NUR 2356 Final Exam Concept Guide- Rasmussen College
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Course
NUR 2356
Institution
NUR 2356
NUR 2356 Final Exam Concept Guide- Rasmussen College NUR 2356 Final Exam Concept Guide- Rasmussen College NUR 2356 Final Exam Concept Guide- Rasmussen College NUR 2356 Final Exam Concept Guide- Rasmussen College NUR 2356 Final Exam Concept Guide- Rasmussen College NUR 2356 Final Exam Concept Guide-...
● Physiological responses are the body's reaction to the
pain.
● Normal BP= 120/80
● Normal RR= 12-20 BPM
● Normal O2= 95-100%
● Normal HR= 60-100 BPM
● Normal temp= 97.8-99 degrees fahrenheit
● Pain S&S
● Grimacing, guarding, verbalization, and holding or
touching the affected area.
● Descriptive words might include mild, sharp, dull,
aching, constant, and intermittent.
● Pain assessment (PQSRT)
P:provoking/relieving; what makes it worse and better
Q: quality; how the pain feels: throbbing, aching, burning
R: radiate; does the pain radiate anywhere else
S: severity; on a scale of 1 to 10 how much does it hurt
T: timing; onset, duration, and frequency
● Prevention strategies (primary, secondary & tertiary)
, ○ Primary: Health promotion. Before a problem occurs.
Ex. Family planning, Nutrition counseling, eye exams,
hearing exams, disease control measures (hand
washing, cooking meat properly).
○ Secondary: Diagnosis and treatment (Early). Acute
ilnesses and injuries. Ex. Urgent care visits, ER vists,
diagnostic centers. Broken limbs, PREdiabetes
○ Tertiary: Highly technical care. Ex. Oncology, ICU,
Burn centers
● Lung sounds (wheezing, crackles, rhonchi)
○ Wheezing: Narrowing of the airway. Can be caused
by inflammation, mucus and spasms or tumors.
Could be asthma or emphysema
○ Crackles: Popping or bubbling sound heard in the
lungs as a result of fluid being in the lungs. (Sounds
like rubbing your fingertips together with hair in
between). Can be a sign of pneumonia, CHF,
Bronchitis and emphysema.
○ Rhonchi: Mucus in the airway. Coarse low pitched
sounds that may get better with coughing. Could be
fibrotic lungs, bronchitis, COPD.
● Effects of immobility (General and by body system):
○ Fatigue, Low energy
○ Decreased ventilation/ Fluid in the lungs (potential
for pneumonia)
○ Muscle tone loss
○ Bone loss
○ Self esteem concerns
○ Inadequate ADL’s
, ○ Increase risk for pressure ulcers
○ Increase risk for renal calculi
Integumentary
● increased pressure on skin; which is aggravated by
metabolic changes.
● decreased circulation to tissue causing ischemia; which
can lead to a pressure injury.
Interventions:
● identify risk for pressure injury (Braden or Norton scale)
● position using corrective devices; pillows, foot boots,
wedge pillows
● turn every 1-2 hours
● instruct patients who move independently to turn/shift
weight at least every 15 min
● asses skin & provide skin and perineal care as needed
● use therapeutic bed/mattress for clients in bed for an
extended time
● monitor nutritional intake
Respiratory
● decreased oxygenation and carbon dioxide exchange
● stasis of secretions and decreased respiratory muscles;
resulting in atelectasis and hypostatic pneumonia.
● decreased cough pressure
Interventions:
● High-fowlers to promote oxygenation
● reposition every 1-2 hours
● remove abd binders every 2 hours and replace correctly
● use chest physiotherapy
● use suction if unable to expectorate secretions
● TCBD every 1-2 hr while awake
● yawn every hour while awake
● use of incentive spirometer when awake
, ● assess lungs and sputum production
● consume at least 2,000 mL of fluid per day
Cardiovascular
● orthostatic hypotension
● less fluid volume in circulatory system
● stasis of blood in the legs
● decreased cardiac output> poor cardiac effectiveness>
resulting in increased cardiac workload
● increased risk of thrombus development
Interventions:
● Dangling feet on side of bed, transfer to chair> to
increase activity/circulation ASAP
● change position as often as possible
● move pt gradually during repositioning
● ROM and antiembolic exercises (ankle pumps, foot
circles, knee flexion)
● use of TED stockings/sequential compression devices
● administer low dose heparin or enoxaparin
subcutaneously
● measure circumference of calves and compare sizes
● assess calves for s/s thrombus formation; warmth redness,
tenderness
● contact provide immediately if absence of peripheral
pulse in LE or indication of venous thrombosis
● AVOID: pillows under knees, crossing legs, tight clothing,
sitting for long periods, massaging legs
Genitourinary
● urinary stasis> increased UTIs
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