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64 Cards in this Set
- Front
- Back
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muscle atrophy
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decrease in muscle size, tone and strength
--wasting due to disuse --buttocks and legs muscles most quickly |
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Contracture
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tightening or shortening of muscle, tendons, ligaments, or skin that prevents normal movement
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Ankylosis
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consolidation and immobilization of a joint, which can be permanent.
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Nursing interventions with muscle atrophy
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active ROM exercises (2x's daily)
Isometric exercises in bed if able OOB and ambulate ASAP |
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Nursing interventions with contractures and ankylosis
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ROM exercises (active or passive)
Protective positioning (moving side to side) Q 2 hour positioning changes PT/OT consult |
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Nursing interventions with Disuse Osteoporosis
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Weight bearing ASAP
Nutrition- adequate calcium (vitamin D) |
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Nursing interventions with back aches
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Firm mattress
scheduled position changes (every 2 hours) back rubs (increase circulation) daily exercise program (pt. has to want to do it) |
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Increased cardiac Workload
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when supine blood distribution is altered.
Poor venous return-->blood pools in veins --> increase venous pressure. |
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Orthostatic hypotension
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vasodilation of blood vessels
decreased muscular activity= decrease blood return to the heart Blood pools in venous circulation and thereby decrease in BP |
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venous Thrombus (DVT)
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most common in leg (pain, swelling, redness, warmth)
*contributing factors: --injury to vein --stasis of blood (nothing is moving) DANGER: thrombus breaks away and becomes a embolus...goes to lung and cause PE |
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Nursing interventions for cardiac workload and orthostatic hypotension
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Encourage mobility and position changes
Encourage Fowlers postion Dangle feet before ambulation |
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Nursing interventions for DVT
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Monitor VS, peripheral pulses, edema, inspect legs (do not flex knees)
ROM exercise Elevate legs to promote venous return TED stockings\ SCD's DO NOT MASSAGE LEGS!!! |
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Atelectasis
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collapse of alveoli due to decrease lung expansion
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Respiratory System Hazards
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Decreased respiratory rate and depth
Stasis & increase of pulmonary secretions Impaired gas exchange --->acid/base imbalance |
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Stasis and increase of pulmonary secretions causes....
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Atelectasis
Pneumonia |
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respiratory system nursing interventions under assessment
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Assess:
--respiratory rate and effort (12-20) --Lung sounds (clear) --cough and sputum (C&S) --Monitor O2 therapy(> 92) Cyanosis (blueing) Confusion and restlessness |
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respiratory system interventions
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Change position q 2 hours
Teach/encourage TCDB Active ROM exercises Incentive spirometer use Encourage hydration Suction as needed |
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Gastrointestinal system hazards
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Constipation/Fecal Impaction
Anorexia/Malnutrition Altered protein metabolism --tissue atrophy and protein catabolism --Inadequate protein for maintaining muscle mass or healing damaged tissue |
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Gastrointestinal system nursing interventions for constipation and fecal impaction
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monitor bowel movements
Assess abdomen and bowel sounds offer pedpan according to pt. usual routine maintain privacy encourage fluid and fiber administer laxatives as ordered |
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Nursing interventions for anorexia / malnutrition
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Stimulate appetite
small frequent meals encourage protein intake allow pt. to select menu Monitor I&O's |
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Nursing interventions for Altered protein metabolism
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High calorie/high protein diet
May need vitamin supplements monitor nutritional intake and body weight Monitor I&O's Dietary consult Monitor lab values (electrolytes and albumin) Access for edema may need enteral or parental nutrition (TPN) |
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Urinary system hazards
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Urinary stasis/urinary retention
--difficulty urinating due to position --Drainage by gravity is impeded in supine position --Overall decrease in bladder muscle tone UTI Formation of renal calculi (kidney stone) |
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Nursing interventions for urinary system
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Increase fluid intakes!!!!
maintain privacy Assess --I&O's --urinary retention/bladder distention --S/S of UTI Frequent position changes perineal hygiene Indwelling catheter only if necessary |
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Metabolic hazards
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Decreased metabolic rate
Tissue atrophy and protein catabolism Fluid and electrolyte imbalances |
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Integumentary system hazards
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Decubitus Ulcers (bedsores, pressure sores)
--three main causes ---pressure ---shearing forces ---frictions --Other factors contributing to decubiti: ---Moisture ---poor nutrition ---anemia ---infection ---fever |
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Psychological hazards
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Depression
Decreased self esteem changes in sleep-wake cycle decreased coping Sensory deprivation / sensory overload Social isolation |
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Nursing interventions for psychological hazards
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Increase sensory stimulation
attention to pt. appearance emotional support encourage visitors explore coping mechanisms consultations: social worker or pastoral care |
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rest
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the body is in a decreased state of activity which restores energy
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Sleep
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state of rest accompanied by altered consciousness, diminshed sensitivity to external stimuli and relative inactivity
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NREM
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non rapid eye movement
--characterized by PSNS activity (decrease in V/S and metabolic rate.) --75-80% of total sleep time |
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REM
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rapid eye movement
--characterized by the loss of skeletal muscle tone and deep tendon reflexes are depressed --20-25% of total sleep time |
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anabolism
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building up
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catabolism
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breaking down
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1st stage of NREM
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loss of some muscle tone and conscious awareness of the external environment.
Light Sleep |
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2nd stage of NREM
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no conscious awareness of the external environment.
Light sleep |
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3rd stage of NREM
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deep sleep
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4th Stage of NREM
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deepest stage of sleep (delta or slow wave sleep)
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REM
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eyes dart back and forth
V/S and metabolic rate increase HR- rapid and irregular RR- irregular, sometimes with apnea Rem Atonia |
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REM Atonia
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large skeletal muscle tone and deep tendon reflexes are suppressed (sleep paralysis)
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sleep cycle
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repeated pattern of NREM and REM
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If awakened, pt returns to ____
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NREM Stage 1
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Completed cycle of REM and NREM is approximately____
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90-100 minutes
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Adults have ____ cycles.
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4-6 cycles
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Sleep disorders may be characterized by...
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difficulty falling asleep
difficulty staying asleep difficulty staying awake during the day Unrefreshing sleep sleeping too much abnormal behaviors during sleep with disrupt sleep |
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Dyssomnias
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broad classification of sleep disorders characterized by a disturbance in the amount, quality, or timing of sleep.
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Examples of Dyssomnias
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Insomnia
Hypersomnia Narcolepsy Sleep apnea restless leg syndrome Sleep Deprivation |
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Parasomnias
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waking behaviors that appear during sleep
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Insomnia
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Most common d/o
Difficulty falling asleep waking up too early and not being able to fall back asleep Frequent awakenings waking up and feeling unrefreshed |
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Treatment for insomnia
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stimulus control- associating bed with sleep, consistent sleep schedule, not staying in bed > 15-20 minutes if you cant sleep No napping
Sleep restriction- napping permitted, but not spending excessive time in bed, but not < than 5 hours. |
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Hypersomnia
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excessive sleep during the day (that does not relieve sleepiness)
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Narcolepsy
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Neurological disorder characterized by an uncontrolled desire to sleep.
Sleep onset REM. |
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Sleep attacks
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irresistible urge to sleep
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Cataplexy
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sudden loss of motor tone that may cause them to fall asleep
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Sleep paralysis
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skeletal muscle paralysis occurs when falling asleep.
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Hypnagogic hallucinations
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nightmares or vivid hallucinations when falling asleep or waking up
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Sleep apnea
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absence of breathing while sleeping
diagnosed by sleep study CPAP |
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Restless leg syndrome
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uncontrollable urges to move the limbs in order to stop uncomfortable painful or odd sensations in the legs.
Worsen at rest Worsen at night Treatment: Requip |
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Sleep Deprivation
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decrease in amount of quality or consistency of sleep (NREM or REM)
S/S= confusion, irritability, daytime sleepiness, inability to concentrate, process information or make decisions, hallucinations, disintegration of personality. |
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Parasomnias
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waking behaviors that occur during sleeping
Often associated with stress and depression |
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Somnanbulism
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sleep walking
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Somniloquy
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sleep talking
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Bruxism
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teeth grinding
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Enuresis
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bed wetting
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What is a normal sleep pattern?
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--Fall asleep with 15-20 minutes
--Adequate amount --remains asleep --wake up feeling refreshed |
