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CSM Nursing > Lecture 13 > Flashcards

Lecture 13 Flashcards

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1
Q

Things that can affect balance

A

1) Disease

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2
Q

why do some self-impose activity restrictions when their balance is impaired?

A

due to a fear of falling; contributes to mobility issues

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3
Q

when is people’s center of gravity at most of the time?

A

@ 55%-57% standing height in the midline

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4
Q

the greater the (BLANK), the greater the friction

A

Surface area

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5
Q

The force exerted against the skin while the skin remains stationary and the bony structures move is called (BLANK)

A

shear

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6
Q

what does body alignment mean?

A

the individuals center of gravity is stable

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7
Q

What is in bones that make them rigid(firm)?

A

Inorganic salts (Calcium and phosphate)

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8
Q

what are the functions of the skeletal system(4)?

A

1) Provides attachment points for muscles and ligaments

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9
Q

What are joints?

A

functional junctions between bones

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10
Q

what are the three classifications of joints(3)?

A

1) cartilaginous

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11
Q

Each joint is classified according to it’s(2):

A

1) Structure

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12
Q

what are ligaments?

A

bands of fibrous tissue that binds joints together and connect bones to cartilage

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13
Q

What is the function of ligaments(2)?

A

Connect bones together and provide:

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14
Q

what is the purpose of tendons?

A

to connect muscle to bone

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15
Q

what are the characteristics of tendons(3)?

A

1) Strong

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16
Q

what is cartilage?

A

Avascular connective tissue

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17
Q

where is cartilage found(6)?

A

1) Joints

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18
Q

the characteristics of cartilage changes with…

A

age

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19
Q

which system regulates movement and posture?

A

The nervous system

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20
Q

Postural abnormalities can cause:

A

pain, impair alignment or mobility, or both

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21
Q

when should you observe body alignment and ROM?

A

during assessment

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22
Q

Damage to any component of the CNS that regulates voluntary movement results in impaired(3):

A

1) Body alignment

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23
Q

Where is the motor strip located?

A

back of frontal lobe

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24
Q

What kinds of things can damage the brain(3)?

A

1) Stroke (CVA)

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25
Q

What does damage to the motor strip cause?

A

impaired voluntary muscle movement

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26
Q

what does damage to the cerebellum cause(2)?

A

1) Problems with balance

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27
Q

What does damage to the spinal cord cause?

A

Impaired mobility (paralysis)

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28
Q

Trauma to the musculoskeletal system causes(4):

A

1) bruises

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29
Q

treatment of a broken bone often includes(2):

A

1) repositioning the bone so it is properly aligned

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30
Q

What occurs when a fracture is temporarily immobilized(3)?

A

1) Muscle atrophy

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31
Q

What is bedrest?

A

an intervention that restricts patients to bed for therapeutic reasons (Regularly prescribed)

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32
Q

how much lack of physical activity does it take for muscular deconditioning to occur?

A

a matter of days

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33
Q

clusters of symptoms related to muscular deconditioning associated to physical inactivity are commonly known as:

A

hazards of immobility

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34
Q

How quickly does a person of average weight and height without a chronic illness lose muscle strength from baseline?

A

average of 3%/day

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35
Q

apart from the muscular system, what other body systems can be affected by physical immobility(2+1)?

A

1) Cardiovascular system

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36
Q

Muscular deconditioning affects patients(3):

A

1) Physiologically

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37
Q

deconditioning related to reduced walking increases a patients risk for…

A

Falls

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38
Q

When possible it’s important that patient’s, (especially older patients) have limited bedrest and that their activity…

A

is more than bed to chair

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39
Q

PDA

A

1) Patient’s overall health

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40
Q

What effect does physical immobility have on metabolism(3)?

A

1) Endocrine metabolism decreased - decreasing metabolism of macros, causing fluid and electrolyte imbalance

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41
Q

if infectious process is present, immobilized patients often have an increased:

A

Basal metabolic rate (BMR) due to fever or wound healing because they increase O2 requirements

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42
Q

What happens with nitrogen when patients are immobile?

A

pt’s body often excretes more nitrogen (end product of amino acid breakdown) than it ingests in protein leading to negative nitrogen balance and tissue breakdown

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43
Q

in immobilized pts, weight loss, decreased muscle mass, and weakness occur due to…

A

tissue catabolism (tissue breakdown)

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44
Q

describe what occurs with calcium in immobilized pts

A

NAME?

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45
Q

what is pseudodiarrhea?

A

frequent passage of small volumes of stools

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46
Q

what are common issues with defecation associated with immobility(3)?

A

1) Constipation

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47
Q

What is the risk level for respiratory complications in pts who are immobile?

A

immobile pts are at a high risk for respiratory complications

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48
Q

what are the most common respiratory complications that arise from immobilization?

A

1) Atelectasis

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49
Q

what is atelectasis?

A

collapse of the alveoli in the lung

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50
Q

what is hypostatic pneumonia?

A

mucous accumulation in the alveoli; inflammation and infection results

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51
Q

D. coagulation of blood.

A

A

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52
Q

What changes can immobilization cause in the cardiovascular system(3)?

A

1) Orthostatic hypotension

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53
Q

what is orthostatic hypotension?

A

When a person’s blood pressure falls more than 20mmHg syst or 10 mmHg Dia when moving from a seated or lying position to a standing position.

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54
Q

What are symptoms of orthostatic hypotension(6)?

A

1) Dizziness

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55
Q

Increased pooling of blood happens in which extremities during prolonged immobilization?

A

the lower extremities

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56
Q

What three factors contribute to thrombus formation in immobilized patients(3)?

A

1) damage to the vessel wall (e.g. during surgery)

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57
Q

what are the three clotting factors related to immobilization known as?

A

Virchow’s triad

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58
Q

what does immobilization do to muscles(2)?

A

1) Lean body mass loss

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59
Q

what is disuse atrophy?

A

muscular atrophy associated with immobilization

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60
Q

are the effects of immobilization on the musculoskeletal system permanent or temporary

A

they can be temporary or permanent

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61
Q

what about immobilization puts pts at risk for falls(3)?

A

1) loss of endurance

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62
Q

Immobilization causes 2 skeletal changes:

A
  1. impaired calcium metabolism
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63
Q

What is disuse osteoporosis?

A

calcium resorption from immobilization leads bone tissue to become less dense or atrophied; pathological fractures can occur

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64
Q

who is at an increased risk of disuse osteoporosis?

A

those that already have some form of osteoporosis(80% of those with osteoporosis are female)

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65
Q

what is joint contracture?

A

an abnormal and possibly permanent condition characterized by fixation of the joint caused by immobility

66
Q

how does the muscles contribute to the direction of contracture?

A

Flexor muscles are often stronger than extensor muscles; contracture usually occurs in the direction of the stronger muscle

67
Q

what causes contracture?

A

disuse, atrophy, and shortening of the muscle fibers causes joint contracture

68
Q

what is footdrop?

A

a contracture that results in permanent plantar flexion; common condition

69
Q

what are risks to the urinary system associated with immobilization(2)?

A

1) Renal Calculi

70
Q

what happens to the urinary system when a pt is recumbent or flat?

A

urinary stasis

71
Q

what is urinary stasis?

A

immobility of urine in the kidney/bladder

72
Q

why does immobility cause urinary stasis?

A

because the movement of urine from the kidneys to the bladder is unaided by gravity and causes the renal pelvis to fill before pushing urine toward the bladder; peristaltic contractions are insufficient to push urine downstream; causes concentrated urine

73
Q

what does urinary stasis put pts at risk for(2)?

A

1) renal calculi

74
Q

what are renal calculi and why are immobilized pts at risk for them(2)?

A

1) Urinary stasis causes urine to be concentrated

75
Q

what increases the risk of UTI by E.coli in women?

A

inappropriate perineal care

76
Q

other than inappropriate perineal care, what increases the risk of UTI?

A

indwelling urinary catheters

77
Q

A pressure ulcer is an impairment of the skin that results from…

A

prolonged tissue ischemia

78
Q

when does ischemia develop in tissue?

A

when the pressure on the skin exceeds the pressure inside the peripheral blood vessels supplying blood to the skin

79
Q

how does pressure affect cellular metabolism in the skin?

A

by decreasing or eliminating tissue circulation and starving the cells of oxygen and nutes

80
Q

where is the prevalence of pressure injuries greatest?

A

long-term care facilities; prevalence of facility-acquired pressure injury highest in adult ICUs

81
Q

Integumentary system is at risk for (BLANK) when the body is immobilized

A

1) Pressure injury

82
Q

What are the potential emotional and behavioral responses to immobilization(4)?

A

1) Hostility

83
Q

What sort of sensory alterations are associated with immobilization?

A

altered sleep patterns

84
Q

What sort of psychological effects associated with immobilization(3)?

A

1) Depression

85
Q

What is depression(6)?

A

Exaggerated feelings of:

86
Q

What are the developmental changes that can occur in infants, toddlers, and preschoolers due to immobilization?

A

prolonged immobility can delay:

87
Q

What are the developmental changes that can occur in adolescents due to immobilization?

A

can cause delay in gaining independence and in accomplishing skills; social isolation can occur

88
Q

What are the developmental changes that can occur in adults due to immobilization?

A

physiological systems are at risk; changes in family and social structures occur; some lose their jobs which can affect self-concept

89
Q

a progressive loss of total bone mass occurs in which developmental stage?

A

the older adult stage

90
Q

immobilization of older adults increases their…

A

dependence on others; accelerates functional losses

91
Q

how can older adults maintain the highest level of function when immobilized?

A

encourage them to perform as many self-care activities as possible

92
Q

Assessment of patient mobility focuses on(4):

A

1) ROM

93
Q

what is is the sagittal plane?

A

passes through pt from front to back through the midline

94
Q

what is the frontal plane?

A

divides body into anterior and posterior (front and back)

95
Q

what is the transverse plane?

A

divides the body into superior and inferior parts (top and bottom)

96
Q

define ROM

A

the maximum amount of movement available at a joint in one of the three planes of the body

97
Q

anatomically, what may limit joint mobility(3)?

A

1) ligaments

98
Q

what kinds of movements are made in the sagittal plane(3)?

A

1) flexion and extension (fingers and elbows)

99
Q

what kinds of movements are made in the frontal plane(2)?

A

1) abduction and adduction (arms and legs)

100
Q

what kinds of movements are made in the transverse plane(2)?

A

1) pronation and supination (hands)

101
Q

when assessing ROM, ask questions and physically examine the patient for(5):

A

1) stiffness

102
Q

nurses use exercise as a therapy to correct…

A

a deformity or restore the body to the maximum state of health

103
Q

what systems are involved in gait(3)?

A

a coordination of:

104
Q

assessment of a pts energy level includes(2):

A

1) the physiological effects of exercise

105
Q

what is activity tollerance?

A

the type and amount of exercise or work a person is able to perform

106
Q

activity tolerance assessment includes data from(3):

A

1) physiological domain

107
Q

assessment of activity tolerance is necessary when planning activities such as(3):

A

1) walking

108
Q

what type of emotional factors are associated with activity tollerance?

A

those who are depressed, worried, or anxious tend to have low activity tollerance

109
Q

what are some physiological things you should look out for when assessing activity tolerance or monitoring a patient doing activities(4)?

A

1) dyspnea

110
Q

How does the slides define body alignment?

A

the condition of joints, tendons, ligaments, and muscles in various body positions

111
Q

balance occurs when…

A

a wide base of support is present, 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

112
Q

objectives of body alignment assessment(6):

A

1) determine normal changes in body alignment from growth and development

113
Q

what position should you put an immobilized person in to assess body alignment?

A

lateral position; remove all positioning supports from pt’s bed except the one under the head

114
Q

why do you put pt in lateral position and remove all pillows except the one under head to assess body alignment?

A

this position gives full view of the spine and back; also allows you to assess if pt can maintain this position without help; also a comfortable position for the pt

115
Q

who is at risk for damage while lying down(4)?

A

patients with:

116
Q

Assessment reveals clusters of data that…

A

indicate whether a pt is at risk or if an actual problem exists

117
Q

What are these?

A

Nursing clinical problems (diagnoses)

118
Q

what is involved with setting outcomes?

A

1) organize outcomes according to priority

119
Q

health promotion includes a variety of interventions such as(3):

A

1) education

120
Q

What are some examples of health promotion activities that address mobility?

A

1) prevention of work-related injury

121
Q

most work-related injury in healthcare are due to:

A

overexertion which results in back or other musculoskeletal injuries

122
Q

nurses and other healthcare workers are at risk for injury to…

A

lumbar muscles when lifting, transferring, or positioning immobilized patients

123
Q

especially when immobilized, its important that pts diagnosed with osteoporosis receive…

A

early evaluation, consultation, and a team approach

124
Q

ADLs help pts maintain…

A

independence

125
Q

why do immobilized patients need protein and carbs?

A
  • protein is needed to repair injured tissue and rebuild depleted protein stores
126
Q

why do immobilized pts need supplemental vitamin C?

A

vitamin C is needed for skin integrity and wound healing

127
Q

why is vitamin B needed in pts who are immobilized?

A

vitamin B complex assists in energy metabolism

128
Q

why do immobilized people need to cough and take deep breathes every 1-2 hours?

A

pts need to fully expand their lungs regularly to maintain lung elasticity; coughing helps to prevent secretion buildup in the lungs and prevent pneumonia

129
Q

pulmonary assessment in immobilized pts includes(3):

A

1) assess pt respiratory status per agency policy

130
Q

what are signs of pneumonia(5)?

A

1) productive cough with greenish/yellow sputum

131
Q

pts should drink enough non-caffeinated liquid while immobilized unless contraindicated. how much fluid does a pt need to drink to keep mucociliary clearance normal?

A

1100 to 1400mL

132
Q

what is a primary prevention to reduce orthostatic hypotension in immobilized patients?

A

mobilize pts as soon as the physical condition allows, even its just dangling legs from bedside

133
Q

what is a primary intervention to reduce cardiac workload?

A

NAME?

134
Q

what is the valsalva maneuver?

A

A process that involves expiring against a closed windpipe, creating additional intrathoracic pressure

135
Q

what is the most cost-effective way to reduce occurrence of DVT(5)?

A

through an aggressive program of prophylaxis:

136
Q

what are the cardiovascular concerns of immobilization(3)?

A

1) Orthostatic hypotension

137
Q

how can you prevent muscular atrophy and joint contractures?

A

Exercise:

138
Q

How can you prevent injury to integumentary system in immobilized pts?

A

1) repositioning

139
Q

how can you prevent renal calculi and UTI from urinary stasis in immobilized pts?

A

adequate hydration - pt needs at least 1100mL non-caffeinated liquids but 2000-3000mL is recommended

140
Q

how can you promote optimal digestion in immobilized pts?

A

provide diet rich in fluids, fruits, vegetables, and fiber to facilitate normal peristalsis

141
Q

How can you provide interventions against the psychological and developmental issues that may arise due to immobilization(2)?

A

1) anticipate these issues

142
Q

how can you reduce the risk of social isolation in older adults who are immobilized(3)?

A

1) maintain a calendar and a large clock

143
Q

what is the supported fowler’s position?

A

45-60 degree elevation

144
Q

what are common troubles with the supported fowler’s position?

A

1) increased cervical flexion

145
Q

what are common troubles of supine position(8)?

A

1) pillow @ head too thick => cervical flexion

146
Q

what are common troubles with the prone position(4)?

A

1) neck hyperextension

147
Q

what are the common troubles for the side-lying (lateral) position(6)?

A

1) lateral flexion of the neck

148
Q

what are the common troubles of the sim’s position(4)?

A

1) lateral flexion of the neck

149
Q

what are the consideration of moving patients who are immobile(5)?

A

1) safety first

150
Q

what is the purpose of restorative care with immobilized px?

A

maximize functional mobility and independence and reduce residual functional deficits such as impaired gait and decreased endurance

151
Q

the focus of restorative care is not only ADLs. what else is considered?

A

instrumental activities of daily living (IADLs)

152
Q

what are ADLs?

A

activities of daily living (personal daily care tasks: bathing, dressing, caring for teeth and hair, toileting and eating and drinking)

153
Q

what are IADLs?

A

Activities that are necessary to be independent in society; include skills like shopping, prepping meals, banking, taking medications

154
Q

where do nurses stand during ROM exercises?

A

at the side closest to the joint being exercised

155
Q

what sequence do you perform passive ROM exercises?

A

from head-to-toe moving from larger to smaller joints

156
Q

When a pt has limited ability to walk, assess:

A

1) activity tolerance

157
Q

before walking with an immobilized pt, explain…

A

1) how far

158
Q

provide support using a (BLANK) so the center of gravity remains at pt’s midline

A

Gait belt

159
Q

what is required in evaluation of nursing interventions associated with immobilization?

A

1) evaluate if the patient perceives goals met

160
Q

after teaching px2, what is an essential evaluation?

A

its essential to evaluate their understanding of the teaching

CSM Nursing (9 decks)

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