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142 Cards in this Set

  • Front
  • Back
__________ allows individuals to care for themselves, to interact with the environment, and to carry out purposeful activities
Mobility
balance, strength, and endurance are all components of _________
mobility
The musculoskeletal system is one of the body's largest systems and accounts for ___% of body weight
50%
Muscle strength peaks at ___ to ___ years old and is maintained through the fifth decade; after the fifth decade, the system decreases in strength
25-30 years old
bones heal in children in approximately __ to __ weeks
1 to 2 weeks
bones heal in young adults in approximately __ to ___ weeks
4 to 6 weeks
bones heal in older adults in approximately up to ___ months
3 months
______ occurs with the use of bones, joints, muscles, soft tissue, and the neurological system
Mobility
______________ assists in balance. When the body's center of gravity is stable, there is no strain on muscles.
correct body alignment
without correct body alignment, the patient has less control over his/her balance and is at increased risk for _____.
falls
Older adults have a progressive total bone mass loss due to :
physical inactivity
hormonal changes
increased osteoclastic activity (activity by cells responsible for bone tissue absorption)
the effect of bone loss is:
weaker bones
Smaller steps taken by older adults increases their risk for _______
falls and fractures, because it decreases their base support
these are common causes for _____
pain, motor function impairment, structural problems, generalized inactivity, psychological problems and medically induced problems such as surgery
immobility
a client who is experiencing pain will _____ spontaneous movement in an attempt to decrease painful stimuli
decrease
disorder of the musculoskeletal and nervous system that can limit mobility are:
multiple sclerosis, parkinson's disease
arthritis and amputations can impair ______
mobility
chronic conditions such as COPD, Congestive Heart Failure, angina, & obesity can limit the supply of oxygen and nutrients to the body will affect _________ and energy
activity tolerance
People who are severely _______ have low hemoglobin and will have decreased O2 carrying capacity of the blood which will cause fatigue and impair mobility
anemic
evaluate range of unassisted active motion of both sides
range of motion (ROM)
ability to turn side to side, move up in bed, move to the side of the bed, sit up in bed, and bridge is called
bed mobility
ability to move between wheelchair and bed, toilet, bath bench or shower chair, and std seating is called
transfer ability
______ & ______ are awareness of body position, posture, & movement
coordination and proprioception
Nursing Diagnosis:
a limitation in independent purposeful physical movement of the body or of one of the extremities.
impaired physical mobility
Nursing Diagnosis:
insufficient physiological or psychological energy to endure or complete required or desired daily activities
activity intolerance
______ is performed to maintain joint flexibility, movement, promote circulation, prevent venous stasis, and help prevent skin breakdown
Range of motion
The full range of movement that a joint can normally perform
Range of motion
patient moves all joints through their full range of motion
Active ROM
this is performed by the nurse because the patient is unable to carry out this activity. The nurse supports the joint to prevent muscle strain or injury and then moves the joint through the range gently
Passive ROM
in active and passive ROM, all joints are moved ____ times each.
Five
machines are used post op to place joints through a selective range of motion.
continuous passive motion (CPM)
a continuous grating sound caused by joint deterioration
crepitus
move away from the body
abduction
move toward the body
adduction
bending of the joint in the natural direction of movement
flexion
rotate palm downward
pronation
rotate palm upward
supination
movement of ankle away from midline
eversion
movement of ankle toward midline
inversion
flexion of foot upward
dorsal flexion
extension of foot downward
plantar flexion
combination of movements that causes body part to move in a circle
circumduction
pivoting a body part on its axis
rotation
associated with the action and function of muscles that are used to maintain the balance and posture during all activities of daily living
body mechanics
improper ______________ can cause fatigue, back strain or injury
body mechanics
the body is more stable with a ____ base of support
wide
holding an object ___ to the body requires less energy
close
when a person moves, the center of gravity shifts continuously in the direction of ____________
moving parts
facing the direction of work and using the pelvic tilt before an activity ________ the chance of injury
decreases
if pushing, move the front foot _____,
forward
if pulling, move the rear leg ____ to promote stability
back
avoid _____ movements of the spine
twisting
adjust the ____ of the work to a comfortable level
height
bend at ____ and ____ to alter position of the body
hips & knees
when lifting, use _____ muscle groups
large
avoid repetitive movements of the hands, wrists, and shoulders. Take a break every __ to __ minutes to flex and stretch joints and muscles
15 to 20 minutes
___ and ____ should be in line with the pelvis to avoid neck flexion and hunched shoulders which can cause impingement of nerves in the neck
head and neck
Do not pull patient up by the _____
arms
patients taking ____ medication are more sensitive to orthostatic hypotension
pain
allow time for patient to adjust to _____ changes
position
if the patient cannot help with the transfer, use at least ___ people for the transfer
two
if patient has weakness on one side always have ____ side leading
strong
always make sure the patient has _______ on their feet
non-skid slippers or shoes with grip
use a ___________ to provide security and safety during the transfer
transfer belt
the bed should always be _____ before transfer
locked
make sure the wheelchair is _______ correctly, brakes are _____, and foot pedals are moved out of the way
positioned, locked
used to help with balance and forward gait. Elbows bent at 30 degrees; requires the patient to lift the device up and forward
walker
used to increase balance especially when there is weakness to one side
hemi-walkers or platform canes
used to provide stability and strength to one leg. Elbow should be slightly bent. Used by placing ahead of and with the movement of the weak leg. It is held on the stronger side.
cane
used for protected or partial weight bearing or for nonweight bearing. Should be 3 to 4 finger widths below the axillae to a point 6-8 inches to the side from the heels.
crutches
when assisting a pt with ambulation, stand to the pt's ___ side to provide support. Provide support at the waist
weak
less than 20%; just enough weight bearing on toes to help maintain the balance
TTWB (toe touch weight bearing)
approximately up to 50% weight bearing on affected limb
PWB (partial weight bearing)
may apply full weight on affected limb
FWB (full weight bearing)
absolutely no weight bearing to affected limb
NWB ( no weight bearing)
may apply as much weight to affected limb as patient can tolerate, up to full weight
WBAT (weight bearing as tolerated)
patient did everything himself and was safe
independent
patient did the activity himself but a helper was needed to standby for safety issues or provide verbal prompting
standby assist
the pt was able to complete at least 75% of the task himself
minimal assist
the pt was able to complete at least 50% of the task himself
Moderate Assist
the pt was able to complete at least 25% of the task himself
minimal assist
the pt did less than 25% of the task and needed considerable assistance
dependent
when you do oral care on a comatose patient, the patient should be ______ lying, and you should have another person helping you provide _____
side lying; suction
the ability to meet one's own needs related to hygiene, dressing, toileting, and feeding without the assistance of another person
self care
if the body is not kept clean, the skin is compromised and the body is threatened by _____ or _______
disease or infection
cleanse the body, relax it, and enhance healing is the purpose of _____
bathing
____ is the body's first line of defense
skin
outer portion; composed of keratinocytes that produce keratin. Keratin protects the skin & underlying tissues and plays a part in immune function.
epidermis
pigment responsible for skin color & tanning - at bottom of epidermis
melanin (which is produced by Melanocytes)
layer of kin shields underlying tissue against water loss & injury and prevents entry of disease production microorganisms
epidermis
layer of skin composed of connective tissue containing collagenous and elastic fibers. Blood vessels, nerves, glands, and hair follicles are embedded in this layer
Dermis - 2nd layer
layer that contains loose connective and fatty tissue. Provides blood supply to the dermis. Contains blood vessels, nerves, lymph, and loose connective tissue filled with fat cells. (insulator for the body)
subcutaneous tissue - 3rd layer
glands connected to hair follicles. Secreting portions of these glands line in the dermis. Absent in palms and soles of feet
sebaceous glands
____ sweat glands: Most are eccrine and located in the subcu. layer. Numerous in palms and soles of feet. Increased wetness when anxious or under stress. Primary function is perspiration to regulate body temp.
eccrine sweat glands
____ sweat glands are located in axilla and the pubic region in the dermis layer. they begin to function at puberty
apocrine
secretes cerumen - ear wax
ceruminous gland
A kind of bath:
decrease pain and inflammation after rectalor perineal surgery, after childbirth, or with hemorrhoids
Sitz bath
A kind of bath:
bath given to totally dependent patients in bed
complete bath
A kind of bath:
bed bath that consists of bathing only body parts that would cause discomfort if left unbathed, such as the hands, face, axillae, and perineal area. Includes washing the back and provide back massage.
Partial bed bath
A kind of bath:
involves bathing at the sink with the patient sitting in a chair. Pt is able to perform a portion of the bath independently. Assistance is needed ofr hard-to-reach areas
sponge bath at sink
A kind of bath:
involves immersion in a tub of water
tub bath
A kind of bath:
pt sists or stands under a continuous stream of water. The shower can provide more thorough cleansing than a bed bath but is more fatiguing.
shower
A kind of bath:
bath contains several soft, nonwoven cotton cloths that are premoistened in a solution of no-rinse surfactant cleanser and emollient
bed bath/travel bath
before getting a patient up, you should always check __________
the physicians orders
a cheese lie substance secreted by sebaceous gland under the foreskin on the penis is called:
smegma
loss of hair or baldness
alopecia
yellow or thick nails may be signs of impaired ______________ or __________
peripheral circulation or fungal infection
clubbing of nails (marked curvature) may be a sign of serious _______ or ________ problems
respiratory or cardic
while performing oral care in unconscious patients make sure you position the client ________ and make sure to use _________
side-lying; suction
lubricate the client's lips with petroleum jelly unless on oxygen; if using oxygen, use _______ ______ lubricate
water base
during oral care in conscious pt, place pt in _______ and _______ position to prevent aspiration and choking
fowlers & semifowlers
peds oral care:
tooth brushing begins about ___ months with water
18 mts
advise pt to have a dental check-up at least ever _ months
6
do not use __________sponges because they dry mucous membranes and erode tooth enamel
lemon-glycerin
to prevent bleeding in pt receiving chemotherapy or are on anticoagulants, use _______ floss
unwaxed
soft, thin layer of food debris and dead epithelial cells; provdes a medium for bacterial growth
plaque
yellow film of calcium phosphate, food particles and other organic matter deposited on teeth by saliva
tarter
inflammation of the gums; signs of bleeding often present
gingivitis
these ppl are at risk for:
mouth breathers
orthodonic supplies
diabetes
hormonal fluctuations - pregnancy, oral contraceptives
Gingivitis
inflammation of the oral mucosa. Normal saline rinses ever 2-4 hours may be helpful to cleanse the oral cavity
Stomatitis
these ppl are at risk for:
drugs - i.e. anticholinergics
poor oral hygine
chemotherapy
immune deficiency
anemia-due to dietary deficiencies
mouth breathers
Stomatitis
fungal infection of the oral mucosa; characterized by white fim on tongue. Mouth may be sore and oral intake difficult due to tenderness of the mouth
Thrush
Apply moisturizer to feet, but not ____________
between toes
avoid OTC products that contain ____ or other strong chemicals
alcohol
when preparing to shave a pt, you should check for any _______ precautions
bleeding (Coumadin or other anticoagulants)
these pt's need:
DVT
large involved surgeries such as a bowl resection
severely confused pt
traction
extremly weak pt
pt that cannot be transferred safely
require an occupied bed linen change
scholarly nursing literature reports that the number one reason a pt falls in the hospital is when they are trying to get to the ___________ unassisted
bathroom
make sure the _______ is within reach at all times and the pt knows how to use it correctly.
call light
Offer a toileting opportunity ever __ hours especially to pt's with an altered mental status
2 hrs
type of back massage strokes:
long smooth stroke sliding over skin
effleurage
type of back massage strokes
kneading of skin muscles
type of back massage strokes
scholarly nursing literature reports that the number one reason a pt falls in the hospital is when they are trying to get to the ___________ unassisted
bathroom
make sure the _______ is within reach at all times and the pt knows how to use it correctly.
call light
Offer a toileting opportunity ever __ hours especially to pt's with an altered mental status
2 hrs
type of back massage strokes:
long smooth stroke sliding over skin
effleurage
type of back massage strokes
kneading of skin muscles
petrissage
type of back massage strokes
percussion or tapping. Do gently. Use over particularly tense muscles
tapotement
type of back massage strokes
small circular strokes
friction
focus on the muscles, moving down both sides of the vertebral column. Use __________ strokes
circular friction
focus on the small of the back. use ________ from the center of the spine and out in all directions
effleurage
finish with ______ stroke - most find this most relaxing stroke and will induce sleep in some clients
Effleurage
Because effleurage causes an immediate rise in blood pressure & heart rate in pt's who have had coronary artery bypass surgery, do not massage those pt's within the first ____ hours of their surgery
48 hours