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;
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
|