NUR 1022

What are some examples of pathological influences on mobility? - Postural abnormalities - e.g. scoliosis, lordosis, kyphosis, club foot, knock knee - Damage to CNS - spinal cord injuries, MS = multiple sclerosis - Musculoskeletal Trauma - Impaired muscle dvlpmt - muscular dystrophy - decreased flexibility What is chvostek's sign? Push the cheek and it spasms (low calcium) due to hypocalcemia What are some therapeutic reasons for bed rest? Definition: Mobility restriction where the pt. Is confined to their bed for Tx reasons i.e. Weakness, decreased O2 consumption, major surgery/ blood loss, to rest a body part I.e. fractures, safety reasons, reduces pain, preeclampsia What is CBR? Complete Bed Rest, pt uses a bedpan What is BRP? Bed rest with bathroom privileges, pt should use the call light What is BSC? Bed rest with bedside commode, usually with assistance What is dangle on the side of bed? Used with hypotensive pts, pts who have had major surgery What is up to bedside chair? The pt goes from bed to bed side chair, always use another nurse for heavy pts. What is disuse atrophy? When cells and tissues reduce in size due to disuse What is OOB with assistance? Out of bed with assistance What is OOB Ad lib? Out of bed at liberty, they can freely walk around, make sure catheters/foleys are empty, supportive shoes What are the systemic effects of immobility? - Glucose intolerance high blood glucose - decreased calcium absorption bone breakdown (osteoporosis) - decreased peristalsis fecal impaction/ constipation - muscle breakdown negative nitrogen balance fatigue - atelectasis (collapsed alveoli) - pts can 't expand their lungs as often can't move secretions out of their respiratory track secretions can end up in their lungs hyperstatic pneumonia - decreased metabolic activity, metabolize protein in the muscles - orthostatic hypotension, decreased cardiac output, blood clots due to reduced circulation, ischemia necrosis, tachycardia - urine can stay in the pelvic area and lead to renal calculus aka kidney stones - urinary retention infection - pressure ulcers - psychosocial issues - depression, anxiety What is hypostatic pneumonia? An infection of the lungs associated with immobility caused by pts not being able to take deep breaths or cough What are the metabolic changes that can occur due to immobility? Muscle atrophy (cells and tissue decrease in size due to immobility), protein muscles breakdown into amino acids, amino acids breakdown into nitrogen. The pt basically loses more nitrogen then they can intake protein supplements Can lead to anorexia (not hungry, no appetite) and fatigue What subjective data can a nurse collect as part of her respiratory assessment on a pt? Can the pt cough? Does the pt have SOB? Does the pt have angina w/ breathing? (maybe pleuritic) Does the pt have a hx of respiratory disease? (Asthma, COPD) Does the pt smoke? What objective data can a nurse collect as part of her respiratory assessment? Chest shape (e.g. barrel shape = continuous over inflation of the lungs, kyphosis) Positioning (tripod, laying down using pillows due to orthopnea) Color ( cyanotic, pallor) Symmetric expansion (do they have fractured ribs or pneumothorax?) WOB (are they using accessory muscles?) Sputum color ( e.g. pink = heart failure, clear = cold, bronchitis, yellow/green = bacterial infection) What measurements can a nurse use to assess a pt's respiratory function? Pulse oximetry (are their O2 stats greater than 95%?) Cap refill (can tell the nurse if the pt has good peripheral perfusion) Temperature (are they the same temp on both sides of their body? Are their fingers and toes cold? If so, this can indicate poor peripheral perfusion) Lung sounds (Are they diminished? Are they clear? Does the pt have crackles or wheezing? Do they have patent airways?) What does TCDB mean? turn, cough, deep breathe every 2 hours, respiratory intervention What are some respiratory interventions? TCDB so they can get air all the way to their bases and move secretions. Incentive spirometer (inspiration/inhalation) = helps the pt expand their lungs, suction oropharyngeal airway prn, chest physiotherapy, hydration = breaks up the mucus What are some interventions for orthostatic hypotension? - Anti-embolism socks (when pts are immobile blood will pool in the legs) - mobilize pts ASAP - Raise bed to Fowler's position, before ambulatory pts have them sit up for 5 minutes first before movement - dangle legs over the side of the bed - increase fluids = loosens/breaks up secretions - stretch and flex calf muscles - squeeze buttock muscles - Watch the pt for S/S of orthostatic hypotension - assist client to stand = ambulated pt with assistance What comes first blood cultures or antibiotics? Blood cultures How long should you leave a tourniquet on? 1 minute or less What is one thing nurses forget to do when taking blood? To initial and date samples What is the normal glucose range? 74 - 106 mg/dL fasting and 200 mg/dL non-fasting What are some potential causes of hypoglycemia? Insulin rxn, inadequate/ insufficient intake, What are some clinical manifestations of hyperglycemia? 3 P's - polydipsia, polyphagia, polyuria What are some clinical manifestations of hypoglycemia? Hunger, irritability, restlessness, confusion, weakness, diaphoresis, What are some potential causes of hyperglycemia? Diabetes, steroids, TPN What is a nursing intervention for glucose? Blood glucose monitoring What is the normal range of sodium? 136 - 145 mEq/L What are the functions of sodium? - Regulates water balance - controls extracellular fluid volume - increases cell membrane permeability - stimulates conduction of nerve impulses - helps maintain neuromuscular irritability - controls contractility of muscles Most abundant extracellular electrolyte What are some s/s of hyponatremia? - crave salt - CNS changes - Seizures What are the causes of hypernatremia? - Dehydration - Diuretic therapy (I.e. meds that increase excretion) What are some s/s of hypernatremia? - crave water - CNS changes - seizures What are some causes of hyponatremia? - Excess body water - ️ failure - inadequate intake - dilutional fluid overload What is the normal range for potassium? 3.5 - 5 mEq/L Most abundant intracellular cation mneumonic: "3.5. to 5 keeps my heart alive" What is the fx of potassium? - Transmission of electrical impulses in cardiac & skeletal muscles - Involved in the rate & force cardiac contractions & output What part of the body controls the excretion of potassium? Kidneys How do we generally intake potassium? Via diet What are some s/s of hypokalemia? ️ dysrhythmias Leg cramps Decreased GI motility What are the causes of hyperkalemia? - renal failure - burns - crush injuries - meds (k- sparing diuretics) What are the s/s of hyperkalemia? - ️ dysrhytmias - muscle weakness - increased GI motility What can cause hypokalemia? - diuresis (also causes hypernatremia) - vomiting and diarrhea - meds (k-wasting diuretics e.g. lasix) Why does potassium have to be diluted? It is irritating to the veins so it must be diluted 10 mEq in 100 mL and you can only give 10 mEq an hour How should potassium be given PO? On a full stomach What are the 2 ways potassium can NOT be given? IV push or IM, irritating to the veins What is the normal range of magnesium? 1.3 - 2.1 mEq/L What is the normal range of calcium? 9 - 10.5 mg/dL What is the normal range for creatinine? 0.6-1.2 mg/dL for males and 0.5 - 1.1 mg/dL for females What is a complete blood count (CBC)? The calculation of the cellular elements of blood = wbc + rbc + platelets What is the normal range of RBC? 4.2 - 5.4 million/microliters for females and 4.7 - 6.1 million/microliters What is Trousseau's sign? a sign of hypocalcemia where a blood pressure cuff is used as turniquet and the pt experiences their hand contracting in on itself What two glands regulate calcium? parathyroid and thyroid glands What is the normal range for specific gravity in a urinanalysis? 1.005 - 1.030 What is the normal range for Blood Urea Nitrogen? 10 - 20 mg/ dL What is ventilation? the movement of gases in and out of the lungs What is diffusion? when respiratory gases are exchagned in the alveoli and capillaries What is perfusion? The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs -poor peripheral perfusion is characterized by cold extremities, poor cap refill, decreased hair growth, cyanosis, or pallor What is the normal range of WBC? 5,000 - 10,000/ mm^3 What is transport? ventilation + perfusion how well can the hemoglobin carry oxygen What is WOB? Work of Breathing = inspiration + expiration = expansion and contraction of lungs - when a pt has increased WOB you may see them using accessory muscles such as supraclavicular muscles, suprasternal, substernal, intercoastal, subcoastal or nose flaring - when there is decreased surfactant in the lungs this may lead to atelectasis = collapsed alveoli decreased gas exchange in the lungs - decreased compliance pt has a decreased ability to expand their lungs What is hemoglobin? an oxygen-carrying protein, the normal range for hemoglobin is 12-16 g/dl for females and 14 -18 g/dl for males