TOPIC 3 Flashcards
body mechanics
coordinated efforts of the musculoskeletal and nervous systems
Alignment and balance
posture
gravity
weight force exerted on the body
friction
force that occurs in a direction opposite to movement
skeletal system
provides attachments for muscles and ligaments, protects vital organs, aids in calcium regulation
joints
Areas where two or more bones join together
ligaments
Connect bone to bone
Tendons
connect muscle to bone
cartilage
strong connective tissue that supports the body and is softer and more flexible than bone
skeletal muscles are…
working elements of movement because of their ability to contract and relax (activity practice)
Postural abnormalities
can cause pain, impair alignment or mobility to both
Torticollis
head tilt due to shortening or spasm of one sternomastoid muscle
lordosis
exaggeration of anterior convex of lumbar spine
kyphosis
excessive outward curvature of the spine, causing hunching of the back.
scoliosis
Lateral S- or C-shaped spinal column with vertebral rotation, unequal heights of hips and shoulders
Congenital Hip Dysplasia
Hip instability with limited abduction of hips and occasionally adduction contractures
Knock-knee (genu valgum)
Legs curved inward so knees come together as person walks
Bowlegs (genu varum)
One or both legs bent outward at knee, which is normal until 2 to 3 years of age
clubfoot
95%: medial deviation and plantar flexion of foot (equinovarus) 5%: lateral deviation and dorsiflexion (calcaneovalgus)
footdrop
Inability to dorsiflex and invert foot because of peroneal nerve damage
mobility
refers to a person’s ability to move about freely
bed rest
an intervention that restricts patients to bed for therapeutic reasons
what are the hazards of immobility? (effects of muscular deconditioning?)
disuse atrophy
physiological
psychological
social
disuse atrophy
tendency of cells and tissue to reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting, or local nerve damage
Immobility: Metabolic Changes
-Decreased metabolic rate
-Altered metabolism of carbs, fats, and proteins
-Fluid, electrolyte, and calcium imbalances
-Calcium reabsorption, release of calcium into circulation leads to hypocalcemia with increased chance of renal calculi
-Negative nitrogen balance
calcium reabsorption and immobility
immobility causes the release of calcium into the circulation (usually the kidneys excrete calcium but are unable to do so)
so hypercalcemia results
GI system and immobility
can cause constipation due to slowing peristalsis
immobility can alter metabolism which alters_______?
wound healing
metabolic effects of immobility
Endocrine, calcium absorption (hypercalcemia), and GI function(constipation)
Respiratory effects of immobility
Atelectasis and hypostatic pneumonia
cardiovascular effects of immobility
orthostatic hypotension, thrombus
musculoskeletal effects of immobility
loss of endurance and muscle mass, decrease in stability and balance
muscle effects of immobility
loss of muscle mass
muscle atrophy
skeletal effects of immobility
Impaired calcium absorption
Joint abnormalities
urinary effects of immobility
urinary stasis, renal calculi, UTI
integumentary effects of immobility
Pressure ulcer
Ischemia
atelectasis
collapsed lung; incomplete expansion of alveoli
hypostatic pneumonia
inflammation of the lung from stasis or pooling of secretions
-decrease oxygenation and prolonged recovery ass to the patients discomfort
why do respiratory changes happen due to immobility?
decline in the patients ability to cough productively
so mucus in bronchi increases (especially in supine, prone and lateral position)
resulting in hypostatic pneumonia
orthostatic hypotension
a drop of blood pressure greater than 20 mmHg systolic or 10 mmHg diastolic
increased cardiac workload due to immobility
the immobile patients has decreased circulating fluid volume and pooling of blood in the lower extremities
therefore the workload of the heart increases and so does oxygen consumption
thrombus
Accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery, sometimes occluding the lumen of the vessel.
what are the three factors that contribute to venous thrombus formation?
- damage to vessel wall
- alterations of blood flow
- alteration in blood constituents
disuse osteoporosis
Because immobilization results in bone resorption, bone tissue is less dense or atrophied.
joint contracture
an abnormal and possibly permanent condition characterized by fixation of the joint (flexor muscles are stronger that extensor muscles )
urinary stasis and immobility
when the patient is recumbent (lying flat) the kidneys and ureters are on a more level plane so gravity is not helping urine into the bladder
so the renal pelvis fills before urine enters the ureters
urinary stasis can cause
renal calculi and UTI
renal calculi
calcium stones that lodge in the renal pelvis or pass through the ureters (kidney stones)
concentrated urine formation
increases risk of calculi and infection
pressure ulcers
an impairment of the skin that results from prolonged ischemia (decreased blood supply) in tissues
pressure ulcers and inflammation
ulcer is characterized initially by inflammation and usually forms over a bony prominence
psychological effects of immobility
Depression
Anxiety
Hostility
Fear
Isolation
Restriction of self-image and independence
Sensory deprivation
Difficulty sleeping
assessment of patient mobility
focuses on ROM, gait, exercise and activity tolerance and body alignment
(movement assessment starts while the patient is lying and proceeds to assessing sitting positions, transfer to chair, finally walking)
gait
a person’s manner/style of walking
exercise
physical activity for conditioning the body, improving health, and maintaining fitness
activity tolerance
type and amount of exercise or work that a person is able to perform
physiological activity tolerance
monitor patients for s/s such as dyspnea, fatigue, chest pain or change in VS
emotional activity tolerance
people who are depressed, worried, or anxious are frequently unable to tolerate exercise
developmental activity tolerance
as a person grows older, activity tolerance changes, muscle mass is reduced,
posture and bone composition change,
decreased maxim heart rate and lung compliance
sagittal plane
vertical division of the body into right and left portions
sagittal plane movements
flexion and extension
frontal plane
Divides the body into front and back portions.
frontal plane movement
abduction and adduction
transverse plane
horizontal division of the body into upper and lower portions
transverse plane movement
pronation, supination
planning and immobility.
develop plan and goals and expected outcomes in achieving his or her highest level of mobility and reducing hazards of immobility
individualize plan for the patients developmental stage, level of health and lifestyle
health promotion for immobility
education and early detection
prevent work related musculoskeletal injuries
exercise
bone health in patients with osteoporosis
implementation of acute care; metabolic
Provide high-protein, high-calorie diet with vitamin B and C supplements
implementation of acute care; respiratory
-cough and deep breathe every 1 to 2 hours
-provide chest physiotherapy
implementation of acute care; cardiovascular
reducing orthostatic
reducing cardiac workload
preventing thrombus formation
implementation of acute care; integumentary
reposition every 1 to 2 hours
provide skin care
implementation of acute care; elimination system
-provide adequate hydration
-serve a diet rich in fluids, fruits, vegetables, and fiber
what is trochanter roll used for
prevents external rotation of the hips when a patient is in a supine position
how is trochanter roll implemented?
fold cotton towel length wise to a width that extends from greater trochanter of the femur to lower border of popliteal space
hand roll
roll placed in the hand to prevent hand contraction
trapeze bar
allows the client to pull with the upper extremities to raise the trunk off the bed, assist in transfer, or to perform exercises
increases independence
supported fowlers
the head of the bed is elevated 45 to 60 degrees, and the patient’s knees are slightly elevated without pressure to restrict circulation in the lower legs
supine
lying face up
prone
lying face down
side-lying
patient rests on the side with the major portion of body weight on the dependent hip and shoulder
Sims position
patient places the weight on the anterior ileum, humerus, and clavicle
when moving a patient….
safety is first priority
ask patient to help as much as possible
determine if patient comprehends what is expected
determine patients comfort level
determine if you need assistance moving the patient
what is the importance of hygiene?
is good for infection prevention
proper hygiene care requires an understanding of the anatomy and physiology of…
skin, nails, oral cavity, eyes, ears, and nose
to resist injury and disease cells require…
adequate nutrition, hydration, and circulation
what are the functions of skin
Protection, secretion, excretion, temperature regulation, and sensation
epidermis
shields underlying tissue against water loss and injury and prevent entry of disease-producing microorganisms.
-Bacteria commonly reside on the outer epidermis
dermis
contains bundles of collagen, nerve fibers, blood vessels, sweat glands, sebaceous glands, and hair follicles
subcutaneous tissue
Lies just beneath the skin; contains blood vessels, nerves, lymph, and loose connective tissue filled with fat cells
sebaceous glands secrete
sebum
sebum has
bactericidal action
disease of the nail has what characteristics?
changes in the shape, thickness, and curvature of the nail
foot pain can cause..
change in the patients gait causing strain other muscles and joints
Medications, exposure to radiation, and mouth breathing can cause
impaires salivary secretions (often dry mouth)
xerostomia
dry mouth
gingivitis
inflammation of the gums
dental caries
tooth decay
what are the functions of saliva?
-cleanses the mouth
-dissolves food chemicals to promote taste
-moistens food to facilitate bolus formation
-contains enzymes that start the breakdown of starchy foods.
what can affect hair characteristics
Hormonal changes, nutrition, emotional stress, physical stress, aging, infection, and other illnesses
why is individualized hygiene care important?
Because no two individuals perform hygiene care in the same manner, patient care is individualized on the basis of learning about his or her unique hygiene practices and preferences.
During hygiene, assess:
-emotional status
-health promotion practices
-health care education needs
social practices and hygiene
Social groups influence hygiene preferences and practices, use of hygiene products used and the nature and frequency of personal care practices.
body image and hygiene
Surgery, illness, or a change in emotional or functional status often affects a patient’s hygiene
socioeconomic status and hygiene
resources may not be available to attain hygiene
developmental stage: adult and hygiene
bathing practices and environmental exposure determine driness/hydration of the skin
skin loses resiliency with age
physical condition and hygiene
Discomfort and pain, emotional stress, and fatigue diminish the ability or desire to perform hygiene self-care and require extra effort to promote hygiene and grooming.
assessment and hygiene
-Explore a patient’s viewpoint regarding hygiene care asking them about preferred practices
-Assess a patient’s physical and cognitive ability to perform basic hygiene measures.
-Perform an assessment of the skin, feet, nails, oral cavity, eyes, nose, ears
Nursing Diagnosis for hygiene
o Activity intolerance
o Bathing self-care deficit
o Dressing self-care deficit
o Impaired physical mobility
o Impaired oral mucous membrane
o Ineffective health maintenance
o Risk for infection
what is important when performing hygiene measures on a patient?
reduce the patient’s anxiety and promote comfort and relaxation.
o A soft, gentle voice while conversing with patients relieves fears or concerns.
o Some patients fear pain or are frightened about falling or sustaining injury associated with hygiene care.
always use _______ during hygiene instruction to confirm patients understanding
teach back
Therapeutic: sitz, medicated
A sitz bath cleans and reduces pain and inflammation of perineal and anal areas.
complete bed bath, shower
-A complete bed bath often exhausts a patient.
-Assessing heart rate before, during, and after the bath provides a measure of a patient’s physical tolerance.
-In a shower, implement safety measures to prevent fall injuries.
partial bed bath
-Provide a partial bed bath to patients who are aging, dependent, in need of only partial hygiene, or bedridden and unable to reach all body parts.
Soap and water vs. Chlorhexidine Gluconate (CHG)
The use of Chlorhexidine Gluconate (CHG) 4% solution in place of standard soap and water in wash basins has been shown to decrease bacterial growth in basins and reduce critical care unit acquired methicillin-resistant Staphylococcus aureus.
perineal care
Patients most in need of perineal care include those at greatest risk for acquiring an infection. Encourage patients to perform their own perineal care.
bath guidelines
- Provide privacy
- Maintain safety
- Maintain warmth
- Promote independence
- Anticipate needs
Patients with decreased levels of consciousness
need special attention because they often do not have a gag reflex. Proper oral hygiene requires keeping the mucosa moist and removing secretions that contribute to infection.
When providing oral hygiene to an unconscious patient
you need to protect him or her from choking and aspiration.
stomatitis
inflammation of the mouth
what can stomatitis cause
burning, pain, and change in food and fluid tolerance.
denture care
-Everyday cleaning to help maintain good dental health.
-Keep dentures covered in water when they are not worn
-Store in an enclosed, labeled cup with the cup placed on patient’s bedside stand
braiding
· helps to avoid repeated tangles; however, patients need to unbraid hair periodically and comb it to ensure good hygiene.
shave the hair in
direction of hair growth
