yuli test 3 study guide

Unit 6 Moving and Positioning – Morse Scale – History of Falling

Checks whether the patient has a history of falling.

Morse Scale – Secondary Diagnosis

Checks whether the patient has more than one medical diagnosis.

Morse Scale – Ambulatory Aid

Identifies what the patient uses to walk, such as a cane, crutches, walker, or furniture for support.

Morse Scale – IV Therapy

Checks whether the patient has an IV or is receiving IV therapy.

Morse Scale – Gait

Assesses how the patient walks, including whether their gait is weak or impaired.

Morse Scale – Mental Status

Checks whether the patient understands their ability to walk safely or overestimates their abilities.

Effects of Immobility on the Cardiovascular System

Venous thromboembolism (VTE); deep vein thrombosis (DVT); pulmonary embolism (PE); orthostatic hypotension; syncope (fainting).

Nursing Measures to Prevent Cardiovascular Complications

Encourage the movement of extremities (e.g., ROM); gradually move the patient from lying to sitting or to a standing position; change the patient’s position frequently; remain with the patient the first few times getting out of bed and dangling.

Effects of Immobility on the Respiratory System

Decreased respiratory movement leading to decreased oxygenation; status of secretions; atelectasis; hypostatic pneumonia; decreased cough response.

Nursing Measures to Prevent Respiratory Complications

Turn the patient from side to side every 2 hours; elevate the head of the bed 45 degrees; encourage coughing and deep breathing; encourage use of the incentive spirometer.

Effects of Immobility on the Musculoskeletal System

Decreased muscle strength and endurance; muscle atrophy; decreased stability; osteoporosis; pathological fractures; contractures; foot drop; altered joint mobility.

Body Alignment

Keep head, trunk, and hips in a straight line. Support extremity weight at joints.

Hip Rotation

Prevent legs from rotating in the hip socket medially or laterally.

Arm Alignment

Maintain arms in correct alignment with the shoulders.

Positioning

Ensure scheduled Q2 hour patient positioning.

ROM Exercises

Perform range of motion exercises every 8 hours (q 8 hours).

Therapy (PT/OT)

Integrate Physical Therapy and Occupational Therapy plans.

Ambulation

Encourage active patient movement and regular ambulation.

Psychological Effects of Immobility

Depression; anxiety; hostility; fear; isolation; restriction of self-image and independence; sensory deprivation; difficulty sleeping.

Nursing Measures for Psychological Complications

Minimize sensory deprivation; involve patient senses when with the patient; encourage the patient to remain awake during the day and do as much for the self as possible; allow the patient to express concerns; encourage visits from family and friends.

Effects of Immobility on the GI System

Decreased peristalsis; decreased fluid intake; constipation, then fecal impaction, then diarrhea.

Nursing Measures to Prevent GI Complications

Assist the patient with early ambulation; reposition the patient every 2 hours and encourage ROM exercises; place the patient in a sitting position on the bedpan; inquire about food likes and dislikes and plan balanced meals; encourage fiber and fluid intake; administer a laxative or stool softener PRN.

Effects of Immobility on the Integumentary System

Pressure ulcers.

Nursing Measures to Prevent Integumentary Complications

Provide adequate nutrition; reposition the patient every 2 hours; inspect bony prominences for redness every 2 hours and massage the area around the redness; use mild soaps for cleansing skin; provide an appropriate surface for the patient.

Supine

Lying on back, arms at side.

Prone

On stomach with head to side.

Dorsal Recumbent

Lying on back, arms at sides, legs apart, knees bent, feet flat.

Trendelenburg

Lying on back, arms at side, feet higher than head.

Reverse Trendelenburg

Lying on back, arms at side, head higher than feet.

Lateral

Lying on side, supported by pillows.

Left Sims

Left side semi-prone, right leg drawn up to chest, left arm along patient back.

Right Sims

Right side semi-prone, left leg drawn to chest, right arm along patient back.

Lithotomy

On back, legs in stirrups.

Fowler’s Position

Sitting position with the head of the bed elevated about 45–60 degrees.

Semi-Fowler’s Position

Sitting position with the head of the bed elevated about 30–45 degrees.

Orthopneic Position

Sitting upright, leaning forward over a bedside table with arms supported.

Deep Tissue Injury

Area over a bony prominence that differs from surrounding tissue; may be blister-like or a discoloration.

Pressure Ulcer – Stage I: Erythema

The skin is still intact, but the area is red and does not blanch. Stays red. There may be warmth, hardness, and discoloration of the skin.

Pressure Ulcer – Stage II: Partial-Thickness Loss of Dermis

There is a partial-thickness skin loss of epidermis, dermis or both. The ulcer may appear as an abrasion, a shallow crater, or a blister.

Pressure Ulcer – Stage III: Full-Thickness Skin Loss

Damage to epidermis, dermis, and subcutaneous tissue but not fascia. The ulcer looks like a deep crater.

Pressure Ulcer – Stage IV: Full-Thickness Skin Loss

Damage to deep tissue, muscle, fascia, tendon, joint capsule, and/or bone.

Pressure Ulcer – Unstageable

Eschar covers the wound, making it impossible to tell the depth.

Pressure Ulcer – Nursing Interventions

Frequent skin assessment; utilization of skin-risk assessment tools; avoid the use of soap and water on dry skin areas; use a moisture barrier cream or ointment on dry skin areas before bathing to protect the skin from the drying effects of water; use mild soap if it’s the only option; use perineal cleansing products to cleanse urine and feces from the perineum and anal areas; use moisturizing creams that have no alcohol or perfume that can irritate the skin.

Avoiding Areas of Pressure

Assist to change positions on a regular basis (q2hrs); use overlay or egg crate mattress; specialty bed, pillows, and pads; heel protectors.

Chain of Infection – Link 1: Causative Agents

Bacteria; virus; fungi; protozoa; helminth (parasitic worm).

Chain of Infection – Link 2: Reservoir

Environmental home for infectious agents. Animate: people, insects, animals, plants. Inanimate: water, soil, medical devices.

Chain of Infection – Link 3: Exit Portal

Route infectious agent uses to leave; host who has become reservoir for infection.

Chain of Infection – Link 4: Mode of Transmission

Direct contact; indirect contact; airborne.

Chain of Infection – Link 5: Portal of Entry

Entry into susceptible host. Portals: respiratory tract, skin, mucous membranes, gastrointestinal tract, genitourinary tract, placenta.

Chain of Infection – Link 6: Susceptible Host

From defense breakdown.

Contact Precautions

Designed for patients known or suspected to be infected with microorganisms that can be transmitted through direct contact with the patient or indirect contact via contaminated environmental surfaces or equipment.

Contact Precautions – Pathogen Examples

MRSA (Methicillin Resistant Staphylococcus Aureus); VRE (Vancomycin Resistant Enterococci); Clostridium difficile; Respiratory Syncytial Virus (RSV); scabies; lice; shingles; conjunctivitis; Herpes Simplex Virus.

Droplet Precautions – Target Patients

Used in addition to Standard Precautions for patients known or suspected to have illnesses transmitted by large particle droplets.

Droplet Generation

Droplets can be generated by coughing, sneezing, or performing procedures likely to generate sprays or aerosolization.

Droplet Precautions – Common Pathogens

Diphtheria; pertussis (whooping cough); meningitis and streptococcal meningitis; influenza; rubella (German measles); mumps.

Airborne Precautions – When to Apply

In addition to standard precautions, use airborne precautions for any patient known or suspected to have an illness transmitted by small airborne droplet nuclei.

Airborne Transmission Hazard

These microscopic particles remain suspended in the air for extended periods and can be widely dispersed by ambient air currents, requiring specialized engineering and respiratory controls.

Airborne Precautions – High-Risk Pathogens

Tuberculosis (TB); measles (rubeola); smallpox (variola); varicella (chickenpox), also requires Contact Precautions if shingles is present; SARS (Severe Acute Respiratory Syndrome).

Opening Sterile Packs

Set the sterile pack on the clean surface positioned so that the first flap will open away from you. Open the flap that folds away from you first, then open each of the side flaps. Open the flap that folds toward you last.

Sterile Field – Outer Edge

The outer 1 inch of the sterile drape is considered contaminated.

Sterile Field – Below Table

Anything below the surface of the draped table is considered unsterile. All parts of the sterile drape below the table surface are considered unsterile.

Sterile Field – Items

Only sterile items can be placed on the sterile field.

Sterile Field – Damp or Wet

If the sterile field becomes damp or wet, it is no longer sterile.

Constipation

Constipation is a bowel pattern characterized by difficult and infrequent evacuation of hard, dry feces.

Constipation – Key Characteristics

Infrequent stool passage; difficult evacuation; hard, dry stool consistency; firm, distended abdomen; vomiting (severe).

Constipation – Risk Factors

Frequent use of laxatives; advanced age; inadequate fluid intake; inadequate fiber intake; immobilization due to surgery, trauma or medical condition; sedentary lifestyles; pregnancy; medication effects.

Constipation – Assessment and Stool Evaluation

Assess elimination pattern; assess characteristics of stool using Bristol scale.

Constipation – Fluid Monitoring

Assess fluid status; monitor fluid input and output.

Constipation – Increase Fiber in Diet

Target 25–30 g/day. Examples: prunes, bran.

Constipation – Pharmacology

Administer bulk-forming medications, e.g., Metamucil, as prescribed.

Constipation – Fluid Intake

Ensure adequate fluid intake. Target: 2000–3000 mL/day.

Constipation – Medications

Stimulants, softeners, and suppositories. Use if conservative measures are not effective.

Constipation – Physical Activity

Ensure adequate activity. Minimum 20–30 minutes walking/day or chair/bed-bound exercises.

Constipation – Advanced Intervention

Administer enemas as prescribed as a last resort.

Diarrhea – Primary Sign

Loose, watery stools three or more times in a single day.

Diarrhea – Other Symptoms

Abdominal pain; bloating; bowel urgency.

Diarrhea – Causes and Risk Factors

Viral gastroenteritis; bacterial gastroenteritis; antibiotic therapy; inflammatory bowel disease (IBD); irritable bowel syndrome (IBS); excessive constipation medications (overuse of laxatives).

Diarrhea – Assess Elimination Pattern

Monitor frequency, consistency, and changes over time to establish a baseline.

Diarrhea – Stool Characteristics

Evaluate stool characteristics using the Bristol Stool Scale for accurate categorization.

Diarrhea – Fluid Status and Intake

Track strict intake and output (I&O) and encourage adequate fluid intake.

Diarrhea – Determine and Treat Cause

Assist healthcare team in identifying primary underlying etiology for targeted treatment.

Diarrhea – Slow Peristalsis

Administer prescribed anti-diarrheal medications as ordered to decrease GI motility. Avoid with infectious diarrhea.

Diarrhea – Perineal Care and Skin Protection

Provide gentle perineal hygienic care after each bowel movement and apply a moisture barrier to prevent excoriation.

Diarrhea – Gut Health Re-establishment

Once diarrhea resolves, encourage consumption of probiotics or yogurt containing active live cultures to restore normal flora.

Diarrhea – Complications

Dehydration due to fluid loss; muscle weakness due to loss of potassium in the stool; severe complication: cardiac arrhythmias due to low potassium (hypokalemia).

Hypokalemia – Normal Potassium

3.5 to 5.0 mEq/L.

Fluid Volume Excess (Hypervolemia) – Isotonic Fluid Retention

Retention of water and sodium (isotonic).

Fluid Volume Excess – Causes/Factors

Excess intake of sodium; interstitial fluid shifts; impaired fluid balance regulation; overhydration.

Fluid Volume Excess – Osmolar Fluid Imbalance

More water is gained than electrolytes (osmolar imbalance); water replacement without electrolyte replacement.

Fluid Volume Excess – Nursing Interventions

Monitor weight; assess vital signs; assess lung sounds; assess for edema; monitor I&Os; administer diuretics; restrict fluid and/or sodium intake; Semi-Fowler’s position.

Fluid Volume Deficit – Manifestations

Weight loss; dry mucous membranes; tachypnea; tachycardia; low grade fever; hypotension; increased urine concentration; decreased urine output; increased hematocrit/BUN.

1 kg of Weight Gain

1 L of fluid.

FVE – NCLEX Tip

Think FVE = “WET”: W—Weight gain; E—Edema; T—Trouble breathing.

FVE – Lungs

FVE → lungs → crackles → decreased O₂ → HIGH PRIORITY.

Furosemide

Think K⁺ loss.

Normal Urine Output

1500–2000 mL in 24 hours; 30 mL each hour; 280 every 8 hours.

Stress Incontinence

The loss of urine that occurs from a sudden increase of abdominal pressure (coughing, sneezing, laughing, lifting or jumping). Common after childbirth.

Stress Incontinence – Pathophysiology

Pelvic muscle relaxation; weakness of urethra and surrounding tissues decreases urethral resistance.

Stress Incontinence – Contributing Factors

Multiple pregnancies; decreased estrogen levels (menopause); prostate surgery.

Urge Incontinence (Overactive Bladder)

The bladder suddenly contracts without warning and there is an urgent need to pass urine.