NUR 1022C - Foundations of Nursing Complete Solutions

NUR 1022C - Foundations of Nursing Study online at 1. 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 2. What is chvostek's sign?: Push the cheek and it spasms (low calcium) due to hypocalcemia 3. 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 4. What is CBR?: Complete Bed Rest, pt uses a bedpan 5. What is BRP?: Bed rest with bathroom privileges, pt should use the call light 6. What is BSC?: Bed rest with bedside commode, usually with assistance 7. What is dangle on the side of bed?: Used with hypotensive pts, pts who have had major surgery 8. What is up to bedside chair?: The pt goes from bed to bed side chair, always use another nurse for heavy pts. 9. What is disuse atrophy?: When cells and tissues reduce in size due to disuse 10. What is OOB with assistance?: Out of bed with assistance 11. What is OOB Ad lib?: Out of bed at liberty, they can freely walk around, make sure catheters/foleys are empty, supportive shoes 12. 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 1 / 15 Exam #2 - NUR 1022C - Foundations of Nursing Study online at - urinary retention infection - pressure ulcers - psychosocial issues - depression, anxiety 13. What is hypostatic pneumonia?: An infection of the lungs associated with immobility caused by pts not being able to take deep breaths or cough 14. 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 15. 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? 16. 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) 17. 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?) 18. What does TCDB mean?: turn, cough, deep breathe every 2 hours, respiratory intervention 19. What are some respiratory interventions?: TCDB so they can get air all the way to their bases and move secretions. Incentive spirometer (i