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NURS 100 EXAM 1 STUDY GUIDE LATEST AND UPDATED GUIDE RATED A.
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NURS 100 EXAM 1 STUDY GUIDE LATEST AND UPDATED GUIDE RATED A.
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NURS 100 EXAM 1 STUDY GUIDE LATESTAND UPDATED GUIDE RATED A.
Immobility & Nutrition
✔✔Decrease activity from immobility causes a decrease in basal
metabolic rate (BMR) which then makes the body break down muscle for
protein energy
This can lead to anorexia, nausea, serum albumin levels
Nursing- monitor food intake, food preferences, and any weight changes
Urinary system
✔✔assess intake & output (I&O), concentration of urine, odor of urine, and
frequency of urine output
GI system-
✔✔inactivity causes decrease in appetite, and decrease in fluid intake due
to hypomotility of GI tract
Elimination Assessment
✔✔Urinary system- assess intake & output (I&O), concentration of urine,
odor of urine, and frequency of urine output.
GI system- inactivity causes decrease in appetite, and decrease in fluid
intake due to hypomotility of GI tract
Nursing- assess abdomen- auscultate all four quadrants, palpate for any
discomfort, monitor dietary intake for adequate fiber, document/monitor
bowel movement
,Ischemia
✔✔decreased supply of Oxygen to tissue
Necrosis
✔✔tissue death
Pressure ulcers-
✔✔inflammation, sore, or ulcer to skin
Usually noted on bony prominences (Coccyx, heels, hips, shoulders,
elbows, ears)
Skin Assessment
✔✔Ischemia- decreased supply of Oxygen to tissue
Necrosis- tissue death
Pressure ulcers- inflammation, sore, or ulcer to skin
Usually noted on bony prominences (Coccyx, heels, hips, shoulders,
elbows, ears)
Assess color, texture, warmth, & intactness of skin/blanching
Psychosocial Assessment
✔✔Isolation- inactivity, bedrest- may become lonely, anxious, angry,
depressed
Self-concept- lack of external stimuli- decrease interaction with
environment
,Sleep patterns- disturbed from inactivity, noise, disruptions, naps during
the day.
Assess for changes in patients mood, behavior, & sleep patterns
Develop a baseline
These factors can lead to decrease exercise and movement
Isolation-
✔✔inactivity, bedrest- may become lonely, anxious, angry, depressed
Self-concept
✔✔lack of external stimuli- decrease interaction with environment
Sleep patterns-
✔✔disturbed from inactivity, noise, disruptions, naps during the day.
M.G, a 76 y.o female is getting out of bed for the first time since her
admission date. She is admitted to the hospital with a diagnosis of
weakness. She has been laying flat for the past two days with turning and
positioning every two hours. You as the nurse are by her side when she
goes to stand. She gets dizzy with standing.
What system are we concerned with?
Why?
✔✔Nervous System Assessment
We are concerned due to the dizziness which could be cerebellar
complications
Cardiovascular System Assessment
If the pt is dizzy with standing we would be concerned with Orthostatic
Hypotension
, T.D, an 87 y.o female is admitted to the hospital for a hip fracture after
sustaining a fall. She is incontinent of urine and is not able to turn and
position on her own.
As a nurse what system assessment are we concerned for?
✔✔Elimination Assessment
She is incontinent of urine- we want to know if this is her baseline or if
this is new findings
Skin Assessment
She is not able to turn and position herself, we want to monitor her skin
for breakdown
Exercise
✔✔highly effective intervention, pts should be encouraged to complete
Promotes muscle strength
Maintains joint flexibility
Minimizes joint pain & stiffness
Eliminates bone reabsorption
Reduces risk for pneumonia, blood clot, constipation
Types of Exercise
✔✔Isotonic- active movement with constant muscle contraction (walking,
turning in bed, self-feeding)
Isometric- tension & relaxation of muscles with no joint movement (kegel
exercises)
Aerobic- require Oxygen metabolism to produce energy (rigorous walking,
stair-climbing)
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