Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
63 Cards in this Set
- Front
- Back
|
PQRST model of symptom analysis
|
P-what was the PRVOKING INCIDENT the caused the pain, if any?
Q-What is the QUALITY of the pain? Is it burning,throbbing, stabbing? R-Where is the REGION of the pain? Does it RADIATE? Does anything RELIEVE the pain? S-How SEVERE is the pain? T-What is the TIMING of the pain? When does it occur and how long does it last? |
|
|
CMS neurovascular assessment
|
Circulation
Movement Sensation (skin color, temperature, mvmt, sensation, pulses, capillary refill, pain) especially important when external devices such as casts and bulky dressings can compress compartments created by sheaths if inelastic fascia, causing extensive tissue damage |
|
|
Body alignment assessment
|
observe posture/positioning while sitting, lying,standing
assess for scoliosis and kyphosis |
|
|
gait assessment
|
observe while client ambulates if client can walk
notice stance and swing phases |
|
|
joint assessment
|
head to toe
proper alignment symmetry redness swelling ROM for function and crepitus |
|
|
skeletal muscle assessment
|
examine at same time as joints
observe each major muscle group for symmetry in: size shape tone strength |
|
|
assess neurovascular status:
skin color |
inspect area distal to injury
normal is no change compared with other parts of body |
|
|
assess neurovascular status:
skin temperature |
palpate area distal to injury
skin should be warm |
|
|
assess neurovascular status:
movement |
ask client to move affected area or area distal to injury
normal-client can move w/o discomfort |
|
|
assess neurovascular status:
sensation |
ask if numbness/tingling present
palpate w/safety pin or paper clip, esp. the web space between first and second toes or between thumb and forefinger normal is no numbness or tingling, no difference in sensation in affected& unaffected extremities loss of sensation in these areas idicates peroneal nerve or median nerve damage |
|
|
assess neurovascular status:
pulses |
palpate distal to injury
normal is pulse that is strong and easily palpated; no difference in affected/unaffected extremities |
|
|
assess neurovascular status:
capillary refill |
press nail bed distal to injury until blanching
normal is blood return within 3 seconds, 5 seconds for older adult |
|
|
assess neurovascular status:
pain |
ask about location, nature, frequency of pain
|
|
|
CT computed tomography
|
provides better picture of soft tissues and less-dense bone than x-rays, esp. in vertebral column
can identify CNS probs., strokes/tumors may be done with or w/o contrast If contrast used, make sure NPO for 4 hours, no allergy to iodine or seafood, signed informed consent form |
|
|
x-ray
|
detect bone density,swelling, alignment, continuity
|
|
|
MRI
|
often more accurate than x-ray or CT for detecting soft tissue damage
contrast may be used ask pt. to remove any metal objects joint implant safe pacemakers not safe |
|
|
arthrogram
|
enhanced radiogram of joint obtained after contrast injected
most common for knees and shoulders allergies to iodine/seafood? joint swelling caused by injection fluid will diminsh w/in 1-2 days usual activities resume w/in 24 h. |
|
|
myelogram
|
radiograph of vertebral spine obtained after injecting contrast into lumbar subarachnoid space
can visualize spinal cord, vertebral bones, intervertebral disks, surrounding soft tissue after test, client must be properly positioned to prevent CSF leakage and headaches |
|
|
arthrocentesis
|
diagnostic or treatment
sample of synovial fluid withdrawn and sent to lab for analysis excess fluid can be removed |
|
|
alkaline phosphatase
|
enzyme that tends to increase when bone or liver damaged
increase in serum levels reflect increase in osteoblastic activity |
|
|
quadriplegia
|
paralysis of arms,legs, trunk below level of injury
|
|
|
quadriparesis
|
numbness or other abnormal or impaired sensation in all four limbs and trunk
|
|
|
paraplegia
|
paralysis characterized by motor or sensory loss in legs and trunk
|
|
|
paraparesis
|
numbness or other abnormal or impaired sensation in legs and trunks
|
|
|
hemiplegia
|
paralysis of one side of body
|
|
|
hemiparesis
|
numbness or other abnormal or impaired sensation on one side of body
|
|
|
kyphosis
|
increased convexity in the throacic spine when viewed from side
shoulder slouched vertebral bones prominent make sure not interfering w/ breathing |
|
|
crepitus
|
grating sound caused by joint deterioration
|
|
|
spastic
|
muscle contraction caused by reflex rather than by CNS control
|
|
|
flaccid
|
state of being weak, soft, flabby, lacking normal muscle tone, having no ability to contract
|
|
|
proprioception
|
sensation pertaining to stimuli originating from within the body regarding spatial position and muscular activity or to the sensory receptors that they activiate
|
|
|
isotonic
|
form of active exercise in which muscle contracts and move with little change in resistance
|
|
|
isometric
|
increase muscle tension by applying pressure against stable resistance where there is no joint mvmt and the length of the muscle remains unchanged, but the tone and strength are maintained or increased
|
|
|
Diagnosis:
Impaired physical mobility goal/expected outcome |
overall goal is to improve mobility and prevent complications of immobility
move independently in wheelchair transfer independently from bed to chair using sliding board performs ADLs independently using assitive or adaptive devices maintains intact skin |
|
|
Diagnosis:
activity intolerance goal/expected outcome |
overall goal is to improve endurance and tolerance to activities
client tolerated activity w/o evidence of dizziness, fatigue, weakness, abnormal VS, ECG changes, exertional discomfort, or dyspnea |
|
|
disuse
|
decrease or cessation of use of an organ or body part, restriciton of activity or immobility
|
|
|
immobility
|
inablility to move whole body or body part
|
|
|
bed rest
|
prescribed or self-imposed restriction to bed for therapeutic reasons
|
|
|
atrophy
|
decrease in size or physiological activity of normally developed tissue or organ as result of inactivity or diminished function
after 24-36 hours of inactivity, muscle begins to lose contractile strength |
|
|
contracture
|
abnormal condition of joint flexion resulting from shortening of muscle fiber and associated connective tissue, with resistance to stretching and eventually flexion and finally to permanent fixation
can result from loss of normal skin elasticity as in scar formation |
|
|
footdrop
|
contracture deformity in which muscles on anterior lengthen. At same time, muscles of plantar flexion and achilles tendon shorten, resulting in plantar flexion of foot
|
|
|
osteoporosis
|
condition in which there is a decreaed mass per unit volume of normally mineralized bone, primarily from a loss of calcium, that makes bones brittle and porous
|
|
|
shearing force
|
mechanical force that acts on an area of skin in a direction parallel to the body's surface.
shear injuries are serious form of pressure injury because they result in necrosis and ulceration |
|
|
excoriation
|
injury to epidermis caused by abrasion, scratching, burn, chemicals such as sweat, wound drainage, feces or urine coming in contact w/ skin
|
|
|
maceration
|
softening of epidermis caused by prolonged contact w/ moisture, such as from a wet sheet or diaper
increases risk for damage by decreasing skin's ability to resist trauma |
|
|
orthostatic hypotension
|
drop in systolic BP of 20mmHg or more and drop in diastolic BP of 10mmHg or more for 1 or 2 minutes after moving to standing position
|
|
|
deep vein thrombosis
|
blood clot develops in lumen of deep leg vein, such as tibial, popliteal, femoral or iliac vein
|
|
|
hypostatic pneumonia
|
inflammation of lungs caused by stasis of secretions, which become medium for bacterial growth
signs are thickened yellow sputum, ronchi, crackles, wheezes, fever, rapid shallow breathing |
|
|
pulmonary emboli
|
piece of thrombus that breaks free, carried by veins to right heart and pulmonary circulation, lodges in pulmonary blood vessel
blood flow and o2 can't reach area of lung tissue served by the blocked vessel S &S: sudden onset of dyspnea, cough, sudden chest pain, hemoptysis, tachycardia, tachypnea emergency |
|
|
renal calculi
|
stones formed in kidney when excretion rate of calcium or other minerals is high, as when osteoclastic activity releases calcium from bones during immobility
exacerbated because end products of metabolism in inactive client are generally alkaline because of decreased muscle activity occur after only 1-2 weeks of inactivity |
|
|
muskuloskeletal effects of immobility
|
deconditioning
atrophy body breaks down muscle mass to obtain energy, can result in negative nitrogen balance more susceptible to ambulation and falls after 5 days, calcium and fibrotic cells deposit joints causing them to become stiff and lose range of motion contractures fibrosis footdrop osteoporosis |
|
|
integumentary effects of immobility
|
pressure ulcer
shear friction injury excoriation maceration |
|
|
cardiovascular effects of immobility
|
oxygen demand on cells decrease, cardiovascular workload may increase
deconditioning workload on heart increases when pt changes position or performs ADLs valsalva maneuver orthostatic intolerance edema DVT pulmonary embolus |
|
|
respiratory effects of immobility
|
prolonged bed rest has negative effects on resp function
recumbent position compromises respiratory function and predisposes pt to resp. complications, hypoventilation, atelectasis, stasis of secretions, altered gas exchange resp. muscles weaken, decrease bellows effect compromises ability to cough hypostatic pneumonia |
|
|
GI effects of immobility
|
slows BMR and GI motility, manifestd as anorexia, constipation, increased storage of fat and carbs, negative nitrogen balance
may become malnourished: anemia, albuminemia, decreased immunity, dry cracked skin blood cells can't be synthesized w/o sufficient protein not enough WBC= lowered immunity not enough RBC's=fatigue, anemia, poor wound healing skin, nails, hair become dry and brittle loss of sub q fat affects ability to conserve heat and protect bony prominences decreased fluid intake: dehydration-> constipation decreaed blood volume decreased tissue perfusion decreaed urine output stasis of respiratory secretions |
|
|
GU effects of immobility
|
diminishes kidney and bladder function
increased urinary stasis, retention, renal calculi, UTI's UTI most prevalent hospital acquired infections inadequate personal hygiene predisposes client to to UTI - reflux of urine can spread microorganisms to kidneys |
|
|
factors affecting a client's ability or desire for mobility
|
pain
therapeutic or prescribed inactivity change in LOC change musculoskeletal function emotional or psychological disturbances chronic illnesses |
|
|
assess pt at risk for disuse syndrome
|
primary risk factor: immobility
level of inactivity and duration of inactivity other related factors A-age B-body weight C-chronic illness D-discomfort E-environment |
|
|
intervention to prevent skin breakdown
|
monitor client
cleanse skin increase circulation decrease microorganisms remove excess moisture decrease friction/excoriation Provide nutrition Position client properly prevent shear decrease pressure Use support surfaces when indicated |
|
|
intervention to maintain circulatory function
|
decrease edema formation
elevate decrease blood stasis TEDs leg exercises SCDs maintain venous return don't cross legs at knee avoid tight socks encourage correct breathing prevent orthostatic intolerance |
|
|
intervention to maintian respiratory function
|
encourage lung expansion
mobilize secretions |
|
|
compartment syndrome
|
increased pressure w/in muscle compartment
|
|
|
symptoms of compartment syndrome
|
Acute Compartment Syndrome
The classic sign of acute compartment syndrome is pain, especially when the muscle within the compartment is stretched. •The pain is more intense than what would be expected from the injury itself. Using or stretching the involved muscles increases the pain. •There may also be tingling or burning sensations (paresthesias) in the skin. •The muscle may feel tight or full. •Numbness or paralysis are late signs of compartment syndrome. They usually indicate permanent tissue injury. Chronic (Exertional) Compartment Syndrome Chronic compartment syndrome causes pain or cramping during exercise. This pain subsides when activity stops. It most often occurs in the leg. Symptoms may also include: •Numbness •Difficulty moving the foot •Visible muscle bulging |
