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Last updated 12:21 AM on 10/18/22
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46 Terms
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sims
semi prone, stomach with one arm and leg bent up
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prone
on abdomen with head to one side
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right lateral
on right side
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dorsal recumbent
supine, head elevated on small pillow
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promote optimal respiratory functioning
TCDB every 2 hours, incentive spirometer (1-2 hours), force fluids (2000,3000) chest PT, suctioning as needed
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braden scale
risk factors that place patient at risk for skin breakdown
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braden scale at risk
less than 18
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psychological immobility
depression, change in sleep/wake
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nutrition immobility
decreased BMR, changes in GI
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respiratory immobility
decrease lung expansion, weak cough, decrease hemoglobin
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cardiovascular immobility
orthostatic hypertension, thrombus formation (redness, tenderness, swelling)
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musculoskeletal immobility
loss in endurance and muscle mass, atrophy
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uruinary immobility
renal calculi, UTI, decreased output
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skin immobility
increased pressure injury (never massage redened area)
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increase cardiac output
increase heart rate and stroke volume
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hemoglobin men
14-18
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hemoglobin women
12-16
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hematocrit men
40-45
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hematocrit women
38-43
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ineffective airway clearance
ineffective or absent cough, inability to remove airway secretions, abnormal breath sounds, abnormal respiratory rate, rhythm, depth
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most water in body
intracellular (not truly measurable)
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dehydration (hypo)
dry lips/skin, tachycardia, weak pulse, decrease BP, increased heart rate
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hypervolema
full bounding, increased BP, bounding pulse, crackled/course lung sounds, edema in legs/ankles, sob, coughing
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normal potassium
3.5-5
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normal sodium
135-145
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specific gravity
1.005-1.030 no glucose, blood, WBC, protein, acetone
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BUN
10-20
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creatinine
0.7-1.5
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urinary retention
catheter
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breast milk / formula until
4-6 months
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pregnancy needs
+300 cal, 20g protein
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lactation
+500cal, 30g protein
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weight change
wt change / usual wt x 100
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significant weight loss
1-2% 1 week
5% 1 month
7.5% 3 months
10% 6 months
5% 1 month
7.5% 3 months
10% 6 months
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serum albumin
3.5-5.5
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cholesterol
less than 200
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HDL
over 45 male, over 55 female
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blood glucose (FBS)
70-110
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acute
sympathetic
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chronic
parasympathetic
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intractable
high resistance to relief
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pain is
5th vital sign
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PLISST
Permission
Limited Information
Specific Suggestions
Intensive Therapy
Limited Information
Specific Suggestions
Intensive Therapy
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rest
repair damaged cells, remove waste, restore tissue
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NREM
75%, heal, grow, physical
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REM
25% vivid dreams, 90 mins after falling asleep, fluxation in BP heart rate and respiratory