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236 Cards in this Set
- Front
- Back
What are the fat soluble vitamins?
|
A
D E K |
|
What are the water soluble vitamins?
|
B complex (Thiamin, Riboflavin, Niacin, B6, Folate, B12)
C |
|
What is the function of vitamin C?
|
collagen formation
antioxidant enhances iron absorption |
|
What are the s/s of vitamin C deficiency?
|
scurvy
hemorrhaging delayed wound healing |
|
What are the s/s of vitamin C excess?
|
kidney stones
N/V |
|
What are the food sources of thiamin?
|
pork
liver whole/enriched grains |
|
What is the function of thiamin?
|
it is a coenzyme in key energy reactions
|
|
What are the s/s of thiamin deficiency?
|
beriberi
fatigue mental confusion |
|
What are the food sources of riboflavin?
|
dairy products
organ meats |
|
What is the function of riboflavin?
|
nutrient metabolism
|
|
What are the s/s of riboflavin deficiency?
|
inflammation
poor healing |
|
What are the food sources of niacin?
|
grains
lean meat |
|
What is the function of niacin?
|
nutrient metabolism
|
|
What are the s/s of niacin deficiency?
|
pellagra
dermatitis |
|
What are the s/s of niacin excess?
|
flushing
itching N/V |
|
vitamin found in fruits and dark green vegetables
functions as a coenzyme in metabolism s/s of deficiency: anemia, CNS problems, confusion s/s of excess: difficulty walking |
B6 (pyridoxine)
|
|
vitamin found in green leafy vegetables and liver
functions in RNA and DNA synthesis; and the formation and maturation of RBCs s/s of deficiency: macrocytic anemia (fatigue, weaknes, pallor) |
folate
|
|
vitamin found in only animal and fortified foods - organ meats, meat, seafood
functions as a coenzyme in protein metabolism and the formation of the heme portion of hemoglobin s/s of deficiency: pernicious anemia due to lack of intrinsic factor or alcoholism |
B12 (cobalamin)
|
|
vitamin found in fruits and dark green vegetables
functions as a coenzyme in metabolism s/s of deficiency: anemia, CNS problems, confusion s/s of excess: difficulty walking |
B6 (pyridoxine)
|
|
vitamin found in green leafy vegetables and liver
functions in RNA and DNA synthesis; and the formation and maturation of RBCs s/s of deficiency: macrocytic anemia (fatigue, weaknes, pallor) |
folate
|
|
vitamin found in only animal and fortified foods - organ meats, meat, seafood
functions as a coenzyme in protein metabolism and the formation of the heme portion of hemoglobin s/s of deficiency: pernicious anemia due to lack of intrinsic factor or alcoholism |
B12 (cobalamin)
|
|
vitamin found in liver, carrots, and egg yolk
functions in visual acuity and healthy skin s/s of deficiency: night blindness, rough skin s/s of excess: anorexia, loss of hair, dry skin |
vitamin A (retinol)
|
|
vitamin found in fortified milk and sunlight
functions in calcium and phosphorus metablism, stimulates calcium absorption s/s of deficiency: retarded bone growth s/s of excess: excessive calcification of bones, renal calculi |
vitamin D
|
|
vitamin found in liver, carrots, and egg yolk
functions in visual acuity and healthy skin s/s of deficiency: night blindness, rough skin s/s of excess: anorexia, loss of hair, dry skin |
vitamin A (retinol)
|
|
vitamin found in fortified milk and sunlight
functions in calcium and phosphorus metablism, stimulates calcium absorption s/s of deficiency: retarded bone growth s/s of excess: excessive calcification of bones, renal calculi |
vitamin D
|
|
vitamin found in liver, carrots, and egg yolk
functions in visual acuity and healthy skin s/s of deficiency: night blindness, rough skin s/s of excess: anorexia, loss of hair, dry skin |
vitamin A (retinol)
|
|
vitamin found in fortified milk and sunlight
functions in calcium and phosphorus metablism, stimulates calcium absorption s/s of deficiency: retarded bone growth s/s of excess: excessive calcification of bones, renal calculi |
vitamin D
|
|
vitamin found in vegetable oils and whole grain products
functions as an antioxidant, protects vitamin A, heme synthesis s/s of deficiency: anemia s/s of excess: fatigue, diarrhea |
vitamin E
|
|
vitamin found in dark, green leafy vegetables
synthesized in intestines from gut bacteria functions in blood clotting s/s of deficiency: delayed blood clotting s/s of excess: hemolytic anemia and liver damage |
vitamin K
|
|
mineral found in dairy products and green
functions in bone/tooth formation and nerve transmission s/s of deficiency: tetany, osteoporosis s/s of excess: renal calculi |
calcium
|
|
mineral found in soft drinks, processed foods
function in bone/tooth formation and acid-base balance s/s of deficiency: muscle weakness s/s of excess: symptoms of hypocalcemic tetany |
phosphorus
|
|
mineral found in green leafy vegetables, nuts, beans
function in bone/tooth formation, protein synthesis s/s of deficiency: poor heart function, torsade de pointe s/s of excess: CNS depression |
magnesium
|
|
mineral found in salt and IV saline
major ion of extracellular fluid s/s of deficiency: clammy skin, confusion, leg cramps s/s of excess: edema, thirst, pattern of weight gain, high BP |
sodium
|
|
mineral found in whole grains, fruits
major ion of intracellular fluid s/s of deficiency: muscle cramps, weaknes, u-wave on EKG s/s of excess: irritability, tall/tented T's on EKG |
potassium
|
|
micromineral found in lean and organ meats
functions in oxygen transport by way of hemoglobin s/s of deficiency: microcytic anemia, pallor fatigue s/s of excess: GI symptoms, possible shock |
iron
|
|
micromineral found in seafood and food additives
functions as a component of thyroid hormones s/s of deficiency: goiter s/s of exces: acne-like lesions |
iodine
|
|
Polysaccharides which cannot be digested and provide no energy
|
fiber
|
|
component of bile salts that aids in digestion; component of cell membranes, required for hormone production, produced in liver of all mammals in response to genetic tendency, saturated and total fat intake
|
cholesterol
|
|
What vegetables are high in fat?
|
avocado
coconut olives |
|
What is the primary role of nurses r/t nutrition?
|
keep patients from starving
|
|
A serving/exchange of carbohydrates in a diabetic diet equals _______ grams or ____ calories.
|
15 grams
60 calories |
|
lipoprotein that transports triglycerides drom the liver to the tissues
|
very-low-density lipoprotein (VLDL)
|
|
plasma protein with triglyceride components that carries cholesterol to cells
|
low-density lipoprotein (LDL)
|
|
plasma protein that carries fat in bloodstream to tissue or to liver to be excreted
|
high-density lipoprotein (HDL)
|
|
What is the diet for gastric bypass?
|
small meals: low fat, high protein
NO carbonated beverages |
|
type of diet that minimizes elimination, restricts high fiber food, fried food, pepper, alcohol, and heavy seasonings
|
low-residue diet
|
|
type of diet for malabsorption, chronic pancreatitis, gallbladder disease, or patients with CVD, CHF
|
fat-controlled diet
|
|
type of diet for patients with renal disease or liver disease
|
protein-controlled diet
|
|
What is restricted in patients with celiac disease?
|
gluten (wheat, barley)
|
|
type of diet used for patients with gout, tumor lysis syndrome, or multiple myeloma
use dairy products; restrict organ meats, anchovies, alcohol, and seafood |
purine-controlled diet
|
|
type of diet used for patients with renal failure (treats hypertension, fluid restrictions, CVD)
|
sodium-controlled diet
|
|
type of diet used for patients with diabetes
|
carbohydrate-controlled diet
|
|
type of diet that promotes normal bowel function (complex carbs, low fat, whole grains, vegetables, fruits)
|
high-fiber diet
|
|
type of diet used for patients with potassium losses (ex. ppl on diuretics)
contains orange juice, apricots, cantaloupes, and bananas |
high-potassium diet
|
|
type of diet used for patients with osteoporosis or kidney failure
|
high-calcium diet
|
|
type of diet used specifically by some athletes
dietician or MD needs to prescribe this |
high-protein diet
|
|
type of diet used by patients with impaired immune function
restricts fresh fruits, raw veggies, nuts, seeds, dried fruits, black pepper, any foods that carry pseudomonas heat treat all foods to destroy bacteria |
neutropenic diet
|
|
What nutrition care should be used for patient with cancer?
|
small frequent meals (nutrient DENSE --> high calorie and high protein)
add extra nutrient dense foods such as honey, powdered skim milk, peanut butter, and cheese limit liquids with meals - they contribute to nausea |
|
What are some nutrition interventions nurses can do with HIV/AIDs patients?
|
Monitor weight and protein status (albumin, transferrin, total lymphocyte count)
Good handwashing, food safety, low-fat diets, and small frequent nutrient dense meals possible neutropenic diet |
|
What is the BRAT diet?
|
bananas, rice, applesauce, and toast
used for clients with GI upset (esp. used after flu or other virus) |
|
used for provide essential fatty acids
exist in different concentrations (10-30%) considered isotonic clients allergic to ________ should not get this solution |
IV lipids
eggs |
|
type of diet that consists of broth, bouillon, coffee, tea, carbonated beverages, clear fruit juice, gelatin, and popsicles
|
clear liquid diet
|
|
type of diet that consists of clear liquids as well as smooth-textured dairy products, custards, refined cooked cereals, vegetable juice, pureed vegetables and all fruit juices
|
full liquid diet
|
|
type of diet that consists of all liquids plus scrambled eggs, pureed meats, vegetables, fruits, mashed potatoes, and gravy
|
pureed diet
|
|
type of diet that consists of all liquids, pureed foods, and also ground/finely diced meats, flaked fish, cottage cheese, rice, potatoes, pancakes, light breads, cooked veggies, cooked/canned fruits, bananas, soup, and peanut butter
|
mechanical soft diet
|
|
type of diet that includes liquids, pureed, soft foods, as well as low-fiber, easily digested foods (pasta, casseroles, moist meats, desserts, cakes, and cookies without nuts/coconut)
|
soft/low residue
|
|
A low cholesterol diet limits cholesterol to:
|
300 mg/day
|
|
If the patient's ABGs and O2 sat are normal, the problem is NOT with _________________.
|
gas exchange
|
|
the sticky pads/tabs that attach to skin and pick up electrical energy for transmission on an EKG
|
electrodes
|
|
the wires that connect electrode to the EKG equipment
also the standardized patterns of electrode placement; they provide an electrical view of the heart |
leads
each lead has a negative and positive pole |
|
On EKG paper, the smallest vertical squares represent:
|
1 mm voltage (measure height and depth of a wave)
|
|
On EKG paper, the smallest horizontal squares represent:
|
0.04 seconds
|
|
a clinical syndrome resulting in decreased blood flow to body tissues causing cellular dysfunction and eventual organ failure
|
shock
|
|
acute and possibly life threatening allergic reaction that results in increased capillary permeability and dilation of arterioles due to severe Type I hypersensitivity response
can cause SOB, bronchospasm, laryngeal edema, hypotension, and rash |
anaphylaxis
|
|
the effective delivery of oxygen-rich blood to the tissues
OR treating with oxygen |
oxygenation
|
|
term that refers to the cardiovascular element of oxygenation
|
tissue perfusion
|
|
the molecular exchange of gases (oxygen and carbon dioxide) in the respiratory system
|
respiration (breathing independently)
|
|
the process of moving air into and out of the lungs; the act of breathing which include inhalation and exhalation
|
ventilation (assisted breathing)
|
|
What are the earliest signs of hypoxia?
What are later signs of hypoxia? |
anxiety
restlessness diminished mental acuity or LOC |
|
The nurse should change the sensor site for pulse oximetry how often?
|
q4h
|
|
If peripheral tissue perfusion is poor, what type of pulse oximetry probe should be used?
|
nasal or earlobe
|
|
What is the normal PaO2?
|
80-100 mmHg
|
|
What is the normal PaCO2?
|
35-45 mm Hg
|
|
What is the normal HC03?
|
22-26
|
|
What is the normal H+/H2CO3?
|
1:20
|
|
What is the normal base excess?
|
-2 to +2
|
|
What is the normal O2 saturation?
|
90-100%
|
|
If pH is above 7.40, you should next check:
|
to see if HCO3 is above 26 (metabolic alkalosis)
|
|
If pH is below 7.40, you should next check:
|
to see if pCO2 is above 45 (respiratory acidosis)
|
|
occurs when exhalation of CO2 is inhibited (carbonic acid excess)
|
respiratory acidosis
|
|
occur with excessive exhalation of CO2 (hyperventilation)
|
respiratory alkalosis
|
|
occurs with heavy acid losses or increased bicarbonate levels
|
metabolic alkalosis
|
|
occurs with excessive acid production or increased loss of bicarbonate
|
metabolic acidosis
|
|
tests that assess a client's range of respiratory volumes and respiratory capacity
provide a yardstick to measure the amt of disease or disability in the course of a pulmonary disease |
pulmonary function tests
|
|
volume of gas moved in and out of the lungs during eupnea per breath
|
tidal volume
|
|
volume of gas in the lung at the end of maximum inspiration (5000-6000 cc)
|
total lung capacity
|
|
maximum amount of air that can be expired at normal breathing rates after a maximum inspiratory effort (4500-4800 cc)
|
vital capacity
|
|
the volume of air that can be forcefully exhaled in one second after full inspiration
(2.5-3.5 L/first sec) |
forced expiratory volume (FEV-1)
|
|
What correlates closely to the measurement of peak flow (max flow rate during exhalation)?
|
forced expiratory volume (FEV-1)
|
|
What parts of the lung should air movement be present in?
|
ALL parts!
|
|
the volume of air that can be forcefully exhaled in one second after full inspiration
(2.5-3.5 L/first sec) |
forced expiratory volume (FEV-1)
|
|
What correlates closely to the measurement of peak flow (max flow rate during exhalation)?
|
forced expiratory volume (FEV-1)
|
|
What parts of the lung should air movement be present in?
|
ALL parts!
|
|
What patients are oral airways used in?
|
unconcious or semi-conscious clients or clients with noisy breathing, gurgling, or tongue obstruction
|
|
Insert an oral airway with the curved side facing:
|
up!
(flip it over once inside) |
|
Oropharyngeal suctioning is a _______ procedure.
Endotracheal or tracheostomy suctioning is a ____________ procedure. |
clean
sterile |
|
Back off 1-2 cm on suction catheter insertion when:
|
you reach resistance at the carina
|
|
What should you do before airway suctioning?
|
maximize ventilation
|
|
What are the s/s of oxygen toxicity?
|
red skin
red mucous membranes headache |
|
Why should the nurse check the nasal cannula every 6 hours?
|
there is an increased risk for skin breakdown
|
|
What are the s/s of carbon monoxide poisoning?
|
throbbing headache = first!
N/V, cherry red color, death |
|
100% oxygen delivered under pressure
|
hyperbaric oxygen
|
|
What is the primary purpose of incentive spirometry?
|
prevent atelectasis in the immobile and/or post-op client
atelectasis precedes post-op pneumonia! |
|
acute inflammation/infection of the lung parenchyma
s/s: sputum, fever, dry cough, painful breathing |
pneumonia
|
|
complete or partial collapse of the lung due to air in the pleural space
can be closed or open |
pneumothorax
|
|
What is the first sign of pneumothorax?
|
difficult, painful breathing that is abrupt in onset
|
|
pleural pus pocket due to infection
|
empyema
|
|
frank bleeding in the pleural space causing lung collapse
|
hemothorax
|
|
What should the nurse do if a chest tube is pulled out?
|
FIRST, apply pressure to the site.
Have someone call MD. |
|
What are some pulmonary medications that relieve symptoms/rescue?
|
beta 2 agonists
methlyxanthines oral/IV corticosteroids ipratropium |
|
What are some pulmonary medications that maintain (prevent/control)?
|
Cromolyn and Nedocromil
Leukotriene modifiers inhaled steroids |
|
inflammation of the mucosal lining of the tracheobronchial tree
caused by repeated infections and/or long-term inhaled irritants |
COPD: bronchitis
|
|
What are 3 ways to use an inhaler?
|
open mouth
spacer in the mouth |
|
What position should a patient be in to use a peak flow meter?
|
standing or sitting up tall
|
|
disease characterized by alveolar dilation and eventual collapse
|
emphysema
|
|
a bacterial infectious disease that usually involves the lungs but can also infect the kidneys, bones, lymph nodes, and meninges
|
pulmonary tuberculosis
|
|
What is a major problem with patients who have tuberculosis?
|
the medicines have many side effects, so most patients are noncompliant!
|
|
What are the s/s of tuberculosis?
|
asymptomatic at first
later: fatigue malaise weight loss fever night sweats bloody cough chest pain |
|
Never run a nasal cannula above _____ LPM.
|
6
|
|
Never run a simple oxygen mask above _____ LPM.
|
12
|
|
Never run a pediatric oxygen mask above ____ LPM.
|
4
|
|
A non-rebreathing oxygen mask should be run between ____ and _____ LPM.
It is for what percentages? |
10
15 80-99% |
|
A partial rebreather mask should be run between ____ and _____ LPM.
It is for what percentages? |
10
12 60-80% |
|
What is the major muscle used in breathing?
|
the diaphragm
|
|
COPD causes the diaphragm to become ____________.
|
weak and flattened
|
|
With diaphragmatic breathing, the abdomen should be pushed ____ during inhalation and _____ during exhalation.
|
out
in |
|
How does pursed lip breathing help patients with COPD?
|
it creates a back pressure in the lungs that helps the airway to stay open
|
|
How long does the PR interval normally last?
|
0.12 - 0.20 sec
|
|
How long does the QRS complex normally last?
|
< 0.12 sec
|
|
How long does the QT interval normally last?
|
0.36 - 0.40 sec
|
|
What causes artifact to show up on an EKG?
|
some type of problems with the electrodes (loose connections, broken leads)
|
|
What are the 4 lethal dysrhythmias?
|
3rd degree block
ventricular tachycardia ventricular fibrillation asystole |
|
part of the sensory experience which includes receiving the stimulus and converting it into a nerve impulse
|
reception
|
|
integration and interpretation of a stimulus based on a person's experiences
|
perception
|
|
A person will usually react to stimuli that:
|
are the most meaningful at the time
|
|
a change in the ability to receive or perceive sensations
|
sensory alteration
|
|
impaired function in one or more senses (visual, auditory, gustatory, olfactory, tactile, or kinesthetic)
|
sensory deficit
|
|
a decrease or lack of meaningful stimuli, such as monotonous or meaningless stimuli
|
sensory deprivation
|
|
What are some examples of sensory deprivation?
|
isolation
institutionalized patients patients confined to a small living space impaired vision or hearing patients with bandages/casts patients with bipolar or depression spinal cord injury confusion or disorientation patients on drugs |
|
excessive stimuli over which an individual feels little control; the brain is unable to meaningfully respond to or ignore stimuli
|
sensory overload
|
|
What are some examples of sensory overload?
|
patients in pain
patients with intrusive monitoring or treatment/equipment patients in critical care settings |
|
ring of light around the visual field
|
halo
|
|
perceived flashes of light
|
photopsia
|
|
spots perceived in the visual field
|
floaters
|
|
double vision
|
diplopia
|
|
excess secretion of tears
|
epiphora
|
|
decreased accomodation with aging
|
presbyopia
|
|
opacity that develops in the lens of the eye or its envelope
|
cataract
|
|
loss of peripheral vision, then progressive
caused by increased intraocular pressure |
glaucoma
|
|
malfunction of the light sensing cells in the macula
|
macular degeneration
|
|
half-blindness
bitemporal sight in lost in the outer half of each eye |
hemianopsia
|
|
common form of sensorineural hearing loss in older adults
|
presbycusis
|
|
What are some causes of increased intracranial pressure?
|
tumors
intracranial hemorrhage blocked CSF reabsorption inflammation (meningitis) concussion/contusion |
|
What are some early indicators of increased ICP?
What are some late indicators of increased ICP? |
change in LOC --> drowsiness
headache change in LOC --> stupor and coma projectile vomiting |
|
For a patient with IICP, why should you limit suctioning to 10-15 seconds?
|
it will increase pressure even more
|
|
How should a patient with IICP be positioned?
|
HOB 30-45 degrees (promotes venous drainage)
|
|
What happens if IICP goes untreated?
|
the brain will herniate, causing irreversible damage and possible death
|
|
alteration in respiration, phonation, resonance, articulation, or movements of the jaw/tongue
|
dysarthria
|
|
loss of ability to recognize objects, people, sounds, shapes, or smells while the specific sense is NOT defective
|
agnosia
|
|
continuous repetition of a word or phrase
|
perseveration
|
|
type of aphasia in which patients can understand but have difficulty speaking
|
expressive
|
|
type of aphasia in which patients have difficulty comprehending what you are trying to communicate
|
receptive
|
|
complete loss of sense of smell
|
anosmia
|
|
overly sensitive to tactile stimuli
|
hyperesthesia
|
|
a lack of cultural assistance, supportive or facilitative acts
|
cultural deprivation
|
|
characterized by personality disintegration and loss of contact with reality
|
ICU psychosis
|
|
What is the normal albumin level?
|
3.5-5 g/dL
|
|
What is the normal total lymphocyte count?
|
1800-3000
can indicate poor nutrition |
|
What is the normal total iron-binding capacity?
|
250-460 ug/dl
|
|
What is the normal prealbumin level?
|
15-36 mg/dl
|
|
What lab value is useful in telling us whether a patient has acute starvation (ex. in the hospital?
|
prealbumin
|
|
How much fiber should you eat per day?
|
20-35 g
|
|
type of fiber that slow gastric empyting and lowers serum cholesterol
adds weight to stool but NO bulk to aid elimination |
water soluble
|
|
type of fiber that increases fecal bulk in the large intestine and aids elimination
|
water insoluble
|
|
A patient should be on a clear liquid diet for NO LONGER THAN ____ days.
|
3
|
|
What is the RDA for Vitamin C?
|
60 mg
60-100 mg for smokers |
|
What is the RDA for folate?
|
180-200 micrograms
|
|
What is the RDA for Vitamin A?
|
800-1000 mg
|
|
What is the RDA for Vitamin K?
|
65-80 micrograms
|
|
What is the RDA for calcium?
|
at least 800 mg
|
|
What is the normal serum calcium level?
|
9.5 - 10.5 mg/dL
|
|
What is the normal serum phosphorus level?
|
3 - 4.5 mg/L
|
|
What is the normal magnesium level?
|
1.3 - 2.1 mEq/L
|
|
What is the RDA for sodium?
|
500 mg
|
|
What is the normal serum sodium level?
|
136 - 145 mEq/L
|
|
What is the RDA for potassium?
|
1600-2000 mg
|
|
What is the normal serum potassium level?
|
3.5 - 5 mEq/L
|
|
What is the RDA for iron?
|
10-15 mg
|
|
What is the normal range for LDL cholesterol?
|
60-100 mg/dl
|
|
What is the normal range for HDL cholesterol?
|
above 35 mg/dl
|
|
How old should an infant be before food (other than formula/breast milk) is introduced to him/her?
|
4 months
foods should be introduced one at a time |
|
What foods should not be given before age 1?
|
cows milk
corn syrup honey *risk of botulism |
|
any loss or abnormality of psychological, physical, or anatomical structure or function; change at the organic level
|
impairment
|
|
an impairment severe enough to cause a change in functioning
|
disability
|
|
What type of bones contribute to height?
|
long
|
|
What type of bones occur in cluster and permit more fine motor movement in hands/feet?
|
short
|
|
What type of bones are found in the vertebral column, skull, and mandible for specialized movements?
|
irregular
|
|
What type of bones provide structure, contour, and protection?
|
flat
|
|
bones jointed to bones
|
synstotic
|
|
joint with little movement; uses cartilage to unite body surfaces
|
cartilaginous
|
|
2 bony surfaces joined by a ligament or membrane
|
fibrous joint
|
|
freely movable ball and socket, pivot, or hinge joint
|
synovial (true) joint
|
|
bind joints together and connect bones and cartilage
|
ligaments
|
|
connect muscle to bone
|
tendons
|
|
injury to tendons and ligaments
|
sprain
|
|
injury to muscle
|
strain
|
|
When does the benefit of bedrest outweigh the risk of immobility?
|
*after significant trauma to allow healing
*in unstable CV diseases to reduce oxygen demand *in patients with an unstable thrombus to reduce risk of emboli |
|
How does immobility affect the cardiovascular system?
|
orthostatic hypotension
increased cardiac workload thrombus formation |
|
How does immobility affect the respiratory system?
|
decreased respiratory movement
stasis of secretions in the lungs O2/CO2 exchange |
|
How does immobility affect the musculoskeletal system?
|
osteoporosis
contractures pressure ulcers |
|
How does immobility affect the GI system?
|
inhibits ingestion
constipation affects diet |
|
How does immobility affect the urinary system?
|
urinary stasis
increased formation of renal calculi increased risk of urinary infection |
|
localized area of tissue necrosis that develops when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time
|
pressure ulcer
|
|
pressure ulcer where the skin is intact with observable changes in color, temp, consistency, and sensation
a defined area of persistent redness, or red/blue/purple hues in dark pigment skin |
stage I
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pressure ulcer where the skin is broken and there is partial thickness skin loss involving damage to the epidermis and/or dermis
superficial, and clinically appears like an abrasion, blister, or shallow crater |
stage II
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pressure ulcer where the skin in not intact with full thickness skin loss and damage/necrosis of subcutaneous tissue that may extend down to, but not through the underlying fascia
deep crater with/without undermining of adjacent tissue |
stage III
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pressure ulcer that presents with necrosis, full thickness skin loss and extensive destruction to the underlying fascia through to the muscle, support structures, and/or bone
there may be undermining and sinus tracts/tunneling present osteomyelitis is a risk |
stage IV
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healing of a surgical wound where the skin edges are approximated
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primary intention
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healing of a wound with loss of tissue: burn, pressure ulcer, or severe laceration
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secondary intention
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How often do you change a dressing on a wound that is using a wound vac?
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q48h
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Do you hold a cane on your weaker side or your stronger side?
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stronger side
*but it moves with the weaker extremity |
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How far should a cane or crutches be in front of a patient's feet?
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6-10 inches
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How should the elbows be when using crutches?
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15-30 degrees of flexion
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How far below the axilla should the axillary pad of the crutches be?
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3-4 fingerbreadths
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If a patient is paralyzed from C8 up, he is:
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quadriplegic
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If a patient is paralyzed from T1 down, he is:
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paraplegic
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