NURS 280 test 1 Questions With Complete Solutions
Management SCI
Gas exchange
Assess: breath sounds, ABGs, Tidal volume, vital capacity, skin
color, patterns of respirations, secretions
Implement methods to promote gas exchange and prevent
complications due to issues with breathing mechanics.
Cough and deep breathe, ventilator, chest physiotherapy
(vibration/percussion to move secretions)
Management SCI
Perfusion
Assess: vitals, pulses, capillary refill
Interventions promote perfusion
Heart function: Pacemaker: Medications
Promote venous return (compression stockings, positioning)
Labs: Hemoglobin, hematocrit, INR, clotting times
Manifestations SCIs
Elimination
Common manifestation is Retention (review the nursing
diagnosis for urinary retention)
Reflexive emptying
Loss of bladder control
Bladder scans Video
,Frequent catheterizations (risks?)
Surgical procedures for permanent rerouting (ostomy for urine)
Management*** SCI
Elimination
Watch for autonomic dysreflexia****
Distended bladder or rectum
Hypertension (significant elevated blood pressure)
(>300mmHg), HA, diaphoresis, flushing, blurred vision, nausea,
congestion
AD results from some type of significant stimulus that results in
the neurological response
Safety and resolution of stimuli (may be as simple as
repositioning a catheter bag to improve flow)
Prevention!!!!
General management SCI
Safety (transfers, ADLs)
Prevent complications (think about how concepts influence each
other)
Compression stockings, range of motion, positioning, exercises,
nutrition, elimination (all dependent on degree of injury)
Assessments
Risk for infection (what interventions would you do/teach to
reduce infection risk?)
Goals SCI
Maintain optimal level of neurologic functioning
Minimal or no complications of immobility**
,Learn new skills, gain new knowledge to care for self
Return to home and community at optimal level of functioning
Exemplar - Amputation
Congenital absence, traumatic loss, surgical amputation
Surgical repair of severed limb
Management of....
Prosthetics
Promotion of optimal function
Pain management/phantom pain
Amputation Goals
Adequate relief from underlying health problem
Satisfactory pain control
Maximize rehabilitation potential (ex. Prosthesis)
Cope with body image changes
Make satisfying lifestyle adjustments
Application: Amputation
For one lifespan group, Google causes of amputation (review
Informatics searches from Nurs 270).
Choose one common type of amputation.
What is the nursing role in education, prevention, or health
policy related to that type of amputation?
Mobility is defined as
a state or quality of being mobile or movable.
, Scope mobility
completely mobile to completely immobile
Nursing interventions r/t immobility depend on
degree and type of immobility.
Goals are to
promote wellness, prevent decline (if possible), and
anticipate/prevent complications.
Substance Abuse
Overindulgence of a substance that has a negative impact on
psychologic, physiologic, and/or social functioning of an
individual
Substance is defined as a drug, chemical, or biologic entity that
is self-administered.
--Lewis textbook
Currently used terminology = Substance Use Disorders (SUD)
Addiction
Addiction is a compulsive, abnormal dependence on a substance
(such as alcohol, cocaine, opiates, or tobacco) or an a behavior
(such as gambling, Internet, or pornography). The dependence
typically has adverse psychological, physical, economic, social,
or legal ramifications
a disorder of the BRAIN.
primary, chronic disease of brain reward, motivation, memory,
and related circuitry
Management SCI
Gas exchange
Assess: breath sounds, ABGs, Tidal volume, vital capacity, skin
color, patterns of respirations, secretions
Implement methods to promote gas exchange and prevent
complications due to issues with breathing mechanics.
Cough and deep breathe, ventilator, chest physiotherapy
(vibration/percussion to move secretions)
Management SCI
Perfusion
Assess: vitals, pulses, capillary refill
Interventions promote perfusion
Heart function: Pacemaker: Medications
Promote venous return (compression stockings, positioning)
Labs: Hemoglobin, hematocrit, INR, clotting times
Manifestations SCIs
Elimination
Common manifestation is Retention (review the nursing
diagnosis for urinary retention)
Reflexive emptying
Loss of bladder control
Bladder scans Video
,Frequent catheterizations (risks?)
Surgical procedures for permanent rerouting (ostomy for urine)
Management*** SCI
Elimination
Watch for autonomic dysreflexia****
Distended bladder or rectum
Hypertension (significant elevated blood pressure)
(>300mmHg), HA, diaphoresis, flushing, blurred vision, nausea,
congestion
AD results from some type of significant stimulus that results in
the neurological response
Safety and resolution of stimuli (may be as simple as
repositioning a catheter bag to improve flow)
Prevention!!!!
General management SCI
Safety (transfers, ADLs)
Prevent complications (think about how concepts influence each
other)
Compression stockings, range of motion, positioning, exercises,
nutrition, elimination (all dependent on degree of injury)
Assessments
Risk for infection (what interventions would you do/teach to
reduce infection risk?)
Goals SCI
Maintain optimal level of neurologic functioning
Minimal or no complications of immobility**
,Learn new skills, gain new knowledge to care for self
Return to home and community at optimal level of functioning
Exemplar - Amputation
Congenital absence, traumatic loss, surgical amputation
Surgical repair of severed limb
Management of....
Prosthetics
Promotion of optimal function
Pain management/phantom pain
Amputation Goals
Adequate relief from underlying health problem
Satisfactory pain control
Maximize rehabilitation potential (ex. Prosthesis)
Cope with body image changes
Make satisfying lifestyle adjustments
Application: Amputation
For one lifespan group, Google causes of amputation (review
Informatics searches from Nurs 270).
Choose one common type of amputation.
What is the nursing role in education, prevention, or health
policy related to that type of amputation?
Mobility is defined as
a state or quality of being mobile or movable.
, Scope mobility
completely mobile to completely immobile
Nursing interventions r/t immobility depend on
degree and type of immobility.
Goals are to
promote wellness, prevent decline (if possible), and
anticipate/prevent complications.
Substance Abuse
Overindulgence of a substance that has a negative impact on
psychologic, physiologic, and/or social functioning of an
individual
Substance is defined as a drug, chemical, or biologic entity that
is self-administered.
--Lewis textbook
Currently used terminology = Substance Use Disorders (SUD)
Addiction
Addiction is a compulsive, abnormal dependence on a substance
(such as alcohol, cocaine, opiates, or tobacco) or an a behavior
(such as gambling, Internet, or pornography). The dependence
typically has adverse psychological, physical, economic, social,
or legal ramifications
a disorder of the BRAIN.
primary, chronic disease of brain reward, motivation, memory,
and related circuitry
