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81 Cards in this Set
- Front
- Back
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what are body mechanics?
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the coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment.
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when are body mechanics used?
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during lifting, bending, moving, and while performing ADLs.
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what are the 3 components of body mechanics?
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body alignment/posture, balance (wide base of support, feet as wide as shoulders), coordinated body movement.
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what can incorrect body mechanics lead to for the health care worker?
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fatigue, pain/injury, decreased efficiency, decreased ability to perform patient care.
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what are some basic principles?
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client assist if possible, synchronized movement (1, 2, 3), lift rather than pull, position self close to client, use arms and legs (not back), raise bed, know your limitations/ask for assistance.
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what happens with impaired mobility?
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patient may be placed on bed rest or other activity orders such as: up ad lib, up with assist, BRP (bathroom privileges), up to BSC (bedside commode).
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how often should you turn a patient?
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every 2 hours.
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what are the physical effects of impaired mobility?
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metabolic changes (weight loss, decreased muscle mass, Ca loss, GI disturbances)
respiratory changes (diminished cough, atelectasis, pneumonia) cardiovascular changes (orthostatic hypotension, increased workload of heart, formation of clots) musculoskeletal system (decreased muscle mass, weakness, bone resorption) urinary elimination (urinary statis, UTI risk, stone formation risk) |
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what are some psychological efforts of impaired mobility?
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depression, behavioral changes, loneliness, altered sleep patterns, impaired coping.
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nursing assessment
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alignment
balance coordiation gait joint structure/ function muscle mass, tone, & strength |
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nursing interventions
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body alignment, ROM, walking, physical therapy, reduce hazards of immobility (nutrition, position change, regular sleep pattern, elimination)-> prevents ulcers, clots, contractures.
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physiology of urinary elimination
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kidneys (filtration, re-absorption, RBC maintenance, regulation of blood flow), ureters, urinary bladder, urethra.
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factors influencing urination
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growth and development (age dependent- control begins at age 3, older adults- nocturia, frequency, retention, men v. women)
socio-cultural factors psychological factors (privacy) physical factors (privacy, close curtain) |
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normal urine appears...
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clear, yellowish straw to amber depending on concentration.
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odor
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ammonia
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normal amount of urine
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sterile
30cc/hour average void: 250-400cc |
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dysuria
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painful voiding.
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hematuria
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presence of blood in urine.
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nocturia
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voiding during normal sleeping hours.
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oliguria
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formation and excretion of less than 500 mL of urine in 24 hours.
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polyuria
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formation and excretion of large amounts of urine in the absence of a concurrent increase in fluid intake.
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pyuria
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presence of pus in urine.
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urinary retention
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-marked accumulation of urine in bladder
-due to inability to empty bladder -acute or chronic -causes: disease, medication, injury |
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UTI
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-#1 nosocomial infection due to instrumentation
-women and elderly at high risk -signs and symptoms: urgency, pain, burning |
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urinary incontinence
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unable to control urine output
due to: stress, urge, reflex, functional physically. |
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specimen collection
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random: urine cup
clean catch: perineum cleaned then sample sterile: catheterization timed: 24 hours |
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types of urinary tests
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urinalysis, specific gravity, culture.
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diagnostic exams
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kidney ureter bladder (KUB), intervenus pilagram (IVP), cystoscopy
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health promotion
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education, maintain elimination habits, maintain fluid intake, control pain, management of incontinence (bladder training, kegels, external catheters), prevent infection, perineal hygiene, skin care, catheter care.
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what is the purpose of catheterization?
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provide continuous flow of urine, accurate assessment of amount, surgery procedures.
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types of catheters
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indwelling vs. intermittent
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catheter care
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perineal hygiene, clean catheter away from body, avoid kinks in tubing, empty bag every 8 hours, keep below kidney and off the floor.
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GI tract
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series of hollow mucous membrane lined muscular organs
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purpose of GI tract
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absorb fluid and nutrients, prepare food for absorption, temporarily store feces.
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organs
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mouth, esophagus, stomach, small and large intestines, rectum, anus.
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factors affecting bowel elimination
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age, diet, fiber intake, physical activity, stress, personal habits, disease.
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constipation
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infrequent, sometimes painful passage of stool
fullness, bloating, loss of appetite, unable to defecate. causes: inadequate fibers, large intake of refined foods, delay of bowel evacuation, stress, laxative abuse, medications. |
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impaction
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accumulation of hardened feces in the rectum
no BM for 3-5 days, followed by passage of liquid stool. |
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diarrhea
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frequent evacuation of loose or watery stool, cramping, nausea, bloated, gasy
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incontinence
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inability to control passage of feces and gas
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flatulence
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accumulation of gas
cramping, pain causes: swallowed air, carbonated drinks, certain foods, high fiber diets |
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nursing assessment of bowel elimination
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pattern, diet, appearance
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diagnostic exams
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stool specimens, x-rays, direct visualization
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nursing interventions
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promote regular bowel habits, time, location, privacy, skin care.
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mecications
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laxatives, antidiarrheals, antispasmotics, enemas
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vital signs
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a quick and efficient method of monitoring a client's basic physiologic status
(temp, pulse, respirations, blood pressure) |
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body temperature
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heat production - heat loss
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what are mechanisms of heat production/conservation?
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shivering, veins move deeper into body.
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what are mechanisms of heat loss?
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sweat, veins pop out, conduction and convection
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measurement of body temperature
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core (rectal) vs. surface (oral or axillary)
locations: rectal, oral, axillary, tympanic. |
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normal temperature range
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oral: 36.5°-37.5°C / 97.6°-99.6°F
rectal (1° higher) axillary (1° lower) |
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factors affecting temperature
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age (down), exercise (up), hormone levels, circadian variation, stress (up), environment
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fever
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heat loss mechanisms are unable to keep pace with heat production, abnormal rise in body temperature
defense mechanism |
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pulse
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the palpable bounding of blood flow noted at various points on the body (radial, apical)
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pulse rate
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the number of pulsing sensations (pulse waves) occurring in 1 minute
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regulation
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multiple factors influence the strength of heart contractions and stroke volume
very sensitive to conditions in the body can change rapidly |
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factors that influence pulse rate
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age, exercise, fever, medications, ANS stimulation (scared, pain, anxious), postural changes, pulmonary condition
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assessment of pulse
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location, rate, rhythm, strength
normal range: 60-100 beats/min. |
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bradycardia
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slow heart rate, less than 60
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tachycardia
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fast, 100 plus heart beats
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arrhythmia
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irregular heart rhythm
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respiration involves...
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ventilation (movement of O and CO2 in and out of the lungs), diffusion (movement of O and CO2 between alveoli and RBCs), and perfusion (distribution of RBCs to and from pulmonary capillaries).
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respiration is...
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-an unconscious process
-regulated by respiratory center in brain -regulated according to levels of CO2, O2, and blood pH -muscles of chest wall expand and contract to move chest wall and lungs. |
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factors that influence respiration
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age (higher when younger)
exercise (up) acute pain/ anxiety (up) anemia/ altitude (up) body posture medications |
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assessment of respiration
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rate, rhythm, depth
normal range: 12-20 resp/min. in and out is one respiration |
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bradypnea
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abnormally slow respiratory rate (less than 10 per min)
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tachypnea
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abnormally rapid respiratory rate, more than 20 per min.
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Kussmaul
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deep and labored breathing with normal or reduced frequency, a form of hyperventilation.
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Cheyne-Stokes
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an abnormal pattern of breathing characterized by periods of breathing with gradually increasing and decreasing tidal volume.
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blood pressure
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the lateral force on the walls of an artery by the pulsing blood under pressure from the heart.
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systolic
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top # of blood pressure
the pressure needed to get blood past the obstruction, the first sound |
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diastolic
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bottom # of blood pressure
the last sound, the minimum amount of pressure |
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pulse pressure
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systolic - diastolic
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what physiologic variables is blood pressure influenced by?
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cardiac output, peripheral vascular resistance, blood volume, artery elasticity.
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what other factors might influence blood pressure?
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age, stress, ANS stimulation, medications, circadian variation.
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blood pressure assessment
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cuff size/ bladder width
arm position at the same level of heart normal range: 100-120/60-80 |
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hypotension
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low blood pressure
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orthostatic hypotension
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changes when position changes
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pre-hypertension
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systolic 120-140 or diastolic 80-90
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hypertension
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high blood pressure 140/90
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when to take vital signs...
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admissions/transfers
agency routine health care provider orders before/ after surgical procedure before/ after invasive diagnostic procedure before/ after administration of medications change in patient condition patients report of physical distress |
