NU 185
EXAM 2 3
STUDY GUIDE
Medical-Surgical Nursing II
Galen College of Nursing
This Document Description:
❖ This study guide for NU 185 at Galen College of Nursing
focuses on Exam 2 content from the Medical-Surgical
Nursing II course.
❖ It includes essential topics.
❖ The material is clearly organized to help students understand complex
systems and prepare effectively for exam questions.
, Med-Surg 2 Exam 1 Notes
Unit 1
Chapter 40 (ati fundamental books)
Immobility
Mobility versus immobility
● Freedom, independence, purposeful movement
● Inability to move freely or independently at will, risk of complications, physiological and
psychosocial effects
Immobility can be
● Temporary - Ex. Surgery
● Permanent- Ex stroke (difference between a stroke and a rapid, check the blood sugar
first)
● Sudden onset - Ex. stroke, car accident, any kind of injury
● Slow onset - Ex. different types of dementia, MS
Body mechanics
● Coordination between musculoskeletal and nervous system
● Use of alignment, balance, gravity, and friction
Movement
● Dependent upon intact skeletal muscles, skeletal system and nervous system
● Assessment focuses on mobility, ROM, gait, exercise status, activity tolerance and body
alignment (standing/sitting/lying)
○ paraplegia - lower body
○ Hemiplegia - one side of the body
○ Quadriplegia or tetraplegia - affects whole body
Factors affecting mobility
● Alterations in muscles
● Injury to musculoskeletal system
● Poor posture
● Impaired CNS
● Health status and age
Systemic effects of immobility
● Integumentary - skin breakdown, decreased circulation to tissue causing ischemia,
which can lead to pressure injury (you can only have no more than 2 layers on the bed
(flat sheet and chuck)) - spine injury *hint hint*
○ Assessment - observe the skin for breakdown warmth, and change in color, look
for pallor or redness, check skin turgor, use a pressure injury risk scale, assess
at least every 2 hrs.
○ Nursing Interventions - identify clients at risk for pressure injury, position using
corrective devices, turn every 1 to 2 hrs, teach to more independently, limity
sitting in a chair to 1 hr and shift their weight every 15 min, therapeutic bed or
mattress, monitor nutritional intake, provide skin and peri care.
● Cardiovascular - orthostatic hypotension, less fluid volume in the circulatory system,
stasis of blood in the legs, decreased cardiac output, increased cardiac workload,
increased oxygenation requirement, increased risk of DVT.
, ○ assessment - measure orthostatic blood pressure and pulse, palpate the apical
pulse, palpate for edema, assess for DVT.
○ Nursing Action - increase activity, change position, move the client gradually
during position changes, give stool softener, teach ROM.
● Respiratory - pneumonia, decreased respiratory movement resulting in decreased
oxygenation, decreased cough response, weakened respiratory muscles, resulting in
atelectasis and hypostatic pneumonia.
○ Assessment - complete every 2 hrs, observe chest wall movement for symmetry,
observe for productive cough, auscultate lungs, and breath sounds.
○ Nursing actions - reposition every 1 to 2 hrs, remove abdominal binders every 2
hrs, monitor the ability to expectorate secretions, use suction if unable to
expectorate secretions. Turn, cough, and breathe deeply every 1 to 2 hrs, yawn
every 1 hr, incentive spirometer while awake, consume at least 2,00 ml fluid per
day
● Metabolic - need to increase protein, calcium, carbs. Altered endocrine system.
Decreased basal metabolic rate. Weight loss.
○ Nursing actions - high calorie, high protein diet with vitamin B and C
supplements, monitor I’s&O’s
● Elimination (urinary and GI) - CAUTI, urinary stasis(urine just sitting), decreased
peristalsis. Decreased fluid intake, constipation, increasing the risk for fecal impaction.
○ (in&out cath is every four hours) (flomax (oxybutynin) for bladder training)
○ Nursing Actions and Assessment - I’s&O’s, maintain hydration, give stool
softener, provide peri care, teach bladder and bowel training, insert straight or
indwelling catheter, promote urination by pouring warm water over peri area.
● Musculoskeletal - decreased muscle endurance, strength, and mass, imparired balance,
atrophy of muscles, decreased stability, osteoporosis, contractures, foot drop, altered
joint mobility, pathological fractures, impared balance.
○ bisphosphonates (alendronate) needed for osteoporosis, but requires calcium
and vitamin D
■ alendronate (anniversary drug) - first thing in the morning, full glass of
water 8oz, sit upright for 30-60 min (osteoclast - breakdown, osteoblast -
build bones)
■ Risedronate (Actonel)
■ Ibandronate (Boniva)
■ Zoledronate (Reclast)
○ canes/crutches/types of gait (4,3,and 2 point)
■ Four point gait - requires the client to bear weight on both legs. The client
alternates each leg with the opposite crutch so three points of support are
on the floor at all times
■ Three point gait - requires the client to bear all weight on one foot while
using both crutches. The affected leg should never bear weight or touch
the ground
■ Two point gait - requires the client to have partial weight bearing on both
EXAM 2 3
STUDY GUIDE
Medical-Surgical Nursing II
Galen College of Nursing
This Document Description:
❖ This study guide for NU 185 at Galen College of Nursing
focuses on Exam 2 content from the Medical-Surgical
Nursing II course.
❖ It includes essential topics.
❖ The material is clearly organized to help students understand complex
systems and prepare effectively for exam questions.
, Med-Surg 2 Exam 1 Notes
Unit 1
Chapter 40 (ati fundamental books)
Immobility
Mobility versus immobility
● Freedom, independence, purposeful movement
● Inability to move freely or independently at will, risk of complications, physiological and
psychosocial effects
Immobility can be
● Temporary - Ex. Surgery
● Permanent- Ex stroke (difference between a stroke and a rapid, check the blood sugar
first)
● Sudden onset - Ex. stroke, car accident, any kind of injury
● Slow onset - Ex. different types of dementia, MS
Body mechanics
● Coordination between musculoskeletal and nervous system
● Use of alignment, balance, gravity, and friction
Movement
● Dependent upon intact skeletal muscles, skeletal system and nervous system
● Assessment focuses on mobility, ROM, gait, exercise status, activity tolerance and body
alignment (standing/sitting/lying)
○ paraplegia - lower body
○ Hemiplegia - one side of the body
○ Quadriplegia or tetraplegia - affects whole body
Factors affecting mobility
● Alterations in muscles
● Injury to musculoskeletal system
● Poor posture
● Impaired CNS
● Health status and age
Systemic effects of immobility
● Integumentary - skin breakdown, decreased circulation to tissue causing ischemia,
which can lead to pressure injury (you can only have no more than 2 layers on the bed
(flat sheet and chuck)) - spine injury *hint hint*
○ Assessment - observe the skin for breakdown warmth, and change in color, look
for pallor or redness, check skin turgor, use a pressure injury risk scale, assess
at least every 2 hrs.
○ Nursing Interventions - identify clients at risk for pressure injury, position using
corrective devices, turn every 1 to 2 hrs, teach to more independently, limity
sitting in a chair to 1 hr and shift their weight every 15 min, therapeutic bed or
mattress, monitor nutritional intake, provide skin and peri care.
● Cardiovascular - orthostatic hypotension, less fluid volume in the circulatory system,
stasis of blood in the legs, decreased cardiac output, increased cardiac workload,
increased oxygenation requirement, increased risk of DVT.
, ○ assessment - measure orthostatic blood pressure and pulse, palpate the apical
pulse, palpate for edema, assess for DVT.
○ Nursing Action - increase activity, change position, move the client gradually
during position changes, give stool softener, teach ROM.
● Respiratory - pneumonia, decreased respiratory movement resulting in decreased
oxygenation, decreased cough response, weakened respiratory muscles, resulting in
atelectasis and hypostatic pneumonia.
○ Assessment - complete every 2 hrs, observe chest wall movement for symmetry,
observe for productive cough, auscultate lungs, and breath sounds.
○ Nursing actions - reposition every 1 to 2 hrs, remove abdominal binders every 2
hrs, monitor the ability to expectorate secretions, use suction if unable to
expectorate secretions. Turn, cough, and breathe deeply every 1 to 2 hrs, yawn
every 1 hr, incentive spirometer while awake, consume at least 2,00 ml fluid per
day
● Metabolic - need to increase protein, calcium, carbs. Altered endocrine system.
Decreased basal metabolic rate. Weight loss.
○ Nursing actions - high calorie, high protein diet with vitamin B and C
supplements, monitor I’s&O’s
● Elimination (urinary and GI) - CAUTI, urinary stasis(urine just sitting), decreased
peristalsis. Decreased fluid intake, constipation, increasing the risk for fecal impaction.
○ (in&out cath is every four hours) (flomax (oxybutynin) for bladder training)
○ Nursing Actions and Assessment - I’s&O’s, maintain hydration, give stool
softener, provide peri care, teach bladder and bowel training, insert straight or
indwelling catheter, promote urination by pouring warm water over peri area.
● Musculoskeletal - decreased muscle endurance, strength, and mass, imparired balance,
atrophy of muscles, decreased stability, osteoporosis, contractures, foot drop, altered
joint mobility, pathological fractures, impared balance.
○ bisphosphonates (alendronate) needed for osteoporosis, but requires calcium
and vitamin D
■ alendronate (anniversary drug) - first thing in the morning, full glass of
water 8oz, sit upright for 30-60 min (osteoclast - breakdown, osteoblast -
build bones)
■ Risedronate (Actonel)
■ Ibandronate (Boniva)
■ Zoledronate (Reclast)
○ canes/crutches/types of gait (4,3,and 2 point)
■ Four point gait - requires the client to bear weight on both legs. The client
alternates each leg with the opposite crutch so three points of support are
on the floor at all times
■ Three point gait - requires the client to bear all weight on one foot while
using both crutches. The affected leg should never bear weight or touch
the ground
■ Two point gait - requires the client to have partial weight bearing on both
