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81 Cards in this Set

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what are body mechanics?
the coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment.
when are body mechanics used?
during lifting, bending, moving, and while performing ADLs.
what are the 3 components of body mechanics?
body alignment/posture, balance (wide base of support, feet as wide as shoulders), coordinated body movement.
what can incorrect body mechanics lead to for the health care worker?
fatigue, pain/injury, decreased efficiency, decreased ability to perform patient care.
what are some basic principles?
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.
what happens with impaired mobility?
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).
how often should you turn a patient?
every 2 hours.
what are the physical effects of impaired mobility?
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)
what are some psychological efforts of impaired mobility?
depression, behavioral changes, loneliness, altered sleep patterns, impaired coping.
nursing assessment
alignment
balance
coordiation
gait
joint structure/ function
muscle mass, tone, & strength
nursing interventions
body alignment, ROM, walking, physical therapy, reduce hazards of immobility (nutrition, position change, regular sleep pattern, elimination)-> prevents ulcers, clots, contractures.
physiology of urinary elimination
kidneys (filtration, re-absorption, RBC maintenance, regulation of blood flow), ureters, urinary bladder, urethra.
factors influencing urination
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)
normal urine appears...
clear, yellowish straw to amber depending on concentration.
odor
ammonia
normal amount of urine
sterile
30cc/hour
average void: 250-400cc
dysuria
painful voiding.
hematuria
presence of blood in urine.
nocturia
voiding during normal sleeping hours.
oliguria
formation and excretion of less than 500 mL of urine in 24 hours.
polyuria
formation and excretion of large amounts of urine in the absence of a concurrent increase in fluid intake.
pyuria
presence of pus in urine.
urinary retention
-marked accumulation of urine in bladder
-due to inability to empty bladder
-acute or chronic
-causes: disease, medication, injury
UTI
-#1 nosocomial infection due to instrumentation
-women and elderly at high risk
-signs and symptoms: urgency, pain, burning
urinary incontinence
unable to control urine output
due to: stress, urge, reflex, functional physically.
specimen collection
random: urine cup
clean catch: perineum cleaned then sample
sterile: catheterization
timed: 24 hours
types of urinary tests
urinalysis, specific gravity, culture.
diagnostic exams
kidney ureter bladder (KUB), intervenus pilagram (IVP), cystoscopy
health promotion
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.
what is the purpose of catheterization?
provide continuous flow of urine, accurate assessment of amount, surgery procedures.
types of catheters
indwelling vs. intermittent
catheter care
perineal hygiene, clean catheter away from body, avoid kinks in tubing, empty bag every 8 hours, keep below kidney and off the floor.
GI tract
series of hollow mucous membrane lined muscular organs
purpose of GI tract
absorb fluid and nutrients, prepare food for absorption, temporarily store feces.
organs
mouth, esophagus, stomach, small and large intestines, rectum, anus.
factors affecting bowel elimination
age, diet, fiber intake, physical activity, stress, personal habits, disease.
constipation
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.
impaction
accumulation of hardened feces in the rectum
no BM for 3-5 days, followed by passage of liquid stool.
diarrhea
frequent evacuation of loose or watery stool, cramping, nausea, bloated, gasy
incontinence
inability to control passage of feces and gas
flatulence
accumulation of gas
cramping, pain
causes: swallowed air, carbonated drinks, certain foods, high fiber diets
nursing assessment of bowel elimination
pattern, diet, appearance
diagnostic exams
stool specimens, x-rays, direct visualization
nursing interventions
promote regular bowel habits, time, location, privacy, skin care.
mecications
laxatives, antidiarrheals, antispasmotics, enemas
vital signs
a quick and efficient method of monitoring a client's basic physiologic status
(temp, pulse, respirations, blood pressure)
body temperature
heat production - heat loss
what are mechanisms of heat production/conservation?
shivering, veins move deeper into body.
what are mechanisms of heat loss?
sweat, veins pop out, conduction and convection
measurement of body temperature
core (rectal) vs. surface (oral or axillary)
locations: rectal, oral, axillary, tympanic.
normal temperature range
oral: 36.5°-37.5°C / 97.6°-99.6°F
rectal (1° higher)
axillary (1° lower)
factors affecting temperature
age (down), exercise (up), hormone levels, circadian variation, stress (up), environment
fever
heat loss mechanisms are unable to keep pace with heat production, abnormal rise in body temperature
defense mechanism
pulse
the palpable bounding of blood flow noted at various points on the body (radial, apical)
pulse rate
the number of pulsing sensations (pulse waves) occurring in 1 minute
regulation
multiple factors influence the strength of heart contractions and stroke volume
very sensitive to conditions in the body
can change rapidly
factors that influence pulse rate
age, exercise, fever, medications, ANS stimulation (scared, pain, anxious), postural changes, pulmonary condition
assessment of pulse
location, rate, rhythm, strength
normal range: 60-100 beats/min.
bradycardia
slow heart rate, less than 60
tachycardia
fast, 100 plus heart beats
arrhythmia
irregular heart rhythm
respiration involves...
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).
respiration is...
-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.
factors that influence respiration
age (higher when younger)
exercise (up)
acute pain/ anxiety (up)
anemia/ altitude (up)
body posture
medications
assessment of respiration
rate, rhythm, depth
normal range: 12-20 resp/min.
in and out is one respiration
bradypnea
abnormally slow respiratory rate (less than 10 per min)
tachypnea
abnormally rapid respiratory rate, more than 20 per min.
Kussmaul
deep and labored breathing with normal or reduced frequency, a form of hyperventilation.
Cheyne-Stokes
an abnormal pattern of breathing characterized by periods of breathing with gradually increasing and decreasing tidal volume.
blood pressure
the lateral force on the walls of an artery by the pulsing blood under pressure from the heart.
systolic
top # of blood pressure
the pressure needed to get blood past the obstruction, the first sound
diastolic
bottom # of blood pressure
the last sound, the minimum amount of pressure
pulse pressure
systolic - diastolic
what physiologic variables is blood pressure influenced by?
cardiac output, peripheral vascular resistance, blood volume, artery elasticity.
what other factors might influence blood pressure?
age, stress, ANS stimulation, medications, circadian variation.
blood pressure assessment
cuff size/ bladder width
arm position at the same level of heart
normal range: 100-120/60-80
hypotension
low blood pressure
orthostatic hypotension
changes when position changes
pre-hypertension
systolic 120-140 or diastolic 80-90
hypertension
high blood pressure 140/90
when to take vital signs...
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