NU 309 Exam 2


How do you identify your patient?

name and date of birth

What are some factors that may influence hygiene?

culture/religion, level of development, personal preference, economics/living environment, knowledge and cognitive level

Hourly rounding

seeing patient every hour on a schedule; improves patient safety and reduces call light usage; identify 3 P's: pain, position, potty

Early morning care

upon awakening; toileting, wash face and hands, oral care

A.M. (morning) care

After breakfast; toileting, bathing, hair, skin, oral care, dressing, positioning, change or straighten linens

PM care

afternoon - toileting, hand washing, oral care, readying for visitors

H.S. (hour of sleep, bedtime) care

prior to sleep; relaxation activities (back massage especially for the bed bound patient), readying environment to facilitate sleep (water, urinal, call light within reach, etc.)

What should you do prior to delegating your patient?


When delegating patient to a CNA, inform them of

clients limitations, amt. of assistance needed, use of assistance devices, specific safety precautions, presence and care of tubes, observations to make during hygiene care


thicker, outer layer of skin; stratified squamous epithelial tissue; waterproof; sheds; contains melanin


Thinner, second layer of skin; blood and lymphatic vessels; nerves; bases of hair follicles; sebaceous and sweat glands

What are the functions of the skin?

protection, sensation, regulation, secretion/excretion, vitamin D formation (sunlight)

What to look for during a skin inspection?

color (pallor, erythema, jaundice, cyanosis), maceration, pruritus, acne, dryness, excoriation, abrasions, pressure ulcers, burns


yellowing of skin; first occurs in eyes and is caused by the liver


inflammation and redness of the skin


bluish coloring of the skin; low oxygenation; toes, fingers, lips


itching of the skin


soft skin (usually wet)


loss of superficial layers of the skin


deeper tear of the skin

What are common types of baths?

unassisted, assit, complete/total, partial

Unassisted bath

patient does everything themselves

Assist bath

nurse helps with hard to reach areas

Complete/total bath

nurse cleans patients entire body without assistance from patient

Partial bath

bathe only those areas that may cause odor or discomfort

Bed bath

used for bed bound patients or for patients who can't bathe themselves

Basin and water bath

a type of bed bath; water must be warm; each part of body is cleansed with a fresh wash cloth

Therapeutic baths

must be ordered by physician; oatmeal or ritz

What might an oatmeal bath be used for?

skin irritation, rash, abrasions

What might a sitz bath be used for?

for the perineal area

What order should the patient be washed?

Face neck and ears, arms, chest, abdomen, legs and feet, back and buttocks; apply new gloves then provide perineal care

Perineal care for females

wash from front to back, labia majora (outer), labia minora (inner), meatus, catheter

Perineal care for males

Use clean portion of wipe for each stroke, cleanse head of penis, shaft, scrotum, catheter

How to assess the feet:

assess, inspect, palpate

Foot care for a diabetic

they have impaired circulation and increased risk for infection which leads to high risk for problems on the feet; inspect daily

How to assess the mouth for oral care

inspect lips, condition of teeth and gums, conditions affecting the mouth (bad breath, cavities, gingivitis, periodontal disease, oral malignancies

What are some common problems with hair?

dandruff, pediculosis (lice), alopecia (hair loss)

How to care for hair:

brush daily with a stiff bristle brush, comb tightly curled hair with wide toothed comb

How to care for unconscious patient's eyes:

give frequent care every 2-4 hours, use lubricant, use protective shield to keep eye(s) closed if necessary

How to care for patient's ears:

assess for drainage, excess cerumen, and hearing loss during bath

What are the functions of the kidneys?

filter metabolic wastes, toxins, excess ions, and water from the blood and excrete them as urine

What is the anatomy of the kidneys?

Location: retroperitoneal
Weight: avg 5 oz
Layers: Cortex (outer layer), Medulla (inner layer), renal pelvis (innermost layer)

How does urine form?

Nephron: glomerular filtration, tubular reabsorption, tubular secretion

How is urine transported?

renal pelvis --> ureter --> urinary bladder

How is urine stored?

the bladder holds urine until discharged from the body

How long is the urethra in males and females?

Females: 3-4 cm
Males: 20 cm (8 in)

How does urinary elimination occur?

1. Filling of the bladder (200-450 mL)
2. Activation of stretch receptors in bladder wall
3. Signaling to voiding reflex center
4. Contraction of detrusor muscle
5. Conscious relaxation of external urethral sphincter

How much urine do the kidneys produce per hour/day

- 50-60 mL per hour
- 1000-2000 mL per day


Decreased urine output


painful or difficult urination


frequent urination and increased amt of urine

Specific gravity

1.002 - 1.030; dissolves solutes

If there is an increase in solutes there is a ___ in specific gravity.


If there is a decrease in solutes there is a ___ in specific gravity.


Urinary Elimination: Infants

- 15-60 mL per day
- 8-10 wet diapers per day
- No voluntary control
- Normal s.g.: 1.008

Urinary Elimination: Children

- Toilet training requires: mature neuromuscular system, adequate communication skills, and ability to remove clothing


occasional involuntary passage of urine

Nocturnal enuresis

nighttime bedwetting

Urinary Elimination: Older adults

- Kidney function decreases (50 yr. old)
- Urgency and frequency
- Loss of bladder elasticity and muscle tone (nocturia and incomplete emptying)
- Confusion may occur @ first symptoms of UTI


Pyridium; treats bladder and urethral pain, burning, increased urination, and increased urge to urinate; turns urine a deep orange-red color


- "Water pills"
- treats blood pressure, fluid retention, and edema by increasing elimination of urine
- classified as thiazide, potassium-sparing, or loop-acting diuretics


-promotes urine retention
-inhibits involuntary contractions of the bladder, increase bladder capacity, and delaying the urge to void for people with urge incontinence


-reduce stress incontinence by relaxing bladder muscles
-some work by stimulating the nerve controlling urethral sphincter


help stop bladder muscle contractions and prevent urge incontinence

Muscarinic receptors

block nerve receptors in smooth muscle of bladder; control bladder contraction and reduce urinary frequency for people with overactive bladder and urge incontinence


used to improve blood flow to urethral tissues and increase thickness of mucosal and urethral tissues; not approved bu FDA for treatment of stress incontinence

Diuretics: Thiazide

used to treat high blood pressure by reducing the amount of sodium and water in the body and dilating blood vessels

Diuretics: Potassium-sparing

reduce the amount of water in the body; do not cause potassium loss

Diuretics: Loop-acting

Cause kidneys to reabsorb less water; increase urine excretion reduce amount of water in the body and lowers blood pressure

Diuretics: Common side effects

weakness, muscle cramps, skin rash, increase sensitivity to sunlight, dizziness, light-headedness, joint pain

Pathological conditions affecting urinary elimination

bladder/kidney infections, kidney stones, hypertrophy in the prostate (males), mobility problems, decreased blood flow through glomeruli, neurological conditions, communication problems, alteration in cognition


infection in any part of the urinary system

UTI: Transmission

Microorganisms (usually E. coli)

UTI Types: Urethritis

infection limited to urethra

UTI Types: Cystitis

bladder infection caused by microbes within urethra

UTI Types: Pyelonephritis

infection that progresses upward to the ureters or kidneys

Catheter associated UTI

often asymptomatic and likely to resolve spontaneously with the removal of the catheter

UTI risk factors

sexual activity, spermicidal gels, older women, pregnant women, enlarged prostate, kidney stones, indwelling catheter

Treatment of UTI: Cystitis

oral antibiotics for 5 days

Treatment of UTI: Pyelonephritis

IV antibiotics followed by oral antibiotics

Treatment of UTI: Pyridium

relieves burning and urgency

Treatment of UTI: Liberal liquids

flush out bacteria

Blood urea nitrogen (BUN)

8-20 mg/dL


0.5-1.1 mg/dL

Urine Specimens: Freshly voided

when collecting urine sample, pour urine into specimen container labeled with patient's name, date, and time of collection

Urine Specimens: Clean catch

client cleanses genitalia before voiding and collects sample midstream (free of organisms from urethra and perineum

Urine Specimens: Steril

insert catheter into bladder; aids in determining presence of UTI

Urine Specimens: 24 hr. collection

may be prescribed to evaluate renal disorders by showing kidney function at different times of day/night

Urine Studies: Urinalysis (UA)

overall screening test and an aid to diagnose renal, hepatic, and other diseases

Urine Studies: Dipstick

can determine pH and specific gravity and the presence of protein, glucose, ketones, and occult blood in urine

Urine Studies: Specific gravity

-indicator of urine concentration
-refractometer: precise measurement; measures extent to which a beam of light changes direction when it passes through urine

Direct Visualization Studies: Cystoscopy

direct view of urethra, bladder, and urethral offices by scope

Direct Visualization Studies: Cystometry

-determines whether a muscle/nerve problem is causing problems with how well the bladder holds/releases urine
-catheter is inserted into bladder and pressure probe into rectum
-measures how much the bladder can hold and pressure in bladder

Indirect Visual Studies: IVP

IV radiopaque contrast medium to visualize kidneys, bladder, and ureter

The female client says to the nurse, "I'm so distressed. It seems like every time I laugh hard, I wet myself." The nurse knows that this condition is known as __.

Stress incontinence

How do you promote normal urination?

-Provide privacy: Curtains, doors
-Assist with positioning
-Facilitate toileting routines: Client's pattern
-Promote adequate fluids and nutrition
-Assist with hygeine

Straight catheter

single-lumen tube that is inserted for immediate drainage of the bladder; catheter is removed after the bladder is empty

Indwelling (Foley) catheter

used for continuous bladder drainage

Suprapubic catheter

continuous urine drainage when urethra must be bypassed

The nurse prepares to insert an indwelling urinary catheter. Which statement least explains the reason for this intervention?
A. Empty your bladder prior to your procedure.
B. Treat your problem of leaking urine.
C. Obtain a sterile urine specimen for cul

B. Treat your problem of leaking urine

Urge incontinence

involuntary loss of urine with a strong urge to void

Stress incontinence

Involuntary loss of urine with increased intra-abdominal pressure in the absence of an overactive bladder (childbirth, exercise, laughing, sneezing, coughing, lifting)

Mixed incontinence

combination of urge and stress incontinence

Unconscious (reflex) incontinence

Loss of urine when the person does not realize the bladder is full and has no urge to void

Functional incontinence

Untimely loss of urine with no urinary or neurological cause

Transient incontinence

short-term incontinence expected to resolve spontaneously

Overflow incontinence

Leakage of urine with a distended bladder

There is a 24-hr urine collection in process for a client. The nursing assistive personnel (NAP) inadvertently empties one specimen into the toilet instead of the collection "hat." The nurse should
A. Continue with the collection of urine until the 24-hr

D. Dispose of the urine already collected and begin an entirely new 24-hr collection.

What is a urinary diversion?

surgically created opening for elimination of urine

Cutaneous ureterostomy

routes the ureter(s) directly to the surface of the abdomen, forming a small stoma

Conventional urostomy

-Most common type of urinary diversion; simplest to perform surgically and eliminates the need for intermittent catheterization
-ureters are implanted into a loop of the ileum where urine drains freely into the stoma bag

Goals to care for a patient with an indwelling catheter:

1: Prevent Urinary Tract Infection
2: Maintain free flow of Urine
3: Prevent Transmission of infection
4: Promote normal urine production
5: Maintain skin and mucosal integrity

How to insert an intermittent urinary catheter:

1. Work at right side if right handed
2. Places patient into supine
3. Don clean gloves
4. Drape the patient
5. Cleanse the perineal area
6. Remove and discard gloves
7. Organize work area
8. Place sterile underpad
9. Cleanse meatus
10. Prepare urine rece

How to insert an Indwelling catheter

1. Place patient supine
2. Stand on right side
3. Drape patient
4. Don clean gloves
5. If using, insert topical anesthetic gel
6. Remove and discard gloves
7. Organize area
8. Place sterile waterproof underpad
9. Cleanse meatus
10. Lubricate
11. Insert ca

How to insert an external (condom) catheter:

1. Determine size
2. Wash hands and use gloves
3. Organize supplies
4. Position supine
5. Flod down bed linen
6. Gently cleanse penis
7. Change gloves
8. Apply skin prep
9. Hold penis in non dominant hand
10. Secure catheter


body movement


ability to carry out activities of daily living

Physical activity

bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above baseline level

Skeletal system

bones, cartilage, ligaments and tendons


skeletal, smooth, cardiac

Skeletal muscles

moved the skeleton

Smooth muscle

occurs in digestive tract and other hollow structures such as the bladder and blood vessels

Cardiac muscles

can contract spontaneously

Motor nervous system

autonomic (involuntary) and somatic (voluntary)

Body mechanics

the way we move our body

Body alignment

-places the spine in a neutral position


-line of gravity must pass through your center of gravity and the center of gravity must be close to your base of support


-smooth movement requires coorination between the nervous and musculoskeletal system

Cerebral cortex initiates ___

voluntary movement


coordinates movements; largely responsible for controlling the awareness of posture, movement, and position sense

Basal ganglia

located deep in cerebrum and assists with coordination of movement

Joint mobility

range of motion (ROM), active ROM (AROM), and passive ROM


maximum movement possible at a joint


movement of the joint performed by the individual without assistance


involves moving joints through their ROM when the patient is unable to do so for himself

Principles of body mechanics

rules that allow you to move your body while reducing your risk for injury

To maintain proper posture, it is important to __.

Avoid arching shoulders forward when sitting

Baseline activity

light-intensity activities of daily living; standing, walking, lifting


more than baseline to produce health-enhancing benefits

Isometric exercise

-muscle contraction without motion
-usually performed against an immovable surface or object
-Each position is held for 6 to 8 seconds and repeated 5 to 10 times
-patients who are bed bound

Isotonic exercise

-movement of the joint during the muscle contraction
-weight training with free weights


pull-ups, push-ups, and planks, all of which use body weight as the resistance force, are also isotonic exercises

Isokinetic exercise

-performed with specialized apparatuses that provide variable resistance to movement
-both isometrics and weight training
-use of machines

Aerobic exercise

-occurs when the amount of oxygen takin into the body meets or exceeds the amount oxygen required to perform the activity
-increases heart and respiratory rates
-exercises cardiovascular system and skeletal muscles
-jogging, brisk walking, cycling

Anaerobic exercising

-occurs when the amount of oxygen taken into the body does not meet the amount of oxygen required to perform the activity
-lifiting heavy objects, sprinting

Steps in planning a fitness program:

1. Medical evaluation
2. Type of activity, duration, intensity, and frequency determined by health

Flexibility training

-stretch before/after exercising
-helps maintain mobility

Aerobic conditioning

-Improves fitness and body composition
-Components: intensity, duration, frequency, and mode

Resistance training

-movement against resistance increases muscular strength and endurance

Risks of exercise

cardiac injury, musculoskeletal injury, dehydration, temperature regulation

Cardiac injury

fear of triggering a cardiac event deters some people from exercising

Musculoskeletal injury

-high-impact exercises may pose a risk for injury to bones, joints, muscles
-prevent by proper body alignment


fluid and electrolyte loss


-can occur when one exercises in hot climate
-often accompanied by dehydration

Heat exhaustion

-potentially life threatening
-signs: light-headedness, nausea, headache, fatigue, hyperventilation, abdominal cramps, high temp., cold, clammy skin


-can occur when one does not wear proper clothing or is exposed to cold water for an extended time


fusion of two or more fingers/toes

Developmental dysplasia of the hip

-congenital abnormality of the development of the femur, acetabulum, or both that shows as a hip dislocation

Foot deformities



a lateral curvature of the spine

Osterogenesis imperfecta (OI)

congenital disorder of bone and connective tissue that is characterized by brittle bones that fracture easily


dwarfism; when bones ossify (harden) prematurely

Paget's disease

increased bone loss results in pain, pathological fractures, and deformities; skull, vertebrae, femur, and pelvis

Osteoarthritis (OA)

loss of articular cartilage in the joint, with pain and stiffness as the primary symptom

Rheumatoid arthritis (RA)

autoimmune disease involving chronic inflammation of the joints and surrounding connective tissue, frequently resulting in difficulty performing ADLs

Ankylosing spondylitis

chronic inflammatory joint disease; stiffening and fusion of the spine and sacroiliac joints


inflammatory response to high levels of uric acid; crystals form in synovial fluid, and small white nodules form in subcutaneous tissues


decrease in total bone density


infection of the bone


-breaking of bone
-one of most common forms of trauma

Sprains and strains

-more common than fractures


a stretch injury of a ligament that causes the ligament to tear; a partial tear can usually heal with rest, but a complete tear often requires surgery


injury to a muscle caused bu excessive stress on the muscle

CNS Disorder: Cerebrovascular accident


CNS Disorder: Multiple sclerosis

disorder affecting nerve transmission

CNS Disorder: Myasthenia gravis

disease caused by antibodies to the acetylcholine receptors at the neuromuscular junction

Respiratory disorders

-affects oxygenation
-asthma, pneumonia

Circulatory disorder

impaired arterial circulation limits oxygen delivery to tissue


acute illnesses that produces fatigue; influenza, anemia, anorexia nervosa, cancer, depression, and grief

Activity intolerance

state in which a patient has insufficient physical or psychological energy to carry out daily activities.

Impaired physical mobility

limitation of independent purposeful movement of the body

risk for disuse syndrome

when a patient's prescribed or unavoidable inactivity creates the risk for deterioration of other body systems

Sedentary lifestyle

habit of life that is characterized by a low physical activity level

Semi-Fowler's Position

the head of the bed is raised 30 degrees

High Fowler's Position

head of the bed is raised 90 degrees

orthopneic position

head of bed is elevated 90 degrees and an overbid table with a pillow on top is positioned in front of the patient

Lateral position

side-lying position with the top hip and knee flexed and placed in front of the rest of the body

Prone position

-patient lies on his abdomen with his head turned to one side
-allows full extension of the hips and knees
-allows secretions to drain freely from mouth

Sims position

-The lower arm is positioned behind the patient, and the upper arm is flexed. The upper leg is more flexed than the lower leg
-drainage from the mouth and limits pressure on trochanter and sacrum

Supine position

-patient lies on his back with head and shoulders elevated on a small pillow
-spine is aligned and the arms and hands comfortably rest at the side


used when the patient's spine must be kept in straight alignment

Of the following interventions for the client who is immobile, the nurse will give priority to

having the client use the incentive spirometer q2hr; helps to
prevent atelectasis, which improves
oxygenation�a priority need.

Oblique position

alternative to the lateral position that places less pressure on trochanter
lying on side with top hip and knee flexed with top leg placed behind body

Transfer board

a wood or plastic device designed to assist with moving patients

mechanical lift

a hydraulic device used to transfer patients; a fabric sling with chains or straps attaches to the lifting device

Transfer belt

a heavy belt several inches wide that is used to facilitate transfer or provide a secure mechanism to hold the patient when ambulating

How to assist patient to walk:

1. Assess patient
2. Promote safety non-skid socks, remove rugs/equipment, make sure floor is clean

What do you do if a patient begins to fall?

Gently guid one to a seated or lying position; create a wide base support, project forward the him and slide patient down your leg

How to assist an older adult to ambulate:

1. Observe constantly for weakness and fatigue
2. Move patient gradually
3. Assess for fall risk factors
4. Use assistive devices as needed
5. Be cautions when using transfer belt

Single-ended cane with half circle handle

ideal for patient who needs minimal support and can negotiate stairs

Single-ended cane with a straight handle

ideal for patient with hand weakness who has good balance

Multiprong canes

most have 3 or 4 prongs; all types have a straight handle; provide a wide base of support for patients with balance problems


A lightweight metal frame divide with 4 legs that provides a wide base of support as a patient ambulates; best for patients whose mobility problems are related to fatigue or shortness of breath rather than gait instability


support joints and muscles that cannot independently support the body's weight


commonly used for rehabilitation of an injured lower etremity; limit weight bearing on leg(s)

forearm support crutch

likely used by a patient with permanent limitations

Axiallary crutches

for both short and long term use; support the body weight in the hands and arms

How to use a cane:

1. pt should hold cane on the stronger side of the body
2. Distribute weight evenly b/t feet and cane
3. Move his weaker leg and cane simultaneously
4. Avoid leaning over or on cane

How to use a walker:

1. Stand between back legs of walker
2. Pick it up and advance it as you step ahead
3. If one leg is weaker, move it forward as the walker moves forward
4. Pick up, rather than slide, the walker

How to use crutches:

Tripod position - place crutches 6 in. in front of feet, with crutch point 6 in. from patients center (triangle form)

How to turn a patient in bed:

1. Lock bed wheels
2. Position pt for turning
3. Place pt's near leg and foot across the far one
4. Place pt's near arm across chest
5. Nurses position wide base of support
6. Instruct pt turn will occur on count of 3
7. On 3, flex knees and hips and shif

How to logroll a patient:

1. Lock bed wheels
2. Place drawsheet with underlying friction-reducing device
3. Position one staff member at patient's head and shoulders
4. Nurse position feet as wide base of support
5. Use drawsheet to move pt to side of bed
6. Instruct pt to fold ar

How to move patient up in bed:

1. Lock bed wheels
2. Place friction-reducing device
3. Remove pillow
4. Instruct pt to fold arms over chest
5. Instruct pt to flex his neck
6. With nurses on both sides, grasp and roll drawsheet close to pt
7. Instruct pt, on count of 3, to lift truck an

Dangling how to:

1. Lock bed wheels
2. Apply a gait transfer belt
3. Place bed in low position
4. Instruct pt to bend his knees and turn the pt onto side keeping knees flexed
5. Stand at side of bed with wider BOS
6. Position hands on each side of gait belt
7. Rock onto b

Assisting with ambulation (one nurse)

1. Put nonskid footwear on pt
2. Place bed in low position
3. Apply transfer belt
4. Assist pt to dangle
5. Face pt
6. Instruct pt to place arms around you between shoulders and waist
7. Ask pt to stand and allow to pt to steady
8. Stand at pt's side with

Assisting with ambulation (two nurses)

1. Put nonskid footwear on pt
2. Place bed in low position
3. Apply transfer belt
4. Assist pt to dangle
5. Each nurse face pt
6. Instruct pt to place arms around each of you between shoulders and waist
7. Ask pt to stand and allow pt to steady
8. Nurses

Identify the true statement about devices used when assisting clients to ambulate.
a. The client should stand a foot back from the back legs of a walker.
b. A cane should be used by the client to support the weakest side of the body.
c. A transfer belt sh

d. Each crutch-walking "gait" begins with the client in the tripod position.