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47 Cards in this Set

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Anthropometric measurements
indicate loss of muscle tone and mass
Atelactasis
collapse of alveoli. Can occur when secretions block a bronchiole or broncus and distal tissue collapses as air is absorbed. May cause hypoventilation
CPT
Chest Physiotherapy. Includes percussino and positioning to prevent pneumonia
Concentric tension
muscles contract, shorten and movement results
Eccentric tension
helps control speed and direction of movement such as slowly lowering from a chin-up
Embolus
a dislodged thrombus that can move to critical areas such as lungs or brain and create a blockage that could be life threatening
foot drop
a common debilitating contracture. Ankle is fixed in plantar flexion
hypostatic pneumonia
inflamation of the lung from stasis or pooling of secretions. Lowers O2 and increases recovery time from underlying cause of immobility
Immobility
refers to an inability to move about freely
Joint contracture
abnormal and possibly permanent condition characterized by fixation of the joint. Caused by disuse atrophy and shortening of muscle fibers
pathological fractures
those caused by weakened bone tissue
Renal calculi
"kidney stones" calcium crystals that lodge in the renal pelvis or pass through ureters
Synostoic joint
bones fused together with no movement at all e.g. plates of the skull
Thrombus
static clot
3 Factors leading to thrombus
Damage to vessel wall, alterations of blood flow, alterations in blood constituents (Virchow's triad)
Long bones
contribute to height (eg - femur, fibula, tibia) and length (eg - phalanges of fingers and toes)
How changes in bone reflect use at various developmental stages
Infant - max flexibility and cartilage but not weight bearing. Toddler withstands falls but not as stable, adult has strength/stability but may be brittle.
tonus
muscle tone - normal state of balanced muscle tension
An immobile client with no known digestive issues is showing signs of inadequate calorie and protein intake. This is likely due to _________. If left untreated, the client may excrete more nitrogen than ingested leading to ___________
decreased appetite secondary to immobility
negative nitrogen balance
3 major effects on cardovascular system due to imobilization -
Orthostatic hypotension, increased cardiac workload, thrombus formation
What factors lead to increased cardiac work load and other cardiac issues during immobility?
Decreased circulating fluid volume, pooling of blood in extremeties, decreased autonomic response, These lead to decreased venous return and decreased cardiac output
2 primary skeletal effects of immobility
impaired calcium metabolism, joint abnormalities
Older adults may begin to develop contractures after only ____ hours of immobility.
8
pressure ulcer
is an impairment of the skin as a result of prolonged ischmia (decreased blood supply) in tissues. Usually forms over bony prominence. If P on skin is greater than P in small peripheral blood vessels.
An older adult immobilized on a back board can develop skin breakdown and pressure ulcer within ___ hrs
3
In the saggital plane, movements are described as
Flexion and extension for fingers/elbows. Dorsiflexion and plantar flexion for feet. Extension for hip
In the frontal plane, movements are described as
abduction and adduction for arms and legs. Eversion and inversion for feet
In the transverse plane movements are described as
pronation and supination for hands, internal and external rotation for hips
Monitoring what lab values are particularly high priority for assessing metabolic function of an immobile client
Electrolytes, serum protein, blood urea nitrogen (BUN)
perform a respiratory assessment at least every ____ hours for clients with restricted activity
2
When assessing respiratory function of an immobile client, observe chest wall movements during a full inspiratory - expiratory cycle. Asymetrical movement may indicate ______________
an atelectactic area
When assessing lungs of an immobile client, auscultate entire lung region for __________, _________, ___________ . Focus on depenent lung fields because _______________
diminished breath sounds, crackles, wheezes
pulmonary secretions tend to collect in these lower regions
Cardiovascular assesment of an immobile client includes monitoring __________, evaluation of ______ and ______ and observing for signs of _________ (eg - edema, delayed wound healing)
BP
apical and peripheral pulses
venous stasis
Lying down causes __________(increased/decreased) pulse rate.
increased
When and how should you assess for DVT?
Assess for Deep Vein Thrombosis by removing elastic stockings or SCD every 8 hrs and observe for redness, warmth, tenderness, pain in calf if client initiated dorsiflexion of foot (Homans' Sign - may dislodge thrombus). Measure bilateral calf circumference daily @ 10cm inferior to midpatella. Monitor for any unilateral changes
Early assessment of ROM
Provides a baseline for comparison - to determine if any range of motion has been lost during immobilization
A tool to measure ROM
Goniometer
What factors, other than immobility, may cause an increased risk for disuse osteoporosis?
postmenopausal female, steroid use, increased serum and urine calcium levels
Skin assessment should be done at least every ____ hrs
2
Dehydration increased risks for what 4 conditions common to immobile clients?
skin breakdown, thrombus formation, respiratory infections, constipation
2 nursing diagnoses most directly related to mobility problems are
Impaired physical mobility
Risk for disuse syndrome
These can be qualified i.e. impaired physical mobility related to reluctance to initiate movement
Which 2 vitamin supplements are particularly helpful for immobilized clients?
C - to help replace protein stores
B - promotes skin integrity and wound healing
Parenteral nutrition is delivered _____
through a central or peripheral IV catheter
Enteral nutrition is delivered __________
through nasogastric, gastrostomy, or jejunostomy tube
Encourage immobilized clients to deep breathe and cough every _____ to ____ hrs. Teach alert clients to deep breath, _______, cough, and/or use an incentive _____ every hour.
1 to 2 hours
yawn
spirometer
Unless contraindicated, ensure immobile clients take in at least _______ mL of fluid per day
2000
Steps when repositioning a client
1 - Assess client's comfort, ability, limitations, restrictions, etc. to determine best approach/goal

2 - if patient can provide some assistance and is less than 200lbs, use a friction-reducing device and 2-3 caregivers (use 3+ caregivers for client over 200lbs). If unable to assist, use full body lift and 2+ caregivers

3 - evaluate outcome, patient comfort, check devices, etc