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220 Cards in this Set

  • Front
  • Back
The most obvious signs of prolonged immobility are often manifested in what system?
Musculoskeletal system
What are 3 adverse effects on the musculoskeletal system due to immobility?
1. atrophy of muscles
2. decrease in strength and endurance
3. disuse osteoporosis
A decrease in muscle mass is referred to as _________.
atrophy
What occurs when muscle fibers don't contract as much as they do with normal activity?
atrophy
As much as a ____% loss of in muscle mass may occur after only 1 week of bedrest and each succeeding week following.
20%
The decrease in strength and endurance is the result of what?
muscle atrophy
(def)

increased amounts of calcium are extracted from bone, resulting in a significant decrease in bone mass
disuse osteoporosis
What are 3 causes of disuse osteoporosis?
1. lack of weight bearing exercise
2. decreased muscular activity
3. complex endocrine and metabolic disturbances which cause calcium levels in the blood to increase
The complex endocrine and metabolic disturbances that accompany bedrest begin in what days of immobilization? After two weeks, the result of this is measurable by detecting an increase of what in the blood?
begins in the 2nd or 3rd day of immobilization; detectable by an increase of calcium in the blood
Calcium increases in the blood due to immobility makes clients more prone to what?
the development of kidney stones
(def)

a deformity caused by the prolonged flexion of a muscle, resulting in the shortening of the muscle, freezing of the joint and inability to extend the joint
contracture
True/False:

Contracture formation is a reversible process
False - contractures are permanent
Contractures result from what 3 complications of bedrest?
1. fibrosis
2. ankylosis
3. permanent shortening of flexor muscles
(def)

increase in the amount of fibrous connective tissue
fibrosis
(def)

fixation of joining structures whenever joints are not moved
ankylosis
In the development of contractures, why are the flexor muscles shortened rather than the extensor muscles?
because the flexor muscles are stronger
What are the 3 most common locations for the development of contractures?
1. hips
2. knees
3. plantar flexors of the ankles
To determine the nursing implications of immobility, what must you first determine?
who is at risk for the development of specific problems
What are 4 preventative strategies to protect the musculoskeletal system from the effects of immobility?
1. Body repositioning
2. Weight-bearing activity
3. encourage ADLs
4. Isotonic and isometric exercises
5. Active and passive ROM
In regards to the musculoskeletal system, why are preventative measures very important?
because once complications occur, there are no nursing measures that can be employed to correct them
Isometric or Isotonic?

Helps prevent atrophy alone
Isometric
Isometric or Isotonic?

helps prevent atrophy and contractures
Isotonic
In normal urination, the desire to urinate can be sensed by an adult when the bladder contains ___-___ cc of urine.
150-200 cc
Voluntary control of urination is possible if what 3 body systems are intact?
1. nerves supplying bladder and urethra
2. neural tracts of the spinal cord
3. motor area of the cerebrum
By age 80, there is an ____% loss of glomeruli. What does this result in?
30% loss of glomeruli

result in a loss of efficiency
Renal blood flow ________ (increases/decreases) in the elderly.
decreases
Would you expect an increase or decrease in the ability to concentrate urine with the elderly?
a decrease
What are 2 causes for excessive urination at night and increased frequency of urination in the elderly?
- loss of the ability to concentrate urine
- decrease in bladder tone
Mobility problems or neurological impairments may result in what complication with the urinary system?
urinary incontinence
Psychosocial factors may result in difficulty urinating in a hospital setting. What are 6 things that you as a nurse can do to maintain elimination habits and stimulate the micturition reflex?
1. provide privacy
2. continue measures used at home in the hospital
3. provide opportunity to use restroom at times consistent with the client's habits
4. allow adequate time
5. help client assume normal position (women seated, men standing)
6. Promote relaxation (run water, place hand in pan of warm water, warm bed pan, pour water over perineum, have client rock back/forth, gently massage lower abdomen)
8 oz of ice chips is equivalent to how many oz of water?
4 oz
What would you expect drinks containing caffeine and alcohol to do to urine production?
increase
Foods high in fluid content, such as iceberg lettuce and cooked cereal will have what effect on the production of urine?
increase
What type of foods decrease urine production?
foods high in sodium
Unless contraindicated, the nurse can encourage the client to consume how many mL of fluid per day to maintain adequate fluid intake?
2000-2500 cc
If possible, you should always offer the patient what type of fluid to encourage adequate intake?
fluid that they prefer
True/False:

To maintain adequate intake, the nurse should set a schedule for the client to drink.
true
Why should fluids be avoided before bedtime?
to prevent nocturia
True/False:

Medications always cause increased urine formation.
False -

Depending on the medication, you may see either retention of fluid or increased urine production
In regards to the urinary system, the greater the muscle tone and activity, the greater the what?
urine production
True/False:

The use of a urinary catheter can lead to poor muscle tone.
True
Why might a client have to regain urinary control after a urinary catheter is removed?
Used of a catheter can lead to poor muscle control
What type of exercise can be performed to strengthen pelvic muscles?
Kegel exercises
What effect might you see on the kidney functioning when a client has atherosclerosis?
a decrease in function
True/False:

Diabetes Insipidus decreases urine production.
False - increases urine production
What is the normal amount of urine production in a 24 hour period?
720-2000 mL
Describe the normal color and clarity of urine?
Straw or Amber colored, transparent
Describe the normal odor of urine.
Faintly aromatic
What is the normal pH of urine?
4.5-8
What is the normal range of specific gravity?
1.010-1.025
Alkaline urine may be caused by what 3 things?
1. state of alkalosis
2. UTI
3. diet high in fruits or vegetables
Acidic urine may be caused by what 3 things?
1. starvation
2. diarrhea
3. diet high in protein foods or cranberries
Which would have a higher specific gravity, concentrated or diluted urine?
concentrated
Ketones in the urine may be caused by what 3 things?
- diabetes mellitus
- starvation
- excessive asprin ingestion
Blood in the urine may be caused by what 3 thing?
1. UTI
2. kidney disease
3. bleeding from the urinary tract
When recording I&O, what three things constitute input?
- oral
- IV
- tube feedings
When recording output, what is the primary fluid recorded? What are additional fluids that may be measured?
- urine is the primary
- vomit, diarrhea, bleeding may also be recorded
True/False:

I&O is often ordered by a physician, but it can also be initiated by a nurse.
True
(def)

loss of control over micturation
urinary incontinence
What are 5 classifications of incontinence?
1. total
2. functional
3. stress
4. urge
5. reflex
(def)

total uncontrolled and continuous loss of urine; unconscious loss of urine
total incontinence
(def)

involuntary, unpredictable; passage of urine in client with intact urinary and nervous system
functional incontinence
(def)

increased intra-abdominal pressure that causes leakage of small amounts of urine; occurs in pregnancy, coughing, sneezing, laughing
stress incontinence
(def)

involuntary passage of urine after a strong sense of urgency to void
urge incontinence
(def)

involuntary loss of urine occurring at somewhat predictable intervals when a specific bladder volume is reached
reflex or overflow incontinence
What type of incontinence can be helped with kegal exercises?
stress incontinence
What are 3 treatment methods for different types of incontinence?
1. surgical
2. behavioral (kegal, bladder training, habit training)
3. pharmacological
(def)

accumulation of urine in the bladder with the inability to empty fully
urinary retention
What are 5 symptoms that may accompany urinary retention?
1. pressure
2. discomfort
3. tenderness over symphysis pubis
4. restlessness
5. diaphoresis
What is the key sign of urinary retention?
absence of urine output with bladder distention
What is retention overflow? What type of disorder is the commonly seen in?
when you void 2-3 times an hour but have no relief of distention or discomfort; commonly seen in urinary retention
UTIs account for ____% of hospital-acquired infections.
40%
What is the most common organism responsible for UTIs?
E. Coli
Are women or men more prone to UTIs?
women (due to a shorter urethra and closer proximity of meatus to anus)
Microorganisms can enter the urinary tract through the urethral meatus or the bloodstream. Which is more common?
the urethral meatus route
True/False:

Urinary retention w/ bladder distention makes a person more susceptible to UTIs
True
Alkaline urine _________ (increases/decreases) the risk for UTIs.
increases
What are 4 risk factors for UTIs?
- failure to wipe front to back
- frequent sexual intercourse
- bubble baths or shampoos
- urinary stasis
You should drink ____ 8oz glasses of water a day to flush bacteria out of the urinary system.
8
You should void every ___-___ hours to flush bacteria out of urethra and prevent organisms from ascending.
2-4
True/False:

You should void 1-2 hours after intercourse to decrease the risk of UTIs.
False- you should void immediately after
Why should you avoid using harsh soaps, bubble baths, powder or sprays in the perineal area?
to decrease your risk for UTIs
Why should you avoid tight fitting pant or other clothing that creates irritation to the urethra?
to decrease your risk for UTIs
Which is recommended for a decrease in the risk of UTIs, cotton or nylon underwear?
cotton
What is the most common cause of UTIs?
Introduction of instruments into the urinary tract
What are signs/symptoms of UTIs? (6)
1. burning upon urination
2. difficult and painful urination (dysuria)
3. fever, chills, nausea, and vomiting as condition worsens
4. frequency of urgency
5. hematuria
5. increase in WBCs in urine, giving it a cloudy appearance
6. flank pain
What are 2 treatment methods for UTIs?
1. antibiotics
2. force fluids
Routine urinalysis specimens are measured for what 3 things?
- specific gravity
- pH
- glucose levels
True/False:

A sterile container must be used to collect a urine specimen.
False - it must be clean, but not necessarily sterile
True/False:

A client should void before defecating when collecting a urine sample.
True - feces could contaminate the sample
What method is used to obtain urine for a culture and sensitivity test?
clean-catch or midstream specimen
Catheterized urine specimens must be obtained from where?
The port in the catheter; NEVER the drainage bag
What type of test is used to test renal function or urine composition (such as creatinine levels or protein quantitation)?
Timed urine specimen (requires collecting urine over a set time interval)
What happens if you miss a specimen when obtaining timed urine specimens?
it makes the results inaccurate
When is a double-voided specimen required?
at times when the specimen must be fresh
Describe the method for obtaining a double-voided specimen.
Client voids, discards that specimen, drinks plenty of fluid and voids again
What type of precautions are used when collecting urine specimens?
Universal precautions
What are 5 uses for an intermittent catheter (does not have a balloon tip)?
1. immediate relief of acute bladder distention
2. long-term management for clients with incompetent bladders
3. to obtain a sterile specimen
4. to assess for residual urine after voiding
5. to instill medications
What are 6 reasons an indwelling catheter (has a balloon) may be used?
1. obstruction to urine flow
2. clients undergoing surgical procedures involving the urinary tract or surrounding structures
3. prevent urethral obstruction from blood clots
4. accurately record output in critically ill or comatose patients
5. to prevent skin breakdown in incontinent or comatose clients
6. to provide continuous or intermittent bladder irrigation
When would an external catheter (condom) be used?
for incontinent or comatose male clients who still have complete and spontaneous bladder emptying
Why is good perineal care so important for clients with an indwelling catheter?
to prevent infection
You should force _____-_____ cc of fluid daily for clients with indwelling catheters.
2000-3000
What type of foods are included in an acid-ash diet? Why do we encourage these in clients with indwelling catheters?
meat, eggs, whole grains, cranberries, prunes, plums

encouraged because acidic urine decreases the risk for UTIs
The lowest point of the tubing should be ________ (above or below) the level of urine in a drainage bag.
above
True/False:

The placement of the drainage bag of an indwelling catheter is irrelevant.
False- the bag should be place below the level of the bladder
What are some special considerations regarding the tubing of an indwelling catheter?
- should not be kinked
- lumen should not be occluded
- should be pinned to the bed and kept flat
Where should a catheter be secured on a woman? on a man?
to the inner thigh of a woman
to the abdomen of a man
How often should you observe the urine flow of a patient with an indwelling catheter? What should you specifically observe?
every 2-3 hours

observe color, odor, and any abnormal constituents
The emptying spout of an indwelling catheter should always be clamped except when?
during emptying
True/False:

To reduce costs, you may use the same emptying container for all of your patients with indwelling catheters.
False- each patient should have their own
You should turn an immobilized client every _____ hours to facilitate drainage of urine.
2
True/False:

You must have a physician's order to remove a catheter.
True
Describe the procedure for removing a catheter.
Deflate balloon by withdrawing contents with a syringe. Gently but firmly pull the catheter out
Following a catheter removal, what must be documented by the nurse?
- the amount of urine in the bag
- the time the catheter was removed
- color and clarity of urine
- intactness of the catheter
True/False:

It is normal for a client to have some dribbling of urine for a few hours after removal
true
After removing a client's catheter, you should note if the client voids. If the client has not voided in ____-____ hours, contact the physician.
6-8
How long should I&O be recorded after catheter removal?
24-48 hours
(def)

stagnation of urine in the kidneys or bladder
urinary stasis
The horizontal position often seen in immobilized clients has what effect on the urinary system?
impedes emptying urine from the kidneys
A decrease in the muscle tone of the ________ muscle compromises bladder emptying in immobilized clients.
detrusor
Urinary Stasis contributes to what 3 disorders?
UTIs
Kidney Stones
Urinary Incontinence
To prevent urinary stasis in immobilized clients, what should be done to facilitate micturition?
the client's position should be changed frequently
Immobilized client's tend to have more _________ (acidic or alkaline) urine.
alkaline
Why do you often see an increase in calcium in the urine of immobilized clients?
disuse osteoporosis
What occurs to urine production (volume) in immobilized clients?
decreases, thus is more concentrated
Bladder distention often occurs in immobilized clients. Give 2 reasons why.
1. urinary stasis
2. inability to empty the bladder completely
Calculi formation is a common problem of immobility. What are 5 contributing factors to the formation of calculi?
1. urinary stasis
2. decreased volume of urine
3. UTIs
4. increased calcium in urine
5. Alkalinity of urine
What are 3 activities that can prevent urinary stasis in an immobilized client?
1. turn at least every 2 hours
2. active and passive ROM
3. ambulate as soon as possible
What preventative measure should be implemented (if not contraindicated) to prevent a decrease in the volume of urine in an immobilized client?
force fluids, at least 2000-3000 cc a day
What are 3 methods that should be used to prevent UTIs in immobilized clients?
1. aseptic technique at all times
2. follow guidelines of catheter care
3. wellness teaching
What are 2 preventative measures to prevent an increase in the calcium in the urine of immobilized clients?
1. weight-bearing exercises
2. normal or low calcium diet
What preventative measure should be used to prevent the alkalinity of urine in an immobilized client?
keep pH about 5 by serving a diet that has an acid residue (cranberries, cheese, eggs, fish, meat, poultry)
What are signs/symptoms of kidney stones?
- pain in the back and flank area that radiates down the urinary tract (can be severe)
- nausea, vomiting, sweating, pallor (may be related to pain)
- anxiety, restlessness
- hematuria
What are 5 treatments for kidney stones?
- analgesics to relieve pain
- force fluids
- filter urine to detect the passage of calculi
- prevention
- surgery
____% of kidney stones will pass on their own.
90%
What are 3 complications of untreated kidney stones?
- infection
- hydronephrosis
- pyelonephritis
(def)

backflow of urine into the kidney; will interrupt the bloodflow to the kidney
hydronephrosis
hydronephrosis may eventually lead to the destruction of what?
nephrons in the kidney
(def)

infection of the kidney
pyelonephritis
Because of immobility, a client will have what 4 risk factors for UTIs?
1. stasis of urine
2. increases alkalinity of urine
3. urinary distention can cause minute tears in the bladder mucosa, allowing organisms in
4. indwelling catheters predispose client to infection
Excreted waste products from the GI system are called what?
feces or stool
What are the 3 types of movement of the intestines?
1. haustral churning (shuffling)
2. peristalsis
3. mass peristalsis
(def)

the movement of chyme back and forth within pouches in the large intestine
haustral churning
(def)

wavelike movement that propels intestinal contents forward
peristalsis
(def)

a wave of powerful muscular contraction that moves over large areas of the colon
mass peristalsis
When does mass peristalsis occur (what stimulates it)?
after eating, stimulated by the presence of food in the stomach and small intestine
(def)

expulsion of feces from the anus and rectum
defecation (bowel movement)
True/False:

You should have 2 bowel movements per a day to be considered regular.
False- it is highly individualized, ranging from several times a day to 2-3 times a week
Describe what occurs after peristalsis moves feces into the sigmoid colon and rectum?
sensory nerves are stimulated and the individual becomes aware of the need to defecate
What occurs to the internal anal sphincter becomes stimulated with nerves that supply that area?
it relaxes automatically
True/False:

The external sphincter relaxes automatically once sensory nerves in that region detect that you need to have a bowel movement.
False- external sphincter is controlled by the individual if no deficits are present
How does the contraction of abdominal muscles and the diaphragm contribute to having a bowel movement?
increases abdominal pressure
Contraction of the _______ _____ muscles of the pelvic floor assist a person in having a bowel movement.
levator ani
How does thigh flexion assist a person with having a bowel movement?
increases pressure in the abdomen
Why does a sitting position assist a person in having a bowel movement?
increases downward pressure on the rectum
What happens if the need to defecate is ignored repeatedly?
can lead to a loss of sensation to defecate
What are 4 changes in the elderly that affect defecation?
1. loss of teeth
2. decreases digestive enzymes in saliva, decreased gastric acids
3. decreased peristalsis
4. less sensitivity to nerve impulses
True/False:

a high fiber diet promotes peristalsis
True
What are examples of high fiber diets?
raw fruits (apples/oranges)
cooked fruits (prunes, apricots)
greens (spinach, cabbage)
whole grains (cereal, breads)
Fluid intake should be _____-_____ cc/day to liquefy intestinal contents.
1400-2000
What should be done if a client is losing excess fluid from vomiting or wound drainage?
increase fluid intake
True/false:

Hot beverages and fruit juices harden stool and decrease peristalsis.
False- they soften stool and increase peristalsis
What 2 diets recommendations should be followed to promote regular defecation?
- adequate fluid intake
- high fiber diet
How does increased physical activity encourage regular defecation?
- promotes peristalsis
- prevents weakened abdominal muscles and pelvic floor muscles
If a client is immobile, what type of exercise should be encouraged to strengthen the abdominal and pelvic muscles in order to promote regular defecation?
- isometric exercises
True/False:

Psychological factors can cause peristalsis to increase or decrease.
True
What time of the day is the gastrocolic reflex most easily stimulated?
after breakfast
True/False:

Privacy is important to many people in regards to defecation
True
As a nurse, what can you do for a client to encourage regular defecation?
- encourage client to defecate when the urge is recognized
- allow client to remain on established schedule
- allow for adequate time to defecate
- provide privacy
What are normal positions/activities that assist in defecation?
- leaning forward
- squatting
- exerting intra-abdominal pressure
- contracting thigh muscles
Why would providing a bedside commode be helpful in encouraging a client to defecate?
it allows for mimicking of normal positioning
How might pain in the rectal area affect defecation?
may cause a person to suppress the urge and become constipated
What are 2 examples of medications that soften stool?
- laxatives
- cathartics
True/False:

Overuse of cathartics or laxatives may be harmful.
True
How does surgery affect defecation? How does surgery involving direct manipulation of the bowels affect defecation
- surgery and anesthesia can slow down peristalsis
- surgery involving direct manipulation of the bowel stops peristalsis
Absence of bowel sounds following a surgery that involves direct manipulation of the bowel is known as what?
paralytic ileus
Diagnostic tests of the GI system often require that the patient must do what 2 things?
- client may be NPO
- client may have laxatives or enemas
Black or tarry stool may indicate what 3 things?
- bleeding from upper GI
- drugs (such a iron)
- diet high in red meat and dark greens
Red feces may indicate what 2 things?
- blood in lower GI
- intake of certain foods (ex. beets)
Pale feces may indicate what? (2)
- malabsorption of fats
- diets high in milk and low in meat
Hard, dry feces may indicate what 5 things?
- dehydration
- lack of fiber
- lack of exercise
- emotional upset
- laxative abuse
Increased intestinal motility results in what?
diarrhea
What is the normal shape of feces?
cylindrical and about 1" in diameter
Narrow, pencil shaped stool may indicate what?
obstructive condition of the rectum
Pus in stool may indicate what?
bacterial infection
Mucus in stool may indicate what?
inflammatory condition
Blood in stool may indicate what?
gastrointestinal bleeding
Large quantities of fat in stool may indicate what?
malabsorption
(def)

decrease in frequency of bowel movements accompanied by prolonged or difficult passage of hard, dry stools
constipation
True/False:

Constipation is a disease.
False- constipation is a symptom
What is a common problem associated with straining due to constipation?
hemorrhoids
The valsalva maneuver is especially dangerous in clients with what 3 conditions?
- cardiac disease
- glaucoma
- increased intracranial pressure
What are (7) causes of constipation?
1. irregular habits or ignoring urge to defecate
2. lower fiber diet, low fluid intake
3. heavy laxative use
4. anticholinergic medications
5. advanced age (slows peristalsis, decreases muscle, decreases mucus secretions)
6. bowel obstruction, paralytic ileus, diverticulitis
7. neurological conditions that block impulses from the colon
What are signs/symptoms of constipation?
- decreased frequency of defecation
- hard, dry stool
- straining
- painful defecation
- abdominal pain
- abdominal distention
- rectal pressure or fullness
- headache
- impaired appetite
What should ultimately be treated in order to treat constipation?
the underlying cause
(def)

collection of hardened feces wedged in rectum that cannot be expelled
fecal impaction
What causes fecal impaction?
unrelieved constipation
In severe cases of fecal impaction, the impaction may extend to where?
the sigmoid colon
What clients are at the highest risk for fecal impaction?
- debilitated
- confused
- unconscious clients
What are 3 signs/symptoms of fecal impaction?
- inability to pass stool despite the urge to defecate
- oozing of diarrhea; causes b/c liquid portion seeps around impacted mass
- anorexia, abdominal distention, cramps, and/or rectal pain
How is fecal impaction confirmed?
digital exam
True/False:

Digital exam to confirm fecal impaction requires a doctor's orders.
true
Why is a dr.'s order required to confirm a fecal impaction by digital exam?
b/c vagus nerve stimulation could lower the heart rate, or accidental perforation of the bowel could occur
How do you treat a fecal impaction?
manually remove it using oil or retention enema
(def)

an increase in the number of stools and passage of liquid unformed feces
diarrhea
Why does diarrhea occur?
b/c intestinal contents move through bowel too quickly to allow for proper absorption of fluid
Infants and older adults are particularly susceptible to what complication of diarrhea?
fluid and electrolyte imbalance
What are 8 possible causes of diarrhea?
1. emotional stress
2. intestinal infection
3. food allergies
4. food intolerance (greasy, spicy, alcohol)
5. medications
6. laxatives
7. colon disease (colitis, Crohn's disease)
8. surgical alterations
(def)

inability to control passage of feces and gas from the anus
incontinence
Incontinence of the bowel may be caused by what 2 types of conditions?
- those that impair anal sphincter function and control
- those that create frequent, loose, large volume, watery stools
Incontinence predisposes the skin to what?
breakdowns
(def)

accumulation of gas in the intestine resulting in stretching of bowel wall and distention
flatulence
Normally a person produces several hundred milliliters of gas. When is this problematic?
when it occurs during (or due to) decreased intestinal motility
True/False:

Flatulence can cause SOB.
True - if it becomes severe enough, flatulence can press against the diaphragm and cause SOB
(def)

dilated engorge veins in the lining of the rectum
Hemmorrhoids
What is the most common problem in the digestive system associated with immobility?
constipation (which could lead to fecal impaction)
Since defecation is highly individualized, what should be assessed to determine what is normal for each client? (8)
1. diet
2. fluid intake
3. physical activity
4. psychological factors
5. personal habits
6. position during defecation
7. medications
8. any recent surgery or diagnostic test
What are (4) contributing factors for the development of dysfunctional digestive patterns (ex. constipation) in an immobilized client?
1. lack of exercise leads to muscle weakness
2. decreased fluid intake may occur
3. may have to use bedpan (affects normal position and privacy)
4. inability to maintain personal habits
What is the overall goal for the nurse when addressing the digestive system and an immobilized client?
To maintain normal functioning and prevent constipation
To maintain normal functioning of the digestive system and prevent constipation, what might the nurse have to administer to an immobilized client?
- laxatives or stool softeners