Nursing Process and Mobility Flashcards
he framework nurses use to apply critical thinking in nursing practice for making clinical decisions
nursing process
The nursing process is 5 essential elements:
Assessment, Diagnosis/problem, planning, implementation, and evaluation (ADPIE)
collects pertinent data and information relative to healthcare consumer’s health or situation
Assessment of RN
analyzes the assessment data to determine actual or potential diagnoses,
problems, and issues
Diagnosis
is the systematic gathering of information related to internal and external environments using observation, interview, and physical examination as appropriate to the situation
assessment
is the identification of the person’s responses to health and illness
Diagnosis
patient’s response, determined by the nurse’s clinical reasoning/judgment
nursing diagnosis
is the identification of a disease condition based on a
specific evaluation of physical signs and symptoms, or patient’s medical history, or results of diagnostic tests or procedures. It remains constant as the condition remains
medical diagnosis
A vulnerable person is at higher risk for developing a problem
risk factor
Identifies one or more probable causes of the health problem. Gives direction to the required nursing therapy
Etiology
Appropriate when a person’s internal or external resources are inadequate or diminished
health restoration goals
Appropriate when the person wants to increase the existing internal or external resources or continue using those resources
Health Maintenance Goals
Making Goals (SMART)
Specific
Measurable
Attainable
Realistic
Timed
are any treatments based upon clinical judgment and
knowledge, that a nurse performs to enhance outcomes
Nursing interventions
Activities that nurses are licensed to initiate based on their knowledge and skill
Independent Interventions
Activities conducted under the physician’s orders or supervision or according to specified routines
Dependent Interventions
includes activities such as teaching, monitoring, providing,
counseling, delegating, and coordinating
implementation
four phases of implementation
Reassessing the person, Determining the need for nursing assistance, Implementing the nursing interventions, recording & documenting
the nurse performs the activities
Direct care
the nurse delegates the activities
Indirect care
if the patient was able to achieve the smart goal
Evaluation
Overlapping responsibilities of and collegial relationships between health personnel
collaborative Interventions
Used to prevent venous stasis and thrombi in the lower extremities. Come in knee-high and thigh-high types
Graded Compression Stocking
Plastic sleeves containing air bladders that inflate and deflate once
they are connected to an electric air pump.
Sequential (pneumatic) Compression Devices (SCDs)
Tensing muscle and “holding” or applying pressure against an unyielding object. There is no motion around the joint-the muscle is tensed but does not
Isometric/Resistive
The muscle contracts and shortens. Most gym-type
exercises involve weights or strength machines and aerobic activities (such as running, biking, or swimming)
Isotonic
Unused joints tend to “freeze” in the flexed position forming
contractures. Some patients with altered mobility’don’t have contractures yet but the joints are very stiff. Do NOT force the joint past the point of comfort
Preserve range of motion (ROM)
moving from a flexed to a straight or neutral position
Extension
bending a joint in the natural position of movement
Flexion
pivoting on axis. External rotation: away from midline of body; Internal rotation: toward midline of body
Rotation
movement of a limb away from the midline of the body
Abduction
movement of a limb toward the midline of the body
Adduction
rotation of palm anterior (facing upward)
Supination
rotation of palm posterior (facing downward)
Pronation
flexion of ankle toward floor
Plantar flexion
flexion of ankle toward knee
Dorsiflexion
movement of ankle away from the midline or laterally
Eversion
movement of ankle toward the midline or medially
inversion
to move in a circle
Circumduction
supper important part in data collection for assessment
Validating
a state of decreased or absent use of an organ or body part
Disuse
inability to move the whole body or a body part
immobility
involves comparing data with other sources for accuracy
validate the data
Actual or imminent life-threatening
High priority
Actual or potential health-threatening
Medium priority
Arises from normal developmental changes
Low priority
after surgery or after a bone break in your foot or leg. It can also can help if you have balance problems, arthritis, leg weakness, or leg instability.
walker
if you have minor problems with balance or stability, some weakness in your leg or trunk, an injury, or a pain
cane
are medical devices designed to aid in ambulation, by transferring body weight from the legs to the torso and arms. They are mainly used to assist individuals with lower extremity injuries and/or neurological impairment
Crutches
if you struggle to walk or you’re disabled.
wheelchair
Prolonged periods of immobility, such as bed rest or extended travel, can also contribute to the development of this. The consequences of this include an elevated risk of blood clots, tissue damage, and impaired delivery of nutrients and oxygen to vital organs.
stasis
are the chronic loss of joint mobility caused by structural changes in non-bony tissue, including muscles, ligaments, fascia, and tendons. They develop when these normally elastic tissues are replaced by inelastic tissues.
Contractures
Immobility can lead to an increased______ ______. When we are inactive, the body can experience changes such as increases in blood viscosity (the thickness of the blood) and changes in the vascular system. This can mean that the heart needs to exert more force to circulate blood throughout the body effectively.
Cardiovascular effect
