mobility lecture (exam 3) Flashcards
1
Q
what are some strategies that a nurse can use to use proper body mechanics
A
- important as HealthCare workers have the highest incidences of back injuries
- proper alignment
- proper balance
- proper body movements
- ergonomics
2
Q
what can happen if a pt mobility is limited long term? ie. coma
A
- Joints can contractor
- Muscles atrophy
- Bones start to break down for osteoporosis
- Respiratory: risk for pneumonia
- Cardio: atrophy
- Metabolic: glucose instability
- Skin: pressure ulcers
- Neuro: depression
- Kidney: stones
3
Q
what is a joint contracture?
A
- joint is stuck in one spot for too long and the connective tissue that encloses the bone also encloses on the joint capsule
- joint is permanently stuck in one place
- can happen in only 4 days
4
Q
what is foot drop?
A
- contraction that results in permanent plantar flexion, can happen in 4 days
- can severely impair mobility
5
Q
what are nursing interventions for joint contractures?
A
- ROM exercises (passive)
- positioning devices = pillows, splints, braces, handrolls (on and off for 4 hours)
- bed moved up for a bed board to help prevent foot drip or flat shoes to prevent
- hourly rounding
- ambulation aids, walkers, canes, ect
6
Q
how do nurses preform a assessment of mobility?
A
- activity tolerance: how far can pt walk at home
- ADL’s and how they are doing
- balance, posture, and alignment
- balance can be tested w/ bombard test
- curve in the spine can be kyphosis
7
Q
how do nurses use a gait belt?
A
- used alone with another assistive device mostly
- put belt around waste
- make sure it’s not too tight, two fingers can fit underneath belt when assistance with ambulation
- hold with both hands
8
Q
how do nurses help PT’s use a cane?
A
- on good side, elbow bent 15 - 30 degrees, advice the client to advise the cane first, then support weight on stronger leg and cane, then move the weaker leg last
9
Q
how do nurses help pt’s use a walker
A
- move walker forward 6 - 8 inches, while supporting their weight on the walker, tell the client to move one foot forward following with the other foot
10
Q
how do nurses help pt’s use crutches
A
- inches below axilla, elbow bent 15 - 30 degrees, 4. Point turns
11
Q
define supine
A
flat on back
12
Q
define prone
A
flat on stomach
13
Q
define semi - flowers
A
- pt on back w/ stomach up
14
Q
define flowers
A
- bed sitting with pillow to support thigh & legs
15
Q
define sim’s
A
- pt in semi prone position lying on side
16
Q
define dorsal recumbent
A
- pt laying supine with legs bent
17
Q
define lithotomy?
A
- patient lying supine w/ feet in stirrups (birth giving position)
18
Q
define knee chest position?
A
- patient lying in prone position w/ buttocks and knees drawn to the chest
19
Q
define trendelenburg’s?
A
- patient lying supine w/ legs elevated higher than head
20
Q
what are the nursing interventions for a bed rested client?
A
- muscle strengthening isometric exercises
- passive ROM. joint mobilization
- equilibrium balance, dangling and gait
21
Q
how can nurses protect themselves with full assist patients?
A
- get help
- lift w/ knees
- place one foot between theirs
- use assistive devices
22
Q
define a sensory deficit
A
- no function in one or more of their senses (ex: hard or hearing)
23
Q
define sensory deperventions?
A
- pt not using their senses
- ex: pt not reading and struggling with eyesight
- if you don’t use it you lose it!
24
Q
how are senses assessed?
A
- with crinial nerves
25
what are the problems that can be associated with vision?
- near sided, far sided, blind, partially blind, glaucoma, ect
26
what are the problems that can be associated with hearing?
- pt can't hear, is deaf
- pt needs hearing aids
- partial hearing
27
what are the problems that can be associated with speech?
- stoke pt’s can have a lot of difficulty with speech, ie, aphasia
28
what are the problems that can be associated with touch?
- pt with peripheral neuropathy, or pts with spinal cord injuries, or diabetic pts
29
what are the problems that can be associated with olfactory & taste?
- go hand & hand
- put lots of salts & sugar on food as taste alters as we age
30
what are other factors that can effect senses?
- ototoxicity is hearing loss, some meds change the way food taste, ect
- age has big effect on senses
31
what are nursing interventions for vision issues
- Corrective eyewear
- Adequate lighting
- Objects within reach
- Bigger print
32
what are nursing interventions for hear pt w/ hearing issues?
- face client
- limit background noise
- sign language if need be
33
what is a big concern w/ pt who have touch sensory issues?
- FALL RISK & overall safety precautions
34
what is a med error classified as?
- med error is defined as preventable occurrence that leads to patient harm while medication is in control of the nurse
