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NURS211 (Final Exam) > Lecture 13 > Flashcards

Lecture 13 Flashcards

Mobility Vs. Immobility

1
Q

Things that can affect balance(6)

A

1) Disease

2) Injury

3) Pain

4) Physical development (e.g. age)

5) Life changes (e.g. pregnancy)

6) Some medications

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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

2) Protects vital organs

3) aids in calcium regulation

4) Provides leverage for mobility

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9
Q

What are joints?

A

functional junctions between bones

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10
Q

what types of joints are associated with mobility(3)?

A

1) cartilaginous

2) Fibrous

3) Synovial

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11
Q

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

A

1) Structure

2) Degree of mobility

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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

1) Joint flexibility

2) Support

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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

2) Flexible

3) Inelastic

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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

2) Thorax

3) Trachea

4) Larynx

5) Nose

6) ears

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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

when should you observe body alignment and ROM?

A

during assessment

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23
Q

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

A

1) Body alignment

2) Balance

3) Mobility

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24
Q

Where is the motor strip located?

A

back of frontal lobe

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25
Q

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

A

1) Stroke (CVA)

2) Trauma

3) Bacterial infection (e.g. meningitis)

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26
Q

What does damage to the motor strip cause?

A

impaired voluntary muscle movement

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27
Q

what does damage to the cerebellum cause(2)?

A

1) Problems with balance

2) Motor impairment

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28
Q

What does damage to the spinal cord cause?

A

Impaired mobility (paralysis)

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29
Q

Trauma to the musculoskeletal system causes(4):

A

1) bruises

2) contusions

3) sprains

4) fractures

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30
Q

treatment of a broken bone often includes(2):

A

1) repositioning the bone so it is properly aligned

2) immobilizing it so it can heal and function can be restored

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31
Q

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

A

1) Muscle atrophy

2) Loss of muscle tone

3) Joint stiffness

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32
Q

What is bedrest?

A

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

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33
Q

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

A

a matter of days

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34
Q

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

A

hazards of immobility

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35
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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36
Q

apart from the muscular system, what other body systems can be affected by physical immobility(6)?

A

1) Cardiovascular system

2) Skeletal system

3) respiratory system

4) digestive system

5) urinary system

6) integumentary system

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37
Q

Muscular deconditioning affects patients(3):

A

1) Physiologically

2) Psychologically

3) Socially

Effects can be gradual or immediate (vary from pt to pt)

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38
Q

deconditioning related to reduced walking increases a patients risk for…

A

Falls

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39
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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40
Q

when there is an alteration in mobility each body system is at risk for impairment. what does severity of impairment depend on(3)?

PDA

A

1) Patient’s overall health

2) Degree and length of immobility

3) age

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41
Q

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

A

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

2) Calcium reabsorption increases

3) Appetite and peristalsis decreases

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42
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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43
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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44
Q

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

A

tissue catabolism (tissue breakdown)

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45
Q

describe what occurs with calcium in immobilized pts

A
  • immobility causes calcium reabsorption to occur
  • normally kidneys excrete excess calcium but if they are unable, hypercalcemia occurs
  • if calcium reabsorption continues, pathological fractures occur
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46
Q

what is pseudodiarrhea?

A

frequent passage of small volumes of stools

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47
Q

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

A

1) Constipation

2) Stool impaction (pseudo diarrhea often presents)

3) Diarrhea

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48
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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49
Q

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

A

1) Atelectasis

2) Hypostatic pneumonia

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50
Q

what is atelectasis?

A

collapse of the alveoli in the lung
prevents normal exchange of O2 and co2
hypoventilation occurs

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51
Q

what is hypostatic pneumonia?

A

mucous accumulation in the alveoli; inflammation and infection results

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52
Q

You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with:

A. atelectasis.

B. hypertension.

C. orthostatic hypotension.

D. coagulation of blood.

A

A

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53
Q

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

A

1) Orthostatic hypotension

2) Increased cardiac work - reduced cardiac efficiency

3) Thrombus formation - from reduced circulation volume

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54
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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55
Q

What are symptoms of orthostatic hypotension(6)?

A

1) Dizziness

2) light-headedness

3) nausea

4) tachycardia

5) pallor

6) syncope

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56
Q

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

A

the lower extremities

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57
Q

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

A

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

2) alterations in blood flow (e.g. slow blood flow in calf veins associated with pts on bedrest)

3) alterations in blood constituents (e.g. change in clotting factors or increased platelet activity)

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58
Q

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

A

Virchow’s triad

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59
Q

what does immobilization do to muscles(2)?

A

1) Lean body mass loss

2) muscle weakness/atrophy

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60
Q

what is disuse atrophy?

A

muscular atrophy associated with immobilization

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61
Q

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

A

they can be temporary or permanent

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62
Q

musculoskeletal system

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

A

1) loss of endurance

2) decreased muscle mass and strength

3) joint instability

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63
Q

Immobilization causes 2 skeletal changes:

A
  1. impaired calcium metabolism
  2. joint abnormalities
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64
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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65
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)

66
Q

what is joint contracture?

A

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

67
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

68
Q

what causes contracture?

A

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

69
Q

what is footdrop?

A

a contracture that results in permanent plantar flexion; common condition

70
Q

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

A

1) Renal Calculi

2) Infection

71
Q

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

A

urinary stasis

72
Q

what is urinary stasis?

A

immobility of urine in the kidney/bladder

73
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

74
Q

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

A

1) renal calculi

2) UTI

75
Q

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

A

1) Urinary stasis causes urine to be concentrated

2) many immobilized pts have hypercalcemia

76
Q

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

A

inappropriate perineal care

77
Q

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

A

indwelling urinary catheters

78
Q

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

A

prolonged tissue ischemia

79
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

80
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

81
Q

where is the prevalence of pressure injuries greatest?

A

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

82
Q

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

A

1) Pressure injury

2) tissue ischemia

83
Q

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

A

1) Hostility

2) Giddiness

3) Fear

4) Anxiety

84
Q

What sort of sensory alterations are associated with immobilization?

A

altered sleep patterns

85
Q

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

A

1) Depression

2) social isolation

3) loneliness

86
Q

What is depression(6)?

A

Exaggerated feelings of:

1) Sadness

2) melancholy

3) dejection

4) worthlessness

5) emptiness

6) hopelessness

87
Q

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

A

prolonged immobility can delay:

1) development of gross motor skills

2) intellectual development

3) musculoskeletal development

88
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

89
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

90
Q

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

A

the older adult stage

91
Q

immobilization of older adults increases their…

A

dependence on others; accelerates functional losses

92
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

93
Q

Assessment of patient mobility focuses on(4):

A

1) ROM

2) Gait

3) exercise

4) Activity tolerance

94
Q

what is is the sagittal plane?

A

passes through pt from front to back through the midline

95
Q

what is the frontal plane?

A

divides body into anterior and posterior (front and back)

96
Q

what is the transverse plane?

A

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

97
Q

define ROM

A

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

98
Q

anatomically, what may limit joint mobility(3)?

A

1) ligaments

2) muscles

3) nature of the joint

99
Q

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

A

1) flexion and extension (fingers and elbows)

2) dorsiflexion and plantar flexion (feet)

3) extension (hip)

100
Q

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

A

1) abduction and adduction (arms and legs)

2) eversion and inversion (feet)

101
Q

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

A

1) pronation and supination (hands)

2) internal and external rotation (hips)

102
Q

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

A

1) stiffness

2) swelling

3) pain

4) limited movement

5) unequal movement

103
Q

nurses use exercise as a therapy to correct…

A

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

104
Q

what systems are involved in gait(3)?

A

a coordination of:

1) neurological system

2) skeletal system

3) muscular system

105
Q

assessment of a pts energy level includes(2):

A

1) the physiological effects of exercise

2) activity tolerance

106
Q

what is activity tolerance?

A

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

107
Q

activity tolerance assessment includes data from(3):

A

1) physiological domain

2) emotional domain

3) developmental domain

108
Q

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

A

1) walking

2) ROM exercises

3) ADLs

109
Q

what type of emotional factors are associated with activity tolerance?

A

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

110
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

2) fatigue

3) chest pain

4) change in vital signs

111
Q

How does the slides define body alignment?

A

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

112
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

113
Q

objectives of body alignment assessment(6):

A

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

2) identify deviations in body alignment caused by incorrect posture

3) provide pt with opportunity to observe their own posture

4) identify learning needs of pt

5) identify trauma, muscle damage, or nerve dysfunction

6) obtain info from patient about other factors that contribute to incorrect alignment (fatigue, malnutrition, psychological problems)

114
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

115
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

116
Q

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

A

patients with:

1) impaired mobility (e.g. traction or arthritis)

2) decreased sensation (e.g. hemiparesis following CVA)

3) impaired circulation (e.g. diabetes)

4) lack of voluntary muscle control (e.g. spinal cord injury)

117
Q

Assessment reveals clusters of data that…

A

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

118
Q
  • Impaired physical mobility
  • Activity intolerance
  • Impaired respiratory system function
  • Impaired urinary system function
  • Difficulty coping
  • Risk for impaired skin integrity
  • Impaired socialization

What are these?

A

Nursing clinical problems (diagnoses)

119
Q

what is involved with setting outcomes?

A

1) organize outcomes according to priority

2) work with other healthcare professionals (PT/OT) to achieve best results

120
Q

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

A

1) education

2) prevention

3) early detection

121
Q

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

A

1) prevention of work-related injury

2) fall prevention measures

3) exercise

4) early detection of scoliosis

122
Q

most work-related injury in healthcare are due to:

A

overexertion which results in back or other musculoskeletal injuries

123
Q

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

A

lumbar muscles when lifting, transferring, or positioning immobilized patients

124
Q

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

A

early evaluation, consultation, and a team approach

125
Q

ADLs help pts maintain…

A

independence

126
Q

why do immobilized patients need protein and carbs?

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

-carbs are needed to fuel metabolic needs and replace subcutaneous tissue

127
Q

why do immobilized pts need supplemental vitamin C?

A

vitamin C is needed for skin integrity and wound healing

128
Q

why is vitamin B needed in pts who are immobilized?

A

vitamin B complex assists in energy metabolism

129
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

130
Q

pulmonary assessment in immobilized pts includes(3):

A

1) assess pt respiratory status per agency policy

2) assess for signs of pneumonia

3) pulmonary interventions should be used with all pts, even those without pneumonia

131
Q

what are signs of pneumonia(5)?

A

1) productive cough with greenish/yellow sputum

2) fever

3) pain while breathing

4) crackles or wheezing

5) dyspnea

132
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

133
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

134
Q

what is a primary intervention to reduce cardiac workload?

A
  • discourage pt from using valsalva maneuver
  • encourage pt to breathe out while moving side-to-side
135
Q

what is the valsalva maneuver?

A

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

136
Q

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

A

through an aggressive program of prophylaxis:

1) leg, foot, and ankle exercises regularly

2) SCDs and intermittent pneumatic compression (IPC)

3) Elastic stockings

4) proper positioning

5) ROM exercises reduce risk of contracture and help prevent DVT

137
Q

what are the cardiovascular concerns of immobilization(3)?

A

1) Orthostatic hypotension

2) increased cardiac workload

3) DVT

138
Q

how can you prevent muscular atrophy and joint contractures?

A

Exercise:

1) if pt is unable to move some of all of body, perform passive ROM exercise

2) if one extremity is paralyzed teach pt to perform ROM exercise

139
Q

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

A

1) repositioning

2) skin care

3) use therapeutic devices to relieve pressure

140
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

141
Q

how can you promote optimal digestion in immobilized pts?

A

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

142
Q

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

A

1) anticipate these issues

2) plan nursing activities so the patient is able to talk and interact with staff

143
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

2) conversing with pt about current events and family members

3) encouraging visits from significant others

144
Q

what is the supported fowler’s position?

A

45-60 degree elevation
px knees are slightly elevated without pressure

145
Q

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

A

1) increased cervical flexion

2) extension of knees allows pt to slide to foot of bed

3) decreased circulation to feet from pressure on posterior aspect of knees

4) external rotation of hips

5) arms hanging unsupported at pt’s side

6) unsupported feet or pressure on heels

7) unprotected pressure points at sacrum and heels

8) increased shear force on back and heels when head >60 degrees

146
Q

what are common troubles of supine position(8)?

A

1) pillow @ head too thick => cervical flexion

2) head flat on matress

3) shoulders unsupported + internally rotated

4) elbows extended

5) thumb not in opposition to fingers

6) hips externally rotated

7) unsupported feet

8) unprotected pressure points at the:
-occipital region
-vertebrae
-coccyx
-elbows
-heels

147
Q

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

A

1) neck hyperextension

2) hyperextension of the lumbar spine

3) plantar flexion of the ankles

4) unprotected pressure points at the:
-chin
-elbows
-female breasts
-hips
-knees
-toes

148
Q

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

A

1) lateral flexion of the neck

2) spine not aligned

3) shoulder and hip joints internally rotated, adducted, or unsupported

4) lack of foot support

5) lack of protection for pressure points at the:
-ear
-shoulder
-anterior illiac spine
-trochanter
-ankles

6) excessive lateral flexion of spine if pt has large hips

149
Q

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

A

1) lateral flexion of the neck

2) internal rotation, adduction, or lack of support to shoulders and hips

3) lack of foot support

4) lack of protection to pressure points at the:
-ileum
-humerus
-clavicle
-knees
-ankles

150
Q

what do you do when prepairing to move patients who are immobile(5)?

A

1) safety first

2) ask pt to help as much as possible

3) make sure pt understands what is expected

4) determine pt’s comfort level

5) determine if you need assistance

151
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

152
Q

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

A

instrumental activities of daily living (IADLs)

153
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)

154
Q

what are IADLs?

A

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

155
Q

where do nurses stand during ROM exercises?

A

at the side closest to the joint being exercised

156
Q

what sequence do you perform passive ROM exercises?

A

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

157
Q

When a pt has limited ability to walk, assess:

A

1) activity tolerance

2) for orthostatic hypotension

3) strength

4) pain

5) coordination

6) balance

this assessment determines the amount of assistance needed

158
Q

before walking with an immobilized pt, explain…

A

1) how far

2) who is going to help

3) when the walk will take place

4) why walking is important

159
Q

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

A

Gait belt

160
Q

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

A

1) evaluate if the patient perceives goals met

2) evaluate your own perception of whether outcomes were met or not

161
Q

after teaching px2, what is an essential evaluation?

A

its essential to evaluate their understanding of the teaching

162
Q
A

NURS211 (Final Exam) (6 decks)

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