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23 Cards in this Set
- Front
- Back
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state the four basic elements of normal movement
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alignment and posture
joint mobility balance coordinated movement |
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imaginary vertical line drawn through the body's center of gravity
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line of gravity
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point at which all of the body's mass is centered
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center of gravity
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foundation on which the body rests
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base of support
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the most obvious signs of immobility are manifested in which system?
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musculoskeletal
deconditioning effects can be observed even after a matter of days |
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Inactivity/immobility affect the musculoskeletal system in what ways?
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DISUSE OSTEOPOROSIS-without weight-bearing activity, bones demineralize. Calcium, which gives the bones strength and density, is lost. Regardless of amount of calcium in one's diet, the loss of calcium continues with immobility.
DISUSE ATROPHY-muscles decrease in size, losing most of their strength and normal function. CONTRACTURES-when muscle fibers are unable to shorten or lengthen, a permanent shortening of the muscle forms. This eventually involves the tendons, ligaments, and joint capsules. Irreversible except with surgery. ie-plantar flexion contracture, or "foot drop". stronger muscle dominates opposite muscle. (remember your toe pleats!) STIFFNESS AND PAIN IN JOINTS-without movement, connective tissues at the joint become ankylosed (permanently immobile) Also, as the bones demineralize, calcium deposits in the joints, causing stiffness and pain. |
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whether or not immobility causes any problems often depends on what?
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--duration of inactivity
--client's health status --client's sensory awareness |
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How does immobility affect the cardiovascular system?
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--diminished cardiac reserve
--increased use of the Valsalva maneuver --orthostatic (postural) hypotension --venous vasodilation and stasis --dependent edema --thrombus formation |
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what is the Valsalva maneuver?
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--holding the breath and straining against a closed glottis.
--builds up enough pressure in the large veins of the thorax to interfere with return blood flow. When client exhales and pressure is released, surge of blood flows to the heart. Can cause arrhythmias if client has cardiac disease |
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what is orthostatic hypotension?
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--typically, there is automatic vasoconstriction of the blood vessels in the lower half of the body when one changes from horizontal to vertical position. This prevents pooling of blood in the lower extremities. This reflex becomes dormant in prolonged immobility. When an immobile person attempts to sit or stand, blood pools and person feels faint, dizzy. Cerebral perfusion is compromised, central blood pressure drops, and there is a marked increase in heart rate.
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what are the effects of immobility on the respiratory system?
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--decreased resp. movement
--pooling of resp. secretions --atelectasis --hypostatic pneumonia |
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How does immobility affect metabolism?
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--decreased metabolic rate
--negative nitrogen balance --anorexia --negative calcium balance |
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How does immobility affect the urinary system?
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--urinary stasis
--renal calculi --urinary retention --urinary infection |
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How does immobility affect the GI system?
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increases constipation
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How does immobility affect the integumentary system?
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--reduced skin turgor
--skin breakdown |
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How does immobility affect the psychoneurologic system?
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--negative effects on mood due to decline in production of endorphins.
--loss of control causes anxiety --loss of self-esteem |
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term that means anterior/inward curvature of the spine
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lordosis
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a nurse is assessing the gait of a client. What exactly is she looking for?
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--the chin should be level and the gaze straight ahead.
--the sternum is lifted --shoulders are down and back, relaxed and away from the ears --heel strikes the ground before toe --spine is most rotated when both feet are taking some of the body weight --feet are dorsiflexed in the swing phase --arm opposite the swing-through foot moves forward at the same time --gait is smooth, coordinated, and rhythmic, even weight borne on each foot, hips gently sway with spinal rotation |
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what is pace?
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number of steps taken per minute
normal walking pace is 70-100 pace of an older person may slow to 40 |
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what are the most useful measures in predicting activity tolerance?
when should they be assessed? |
heart rate, strength, rhythm
respiratory rate, depth, and rhythm blood pressure should be assessed before activity to get baseline during the activity Immediatlely after activity stops 3 minutes after activity has stopped and client has rested |
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Changes to watch for when assessing someone during activity. Activity should be stopped immediately if....
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client experiences..
--sudden facial pallor --dizziness/weakness --change in LOC --HR or RR that significantly exceeds baseline or preestablished levels --change in heart or resp rhythm from regular to irregular --weakening of pulse --SOB, dyspnea, chest pain --diastolic pressure change of 10mm/Hg or more |
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We've assessed a client performing an activity. If none of the warning signs developed during the activity and they were able to complete it, how do we determine if it is safe?
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An activity is considered safe if the client tolerates it well and client's HR returns to baseline within 5 min of activity ceasing.
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Describe the 4 levels of the nursing diagnosis-Activity Intolerance
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level I-walk, regular pace indefinitely, climb one flight of stairs or more but more short of breath than normal
level II- regular pace walk one city block or 500 ft on level ground. climb one flight of stairs slowly without stopping level III- walk no more than 50ft on level ground without stopping. unable to climb one flight of stairs without stopping. level IV- dyspnea and fatigue at rest |
