Rasmussen NUR 2356: Multidimensional Care I / MDC 1 Exam 2 Multidimensional CARE Exam 2 Study Guide- Complete 2023/2024 solutions

Rasmussen NUR 2356: Multidimensional Care I / MDC 1 Exam 2 Multidimensional CARE Exam 2 Study Guide- Complete 2023/2024 solutions EXAM 2 STUDY GUIDE Nursing diagnosis: Human response to a disease or stressor going on around them MODULE 4 Negative effects of immobility on each body system SYSTEM EFFECTS Musculosk eletal - Decreased muscle endurance, strength, and mass - Impaired balance/ Decrease stability/Altered joint mobility -Atrophy of muscles -Altered calcium metabolism/ osteoporosis -Pathological fractures -Contractures -Foot drop Gastrointe stinal -Decreased peristalsis - Decreased fluid intake - Constipation, increasing the risk for fecal impaction Respirator y -Decreased respiratory movement resulting in decreased oxygenation & carbon dioxide exchange -Stasis of secretions & decreased & weakened respiratory muscles, resulting in atelectasis & hypostatic pneumonia -Decreased cough response Metabolic -Altered endocrine system -Decreased basal metabolic rate - Changes in protein, carbohydrate, and fat metabolism - Decreased appetite with altered nutritional intake/ Loss of weight -Negative nitrogen balance - Decreased protein resulting in loss of muscle - Alterations in calcium, fluid, and electrolytes - Resorption of calcium from bones - Decreased urinary elimination of calcium, resulting in hypercalcemia Genitourin ary -Urinary stasis -Change in calcium metabolism with hypercalcemia, resulting in renal calculi -Decreased fluid intake and increased use of indwelling urinary catheters, resulting in urinary tract infections Neurologic / Psychosoci al -Altered sensory perception -Ineffective coping CHANGES IN EMOTIONAL STATUS: Depression, alteration in self-concept, and anxiety BEHAVIORAL CHANGES: Withdrawal, altered sleep/wake pattern, hostility, inappropriate laughter, and passivity Integumen tary -Increased pressure on skin, which is aggravated by metabolic changes -Decreased circulation to tissue causing ischemia, which can lead to pressure injury Cardiovasc ular -Orthostatic hypotension -Less fluid volume in the circulatory system -Stasis of blood in the legs -Diminished autonomic response - Decreased cardiac output, leading to poor cardiac effectiveness, which results in increased cardiac workload lOMoARcPSD| -Increased oxygenation requirement/ Increased risk of thrombus development Positioning Techniques Position Description SemiFowler 30 Promotes respiratory function High Fowlers 45-90 Helps with cardiac dysfunction Orthopn eic Patient leans forward to help with respiration Used in shortness of breath (SOB) Lateral Lying sideways Lateral recumbent- Side-lying with legs in line Oblique Lying semi to the side with leg slightly bent Prone Lying on stomach Allows better respiration & chest expansion; should be used for short periods of time Creates a significant lordosis; never use in patients with back surgery or injury Sim’s Lying semi-lateral and semi on the stomach Semi prone; position for suppository, edema administration, or perineal procedures Facilitates mouth drainage, limits trochanter and sacrum pressure Supine Lying on the back Dorsal recumbent- shoulders and head are elevated with pillows Alignment should be comfortable position Usually used with spinal injury patients as the vertebrae needs to be stable Positioning Devices & Equipment Device Description Trochanter roll Tightly rolled towels placed adjacent to the hip and thighs Hand roll Rolled washcloths to keep wrist and hand in natural position and prevent claw hand Abduction pillow Wedge to prevent internal hip rotation, usually used after hip surgery Cradle boots Spongy rubber used to prevent foot drop, skin breakdown, and external hip rotation Foot board Foot cradles used to secure the foot of the bed but allow free movement Transfer board Wood or plastic device to assist with moving the patient Mechanica Hydraulic devices to transfer patients lOMoARcPSD| l lift Transfer belt Heave belt several inches wide to facilitate transfer or secure holding the patient while they ambulate Priority Assessment for Immobile Clients ABC’s- Airway, Breathing, Circulation Assessment focuses on mobility, range of motion (ROM), gait, exercise status, activity intolerance, and body alignment while standing, sitting, and lying Body Mechanics for Healthcare Workers • Arrange for help & use mechanical aids • Encourage patient to assist as much as possible • Keep back, neck, and pelvis, and feet aligned. Avoid twisting • Flex knees and keep feet wide apart • Raise patients’ bed so the patients weight is at the level of the nurses center of gravity • Position self close to patient • Use arms and legs (not back) • Slide client towards yourself, using a pull sheet. When transferring on a stretcher, a slide board would be more appropriate lOMoARcPSD| • Set (tighten) abdominal and gluteal muscles in preparation for the move, tuck pelvis • The person with the heaviest load coordinates efforts of the team involved by counting to 3 Ambulating Patients Crutch Walking • Accurate measurement of the patient for the crutches is important • Distance between the axillae and the arm piece on the crutches should be 2 to 3 finger widths in the axilla space • Elbows should be slightly flexed, 20 to 30 degrees, when patient is walking • When ambulating with patient, stand on affected side • Instruct patient to never rest the axillae on the axillary bars • Instruct patient to look up and outward when ambulating and to place the crutches 6-10 inches diagonally in front of the foot • Instruct patient to stop ambulation if numbness or tingling in the hands or arms occur Assisting the patient with crutches to sit and stand: 1. Place the unaffected leg against the front of the chair 2. Move the crutches to the affected side, & grasp thee arm of the chair with the hand on the unaffected side 3. Flex the knee on the unaffected leg to lower self into chair while placing the affected leg straight out in front 4. Reverse the steps to move from a sitting to standing position Going Up & Down Stairs • Up Stairs: move unaffected leg up first, then move affected leg and crutches up • Down Stairs: Move the crutches and the affected leg down, then the unaffected leg down Crutch Gaits Use Procedure TwoPoint Gait Used with partial weightbearing limitations & with bilateral lower extremity prostheses The crutch on the affected side & the unaffected foot are advanced at the same time ThreePoint Gait Used for partial weight bearing or no weight bearing on the affected leg; requires that the client have strength & balance Both crutches & the foot of the affected extremity are advanced together, followed by the foot of the unaffected extremity Four- Used if weight bearing is The right crutch is advanced, then