Fundamentals - Chapter 2 in Basics Flashcards
exaggerated concavity in the lumbar region
lumbar lordosis
exaggerated convexity in the thoracic region
kyphosis
Physical assessment includes what?
a. Body build, height, weight— proportioned within normal limits b. Posture, body alignment— erect c. Gait, ambulation— smooth d. Joints— freely moveable e. Skin integrity— intact f. Muscle tone, elasticity, strength— adequate
Psychosocial History includes?
Psychosocial assessment 1) Exercise level 2) Rest and sleep patterns 3) Sexual activity 4) Job-related activity
b. Health history includes
1) Pregnancy 2) Structural or functional defects of the nervous system 3) Structural or functional defects of the musculoskeletal system 4) Diagnostic procedures and medical or surgical treatments that require activity restriction 5) Conditions or treatments that result in pain 6) Endocrine disorders that affect rest and activity
What are some gerontoligic consideration for mobility?
- Bones– less dense; less strong; more brittle; decreased mineralization; elderly females have increased osteoclatic bone resorption; osteoporosis incidence higher in women; high incidence of deformity, pain, stiffness, fractures; increased osteoporosis with smoking, decreased calcium intake, alcohol use, physical inactivity 2. Joints– rigid, fragile cartilage; decreased water content in cartilage; decreased intervertebral disk height; limited or painful stiff movement; crepitation with movement3. Muscles– loss of muscle mass, tone, agility and strength; slowed reaction time; muscle fatigue; muscle function can be maintained with exercise
_______Rotate the ankle and sole of foot inward ______Rotate the ankle and sole of foot outward
Inversion
Eversion
_________Point the toes toward the head______ Point the toes away from the head
Dorsiflexion
Plantarflexion
How can we prevent injuries related to mobility?
a. Motor vehicle accidents— use of seat belts and helmetsb. Job-related accidents— following safety proceduresc. Contact sports— proper body conditioning and use of protective devicesd. Aging— rugs should be secure; stairways lit and clear of debris e. Pregnancy— bathtub grips; low-heeled shoes
How can we prevent injuries related to mobility?
a. Motor vehicle accidents— use of seat belts and helmetsb. Job-related accidents— following safety proceduresc. Contact sports— proper body conditioning and use of protective devicesd. Aging— rugs should be secure; stairways lit and clear of debris e. Pregnancy— bathtub grips; low-heeled shoes
How often should the gerontologic population exercise?
30-minute, 5 times a week
What are the benefits of activity and exercise?
- Activity a. Maintains muscle tone and posture b. Serves as outlet for tension and anxiety
- Exercise a. Maintains joint mobility and function b. Promotes muscle strength c. Stimulates circulation d. Promotes optimum ventilation e. Stimulates appetite f. Promotes elimination g. Enhances metabolic rate
What is the importance of positioning?
- Purpose a. To prevent contractures
b. To promote circulation
c. To promote pulmonary function d. To relieve pressure on body parts
e. To promote pulmonary drainage - Common client positions and their corresponding therapeutic functions (see Table II-4 )
What are some important point about ambulation?
a. Weight bearing on long bones to prevent decalcification, resulting in weakening of the bone and renal calculi
b. Stimulate circulation to lower extremities
c. Use elastic stockings to prevent postural hypotension
d. Should be done gradually; blood pressure should be checked during the procedure
e. If blood pressure goes down and dizziness, pallor, diaphoresis, tachycardia, or nausea occurs, stop procedure
What are some important point about ambulation in rehabbing mobility?
a. Weight bearing on long bones to prevent decalcification, resulting in weakening of the bone and renal calculi
b. Stimulate circulation to lower extremities
c. Use elastic stockings to prevent postural hypotension
d. Should be done gradually; blood pressure should be checked during the procedure
e. If blood pressure goes down and dizziness, pallor, diaphoresis, tachycardia, or nausea occurs, stop procedure
What are some adverse effects of immobility?
Integumentary:
Decubitus ulcer, Decreases wound healing
Osteomyelitis, Tissue maceration, Infection
Musculoskeletal:
Osteoporosis, Decreased muscle mass/strength, Atrophy Contractures, Pathological fractures, Loss of endurance, Deformities, Decreased stability
Respiratory:
Change in lung volume, Atelectasis, Stasis of secretions, Decreased lung expansion, Decreased hemoglobin, Respiratory muscle weakness, Pneumonia
Cardiovascular:
Increased cardiac workload, Thrombus formation, Orthostatic hypotension, Tachycardia, Pulmonary emboli ,Weakness, faintness, dizziness
Metabolic:
Decreased basal metabolic rate,Altered nutrient metabolism,Hypercalcemia,Decreased cellular activity
Weight gain,Loss of lean body mass,Negative nitrogen balance,Anorexia, weight loss, debilitation, Slow wound healing and tissue growth, Increased diuresis, Increased excretion of electrolytes
Elimination:
Constipation, Urinary stasis, Fecal impaction, Urine retention, urinary infections, Renal calculi
What are some adverse effects of immobility?
Integumentary:
Decubitus ulcer, Decreases wound healing
Osteomyelitis, Tissue maceration, Infection
Musculoskeletal:
Osteoporosis, Decreased muscle mass/strength, Atrophy Contractures, Pathological fractures, Loss of endurance, Deformities, Decreased stability
Respiratory:
Change in lung volume, Atelectasis, Stasis of secretions, Decreased lung expansion, Decreased hemoglobin, Respiratory muscle weakness, Pneumonia
Cardiovascular:
Increased cardiac workload, Thrombus formation, Orthostatic hypotension, Tachycardia, Pulmonary emboli ,Weakness, faintness, dizziness
Metabolic:
Decreased basal metabolic rate,Altered nutrient metabolism,Hypercalcemia,Decreased cellular activity
Weight gain,Loss of lean body mass,Negative nitrogen balance,Anorexia, weight loss, debilitation, Slow wound healing and tissue growth, Increased diuresis, Increased excretion of electrolytes
Elimination:
Constipation, Urinary stasis, Fecal impaction, Urine retention, urinary infections, Renal calculi
Psychosocial:
Depression Sensory deprivation Confusion Increased dependence Insomnia, restlessness
What are some adverse effects of immobility?
Integumentary:
Decubitus ulcer, Decreases wound healing
Osteomyelitis, Tissue maceration, Infection
Musculoskeletal:
Osteoporosis, Decreased muscle mass/strength, Atrophy Contractures, Pathological fractures, Loss of endurance, Deformities, Decreased stability
Respiratory:
Change in lung volume, Atelectasis, Stasis of secretions, Decreased lung expansion, Decreased hemoglobin, Respiratory muscle weakness, Pneumonia
Cardiovascular:
Increased cardiac workload, Thrombus formation, Orthostatic hypotension, Tachycardia, Pulmonary emboli ,Weakness, faintness, dizziness
Metabolic:
Decreased basal metabolic rate,Altered nutrient metabolism,Hypercalcemia,Decreased cellular activity
Weight gain,Loss of lean body mass,Negative nitrogen balance,Anorexia, weight loss, debilitation, Slow wound healing and tissue growth, Increased diuresis, Increased excretion of electrolytes
Elimination:
Constipation, Urinary stasis, Fecal impaction, Urine retention, urinary infections, Renal calculi
Psychosocial:
Depression Sensory deprivation Confusion Increased dependence Insomnia, restlessness
List the purpose of clients positions: Flat (supine) Side side with leg bent (Sims) Fowler's Head and knees elevated slightly Feet elevated 20 ° and head slightly elevated (modified Trendelenburg) Elevation of extremity Flat on back, thighs flexed, legs abducted (lithotomy) Prone
Flat (supine) Minimizes hip flexion
Side Allows drainage of oral secretions
Side with leg bent (Sims’) Allows drainage of oral secretions (abdominal tension)
Head elevated (Fowler’s) Increased venous return; allows maximal lung expansion
Head and knees elevated slightly Increased venous return; relieves pressure on lumbosacral area
Feet elevated 20 ° and head slightly elevated (modified Trendelenburg) Increased venous return; increased blood supply to brain
Elevation of extremity Increases venous return
Flat on back, thighs flexed, legs abducted (lithotomy) Exposes perineum
Prone Promotes extension of hip joint
How do you properly transfer a patient?
Transfer:
Definition— to move a client from one surface to another. (i.e., from a bed to a stretcher)
Basic guidelines
1) If client has a stronger and a weaker side, move the client toward the stronger side (easier for client to pull the weak side)
2) Use the larger muscles of the legs to accomplish a move rather than the smaller muscles of the back
3) Move client with drawsheet; do not slide a client across a surface
4) Always have an assistant standing by if there is any possibility of a problem in completing a transfer
Kaplan (2014-03-03). The Basics (p. 27). Kaplan Publishing. Kindle Edition.
What is the technique for sitting client at edge of bed?
a. Place hand under knees and shoulders of client b. Instruct client to push elbow into bed; at same time lift shoulders and bring legs over edge of bed, or use one leg to move other leg over edge of bed
What is the technique for assisting client to stand?
a. Place client’s feet directly under body; client should wear nonskid slippers
b. Face client and firmly grasp each side of rib cage
c. Push one knee against one knee of the client
d. Rock client forward as client comes to a standing position
e. Ensure that client’s knees are “locked” while standing f. Give client enough time to balance while standing
g. Pivot with client to position and transfer client’s weight quickly to chair placed on client’s stronger side
Kaplan (2014-03-03). The Basics (p. 27). Kaplan Publishing. Kindle Edition.
How can we encourage our patients when it comes to ADLs?
Give immediate positive feedback after every act of accomplishment
Kaplan (2014-03-03). The Basics (p. 27). Kaplan Publishing. Kindle Edition.
When pt is going up or down stairs with crutches, which food leads? when do crutches go?
To go up stairs: advance good leg first, followed by crutches and affected leg.
To go down stairs: advance crutches with affected leg first, followed by good leg.
(“ Up with the good, down with the bad.”)
Kaplan (2014-03-03). The Basics (p. 28). Kaplan Publishing. Kindle Edition.
When walking with crutches, should the patient bear wait on axillla or handpiece?
Client should support weight on handpiece, not in axilla— brachial plexus may be damaged, producing “crutch palsy”
Kaplan (2014-03-03). The Basics (p. 28). Kaplan Publishing. Kindle Edition.
How far to each side should crutches be positioned?
Position crutches 8– 10 inches to side
Kaplan (2014-03-03). The Basics (p. 28). Kaplan Publishing. Kindle Edition.
How can we prevent constipation?
- Ambulation as appropriate 2. Increase fluid intake 3. Ensure privacy in use of bedpan or commode 4. Administer stool softeners, e.g., Colace
Kaplan (2014-03-03). The Basics (p. 29). Kaplan Publishing. Kindle Edition.
How can we prevent constipation?
- Ambulation as appropriate 2. Increase fluid intake 3. Ensure privacy in use of bedpan or commode 4. Administer stool softeners, e.g., Colace
Kaplan (2014-03-03). The Basics (p. 29). Kaplan Publishing. Kindle Edition.
How can we prevent urinary stasis?
- Have client void in normal position, if possible 2. Increase fluid intake 3. Low-calcium diet— increase acid-ash residue to acidify urine and prevent formation of calcium stones 4. Evaluate adequacy of urine output
Kaplan (2014-03-03). The Basics (p. 29). Kaplan Publishing. Kindle Edition.
How can we prevent pressure ulcers?
- Frequent turning, skin care, keep skin dry
- Ambulation as feasible
- Use draw sheet when turning to avoid shearing force
- Balanced diet with adequate protein, vitamins, and minerals
- Use air mattress, flotation pads, elbow and heel pads, sheepskin
- Assist with use of Stryker frame or Circ-O-Lectric bed (these beds are rad! The move in all types of directions with the patient strapped in. Google it!)
- Gerontologic considerations:
a. Increased risk– poor nutritional status and weight loss, vitamin and protein deficiencies, decreased peripheral sensation, moisture
b. Identify clients at risk– Braden scale (for predicting pressure sores), weight loss greater than total body weight, serum albumin less than 3.5 g/ dL, pressure areas
c. Avoid friction during position change, eliminate moisture, move weight bearing from pressure areas, e.g., heel protectors, include high protein, vitamins, and carbohydrates in diet
Kaplan (2014-03-03). The Basics (p. 29). Kaplan Publishing. Kindle Edition.
How often should a patient do leg exercises to prevent thrombus (or DVT)?
- Leg exercises— flexion, extension of toes and feet for five minutes every hour
Kaplan (2014-03-03). The Basics (p. 30). Kaplan Publishing. Kindle Edition.
How can we prevent thrombus?
Prevent thrombus formation 1. Leg exercises— flexion, extension of toes and feet for five minutes every hour 2. Ambulation as appropriate 3. Frequent change of position 4. Avoid “gatching” bed or using pillow to support knee flexion for extended periods 5. Use of TEDs or elastic hose
Kaplan (2014-03-03). The Basics (p. 30). Kaplan Publishing. Kindle Edition.
How can we prevent stasis of respiratory secretions?
- Teach client the importance of turning, coughing, and deep breathing 2. Administer postural drainage as appropriate 3. Teach use of incentive spirometer
Kaplan (2014-03-03). The Basics (p. 30). Kaplan Publishing. Kindle Edition.
How can we prevent stasis of respiratory secretions?
- Teach client the importance of turning, coughing, and deep breathing
- Administer postural drainage as appropriate
- Teach use of incentive spirometer
Kaplan (2014-03-03). The Basics (p. 30). Kaplan Publishing. Kindle Edition.
In Maslow’s hierarchy of needs, which is the top priority? What is second to that?
Physiological is the number one: breathing, eating, fluid, excretion.
After that, safety is next.
T or F: Nursing has primary responsibility for ensuring the safety of clients in health care facilities and influencing the safety of persons in the home, work, and community environments
True
Kaplan (2014-03-03). The Basics (p. 31). Kaplan Publishing. Kindle Edition.
List factors affecting safety for age groups:
Children TOddlers Preschoolers School ages Adolescents Adults
a. Children— accidents constitute leading cause of death in all age groups except infancy
1) Infants— accidents occur primarily in second half of first year a) Mouthing any object that they handle b) Unsupervised/ unrestrained rolling over, crawling, walking can result in falls and enhance accessibility to small objects, electric cords, poisonous substances, etc.
2) Toddlers— high incidence of accidents a) Increasing curiosity; exploring using all senses (especially taste and touch); learning by trial and error b) Increasing gross and fine motor activity, climbing, running, grasping, etc. c) Totally uncomprehending and fearless of consequences; increasing negativism as part of autonomy
3) Preschoolers— continued risk a) lncreasing imitative behavior b) Refining fine and gross motor ability without cognitive ability to foresee potential dangers
4) School-ages— although better muscular control, increased cognitive capacity, and more readiness to respond to rules, there continues to be increased risk of accidents related to identification with “super heroes,” increased involvement and competitiveness in sports, and sensitivity to peer pressure
5) Adolescents— high incidence; caused by motor vehicles, physical awkwardness related to growth changes, conflict over dependence/ independence; peer orientation and approval seeking; increasing goal orientation and risk-taking behavior; and inner perception of omnipotence and immortality
b. Adults— disregard for safety regulations
c. Elderly— diminished muscular strength and/ or coordination, diminished sensory acuity, and impaired balance create special problems
Kaplan (2014-03-03). The Basics (p. 31). Kaplan Publishing. Kindle Edition.
List factors affecting safety for age groups:
Children Toddlers Preschoolers School ages Adolescents Adults
a. Children— accidents constitute leading cause of death in all age groups except infancy
1) Infants— accidents occur primarily in second half of first year a) Mouthing any object that they handle b) Unsupervised/ unrestrained rolling over, crawling, walking can result in falls and enhance accessibility to small objects, electric cords, poisonous substances, etc.
2) Toddlers— high incidence of accidents a) Increasing curiosity; exploring using all senses (especially taste and touch); learning by trial and error b) Increasing gross and fine motor activity, climbing, running, grasping, etc. c) Totally uncomprehending and fearless of consequences; increasing negativism as part of autonomy
3) Preschoolers— continued risk a) lncreasing imitative behavior b) Refining fine and gross motor ability without cognitive ability to foresee potential dangers
4) School-ages— although better muscular control, increased cognitive capacity, and more readiness to respond to rules, there continues to be increased risk of accidents related to identification with “super heroes,” increased involvement and competitiveness in sports, and sensitivity to peer pressure
5) Adolescents— high incidence; caused by motor vehicles, physical awkwardness related to growth changes, conflict over dependence/ independence; peer orientation and approval seeking; increasing goal orientation and risk-taking behavior; and inner perception of omnipotence and immortality
b. Adults— disregard for safety regulations
c. Elderly— diminished muscular strength and/ or coordination, diminished sensory acuity, and impaired balance create special problems
Kaplan (2014-03-03). The Basics (p. 31). Kaplan Publishing. Kindle Edition.
T or F: Noise-induced hearing loss is hearing loss due to exposure to either a sudden, loud noise or exposure to loud noises for a period of time. A dangerous sound is anything that is 85 dB (sound pressure level – SPL) or higher.
True
Sound— chronic exposure to loud noises can lead to permanent hearing loss, interfere with work performance, precipitate sleep problems and psychological stress
Kaplan (2014-03-03). The Basics (p. 32). Kaplan Publishing. Kindle Edition.
T or F: Noise-induced hearing loss is hearing loss due to exposure to either a sudden, loud noise or exposure to loud noises for a period of time. A dangerous sound is anything that is 85 dB (sound pressure level – SPL) or higher.
True
Sound affects safety— chronic exposure to loud noises can lead to permanent hearing loss, interfere with work performance, precipitate sleep problems and psychological stress
Kaplan (2014-03-03). The Basics (p. 32). Kaplan Publishing. Kindle Edition.
Why would you avoid leaving a 3 months old baby unattended on a flat surface higher than the floor?
Babies can roll over by about 3 months.
NEVER EVER leave a crib rail down even for a second in peds. EVER EVER! Not even to turn around and reach for something. Not worth the risk.
T or F: You should expect turbulent temperament or tantrums from 6 month olds?
False, this type of behavior is from 1 year to 3 years.
“Expect turbulent temperament; tantrums common, (therefore) Control environment; be consistent in expectations”
Kaplan (2014-03-03). The Basics (p. 33). Kaplan Publishing. Kindle Edition.
T or F: You should take special care in explaining all actions in advance when caring for a 3-6 year old.
True.
Illness and procedures are seen as punishment, body mutilation is feared
Kaplan (2014-03-03). The Basics (p. 33). Kaplan Publishing. Kindle Edition.
T or F: You should take an authoritarian approach with adolescents.
False.
Noncompliance is the norm; attempt to impose as few orders as possible Independence is important to their emotional growth.
Kaplan (2014-03-03). The Basics (p. 33). Kaplan Publishing. Kindle Edition.
T or F: At night time, you should turn off all lights.
False.
Never leave the client in total darkness— use night light when room lights are off
Kaplan (2014-03-03). The Basics (p. 33). Kaplan Publishing. Kindle Edition.
What are the hourly rules for restraints?
Restrain client only as necessary; restraints used only as long as necessary; padded to prevent undue pressure/ constriction; checked every 1– 2 h; removed every 2 h while client is awake; never tied to side rail; health care provider order necessary
Kaplan (2014-03-03). The Basics (p. 34). Kaplan Publishing. Kindle Edition.
In a high environmental temperature — __ to __L of fluid/ day (precautions when heart failure or renal failure present), wear natural fiber clothing, use tepid or cool baths or showers, fan, or air conditioning 13.
Low environmental temperature— avoid alcohol, keep room temperature greater than ___ ° F, eat a nutritious, high _____ diet
Kaplan (2014-03-03). The Basics (p. 34). Kaplan Publishing. Kindle Edition.
2 to 3 L of fluid
greater than 65 degrees F
high protein diet
What measures can we take to keep the elderly population safe?
Plan/ implementation– floor mat or mattress by bed, cleared debris from area, call light within reach, lights in room or bathroom, assistive device within reach, elevated toilet seat, sit on edge of bed before getting up, minimize use of hypnotics and sedatives, wear glasses as needed, wear proper footwear, grab bars in bathroom
Kaplan (2014-03-03). The Basics (p. 34). Kaplan Publishing. Kindle Edition.
What is the definition of pain?
Definition of pain—“ whatever the person says it is, and it exists whenever the person says it does”
Kaplan (2014-03-03). The Basics (pp. 34-35). Kaplan Publishing. Kindle Edition.
T or F: 7. If pain-relief measure is ineffective the first time, try it one more time before abandoning the measure
True
III
A
#7
Kaplan (2014-03-03). The Basics (p. 37). Kaplan Publishing. Kindle Edition.
List nursing goals and interventions for pain management…
Nursing goals and interventions (A modified old cart)
- Establish a relationship
a. Tell client you believe description of pain experience b. Listen and allow client to verbalize - Establish a 24-h pain profile
a. Location and radiation:
1) External 2) Internal 3) Both external and internal
4) Area of body affected
b. Character and intensity:
1) Acute/ chronic 2) Mild/ severe 3) Allow client to use own words in describing pain 4) Use same pain scale consistently a) Number rating scale (0 to 10) b) Visual analogue scale (no pain to unbearable pain)
c. Onset 1) Sudden 2) Insidious
d. Duration
e. Precipitating factors/ aggravating factors (e.g., What makes pain worse?)
f. Identify associated manifestations, as well as alleviating or aggravating factors
g. Relieving factors
Kaplan (2014-03-03). The Basics (p. 37). Kaplan Publishing. Kindle Edition.
_______ is a bacterial skin infection with involvement of connective tissue
Kaplan (2014-03-03). The Basics (p. 41). Kaplan Publishing. Kindle Edition.
Cellulitis
