exam of urine - correlation of findings with results of procedures and diagnostic tests |
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How to assess a problem with voiding |
Explore duration, severity, and precipitating factors, note patient's perception of the problem, check adequacy of patient's self care behaviors |
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What to assess with urinary functioning |
Kidneys, urinary bladder, urethral orifice, skin, urine |
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How to promote normal urination |
Maintaining normal voiding habits, promoting fluid intake, strengthening muscle tone, assisting with toileting |
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How to maintain normal voiding habits |
Schedule, urge to void, privacy, position, hygiene, |
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What patients are at risk for UTIs |
Sexually active women, women who use diaphragms for contraception, postmenopausal women, individuals with indwelling urinary catheter,individuals with diabetes mellitus, older adults |
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Reported and recorded information enables the health care team to: |
Plan care that will meet the unique needs of each client, monitor the client's response to treatment, evaluate the client's progress |
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What is included in the chart? |
Admission sheet, physicians order sheet, history sheet, graphic sheet, nurses notes, progress notes, diagnostic tests, consent forms |
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What is the client's chart used for? |
Communication, legal documentation, research, education, statistics |
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Information in a chart must be: |
Factual, accurate, complete, current, organized, and confidential |
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How is info presented factual in a chart? |
Descriptive, objective information about what a nurse hears sees feels and smells |
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How is info in a chart presented accurate? |
Use of institution's accepted abbrieviations & symbols, correct spelling, accurate timing of entry, chronological order, end with caregiver's name and status |
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How currentness is presented in a chart |
Vital signs, administration of med or treatment, any change in condition of client, admission, transfer and discharge |
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Legal guidelines for documenting |
Write legibly in ink, record only facts, do not erase, apply white out or scratch out errors, do not leave blank spaces, ensure that entry has time, date & ends with signature & status, chronological order, addressograph stamp each page, acceptable abbreviations, do not generalize, chart refusals of care, chart when clients leave & details |
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DARP |
Data , action, response, plan |
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What are the 3 layers of the skin? |
1. Epidermis 2. Dermis 3. Subcutaneous tissue |
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Unbroken & healthy skin and mucous membranes do what? |
Defend against harmful agents, regulate temperature, appearance and self esteem, sensation, vitamin D production, absorption & elimination |
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Resistance to injury is affected by what? |
Age, amount of underlying tissues and illness |
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What kind of body cells are resistant to injury? |
Adequately nourished and hydrated body cells |
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What is necessary to maintain cell life? |
Adequate circulation |
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What are the different types of wounds? |
Intentional, unintentional, open, closed, acute, chronic, |
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What is an intentional wound? |
IV's, surgical, edges are clean |
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What is an unintentional wound? |
Trauma or burns, high risk for infection, take longer to heal |
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What is an open wound? |
Skin is broken |
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What is a closed wound? |
Tissue damaged underneath, ecchymosis, hematomas |
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What is an acute wound? |
Surgical, quick healing process |
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What is a chronic wound? |
Healing process is impeded |
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Principles of wound healing |
1.Intact skin is first line of defense against microorganisms 2. surgical asepsis is used in caring for a wound, 3. clean technique is used for abrasions such as excoriation 4. an adequate blood supply is essential for normal body response to injury 5. normal healing is promoted when wound is free of foreign materal 6.extent of damage and persons state of health affect wound healing 7. Response to wound is more effective if proper nutrition is maintained 8. Wounds kept moist will heal faster as opposed to kept dry, because cells migrate across a moist surface |
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Primary/first intention of wound healing |
Surgical, edges straight, together, low risk for infection, edges meet in approximately 24-48 hours |
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Secondary intention for wound healing |
Loss of tissue function |
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Tertiary function in wound healing |
Wait for edema to drain |
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Explain hemostasis |
Occurs immediately after inital injury, involved blood vessels constrict and blood clottong begins, exudate is formed causing swelling and pain, increased perfusion results in heat and redness, platelets stimulate other cells to migrate to the injury to participate in other phases of healing |
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Explain inflammatory phase |
Follows hemostasis and lasts about 4 to 6 days, WBCs move to the wound, macrophages enter wound area and remain for extended period, they ingest debris, and release growth factors that attract fibroblasts to will in wound |
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List 4 ways to minimize risk of UTI in catheterized clients |
Keep catheter bag below bladder, maintain proper hand hygiene and use PPE when touching catheter, check tubing for kinks, change catheter bag regularly |
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Common eating problems |
Dysphagia, drooling, disorientation, poor hand to mouth coordination, weak grasp, poor vison, sore mouth or throat, thick saliva |
