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135 Cards in this Set
- Front
- Back
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Lateral movement away from the body (midline of the body)
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abduction
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Lateral movement of a body part toward the midline
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adduction
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State of being bent
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flexion
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Being in a straight line
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Extension
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Backward bending of the hand or foot
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Dorsiflexion
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Flexion of the foot
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Plantar flexion
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Palm facing downward
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Pronation
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Palm facing upward
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Supination
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What are the 4 functions of the skeletal system?
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1. supports soft tissue
2. protects delicate structures 3. storage areas for minerals and salts 4. produces blood cells |
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What are the 3 functions of the muscular system?
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1. motion
2. posture 3. heat production |
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Part of the nervous system that conveys message from the body to the brain
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Afferent
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Part of the nervous system that conducts impulses from one body part to another
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Neurons
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Part of the nervous system that goes from brain to muscles (from CNS to muscles)
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Efferent
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What is body mechanics directly related to?
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functioning of the body
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When should body mechanics be used?
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Always- in every situation to prevent injury and sore muscles and joints
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What are some applications of body mechanics?
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Use major muscle groups, not minor/weaker ones
Slide, roll, push, pull an object rather than lift it to reduce energy Wide base of support Flex knees, come down close to object to be lifted |
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What are some factors affecting body alignment/mobility?
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developmental, physical health, muscular, skeletal, or nervous system problems
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What are some factors affecting other body systems?
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mental health, lifestyle, attitude/values, fatigue and stress, external factors, and exercise
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Ways that exercise affects the cardiovascular system
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Increased efficiency of the heart
Lower HR and BP Increased blood flow to body Increased circulation of fibrinolysin to help prevent clot buildup |
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Ways that exercise affects the respiratory system
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Improved pulmonary functioning
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Ways that exercise affects the MSK
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Increased coordination, nerve impulse, transmission, and strength
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Ways that exercise affects the metabolic system
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increased efficiency and body temp regulation
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Ways that exercise affects the psychosocial system
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better sleep
better body image positive health behaviors |
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Ways that exercise affects the GI system
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increased appetite
intestinal tone and weight more regular bowel movements |
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Ways that exercise affects the GU system
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increased blood flow to the kidneys to help...
regulate body fluid balance regulate acid base balance excrete wastes |
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Ways that exercise affects the skin
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overall general skin health
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Ways that immobility affects the cardiovascular system
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increased workload on the heart
increased risk for orthostatic hypotension increased risk for venous thrombosis |
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Ways that immobility affects the respiratory system
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decreased depth/rate of respirations (due to more pressure on the lungs)
pooling of secretions (pneumonia) impaired gas exchange poor exchance of CO2 and O2, leading to changes in acid base balance medications (opiods may cause trouble breathing) risk for infection |
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Ways that immobility affects the MSK
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(seen rapidly in someone on bed rest)
Weakness Lethargy Atrophy (decreased muscle size), tone, and and strength Bone demineralization (loss of Ca and PO4) Contractures (ankylosis) Immobilization of a joint |
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What is and immobilization or contortion of a joint?
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ankylosis
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Ways that immobility affects the metabolic process
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increased risk for electrolyte imbalance (arent eating right)
GI problems such as constipation or a blockage |
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Ways that immobility affects the GI system
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slowing of the GI leading to constipation
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Ways that immobility affects the urinary system
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Urinary stasis
Bacteria growth (risk for UTI) kidney stones |
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Ways that immobility affects the skin
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skin breakdown over bony prominences
risk for decubitus ulcers |
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Ways that immobility affects the psychosocial system
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loss of sense of self
depression altered thought processes r/t immobility |
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When does ICU psychoses occur?
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break in normal routine
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What are some things you would ask when assessing immobility?
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exercise
diet illnesses meds activity level normal routine difficulty with adl's |
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What do you asses in immobility?
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Cardiovascular- vital signs
Resp-rate, depth, lung sounds MSK- how do you move? atrophy? weakness? strength? GI/GU- bowels? frequency? last? normal? color? burning? Skin- thin? breakdown? risk? perspiration? urine? moist? edema? |
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What are some diagnoses for immobility?
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activity intolerance
impaired physical mobility |
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What are some interventions for immobility?
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positioning, ROM, ambulating, encourage deep breathing, diet, exercise, flips, sequentials, compression, small frequent meals, fiber, water, routine, privacy, Kegels
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What should you never do to the calves of an immobile person and why?
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massage
may cause a blood clot (thrombosis) |
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What are some interventions for positioning a patient?
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use pillows, special mattresses, side rails, trapeze bar, adjustable bed, turn pt. who cannot turn themselves every 2 hours
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Describe passive range of motion
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The pt is not able to do per self: each exercise should focus on joints not being used. It should be performed until there is resistance but no pain: Do twice a day
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How often should a pt. TCDB?
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every 2 hours
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What stage of pressure ulcer:
Nonblanchable erythema of intact skin the heralding lesion of skin ulceration. In individuals with darker skin, discoloration, warmth, edema, induration, or hardness may be indicators. |
Stage I
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What stage pressure ulcer:
Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The sore presents clinically as a deep crater with or without undermining of adjacent tissue |
Stage III
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What stage pressure ulcer:
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. |
Stage IV
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What stage pressure ulcer:
Partial thickness skin loss involving epidermis, dermis, or both. The lesion is superficial and presents clinically as an abrasion, blister, or shallow center. |
Stage II
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Normal fluid volume
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euvolemia
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How much of an adult's total body weight is water?
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60%
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Percentage of total body weight of water in infant
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77%
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Five major functions of water
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1. transports nutrients, lytes, and O2
2. Excretion of waste products 3. Body temperature regulation 4. Lubricates joints 5. Provides a medium for digestion |
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What is water inside of the cells?
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intracellular
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Fluid outside the cell but inside of blood (plasma)
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intravascular
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Fluid outside of the cell (like pus from a zit)
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interstitial
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Osmosis
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movement of water from a sol'n with a lesser concentration to a sol'n with a higher concentration
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Example of osmosis in body
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Water in the GI tract being absorbed
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What are some regulators of fluid volume?
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thirst, sodium, protein/albumin, ADH, adosterone, renin-angiotensin, organs
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Average daily fluid intake total
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2000-2500 mL (2-2.5 L)
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Average daily fluid intake from liquids
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1000-1500 mL
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Daily fluid intake from food
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800-1000 mL
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Daily fluid intake from oxidation of CHO, proteins and fats
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300 mL
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Average daily body fluid loss total
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1700-3000 mL
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Average daily body fluid loss from urine
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1500 mL
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Average daily body fluid loss from feces
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100-200 mL
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Average daily body fluid loss from lungs
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up to 1000 mL
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Average daily body fluid loss from skin
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500-600 mL (third space edema)
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How often should I and O balance
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every 2-3 days
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Indicates a loss of body fluid from the interstitial and/or intravascular spaces
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Fluid volume deficit
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Some causes of fluid volume deficit
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decreased intake
abnormal loss through: skin, GI tract, renal, bleeding, or third spacing vomiting diarrhea GI suctioning sweating hemorrhage burns |
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What happens to your BP if you have a fluid volume deficit
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goes down
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What happens to your HR with a fluid volume defiici
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goes up
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What may cause drastic daily weight changes
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CHF (congestive heart failure) and renal disease
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What is 1+ edema?
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2 mm indent
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What is 2+ edema?
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4 mm indent
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What is 3+ edema?
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6 mm indent
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What is 4+ edema?
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8 mm indent
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What can you do to help assess fluid volume deficit
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urine specific gravity
serum electrolytes Hematocrit |
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What does hematocrit measure
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percentage of whole blood that is RBCs
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Will specific gravity be higher or lower in dilute urine?
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lower
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What is ascites?
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abdominal swelling (extra fluid in peritoneum)
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What may be some diagnoses for fluid volume deficit?
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fluid volume deficit or altered tissue perfusion
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What may some outcomes be?
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urine output greater than 30 cc/hr within 24 hours
lab results are within normal limits remain free of signs and symptoms of dehydration prior to discharge |
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What are some interventions
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provide fluids, measure I and O, weigh daily, monitor lab values, monitor vitals, teaching, assessment
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What is an increase in either the interstitial space and/or intravascular spaces
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fluid volume overload
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What is too much fluid in the interstitial spaces?
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edema
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What is too much fluid in the intravascular spaces?
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hypertension
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What are some causes of fluid volume overload?
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CHF, renal failure, burns, steroid use, excessive intake
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What are some signs of fluid volume overload?
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neck and hand vein engorgement, peripheral edema, dyspnea or SOB, lung sounds, weight gain, vital sign changes, and constant irritated cough
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What are some diagnoses for fluid volume overload?
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fluid volume excess or ineffective breathing pattern
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What are some interventions for fluid volume excess?
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monitor I and O, weigh daily, monitor diet, limit Na, check for pitting edema, listen to patients concerns
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What are some values to evaluate for success of correcting fluid volume overload
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labs within normal limits, change in vitals, increased urine output (not in renal pt), decreased weight, decreased jugular vein distension, decreased respiratory symptoms
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Where is sodium more plentiful?
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extracellular fluid (plasma and interstitial)
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What is potassium more plentiful?
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intracellular fluid
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What is normal sodium level?
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135-145 mEq/L
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What are major functions of sodium?
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water balance and neuromuscular activity
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What is sodium above 146 mEq/L?
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hypernatremia
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What are some causes of hypernatremia?
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increased aldosterone
increased sodium intake diarrhea poor renal function environment medications vomiting w/o H2O replaced |
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What should you look for in assessing for hypernatremia?
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diet, cariac/renal history, aldosteron, hypervolemia signs and symptoms
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What are some interventions for hypernatremia?
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diet, labs, medication assessment, fluid volume excess interventions
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What is sodium level less than 135?
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hyponatremia
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What are some causes of hyponatremia?
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low sodium diet, drinking large amounts of water, upper GI losses, renal disorders, diuretics
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What are some assessments to check for hyponatremia?
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diet, IV fluids, fluid volume deficit signs and symptoms, neuro
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What are some interventions to check for hyponatremia?
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similar for fluid volume deficit, monitor labs, restrict H2O intake if underlying cause, 3% saline solution (hypertonic IV)
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What is a normal potassium levels?
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3.5-5.0 mEq/L
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What is potassium below 3.5?
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hypokalemia
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What are some causes of hypokalemia?
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upper GI losses (too much NG tube suction, vomiting, diarrhea), renal losses, cellular damage, steroids, dietary changes
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What are some assessments for hypokalemia?
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dysrhythmias, anorexia, decreased peristalsis, weakness, recent surgery, assess muscles (tetany)
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What are some interventions for hypokalemia?
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monitor labs, diet, PO with 6-8 ouces of fluid, Never IV push!, administer 10 mEq/HR continuous IV administration
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Phlebitis
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inflammation of vein
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What is potassium above 5.3 mEq/L?
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hyperkalemia
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What are some causes of hyperkalemia?
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excessive intake, burns, traumatic injury
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What are some assessments to check for with hyperkalemia?
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dysrhythmias, elevated T waves, weakness, abdonimal cramps
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What are some interventions for hyperkalemia?
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insulin and glucose (works at cellular level), kayexalate both routes, dialysis, IV fluids (.9 normal saline)
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What is normal levels of calcium?
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8.5-10.5 mg/dl
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What is responsible for homeostatic regulation?
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parathyroid gland
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What is necessary for calcium absorption?
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Vitamin D
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What inhibits calcium absorption?
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phosphorus
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What does calcium help control?
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neuromuscular activity
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What are some assessments of hypocalcemia?
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parathyroid function, renal failure, diet (calcium, vitamin D, phosphorus), Chevostek's sign, Trousseau's sign, tetany, bleeding, seizures, medications (nicotine, caffeine)
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What are some diagnoses for hypocalcemia?
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altered nutrition or high risk for injury
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What are some interventions for hypocalcemia?
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supply calcium and vitamin D in the diet, check labs for calcium, prothrombin time, administer calcium
PO: calcium carbonate (tums) IV: calcium gluconate/chloride |
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What do those with low calcium have trouble regulating?
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blood pressure
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What is calcium level above 10.5 mg/dl
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hypercalcemia
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What are some causes of hypercalcemia?
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diet, renal disease, immobility, bone malignancy
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What are some things to assess for hypercalcemia?
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CNS changes, lethargy, weakness, skeletal, flank pain, arrhythmias, neuromuscular changes, GI symptoms, renal function
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What are some interventions for hypercalcemia?
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encourage mobility, LOC, position carefully, avoid lactated ringers, strain urine, I and O, vitals, diet teaching
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What are likely with hypercalcemia?
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kidney stones
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The nurse may have the nursing diagnosis excess fluid volume when the patient's skin appears:
a. dry and scaly b. taut and shiny c. red and irritated d. thin and inelastic |
b. taut and shiny
reason: with excessive fluid volume, the increased hydrostatic pressur emoves fluid from the intravascular compartment into the interstitial compartment. As fluid collects in the interstitial compartment (edema), the skin appears taut and shiny |
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Clinical manifestations that are common to both hypokalemia and hyperkalemia are:
a. nausea and vomiting b. irritability and confusion c. muscle weakness and dysrhythmias d.inreased bowel sounds and diarrhea |
c. a deficiency or excess of K can cause both muscle weakness and dysrhythmias because of K's role in the sodium-potassium pump, cellular metabolism, and muscle contraction
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Which adaptation would most specifically indicate that IV fluid replacement is adequate?
a. moist lips b. bounding pulse c. urine output of 50 cc/hr d. blood pressure of 96/60 |
c. urine output of 50 cc/hr- The circulating blood volume perfuses the kidneys and produces a glomerular filtrate of which varying amounts are either reabsorbed or excreted to maintain fluid balance. When a person without kidney disease is adequately hydrated, the minimally acceptable urinary output is 30 cc per hour
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The nurse suspects that a pt receiving IV fluids is experiencing a fluid overload when assessment revels:
a. chills, fever, and generalized discomfort b. dyspnea, earache, and increased blood pressure c. pallor, swelling and discomfort at the insertion site d. a blood return in the tubing close to the insertion site |
b.- IV fluid flows directly into the circulatory system via a vein. Excess intravascular volume (hypervolemia) causes hypertension, pulmonary edema, and headache
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The physician of a critically ill pt should be notified when the patients hourly urine output first falls below:
a. 20 cc b. 30 cc c. 60 cc 3. 120 cc |
B- the cirulating blood volume perfuses the kidneys, producing a glomerular filtrate of which varying amt. are either reabsorbed or excreted to maintain fluid balance. When aperson's hourly urine output is only 30 cc, it indicates a deficient circulation fluid volume, inadequate renal perfusion, and/or kidney disease. The physician should be notified.
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A pt is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals profuse diaphoresis, dry, sticky mucous membranes, weakness, disorientation, and a decreasing LOC. The nurse infers that the pt has:
a. hyperkalemia b. hypercalcemia c. hypernatremia d. hypermagnesiumia |
c. With profuse diaphoresis, the water loss exceeds the Na loss resulting in hypernatremia. Excess serum sodium precipitates changes in the musculoskeletal (weakness), neurologic (disorientation and decreased level of consciousness), and integumentary (dry, sticky mucous membranes) systems.
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What patient assessment is a major indicator that the pt has the nursing diagnosis Deficient fluid volume?
a. increased body temp b. decreased BP c. negative balance of I & O d. shortness of breath |
C- A pt. has a negative balance of I and O when the O exceeds the I. This is a major defining characteristic of the nursing diagnosis deficient fluid volume
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