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Multidimensional CARE I Exam 2 Study
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Guide MODULE 4 -7 EXAM 2 STUDY GUIDE
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Nursing diagnosis: Human response to a disease or stressor going on
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around them
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ne
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Multidimensional Care 1 (Rasmussen University)
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, lOMoAR cPSD| 24448587
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EXAM 2 STUDY GUIDE
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Nursing diagnosis: Human response to a disease or stressor going on around them
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MODULE 4
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Negative effects of immobility on each body system
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SYSTEM EFFECTS
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Musculosk - Decreased muscle endurance, strength, and mass eletal - Impaired
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balance/ Decrease stability/Altered joint mobility
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-Atrophy of muscles
-Altered calcium metabolism/ osteoporosis
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Sp
-Pathological fractures
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-Contractures
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-Foot drop
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Gastrointe -Decreased peristalsis
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Sp
stinal - Decreased fluid intake
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- Constipation, increasing the risk for fecal impaction
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Respirator -Decreased respiratory movement resulting in decreased oxygenation & y carbon dioxide
exchange
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Sp
-Stasis of secretions & decreased & weakened respiratory muscles, resulting in atelectasis &
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hypostatic pneumonia
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-Decreased cough response
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Metabolic -Altered endocrine system
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Sp
-Decreased basal metabolic rate
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- Changes in protein, carbohydrate, and fat metabolism
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- Decreased appetite with altered nutritional intake/ Loss of weight
-Negative nitrogen balance
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- Decreased protein resulting in loss of muscle
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- Alterations in calcium, fluid, and electrolytes
- Resorption of calcium from bones
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- Decreased urinary elimination of calcium, resulting in hypercalcemia sh
Genitourin
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-Urinary stasis
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ary -Change in calcium metabolism with hypercalcemia, resulting in renal calculi -Decreased fluid
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intake and increased use of indwelling urinary catheters, resulting in urinary tract infections
Neurologic -Altered sensory perception
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/ -Ineffective coping
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Psychosoci CHANGES IN EMOTIONAL STATUS: Depression, alteration in self-concept, and anxiety
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tz
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al BEHAVIORAL CHANGES: Withdrawal, altered sleep/wake pattern, hostility, inappropriate laughter,
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and passivity
Integumen -Increased pressure on skin, which is aggravated by metabolic changes tary
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-Decreased
circulation to tissue causing ischemia, which can lead to pressure injury
sh
Sp
Cardiovasc -Orthostatic hypotension
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Sp
, lOMoAR cPSD| 24448587
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ular -Less fluid volume in the circulatory system
-Stasis of blood in the legs
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-Diminished autonomic response
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la - Decreased cardiac output, leading to poor cardiac effectiveness, which results in increased
cardiac workload
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-Increased oxygenation requirement/ Increased risk of thrombus development
sh
Sp
Positioning Techniques
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Position Description
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Semi- 30
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Fowler Promotes respiratory function
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High 45-90
Fowlers Helps with cardiac dysfunction
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Orthopn Patient leans forward to help with respiration
sh
Sp
eic Used in shortness of breath (SOB)
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Lateral Lying sideways
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Lateral recumbent- Side-lying with legs in line
sh
Oblique Lying semi to the side with leg slightly bent
Sp
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Prone Lying on stomach
Allows better respiration & chest expansion; should be used for short periods of
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time
sh
Sp
Creates a significant lordosis; never use in patients with back surgery or injury
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Sim’s Lying semi-lateral and semi on the stomach
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Semi prone; position for suppository, edema administration, or perineal procedures
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Facilitates mouth drainage, limits trochanter and sacrum pressure
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Supine Lying on the back
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Dorsal recumbent- shoulders and head are elevated with pillows
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Alignment should be comfortable position sh
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Usually used with spinal injury patients as the vertebrae needs to be stable
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Positioning Devices & Equipment
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Device Description
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Trochanter Tightly rolled towels placed adjacent to the hip and thighs roll
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Hand roll Rolled washcloths to keep wrist and hand in natural position and prevent claw
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hand
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sh
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Abduction Wedge to prevent internal hip rotation, usually used after hip pillow surgery
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Cradle Spongy rubber used to prevent foot drop, skin breakdown, boots and external
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hip rotation
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Foot board Foot cradles used to secure the foot of the bed but allow free movement
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Transfer Wood or plastic device to assist with moving the patient board
la
Sp
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lOMoAR cPSD| 24448587
as
ne
l
tz
h
Sp
as
ne
l
h
Sp
as
ne
Multidimensional CARE I Exam 2 Study
l
tz
sh
Guide MODULE 4 -7 EXAM 2 STUDY GUIDE
Sp
ne
Nursing diagnosis: Human response to a disease or stressor going on
la
around them
sh
Sp
ne
la
Multidimensional Care 1 (Rasmussen University)
tz
sh
Sp
ne
la
sh
Sp
ne
la
tz
sh
Sp
ne
la
sh
Sp
e
la
n
tz
sh
Sp
ne
la
sh
Sp
la
, lOMoAR cPSD| 24448587
ne
EXAM 2 STUDY GUIDE
sh
Nursing diagnosis: Human response to a disease or stressor going on around them
ne
MODULE 4
la
Negative effects of immobility on each body system
tz
SYSTEM EFFECTS
sh
Sp
Musculosk - Decreased muscle endurance, strength, and mass eletal - Impaired
ne
balance/ Decrease stability/Altered joint mobility
la
-Atrophy of muscles
-Altered calcium metabolism/ osteoporosis
sh
Sp
-Pathological fractures
ne
-Contractures
la
-Foot drop
tz
Gastrointe -Decreased peristalsis
sh
Sp
stinal - Decreased fluid intake
ne
- Constipation, increasing the risk for fecal impaction
la
Respirator -Decreased respiratory movement resulting in decreased oxygenation & y carbon dioxide
exchange
sh
Sp
-Stasis of secretions & decreased & weakened respiratory muscles, resulting in atelectasis &
ne
hypostatic pneumonia
la
-Decreased cough response
tz
Metabolic -Altered endocrine system
sh
Sp
-Decreased basal metabolic rate
ne
- Changes in protein, carbohydrate, and fat metabolism
la
- Decreased appetite with altered nutritional intake/ Loss of weight
-Negative nitrogen balance
sh
- Decreased protein resulting in loss of muscle
Sp
ne
- Alterations in calcium, fluid, and electrolytes
- Resorption of calcium from bones
la
tz
- Decreased urinary elimination of calcium, resulting in hypercalcemia sh
Genitourin
Sp
-Urinary stasis
ne
ary -Change in calcium metabolism with hypercalcemia, resulting in renal calculi -Decreased fluid
la
intake and increased use of indwelling urinary catheters, resulting in urinary tract infections
Neurologic -Altered sensory perception
sh
Sp
/ -Ineffective coping
ne
Psychosoci CHANGES IN EMOTIONAL STATUS: Depression, alteration in self-concept, and anxiety
a
tz
l
sh
al BEHAVIORAL CHANGES: Withdrawal, altered sleep/wake pattern, hostility, inappropriate laughter,
Sp
ne
and passivity
Integumen -Increased pressure on skin, which is aggravated by metabolic changes tary
la
-Decreased
circulation to tissue causing ischemia, which can lead to pressure injury
sh
Sp
Cardiovasc -Orthostatic hypotension
la
Sp
, lOMoAR cPSD| 24448587
ne
ular -Less fluid volume in the circulatory system
-Stasis of blood in the legs
sh
-Diminished autonomic response
ne
la - Decreased cardiac output, leading to poor cardiac effectiveness, which results in increased
cardiac workload
tz
-Increased oxygenation requirement/ Increased risk of thrombus development
sh
Sp
Positioning Techniques
ne
Position Description
la
Semi- 30
sh
Fowler Promotes respiratory function
Sp
ne
High 45-90
Fowlers Helps with cardiac dysfunction
la
tz
Orthopn Patient leans forward to help with respiration
sh
Sp
eic Used in shortness of breath (SOB)
ne
Lateral Lying sideways
la
Lateral recumbent- Side-lying with legs in line
sh
Oblique Lying semi to the side with leg slightly bent
Sp
ne
Prone Lying on stomach
Allows better respiration & chest expansion; should be used for short periods of
la
tz
time
sh
Sp
Creates a significant lordosis; never use in patients with back surgery or injury
ne
Sim’s Lying semi-lateral and semi on the stomach
la
Semi prone; position for suppository, edema administration, or perineal procedures
sh
Facilitates mouth drainage, limits trochanter and sacrum pressure
Sp
ne
Supine Lying on the back
la
Dorsal recumbent- shoulders and head are elevated with pillows
tz
Alignment should be comfortable position sh
Sp
Usually used with spinal injury patients as the vertebrae needs to be stable
ne
la
Positioning Devices & Equipment
sh
Device Description
Sp
Trochanter Tightly rolled towels placed adjacent to the hip and thighs roll
ne
Hand roll Rolled washcloths to keep wrist and hand in natural position and prevent claw
a
tz
hand
l
sh
Sp
Abduction Wedge to prevent internal hip rotation, usually used after hip pillow surgery
ne
Cradle Spongy rubber used to prevent foot drop, skin breakdown, boots and external
la
hip rotation
sh
Foot board Foot cradles used to secure the foot of the bed but allow free movement
Sp
Transfer Wood or plastic device to assist with moving the patient board
la
Sp
