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NUR 151 > Chapter 47 mobility and immobility > Flashcards

Chapter 47 mobility and immobility Flashcards

1
Q

Visible aspect and contributes to self-worth and well-being

A

Movement

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2
Q

Used to show self-defense, perform activities of daily living (ADLs) and recreational activities

A

Mobility

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3
Q

Coordinated efforts of the musculoskeletal and nervous system

A

Body mechanics

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4
Q

Reduces strain, maintains muscle tone, comfort, conserves energy

A

Body alignment

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5
Q

Required to maintain a static position

A

Balance

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6
Q

Force that occurs in a direction to oppose movement

A

Friction

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7
Q

Contribute to height

A

Long bones

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8
Q

Occur in clusters (carpal bones in the foot)

A

Short bones

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9
Q

Provide structural contour (skull)

A

Flat bones

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10
Q

Make up the vertebral column and some bones of the skull

A

Irregular bones

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11
Q

Caused by weakened bone tissue

A

Pathological fractures

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12
Q

Bones jointed by bones with no movement

A

Synostosis joint

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13
Q

Unites bony components

A

Cartilaginous joint

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14
Q

joint in which a ligament unites two bony surfaces (paired bones of the lower leg)

A

Fibrous joint

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15
Q

Ball and Socket Joint (hip)

A

Synovial joint

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16
Q

Fibrous tissue that connect ones an cartilages

A

Ligaments

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17
Q

Connect muscle to bone

A

Tendons

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18
Q

Nonvascular, supporting tissue (joints and thorax)

A

Cartilage

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19
Q

Increased muscle contraction causes muscle shortening resulting in movement

A

concentric tension

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20
Q

Helps control the speed and direction of movement

A

Eccentric tension

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21
Q

Active movement between concentric and eccentric muscle actions

A

Isotonic contraction

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22
Q

Causes an increase in muscle tension or muscle work but no shortening or active movement

A

Isometric contraction

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23
Q

Inducing or compelling force

A

Leverage

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24
Q

Position of the body in relation to the surrounding space

A

Posture

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25
Q

Normal state of balanced muscle tension

A

Muscle tone

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26
Q

Inclining of head to affected side, in which sternocleidomastoid muscle is contracted

A

Torticollis

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27
Q

Exaggeration of anterior convex curve of lumbar spine

A

Lordosis

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28
Q

Increased convexity in curvature of thoracic spine

A

Kyphosis

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29
Q

Lateral S- or C-shaped spinal column with vertebral rotation, unequal heights of hips and shoulders

A

scoliosis

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30
Q

Hip instability with limited abduction of hips and, occasionally, adduction contractures (head of femur does not articulate with acetabulum because of abnormal shallowness of acetabulum)

A

Congential hip dysplasia

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31
Q

Legs curved inward so that knees come together as person walks

A

knock-knee

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32
Q

One or both legs bent outward at knee, which is normal until 2 to 3 years of age

A

Bowlegs

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33
Q

95%: medial deviation and plantar flexion of foot (equinovarus) 5%: lateral deviation and dorsiflexion (calcaneovalgus)

A

Clubfoot

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34
Q

Inability to dorsiflex and invert foot because of peroneal nerve damage

A

Footdrop

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35
Q

Internal rotation of forefoot or entire foot; common in infants

A

Pigeon Toes

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36
Q

Damage to component of the central nervous system that regulates voluntary movement results in

A

impaired body alignment, balance, and mobility

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37
Q

Direct trauma to the musculoskeletal system results in

A

bruises, contusions, sprains, and fractures

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38
Q

inability to move freely

A

Immobility

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39
Q

Identify the objectives of bed rest.

A

a. Reducing physical activity and the oxygen needs of the body
b. Reducing pain, including postoperative pain or after acute injury, to the lower back
c. Allowing ill or debilitated clients to rest
d. Allowing exhausted clients the opportunity for uninterrupted rest

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40
Q

Identify the complications of immobility in relation to the metabolic functioning of the body

A

decreases the metabolic rate; alters the metabolism of CHO, fats, and proteins; causes fluid and electrolyte and calcium imbalances; and causes GI disturbances

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41
Q

collapse of alveoli

A

Atelectasis

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42
Q

inflammation of the lung from stasis or pooling of secretions

A

Hydrostatic pneumonia

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43
Q

increase in heart rate of more than 15% and a drop of 15 mm Hg or more in SBP

A

Orthostatic hypotension

44
Q

accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery that occludes the lumen of the vessel

A

Thrombus

45
Q

Identify the complications of immobility in , relation to the musculoskeletal system

A

a. loss of endurance, strength, and muscle mass and decreased stability and balance
b. impaired calcium metabolism
c. impaired joint mobility
d. osteoporosis
e. joint contractures
f. footdrop

46
Q

Identify the complications of immobility in relation to the urinary system.

A

a. urinary stasis (renal pelvis fills before urine enters the ureters)
b. renal calculi (calcium stones that lodge in the renal pelvis)

47
Q

Identify the psychosocial effects that occur with immobilization

A

a. emotional and behavioral responses
b. sensory alterations
c. changes in coping

48
Q
  1. is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, or transverse
A

Range of Motion (ROM)

49
Q

particular manner or style of walking

A

Gait

50
Q

physical activity for conditioning the body, improving health, and maintaining fitness

A

Exercise and activity tolerance

51
Q

identifies deviations, learning needs, identifies trauma, risk factors

A

Body alignment

52
Q

Which nursing diagnoses is related to an immobilized or partially immobilized client.

A

1 ineffective airway clearance

  1. ineffective individual coping
  2. risk for injury
  3. impaired skin integrity
  4. disturbed sleep pattern
  5. social isolation
  6. impaired urinary elimination
53
Q

List the expected outcomes for the goal “client skin remains intact”

A

a. skin color and temperature return to normal baseline within 20 minutes of position change
b. changes position at least every 2 hours

54
Q

Identify some examples of health promotion activities that address mobility and immobility

A

a. prevention of work-related injury
b. fall prevention measures
c. exercise
d. early detection of scoliosis

55
Q

Identify the nursing interventions that will reduce the impact of immobility on Metabolic Systems

A

a. a high caloric diet

b. vitamin B and C supplements

56
Q

Identify the nursing interventions that will reduce the impact of immobility on Respiratory system

A

a. deep breathe and cough every 1-2 hours
b. CPT
c. ensure intake of 2000 mL of fluid per day

57
Q

Identify the nursing interventions that will reduce the impact of immobility on Cardiovascular system

A

a. deep breathe and cough every 1-2 hours
b. CPT
c. ensure intake of 2000 mL of fluid per day

58
Q

Identify the nursing interventions that will reduce the impact of immobility on Musculoskeletal system

A

a. perform active and passive ROM exercises

b. CPM machines

59
Q

Identify the nursing interventions that will reduce the impact of immobility on Integumentary system

A

a. positioning and skin care

b. use of therapeutic devices to relieve pressure

60
Q

Identify the nursing interventions that will reduce the impact of immobility on Elimination system

A

a. well-hydrated

b. prevent urinary stasis and calculi and infections

61
Q

Identify the nursing interventions that will reduce the impact of immobility on Psychosocial

A

a. anticipate change in the client’s status and provide routine and informal socialization
b. stimuli to maintain client’s orientation

62
Q

prevents external rotation of the hips when the client is in supine position

A

Trochanter roll

63
Q

maintain the thumb in slight adduction and in opposition to the fingers

A

Hand rolls

64
Q

allows the client to pull with the upper extremities to raise the trunk off the bed, assist in transfer, or to perform exercises

A

Trapeze bar

65
Q

HOB elevated 45-60 degrees and the knees are slightly elevated

A

Fowlers

66
Q

rest on their backs; all the body parts are in relation to each other

A

Supine

67
Q

lies face or chest down

A

Prone

68
Q

the client rests on the side with body weight on the dependent hip and shoulder

A

Side-lying

69
Q

client places the weight on the anterior ileum humerus and clavicle

A

Sims

70
Q

Are activities beyond ADLs that are necessary to be independent in society

A

Instrumental activities of daily living (IADLs)

71
Q

Describe how you would assist clients with hemiplegia or hemiparesis

A

Always stand on the client’s affected side and support the client by using a gait belt.

72
Q

Identify the evaluative measures in mobility

A

the client’s ability to maintain or improve body alignment, improve mobility; protect the client from the hazards of immobility

73
Q

What is a potential hazard that you should assess when the client is in a prone position

A

footdrop

74
Q

Abnormal and usually permanent condition of a joint, characterized by flexion and fixation and caused by disuse, atrophy, and shortening of muscle fibers.

A

joint contracture

75
Q

Measures of height, weight, and skinfold thickness to evaluate muscle atrophy.

A

anthropometric measurements

76
Q

A decline is bone density that is associated with impaired mobility or immobilization of an extremity because of fracture, paralysis, or bone or joint inflammation.

A

disuse osteoporosis

77
Q

A foreign object, a quantity of air or gas, a bit of tissue or tumor, or a piece of thrombus that circulates in the bloodstream until it becomes lodged in a vessel.

A

embolus

78
Q

Leather belt that encircles the waist and has handles attached for the nurse to hold.

A

gait belt

79
Q

Loss of muscle tissue.

A

muscle atrophy

80
Q

Condition occurring when the body excretes more nitrogen than it takes in.

A

negative nitrogen balance

81
Q

Not hardened, soft.

A

unossified

82
Q

Group of therapies used to mobilize pulmonary secretions.

A

chest physiotherapy (CPT)

83
Q

Paralysis of one side of the body.

A

hemiplegia

84
Q

Muscular weakness of one half of the body

A

hemiparesis

85
Q

the coordinated efforts of the musculoskeletal and nervous systems as the person moves, lifts, bends, stands, sits, lies down, and completes daily activities

A

body mechanics

86
Q

safe patient handling prevents

A

injuries to nurses and clients when moving and transferring clients

87
Q

The skeletal system provides bony support structure for

A

movement, attachment of ligaments and muscles, protection of vital organs, some of the regulation of calcium, and production of red blood cells.

88
Q

initiation and voluntary control of movement

A

nervous system

89
Q

Coordination and regulation of muscle groups depend on

A

muscle tone; activity of antagonistic, synergistic, and antigravity muscles; and neural input to muscles

90
Q

Body alignment is the condition of

A

joints, tendons, ligaments, and muscles in various body positions.

91
Q

Balance occurs when there is a wide base of

A

support, the center of gravity falls within the base of support, and a vertical line falls from the center of gravity through the base of support.

92
Q

Developmental stages influence

A

body alignment and mobility; the greatest impact of physiological changes on the musculoskeletal system is observed in children and older adults.

93
Q

The risk of disabilities related to immobilization depends on

A

on the extent and duration of immobilization and the client’s overall level of health.

94
Q

illness or trauma or is prescribed for therapeutic reasons.

A

Immobility sometimes results from

95
Q

Immobility presents hazards in

A

the physiological, psychological, and developmental dimensions.

96
Q

The nursing process and critical thinking assist in providing

A

care for clients who are experiencing or are at risk for the adverse effects of impaired body alignment and immobility.

97
Q

Clients with impaired body alignment require nursing interventions to

A

maintain them in the supported Fowler’s, supine, prone, side-lying, and Sims’ positions.

98
Q

Client movement algorithms serve as

A

assessment tools and guide safe client handling and movement.

99
Q

Appropriate friction-reducing assistive devices and mechanical lifts need to be used for

A

client transfers when applicable.

100
Q

No-lift policies benefit

A

all members of the health care system: clients, nurses, and administration.

101
Q

Intervention that restrict patients to bed for therapeutic reasons.

A

Bed rest

102
Q

It is an increase in heart rate or more than 15%, a drop 15mm in systolic Bp, drop 10mm or more in diastolic. when the pt change from supine to standing position

A

Orthostatic hypotension

103
Q

factors that contribute to venous thrombus formation

A

damage on the vessel wall.(injury)
alteration in blood flow
alteration in blood constitute(change in clotting factors)

104
Q

impairment of the skin as a result of prolonged ischemia (decrease blood supplies in tissues)

A

Pressure ulcer

105
Q

head of the bed is elevated 45-60 degrees. Pt knees are slightly elevated without pressure to restrict circulation in the lower legs.

A

Supported Folwer’s Position

NUR 151 (6 decks)

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