306 Final Flashcards

(202 cards)

1
Q

Palliative Care

A

Management of pain, improves quality of life for clients and families, allows dying clients to die with dignity, still able to seek out life-saving measures

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2
Q

Hospice

A

Diagnosis by a physician as having 6 months or less to live

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3
Q

Physiological signs of death

A

Dyspnea
Hypotension
Anorexia, Nausea, Dehydration
Restlessness
Pain

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4
Q

DNR

A

Do not resuscitate

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5
Q

What if family conflicts with client wishes

A

We advocate for clients wishes

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6
Q

Post Mortem Care

A

*Clean and prepare the patient
Including removing lines/drains
*Allow for time for family to be with the patient
* Contact donation services (may happen earlier)
OBody bag & Identification

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7
Q

Pain Assessments – components, when to use

A

PQRST- (Provoke, Quality, Region, Severity, Timing) Adult Pain scale

CRIES (Crying, Requiring O2, Increase in vitals, expression, sleep) Used for infants and newborns

FLACC (Faces, Legs, Arms, Cry, Consolability) 2m-7years or disabled

NVPS (Nonverbal pain Scale) is Used when unable to verbalize pain

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8
Q

Categories of Pain

A

Nociceptive: Pain in the skin, bones, joints, visceral

Neuropathic: Neurological pain, diabetic neuropathy, phantom limb pain

Cancer: Pain from cancer

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9
Q

Non-verbal signs of pain

A

Gaurding, Restlessness, Grimicing

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10
Q

Comforting in pain

A

Pharmaceuticals (Opioids)
Nonpharmacological (TENS, Massage… etc)
Distraction: used for mild pain

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11
Q

Promoting sleep

A

Go to bed and wake up each time every day, keep naps short and before 3 pm, complete exercise 3 hours before going to bed, remove work items and tv from the bedroom when possible.

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11
Q

Benefits of sleep

A

Health and Healing, Transfer of memory from short to long term,

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12
Q

The effects of sleep deprivation

A

Impair judgment, decrease response time, trigger seizure disorders, migraines and tension headaches

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13
Q

Obstructive Sleep Apnea

A

Related to the recurrent episodes of upper airway collapse and obstruction while sleeping combined with waking from sleep (apnea= no breathing for a minimum of 10 seconds)

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14
Q

Carbohydrates

A

The main source of energy
Make up 45-65% of total daily calories

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15
Q

Proteins

A

Found in every cell of the body
The building block of the body
Promotes growth, healing, and overall body maintenance
Builds and repairs tissues

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16
Q

Fats

A

Storage form of excess energy
Body protection
Facilitates absorption of fat-soluble vitamins
A secondary source of energy

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17
Q

Heart healthy Diet

A

Omega3
Less plaque buildup in the arteries

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18
Q

Low Sodium Diet

A

Less salty foods

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19
Q

Fat-soluble vitamins

A

A, D,E, K

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20
Q

Water soluble vitamins

A

C, B complex

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21
Q

Signs and symptoms of Malnutrition & Dehydration

A

Growth failure, compromised immune system, poor wound healing, muscle loss, physical and functional decline

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22
Q

Progression of nutrition following digestive issues – clear to full

A

Clear liquid- Contains only clear liquids such as broth, gelatin, and water
*Full liquid- Contains fluids, foods that are liquids, and foods that are liquids at room temperature
*Pureed- Consists of food that does not need to be chewed
*Soft Diet- Soft foods that are easy to swallow and digest
*Regular diet- Consists of healthy foods coming from all of the food groups

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23
Q

Dysphagia Definition, assessing for, health professional consult

A

Difficulty swallowing, Assessment is done by the RN
Evaluation is done by a speech pathologist
Avoid straws and thin liquids at first

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24
Joint Commission role
Perform evaluations of facilities and assess scores of the monthly submissions of hospitals’ safety and quality performance outcomes. Done 4 times a year
25
Enteral
Nutrition intake through the GI tract that can be by mouth or GI tube
26
Near Miss
Potential error or event that could have caused harm but was caught and avoided
27
Parenteral
Nutrition that is given intravenously through a large vein to clients whose GI tracts don’t work properly
28
Client Safety Event
An unexpected event that did occur but did not cause harm to the client
29
Adverse event
Unexpected event that caused harm to the client
30
Sentinel event
Critical, unexpected event that caused severe physical or psychological harm to a patient including death, dismemberment, or permanent injury.
30
Root cause analysis
Used to probe potential errors
31
HAIs
Hospital-acquired infections CAUTI: Catheter-Associated Urinary Tract Infection CLABSI: Central Line Associated Blood Systemic Infection Surgical Site Infection
32
Correct ID of patients
Two forms of identification Name, DOB, Phone Number, Social Security
33
Fall Prevention- Safety in the client’s room, surroundings
Call don’t fall (Use Call light) De-Clutter Monitor Mental status Bedside sitters Motion alarms Adequate lighting Call light in reach Hourly rounding At HOME Throw Rugs Electrical Cords Hand Rails Stair Lift
34
Standard Precautions
Cautions performed every time in every situation
35
PPE
Contact precautions: Gown, Gloves, (Everything else as needed) Droplet: Gown, Mask, Goggles, Gloves Airbourne: Gown, N95 respirator, Goggles, Gloves
36
Delegation – Nursing License
Dont delegate what you can EAT Evaluation, Assessment, Teaching
37
Basic steps in case of a Fire
R.A.C.E Rescue Alarm Confine Evacuate P.A.S.S *Pull *Aim *Squeeze *Sweep
38
Restraints
To AVOID restraints Close to the RN station Hourly Rounding Orient to surroundings Asses if current meds are therapeutic If restraints ARE ON Educate the family about why restraints are needed Passive ROM Provider Orders every 24 hours Released and repositioned every 2 hours
39
ISBAR
I- Identify S- Situation B- Background A- Assessment R-Recomendations
40
ADPIE
A-Assessment D-Diagnosis P-Planning I-Interventions E-Evaluate Assessment always first!
41
Vital Signs Normal ranges for adults
BP- 120/80 O2 Sat- 95%+ Pulse- 60-100 BPM Temp- 97-99 degrees F RR- 12-20
42
Illness & Disease
Illness: Personal experience with illness Disease: Alteration of body function
42
Modifiable Risks
Risk factors that one can change and prevent. - obesity
43
Health Equity/ Equality – Vulnerable Populations
Health equality- Everyone gets the same resources Health Equity- People who need it more get more resources
44
Social Determinants of Health
Bad environment, Low income, No insurance. Anything that can deter someone from getting healthcare
45
Eye Disorders
Cataracts- A clouding of the lens of the eye that causes vision to be blurry, hazy, or less colorful. Glaucoma- An increase in intraocular pressure due to the buildup of fluid, or aqueous humor, that causes compression of the optic nerve. Open Angle: Tunnel Vision, Gradual loss of vision Closed Angle: Severe pain, sudden onset of decreased vision Eye Exams: Increased Ocular pressure Treatment: Eye drops, Laser eye surgery Acute Macular Degeneration- An irreversible degeneration of the macula that leads to a loss of central vision as clients age. Diabetic Retinopathy- affects blood vessels in the retina causing blindness. Astigmatism- A defect that causes both nearby and faraway objects to appear blurry
46
Acute Macular Degeneration
An irreversible degeneration of the macula that leads to a loss of central vision as clients age.
47
Cataracts
A clouding of the lens of the eye that causes vision to be blurry, hazy, or less colorful.
48
Glaucoma
An increase in intraocular pressure due to the buildup of fluid, or aqueous humor, that causes compression of the optic nerve. Open Angle: Tunnel Vision, Gradual loss of vision Closed Angle: Severe pain, sudden onset of decreased vision Eye Exams: Increased Ocular pressure Treatment: Eye drops, Laser eye surgery
49
Diabetic Retinopathy
affects blood vessels in the retina causing blindness.
50
Astigmatism
A defect that causes both nearby and faraway objects to appear blurry
51
Eye exams as early as
6 months old
52
Comprehensive eye exam at
40 With no comorbidities 2-4 years ages 40-54 1-3 years 44-64 1-2 years 65+
53
Children ages _______ screened at least once
3-5
54
Eye Safety
Wear goggles or safety glasses in an environment that is dangerous
55
Hyperopia
Inability to see nearby objects clearly, also referred to as farsightedness.
56
Myopia
Inability to see faraway objects clearly, also referred to as nearsightedness
56
Astigmatism
A defect in the eye making objects nearby and faraway look blurry or distorted
57
Presbyopia
Age-related farsightedness, or a gradual decrease in the ability to clearly see nearby caused by the loss of flexibility of the lens of the eye.
58
Sensorineural Hearing Deficit
Effects inner ear, nerve pathway Could be associated with tinnitus and vertigo Age related presbycusis, followed by noise-induced hearing loss Congenital, genetic or acquired
59
Noise-induced hearing loss
Associated with prolonged exposure to sounds greeted than 85 dB including loud music Can be caused by single exposure to intense sound over 120dB Wear ear protection, avoid loud situations Warning signs are inability to hear from 3 feet away
60
Conductive Hearing loss
Loss of hearing at all frequencies Most common cause: Obstruction of external ear canal Impacted cerumen Perforated tympanic membrane
61
Otosclerosis
Abnormal growth of bone in the middle ear.
62
Otitis Media
Inflammation in or the accumulation of fluid in the middle ear that can result in conductive hearing loss
63
Occupational Risks for hearing loss
Machinery, Planes, other loud environments
64
Presbycusis
Age-related hearing loss.
65
Hair cells of cochlea ______ With aging
Degenerate
66
______ pitched tones, conversational speech lost initiaially
High
67
Conductive Hearing loss
Inability of sound to travel from the outer ear to the eardrum and middle ear. Blockage in ear canal
68
Sensorineural hearing loss
Hearing loss that occurs from problems either in the inner ear or on the vestibulocochlear (auditory) nerve (cranial nerve VIII).
69
Tinnitus
Hearing sound when no external sound is present, such as ringing, buzzing, roaring, clicking, hissing, or humming noises.
70
Vertigo
a sensation of motion or spinning that is often described as dizziness
71
TORCH
Toxoplasmosis, Rubella, Cytomegalovirus, Syphilis, Herpes
72
Idiopathic neuropathy
Neuropathy due to nerve damage of an unknown cause.
73
Peripheral Neuropathy
Conditions that occur when nerves in the central nervous system become damaged resulting in numbness, pain, and weakness to the extremities.
74
Diabetic neuropathy
Nerve damage that occurs in clients who have diabetes mellitus due to high blood glucose levels and high levels of triglycerides, which cause damage to the nerves and to the small blood vessels supplying blood to the nerves.
75
Rinne test
Tuning fork on mastoid bone, when client cannot hear it place it outside auditory canal
75
Weber Test
Place the tuning fork on the middle of forehead, detect if the client hears the sound equally. Can detect sensorineural issues
76
Sensory processing disorder
When a client appropriately detects sensory stimuli, but their brain has difficulty interpreting and responding appropriately to the stimuli.
77
Sensory Deficit
A deficit in the expected function of one or more of the five senses
78
Sensory Deprivation
A reduction in or absence of stimuli to one or more of the five senses.
79
Sensory Overload
Receiving stimuli at a rate and intensity beyond the brain’s ability to process the stimuli in a meaningful way.
79
Ototoxicity
Causing damage to or dysfunction of the cochlea or vestibule.
80
Aphasia
A disorder that affects a client s ability to articulate and understand speech and written language due to damage in the brain (National Institute on Deafness and Other Communication Disorders).
81
Tactile Hypersensitivity
Being overly sensitive to tactile stimulilation.
82
Tactile Defensiveness
A severe sensitivity to touch that most people would find acceptable that often causes physical pain
83
Tactile Hyposentivity
Under-responsiveness to tactile stimulation.
84
Gustatory Cells
Taste cells that contain specific receptors that allow for differentiation between sweet, sour, bitter, salty, or savory flavors.
85
Hypogeusia
A decreased ability to taste.
86
Dysgusia
A persistent salty, rancid, or metallic taste is said to have dysgeusia.
86
Aguesia
The inability to taste anything.
87
Phantom taste perception
A persistent, foul taste when the mouth is empty
88
Hyposmia
A reduction in the ability to perceive odors.
88
Anosmia
The inability to smell anything.
89
Phantosmia
The sensation of an odor that isn't there.
90
Parosmia
a distortion in smells, such as when a previously pleasant smell becomes unpleasant.
91
Vulnerable Populations
Socioeconomic Different primary language compared to health care site Sexual Orientation Sensory Deficits Demographics
92
Delirium
confused thinking and reduced awareness of the environment.
93
Emic knowledge
An insider's viewpoint of a culture.
93
Health Disparities
Preventable differences in incidence and prevalence of disease, injury, or violence among populations, based on race, ethnicity, gender, gender identity, LGBT, age, or socioeconomic status
93
Socioeconomic
Education level Employment status Household income Poverty status
93
Sexual Orientation
Clients who identify as lesbian, gay, or bisexual, and can also include those clients who are questioning their sexual orientation or sex identity.
93
Demographics
Age English language proficiency Household type Population density Race and ethnicity Sex
94
Cultural Competence
Being able to incorporate effective nursing care with emic and etic knowledge including appreciating, accepting, and respecting all individual s cultural influences, beliefs, customs, and values.
94
Etic knowledge
An outsider's viewpoint of a culture.
95
Culture
The learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular group that guide their thinking, decisions, and actions in patterned ways.
96
Cultural Humility
Being aware of power imbalances and biases and respecting other peoples values Not one culture is better than another
97
Implicit Bias
The involuntary attitudes or associations that affect our perceptions, actions, decisions, and interactions with others, unconsciously.
98
Explicit Bias
Bias that's derived from our conscious thoughts and beliefs that can be reported.
99
Musculoskeletal system:
Muscular system Skeletal System
99
Personal Health Literacy
The extent to which an individual can obtain, process, and comprehend basic health information.
99
Health Equality
The distribution of the same resources, including opportunities, to all individuals within a population.
99
Health Equity
Valuing all individuals equally and removing obstacles to optimal health and health care across different populations.
100
Cultural Health Assessment
Assessments that can be conducted to gather information regarding the client's culture and how it can affect their health.
100
Organizational Health literacy
The extent to which organizations equitably assist individuals with understanding, finding, and using information and services to make informed health-related decisions for themselves and others.
100
Intrapersonal:
“Intrapersonal cultural humility occurs when nurses and nurse faculty are actively engaged in examining and critiquing their beliefs and motives.” (Hughes, et. al. 2020)
100
Muscular system
Muscles and Tendons, ligaments, cartilage
101
Interpersonal
Interpersonal humility happens when individuals critically engage in questioning and understanding the values and cultures of their patients, families and colleagues” (Hughes, et. al. 2020)
101
Skeletal system
Bones, joints of skeletal system
102
Muscular system and skeletal system work together to...
Support body weight, control movements, provide stability, some provide protection for heart, lungs, and brain.
103
Ligaments
Connect bones to other bones
103
Muscle types
Smooth, Cardiac, Skeletal
104
Tendons
Connects muscles to bones
104
Cartilage
Flexible connective tissue
105
Pregnancy complications
Back pain due to weight Postural fixing, physical therapy to strengthen back muscles Caution on meds
105
Acute injury treatment
RICE Rest, Ice, Compress, Elevate POLICE Protection, Optimal, Load, Ice, Compression, Elevation
106
Alteration in muscles, bones, and joints link a variety of health problems
Arthritis Fractures Neurological disorders Traumatic Injuries Parkinsons Spinal cord injuries Back problems Multiple sclerosis
107
Adolescents complication
Most common time to see scoliosis
107
Childhood complications
Growing pains Presents as pain in arms and legs
107
Adult Complications
Back pain
108
Back Pain – Herniated Disc
Perforation on vertebrae leading to escaping fluid to compress nerve root, extremely painful
109
Lumbar Herniated Disc
Hip pain, Lower back pain
109
Herniated Disk interventions
Pharmacologic- Meds Nonpharmacologic- Accupuncture Surgery
110
Cervical Herniated Disc
Upper extremity pain, Shoulder pain, Neck pain
111
Good body mechanics
Wide Base Look at patients Straight back, no bending at the waist Life with the legs
111
Effects of Aging on the body
Loss of bone mass Decrease lean body mass Increased rigidity in tendons and ligaments Foot problems Muscle atrophy Decreased height Decreased range of motion
112
Consequences of immobility
Moving is healing Hospital acquired pressure injuries, DVTs, pneumonia, Falls, Cognition/Delirium, Readmissions, Length of stay, Discharge disposition, Appropriate rehab utilization Closer we get to a zero fall environment, the further away we get from a culture of mobility
113
Clients with Fall Risks
Diagnoses Abnormal lab values (Potassium) Vital signs Cognition Medication (Pain, diuretics)
114
Modifiable Risk Factors for Alterations of Sensory Perception
- Environment (UV light exposure, loud sounds) - Lifestyle (stress, smoking) - Injury - Medications
114
Concepts related to mobility
Collaboration, Comfort, Health, Wellness, Injury, Illness, Mood and Affect, Safety, Stress and coping
115
The 5+ Senses
- Visual - Olfactory - Gustatory -Tactile - Auditory - Kinesthetic: Position in time and space - Stereognosis: Use of tactile and memory to identify object - Visceral: Sensation of knowing something is happening in body
116
Non-Modifiable Risk Factors for Alterations of Sensory Perception
- Genetics - Aging
117
Impacts of Sensory Alteration
- Communication (deaf -> hard to talk/hear) - Psychosocial (can't hear, don't want to do social things) - Independence (challenges independence, confidence, self-esteem)
118
Modifiable and Non-Modifiable Risk Factors for Alterations of Sensory Perception
- Disease/Illness
119
Cataracts
- Lenses get cloudy and yellow - 60-70yrs old becomes a problem
120
Refractive Errors
- Presbyopia: Aging of the eye, close objects become blurry - Myopia: Nearsighted, distant objects appear blurry - Astigmatism: Blurry/distorted visionNursing Interventions for Visually Impaired
120
Glaucoma
- Gradual loss of peripheral vision - Aqueous Humor flow is compromised - Open Angle: Tunnel vision - Closed Angle: Severe pain, sudden vision loss - Treatment: Eye drops, laser eye surgery
121
Acute Macular Degeneration
- Dark area and distortion - Treatment: Antioxidants and zinc
121
Diabetic Retinopathy
- Bleeding in eye and occludes vision
122
Nursing Interventions for Visually Impaired
- Clear pathways - Ensure good lighting - Call light, glasses, assistive devices all in reach - Prevent Sensory overload - Print materials in larger font
123
Tactile Sense
- Access: Touch different texture and temperature objects on patient's skin with their eyes closed - Impairment: Decreased mobility, falls, weak grasp, pressure sores
123
Tactile Impairment Through Lifespan
- Older adults have decreased sensitivity to touch - Uncontrolled diabetes causing peripheral neuropathy - Polyneuropathy: Damage to multiple body parts
124
Symptoms of Peripheral Neuropathy
- Aching, shooting, tingling, burning pain and weakness
125
Tactile Nursing Care
- Address contributing conditions - Change position often to avoid sores - Promote effective coping
126
Olfactory Sense
Smell Often not adequately tested Can use swabs with vanilla Electro-olfactography
127
Olfactory and Gustatory Nursing Care
- Danger cleaning with some chemicals - Gas appliances in good working order - Inspect food for freshness - Suggest healthy way to add flavor besides salting - Maintain good oral care (brush twice, floss once, visit dentist every 6)
128
Olfactory and gustatory Impairment Through Lifespan
Pregnancy: increase sense of smell, leading to nausea and vomiting or food cravings - Older adults: senses diminish - May be affected by cold, flu, coronavirus, sinusitis - MS and Parkinson's can affect them as well
129
Hearing Screenings
- Newborns screened regularly - Preschool and school age screened at school - Adults every 10yrs until 50, every 3yrs after 50
129
Rinne Test
- Place vibrating tuning fork on mastoid bone, remove when can't hear, place outside ear - Air conduction should be twice as long as bone conduction
130
Weber Test
- Place tuning fork on top of head - Should hear equally in both ears
131
Auditory Alterations
Hearing Deficits May: - Be partial or total - Be congenital or acquired - Affect one or both ears - Affect specific frequencies or all frequencies
132
Conductive Hearing Loss
Equal loss of hearing at all frequencies Causes -Obstruction of external ear canal - Wax buildup - Perforated ear drum - Disruption or fixation of ossicles - Chronic and untreated ear infections
133
Sensorineural Hearing Loss
-Effects inner ear, auditory nerve pathway - May be associated with tinnitus and vertigo - Most common cause is age related presbycusis (degeneration of hair cells of cochlea)
134
TORCH
T: Toxoplasmosis O: Other (syphilis, varicella, mumps, parvovirus, HIV) R: Rubella C: Cytomegalovirus H: Herpes simplex
135
Non-pharmacological Auditory Therapies
-Hearing aids -Assistive listening devices -White or pink noise-masking device -TD/TTY telephones -Internet accessibility -Lip Reading -Flashing/vibrating safety alarms
136
Pharmacological Auditory Therapies
-Decongestants -Steroids -Antibiotics (Used to treat cause of temporary hearing alterations)
137
Auditory Health Promotion
- Earplugs - Use email or text instead of call - Use written materials - Closed captions - ASL or Lip reading classes
138
What Components Make Up Muscular System?
- Ligaments - Tendons - Cartilage- - Muscles
139
What Components Make Up Skeletal System?
- Bones - Joints
140
Ligaments
Connect bones to other bones
141
Tendons
Connects bones to muscles
142
Types of Musculoskeletal Alterations
-Back problems -Fractures -Multiple Sclerosis -Osteoarthritis -Parkinson's -Spinal Cord Injuries (SCI)
143
POLICE
P: Protection O: Optimal L: Load I: Ice C: Compression E: Elevation
143
RICE
R: Rest I: Ice C: Compress E: Elevate
144
Concepts Related to Mobility
-Collaboration -Comfort -Health, Wellness, Illness, and Injury -Mood and Affect -Safety -Stress and Coping
145
Lifespan Considerations: Children
-Massive bone growth -Growing pains in legs/arms
146
Lifespan Considerations: Infants
-Flexible -Unfused cartilaginous joints
147
Lifespan Considerations: Adolescents
-Injuries from sports -Continued muscle and bone growth/development
148
Lifespan Considerations: Pregnancy
-Increase weight -Increase stress on muscles and bone
149
Lifespan Considerations: Older Adults
-Compressed Spine -Decrease muscle mass -Stiffer joints
150
Pharmacological Interventions For Back Pain
-Drugs
150
Herniated Disc Description
-Anulus fibrosis ruptures -Nucleus pulposus herniates -Nerve gets compresses
151
Non-pharmacological Interventions for Back Pain
-Acupuncture -RICE/POLICE -Low impact exercise
152
Fall Risks
-Abnormal lab values (low potassium causes muscle weakness) -Vitals out of range -Cognition -Meds (diuretics make you pee, get up to go to bathroom, fall)
153
BMAT
-Bedside Motility Assessment Tool 1. Assess use of assistive device 2. Have patient reach across body to shake your hand 2. Stretch foot out and point toe (with at least one leg) 3. Bear weight on leg for 5 seconds 4. March in place 5. Step forward and back with each leg
154
immobility
An inability to reposition or move self
155
Synovial Joints
Fluid-filled capsules that connect bones and enable movement.
156
proprioception
Feedback from sensory receptors to coordinate, balance, and fine-tune body positioning and movement.
157
Peripheral Nervous System
Nervous system outside of the brain and spinal cord, which regulates the responses of the body to external stimuli.
158
Ergonomics
Study of body mechanics in relation to the demand and design of the work environment and the equipment used.
159
Mobility
Moving from one position to another.
160
Atrophy
Become smaller and weaker often from disuse.
161
Sarcopenia
Loss of lean muscle caused by immobility.
162
Foot Drop
A type of joint contracture that results in the foot and toes permanently pointing downward.
163
Joint Contractures
An abnormal fixation of a joint due to changes in muscles and connective tissue.
164
Activity Intolerance
Inadequate amount of physical or psychological energy to undergo or complete a necessary activity.
165
Kyphosis
Excessive outward curvature of the upper area of the spine.
166
Passive Range of Motion
The movement of a joint by another individual.
167
Active Range of Motion
Voluntary movement of a joint.
168
BMAT Stages
Safety Screen. Level 1 - Sit and Shake Assessment. Level 2 - Stretch and Point Assessment. Level 3 - Stand Assessment. Level 4 - Walk.