Immobility - Part 1 (Basics In Nursing)

Front 1

(def)

a blood clot (or a substance such as air) that has moved from its place of origin and is causing obstruction to circulation elsewhere

Back 1

embolus

Front 2

(def)

abnormally fast respirations; usually more than 24 respirations per minute

Back 2

tachypnea

Front 3

(def)

inflammation of a vein followed by formation of a blood clot

Back 3

thrombophlebitis

Front 4

(def)

difficult or labored breathing

Back 4

dyspnea

Front 5

(def)

insufficient oxygen anywhere in the body

Back 5

hypoxia

Front 6

(def)

a decrease in the caliber (lumen) of blood vessels

Back 6

vasoconstriction

Front 7

(def)

a solid mass of blood constituents in the circulatory system; a clot

Back 7

thrombus

Front 8

(def)

bluish discoloration of the skin and mucous membranes caused by reduced oxygen in the blood

Back 8

cyanosis

Front 9

(def)

an abnormally rapid pulse rate; greater than 100 beats per minute

Back 9

tachycardia

Front 10

(def)

passage of blood constituents through the vessels of the circulatory system

Back 10

perfusion

Front 11

(def)

any activity during which the body takes in more or an equal amount of oxygen than it expands

Back 11

aerobic exercise

Front 12

(def)

involves activity in which the muscles cannot draw out enough oxygen from the bloodstream; used in endurance training

Back 12

anaerobic exercise

Front 13

(def)

a condition that occurs when ventilation is decreased and pooled secretions accumulate in a dependent area of a bronchiole and block it

Back 13

atelectasis

Front 14

(def)

permanent shortening of a muscle and subsequent shortening of tendons and ligaments

Back 14

contracture

Front 15

(def)

a toe-down motion of the foot of the ankle

Back 15

plantar flexion

Front 16

(def)

pain associated with an inflammation of the parietal pleura of the lungs (stabbing pain characterized by dypsnea)

Back 16

pleuritic pain

Front 17

(def)

upward or backward flexion of a part of the body

Back 17

dorsiflexion

Front 18

(def)

the ability of a muscle or person to produce or resist a physical force

Back 18

strength

Front 19

(def)

the ability to continue an activity despite increasing physical or psychological stress

Back 19

endurance

Front 20

(def)

a form of active exercise in which muscles contract and cause movement

Back 20

isotonic exercise

Front 21

(def)

a form of active exercise in which muscle tension is increased while pressure is applied against stable resistance

Back 21

isometric exercise

Front 22

(def)

a form of exercise in which maximum force is exerted by a muscle at each point throughout the active range of motion as the muscle contracts (combines isotonic and isometric)

Back 22

isokinetic exercise

Front 23

(def)

any body exercise involving the muscles, joints and natural movements

Back 23

range of motion exercises

Front 24

(def)

a type of pneumonia associated with elderly or debilitated people who remain in the same position for long periods

Back 24

hypostatic pneumonia

Front 25

(def)

theory that states "The cause of thrombosis must have 3 contributing factors.....stasis of venous flow, hypercoagulability of blood, and damage to the endothelium"

Back 25

Virchow's Triad

Front 26

(def)

a temporary or permanent inability of the external sphincter muscles to control the flow of urine from the bladder

Back 26

urinary incontinence

Front 27

(def)

the process of emptying the bladder (3)

Back 27

urination
micturition
void

Front 28

(def)

production of abnormally small amounts of urine by the kidney (2)

Back 28

oliguria
urinary suppression

Front 29

(def)

the amount of urine remaining in the bladder after a person voids

Back 29

residual urine

Front 30

(def)

the accumulation of urine in the bladder and inability of the bladder to empty itself

Back 30

urinary retention

Front 31

(def)

the weight or degree of concentration of a substance compared with that of an equal volume of another, such as distilled water, taken as standard

Back 31

specific gravity

Front 32

(def)

the production of large amounts of urine by the kidneys without an increased fluid intake (2)

Back 32

diuresis or polyuria

Front 33

(def)

excessive thirst

Back 33

polydipsia

Front 34

(def)

voiding two or more times at night

Back 34

nocturia

Front 35

(def)

the failure of the kidneys to produce urine, resulting in a total lack of urination or output of less than 100 mL per day in an adult

Back 35

anuria

Front 36

(def)

painful or difficult voiding

Back 36

dysuria

Front 37

(def)

bed-wetting; involuntary passing of urine in children after bladder control is achieved

Back 37

enuresis

Front 38

(def)

the feeling that one must urinate

Back 38

urgency

Front 39

(def)

an inflammatory condition of the urinary bladder and ureters, characterized by pain, urgency and frequency of urination, and hematuria

Back 39

cystitis

Front 40

(def)

the presence of bacteria in the urine

Back 40

bacteriuria

Front 41

(def)

a physical, microscopic, or chemical examination of urine

Back 41

urinalysis

Front 42

(def)

a decrease in the force of the stream of urine, often with difficulty in beginning the flow

Back 42

urinary hesitancy

Front 43

(def)

the presence of an excessive number of WBCs in the urine, typically more than four leukocytes per high-power field count

Back 43

pyuria

Front 44

(def)

abnormal presence of a sugar, especially glucose, in the urine

Back 44

glycosuria

Front 45

(def)

abnormal presence of blood in the urine

Back 45

hematuria

Front 46

(def)

the number of repetitions of any phenomenon within a fixed period

Back 46

frequency

Front 47

(def)

the presence in the urine of abnormally large quantities of protein, usually albumin

Back 47

proteinuria

Front 48

(def)

passage of small, dry, hard stool or passage of no stool for an abnormally long time

Back 48

constipation

Front 49

(def)

a wood resin, formally used as a reagent in laboratory tests for the presence of occult blood

Back 49

guaiac

Front 50

(def)

expulsion of feces from the rectum and anus

Back 50

defecation

Front 51

(def)

defecation of liquid feces and increased frequency of defecation

Back 51

diarrhea

Front 52

(def)

a mass or collection of hardened, putty-like feces in the folds of the rectum

Back 52

fecal impaction

Front 53

(def)

loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter

Back 53

fecal incontinence

Front 54

(def)

gas or air normally present in the stomach or intestine

Back 54

flatus

Front 55

(def)

the presence of excessive amounts of gas in the stomach or intestines

Back 55

flatulence

Front 56

(def)

test used to detect hidden blood in the stool using a pre-packaged slide

Back 56

hemoccult slide (test)

Front 57

(def)

test used to detect hidden blood in the stool using a tablet

Back 57

hematest

Front 58

(def)

abnormal black tarry stool that has a distinctive odor and contains digested blood

Back 58

melena

Front 59

(def)

blood that is not obvious on examination but may be detected by means of a chemical test or by microscopic or spectroscopic examination

Back 59

occult blood

Front 60

(def)

wavelike movements produced by circular and longitudinal muscle fibers of the intestinal walls; the movement propels the intestinal contents onward

Back 60

peristalsis

Front 61

(def)

solid, cone-shaped, medicated substance inserted into the rectum, vagina, or urethra

Back 61

suppository

Front 62

(def)

any bodily movement produced by skeletal muscles that results in energy expenditure

Back 62

physical activity

Front 63

(def)

a subset of physical activity defined as any planned, structured and repetitive bodily movement

Back 63

exercise

Front 64

What are 6 benefits of physical activity/exercise?

Back 64

1. Reduction of serum triglyceride levels
2. Reduction of BP (at rest)
3. Increase in level of HDL cholesterol
4. Enhancement of glucose tolerance and insulin sensitivity
5. Decrease risk of severe chronic diseases
6. Increase in joint flexibility and ROM

Front 65

Why is exercise recommended for people with type II diabetes?

Back 65

because it enhances glucose tolerance and insulin sensitivity

Front 66

How does physical activity help prevent osteoporosis?

Back 66

because exercise helps to maintain bone density

Front 67

(def)

the ability to perform moderate to vigorous levels of physical activity without undue fatigue and to maintain that ability throughout one's life

Back 67

physical fitness

Front 68

What are the 4 components of physical fitness?

Back 68

1. muscle strength and endurance
2. cardio-respiratory fitness
3. joint flexibility
4. body composition

Front 69

(def)

the ability to use a muscle fully through its maximum range of motion

Back 69

joint flexibility

Front 70

Body composition should fall within the range of the recommended proportion of ____ to ____ body tissue.

Back 70

fat to lean body tissue

Front 71

Isotonic, Isometric or Isokinetic?

Dynamic exercises; movement

Back 71

Isotonic

Front 72

Isotonic, Isometric or Isokinetic?

tightening and loosening a muscle without movement

Back 72

Isometric

Front 73

Isotonic, Isometric or Isokinetic?

Muscle tension is constant and the muscle shortens to produce contraction and movement

Back 73

Isotonic

Front 74

Isotonic, Isometric or Isokinetic?

Increases muscle tension without changing the length of the muscle or moving the joint

Back 74

Isometric

Front 75

Isotonic, Isometric or Isokinetic?

Involves alternatively tightening the muscle as hard as possible and then relaxing the muscle

Back 75

Isometric

Front 76

What are 3 benefits of Isotonic exercise?

Back 76

1. Increases muscle strength and endurance
2. Improves cardio-respiratory function
3. Heart rate and cardiac output increases blood flow systemically (benefits entire body)

Front 77

Isotonic, Isometric or Isokinetic?

Helpful in maintaining strength of the quadriceps, abdominal and gluteal muscles which are used in ambulation

Back 77

Isometric

Front 78

True/False:

Isometric exercises are useful in preventing joint contractures.

Back 78

False- they are not useful in preventing joint contractures since there is no movement of the joints involved.

Front 79

Isotonic, Isometric or Isokinetic?

Produces a moderate increase in heart rate and cardiac output, but no appreciable increase in blood flow to other parts of the body

Back 79

Isometric

Front 80

True/False:

Isometric exercise does produce an elevation of both systolic and diastolic BP while you are engaged in it.

Back 80

True

Front 81

Having a client exhale while performing isometric exercises can prevent the client from doing what?

Back 81

the Valsalva Maneuver (without proper breathing, the client may unintentionally perform this maneuver during isometric exercises)

Front 82

Which is more effective systemically, isotonic or isometric exercises?

Back 82

isotonic

Front 83

Isotonic, Isometric or Isokinetic?

A combination of resistance and movement

Back 83

Isokinetic

Front 84

Isotonic, Isometric or Isokinetic?

Used in physical conditioning to build up specific muscle groups

Back 84

Isokinetic

Front 85

Kegal exercises are an example of which type of exercise?

Back 85

Isometric exercise

Front 86

Aerobic or Anaerobic exercise?

Improves cardiovascular fitness

Back 86

Aerobic

Front 87

Aerobic or Anaerobic exercise?

Walking briskly, swimming

Back 87

Aerobic

Front 88

Aerobic or Anaerobic exercise?

used to develop muscle tone and improve cardio-respiratory function

Back 88

anaerobic

Front 89

Aerobic or Anaerobic exercise?

running up 3 flights of stairs

Back 89

anaerobic

Front 90

According to the American College of Sports Medicine, how frequent should a person exercise?

Back 90

3-5 days a week

Front 91

According to the American College of Sports Medicine, the intensity of training should be ____-____% of maximum heart rate or ____-____% of maximum oxygen uptake.

Back 91

60-90% of maximum heart rate or 50-85% of maximum oxygen uptake

Front 92

How do you calculate your maximum heart rate?

Back 92

220 - age = maximum heart rate

Front 93

According to the American College of Sports Medicine, how long should you exercise during a session? What determines if you will be on the higher or lower end of this range?

Back 93

20-60 minutes of continuous or intermittent (min. of 10 minute bouts). Time depends on the intensity of the activity

Front 94

Would lower intensity activity require a shorter or longer duration to meet the requirements set by the American College of Sports medicine?

Back 94

it would require a longer duration

Front 95

True/False:

You should be able to carry on a conversation while exercising

Back 95

True - while your breathing may be labored, you should still be able to carry on a conversation

Front 96

The _____ Scale is used to measure your sensation of breathlessness during various activities.

Back 96

Borg

Front 97

The American College of Sports Medicine recommends what 3 criteria for exercise to be considered effective?
What are examples of exercises that meet this criteria?

Back 97

1. uses large muscle groups
2. can be maintained continuously
3. is rhythmical and aerobic in nature

(walking/hiking, running, swimming, cycling, rowing, stair climbing, skating, etc.)

Front 98

What is the recommended guideline(s) for resistance training?

Back 98

- one set of 8-12 reps of 6-10 different exercises that condition the major muscle groups at least 2 times a week

Front 99

Why should flexibility exercises be incorporated into an overall fitness program? How often should these exercises be performed per a week?

Back 99

- incorporated to develop and maintain ROM
- need to be performed a minimum of 2-3 times a week

Front 100

Adults should accumulate ____ minutes or more of moderate intensity physical on most, preferably all days of the week.

Back 100

30

Front 101

Anyone over 35 years and sedentary should obtain what before starting an exercise program?

Back 101

medical consultation

Front 102

What is the recommendation for the elderly regarding exercise?

Back 102

at least 20 minutes of aerobic exercise every 42 hours at 60% intensity

Front 103

All exercise should begin and end with what?

Back 103

begin with a warm-up and end with a cool-down

Front 104

How long after a meal should you wait to exercise?

Back 104

1 1/2 to 2 1/2 hours

Front 105

What should you do if you are exercising and feel pain/pressure in the center of the chest, irregular heart beats, dizziness, fainting, light-headedness or blackout occurs?

Back 105

stop exercising immediately

Front 106

What can the nurse assist the client with in regards to exercise? What can't the nurse do.

Back 106

The nurse CAN counsel clients to adopt and maintain regular physical activity, correct misconceptions, and educate regarding recommendations. The nurse can NOT supervise or plan an intense exercise program.

Front 107

(def)

the ability to move freely in the environment

Back 107

mobility

Front 108

(def)

confined to a position, and one is unable to move or change positions independently

Back 108

immobility

Front 109

True/False:

Immobility can be partial or complete.

Back 109

True- partial may be a fractured limb or complete, such as paralysis

Front 110

What are 5 major reasons for immobility?

Back 110

1. severe pain
2. impairment of the musculoskeletal or nervous system
3. generalized weakness
4. psychosocial problems (such as depression)
5. infectious process

Front 111

Is it ever therapeutic for a client to be immobilized?

Back 111

Yes, for example to stop premature labor. In these instances the physician would order bedrest.

Front 112

What are 3 benefits of bedrest?

Back 112

1. reduces the needs of the body cells for oxygen because of reduced metabolism, secondary to reduced activity
2. directs energy resources toward the healing process rather than toward activity
3. reduces pain in some instances, thereby decreasing the need for analgesics

Front 113

Bedrest is only beneficial if the client is __________ and _________.

Back 113

comfortable and rested

Front 114

The greater the extent and duration of immobility, the greater the what?

Back 114

consequences

Front 115

What does the abbreviation BRP mean?

Back 115

Bathroom Privileges

Front 116

What are 2 effects of immobility on the Psychoneurologic system?

Back 116

- decrease in the quality and quantity of sensory input
- the client's increasing awareness of the limitations imposed by immobility

Front 117

Immobility can lead to social, emotional, and intellectual changes. Minimizing the physiological effects of bedrest will also minimize what effects?

Back 117

psychological effects

Front 118

What are 4 examples of psychoneurologic symptoms you may observe in a client who is immobilized?

Back 118

- depression
- behavioral changes
- changes in sleep pattern
- impaired coping

Front 119

What are 4 effects that immobility has on the metabolic system?

Back 119

1. decreased metabolic rate
2. negative nitrogen balance
3. anorexia
4. negative calcium balance

Front 120

(def)

all physical and chemical process in the body

Back 120

metabolism

Front 121

(def)

minimal energy expended for the maintenance of physical and chemical processes

Back 121

Basal metabolism

Front 122

In regards to metabolism and the immobilized client, ________ exceeds ________.

Back 122

catabolism exceeds anabolism

Front 123

In the immobilized client, catabolism exceeds anabolism. What effect does this have on nitrogen and protein?

Back 123

- creates a negative nitrogen balance
- depletes protein storage (proteins are essential for building muscle tissue and wound healing)

Front 124

(def)

the breakdown of proteins

Back 124

catabolism

Front 125

(def)

the build-up of proteins

Back 125

anabolism

Front 126

Negative nitrogen balance reaches it's peak within ___-___ days of immobility.

Back 126

6-10

Front 127

Why do you see anorexia in clients who are immobilized?

Back 127

because of the decreased metabolic rate and increased catabolism

Front 128

When a greater amount of calcium is extracted from the bone than can be replaced, the result is what?

Back 128

a negative calcium balance

Front 129

What effect does a negative calcium balance have on the skeletal system of immobilized clients? What about the urinary system?

Back 129

skeletal system = greater risk for osteoporosis

urinary system = higher incidence of kidney stones

Front 130

The process of respiration is comprised of what 3 parts?

Back 130

- pulmonary ventilation (external respiration)
- diffusion of gases to and from the blood (external respiration)
- transport of gases via the blood to and from the cells (internal respiration)

Front 131

What 3 negative side effects are seen in the respiratory system due to immobility?

Back 131

1. decreased expansion of the lungs
2. reduced gas exchange in the alveoli
3. decreases hemoglobin (hbg)

Front 132

What are 4 causes of decreased expansion of the lungs in the immobilized client?

Back 132

1. bed presses against the chest and decreases chest movement
2. abdominal organs push against the diaphragm
3. recumbent person rarely sighs
4. muscle atrophy affects respiratory muscles

Front 133

Osteoporosis caused by immobility is called what?

Back 133

disuse osteoporosis

Front 134

What effect does the shallow respirations seen in immobility have on vital capacity?

Back 134

it reduces vital capacity significantly

Front 135

(def)

the maximum amount of air that can be expired after a maximum inspiration effort

Back 135

vital capacity

Front 136

What are 3 reasons for reduced gas exchange in the alveoli of immobilized clients?

Back 136

1. blood and mucus pool in dependent areas of the lungs that are less effectively ventilated
2. mucus and secretions are more viscous
3. coughing mechanism is impaired due to weakened muscles, inability to inhale maximally, and decreased ciliary movement

Front 137

What can a nurse do to decrease the incidence of blood/mucus pooling in the dependent areas of the lungs of immobilized clients?

Back 137

turn the client frequently

Front 138

When assessing the respiratory system in an immobilized patient, what specific things should we note?

Back 138

1. The rate and quality of respirations
2. The use of neck and/or accessory muscles to breath
3. Pulse rate
4. Temperature
5. Cough effort
6. signs of hypoxia

Front 139

Why would we assess the pulse when reviewing the respiratory system of an immobilized patient?

Back 139

because a rapid pulse rate is one of the first indicators of a lack of oxygen

Front 140

Does an increase in temperature ever accompany problems in the lungs?

Back 140

Yes, an increase in temperature may be indicative of an infection in the lungs and is a result of the inflammatory process

Front 141

What are some early signs of hypoxia?

Back 141

- increased pulse
- restlessness
- forgetfulness

Front 142

Would cyanosis be a late or early sign of hypoxia?

Back 142

cyanosis is a late sign of hypoxia

Front 143

What are the 3 goals of the nursing interventions implemented for immobile clients directly related to the respiratory system?

Back 143

1. Increase alveolar expansion
2. Prevent the stasis of respiratory secretions
3. Maintain a patent airway (promote adequate exchange of gases in alveoli)

Front 144

When performing deep breathing exercises, the client inhales deeply and breaths out through _______ lips. What is the purpose of this?

Back 144

pursed lips - this keeps the alveoli from collapsing

Front 145

How would you demonstrate deep-breathing (diaphragmatic) exercises to a client?

Back 145

1. place your hands palm down on the border of your rib cage and inhale slowly and evenly through the nose until the greatest chest expansion is reached
2. Hold your breath for 2-3 seconds
3. exhale slowly through the mouth
4. continue exhalation until maximum chest contraction has been achieved

Front 146

The client should cough voluntarily after performing how many deep breathing exercises?

Back 146

5

Front 147

What technique is used if a client has a painful region of the body during coughing/deep breathing exercises?

Back 147

splinting (holding a pillow in place over an incision site/painful region) to support the area

Front 148

(def)

cleansing of the respiratory system

Back 148

respiratory toiletry

Front 149

What is an incentive spirometer? Does it require a doctor's order?

Back 149

a visual feedback tool used to encourage deep breathing; yes, a doctor's order is needed

Front 150

(def)

the use of positioning to drain secretions from specific segments of the bronchi and lungs into the trachea

Back 150

postural drainage

Front 151

(def)

method of cupping the hands and striking the body in an attempt to loosen respiratory secretions

Back 151

percussion

Front 152

Are doctor's orders required for percussion and postural drainage?

Back 152

Yes

Front 153

What is the recommend amount of fluid intake per day? How will this help an immobilized client in regards to respiratory issues?

Back 153

at least 2000cc - helps to thin mucus secretions making them easier to expectorate

Front 154

How often should constrictive abdominal or thoracic binders be removed to allow the client to deep breath (if allowed by the doctor)?

Back 154

at least every 2 hours

Front 155

In reference to the respiratory system, why should the use of narcotics/sedatives be used cautiously with immobilized clients?

Back 155

because they depress ventilation

Front 156

What causes atelectasis? (2)

Back 156

- blockage of the bronchioles with mucus
- reduction of surfactant

Front 157

What are the defining characteristics of atelectasis? (6)

Back 157

- fever (possibly lowgrade)
- increased pulse and respirations
- dyspnea
- cyanosis
- adventitious breath sounds
- abnormal x-rays

Front 158

What 2 complications may develop in the respiratory system due to immobility?

Back 158

- atelectasis
- hypostatic pneumonia

Front 159

What is the treatment method for atelectasis?

Back 159

- essentially the same as preventative measures but more aggressive

Front 160

(def)

infection of lung tissue resulting from poor circulation or stagnation of secretions

Back 160

hypostatic pneumonia

Front 161

What 3 problems associated with immobility contribute to the development of hypostatic pneumonia?

Back 161

- poor cough reflex
- limited chest expansion
- pooling of secretions

Front 162

What are the defining characteristics of hypostatic pneumonia?

Back 162

- cough
- fever
- pain when breathing
- leukocytosis
- yellowish sputum, may be greenish
- patchy infiltrate on chest x-ray

Front 163

What are the (2) treatments for hypostatic pneumonia?

Back 163

1. antibiotics
2. aggressive preventative measures

Front 164

If atelectasis or pneumonia is not corrected, it can lead to what?

Back 164

respiratory acidosis and carbon dioxide narcosis

Front 165

(def)

condition characterized by increased arterial carbon dioxide, excess carbonic acid, and increased plasma hydrogen ion concentration

Back 165

respiratory acidosis

Front 166

(def)

condition of severe hypercapnia with symptoms of confusion, tremors, convulsions, and possible coma if blood levels are increased to 70mmHg or higher

Back 166

carbon dioxide narcosis

Front 167

Hypostatic pneumonia in the elderly may only produce what 3 symptoms?

Back 167

1. confusion
2. tremors
3. rapid respirations

Front 168

Why are the elderly more prone to hypostatic pneumonia?

Back 168

because they have poor chest expansion

Front 169

What are the 5 major effects of immobility on the cardiovascular system?

Back 169

- diminished cardiac reserve
- orthostatic hypotension
- increased use of valsalva maneuver
- dependent edema
- increased incidence of thrombus formation

Front 170

True/False:

Respiratory acidosis and carbon dioxide narcosis are not compatible with life.

Back 170

True

Front 171

The resting heart rate increases approximately ____ beats/minute for each day of immobilization.

Back 171

0.5 beats per minute

Front 172

If a person is immobilized for 10 days, you can expect the heart rate to increase how much per minute?

Back 172

5 beats per minute

Front 173

What body position makes the heart work 30% harder?

Back 173

supine

Front 174

A rapid heart rate decreases what 3 things?

Back 174

-diastolic pressure
-coronary blood flow
-the capacity to respond to metabolic demands above the basal levels

Front 175

An immobilized person may experience what 2 things (in regards to the cardiovascular system) with even minimal exertion?

Back 175

tachycardia and angina

Front 176

What is the theory for the cause of increased heart rate due to immobilization?

Back 176

- blood pooling to the torso causes cardiac resistance, which increases the force and rate of contractions

Front 177

Orthostatic hypotension is described as a drop in blood pressure of ____ mm/Hg or more systolic or ____ mm/Hg or more diastolic when changing from a lying/sitting to a standing position.

Back 177

20 or more systolic or 10 or more diastolic

Front 178

What symptoms accompany orthostatic hypotension?

Back 178

dizziness, lightheadedness, diaphoresis, and possible syncope (fainting)

Front 179

Why does orthostatic hypotension often occur in immobolized patients?

Back 179

the sympathetic reflex that automatically causes vasoconstriction of the blood vessels in the lower extremities is absent in the immobilized patient; causes inadequate cerebral perfusion as blood pools to the lower part of the body

Front 180

What adjunct equipment may be used to prevent pooling of the blood in the legs of immobilized clients?

Back 180

antiembolic hose
tilt boards
circoelectric beds

Front 181

What is the purpose of gradually increasing the HOB (head of the bed) in regards to the cardiovascular system and immobility?

Back 181

to regain peripheral vasoconstriction; this stimulates this reflex

Front 182

How long should you have a client who has been ambulating lie down before applying antiembolic stockings?

Back 182

15-30 minutes

Front 183

Describe the proper method for applying anti-embolic stockings.

Back 183

- reach inside stocking from the top, grasp heel, and turn the upper portion of the stocking inside out so that the foot portion is inside the stocking leg
- have client point toes and position the stocking on the client's foot (take caution to ensure that the toe and heel portions are on correctly
- grasp the loose portion of the stocking and gently pull the stocking over the leg, turning it right side out in the process

Front 184

How often should antiembolic stockings be removed? What should be done during this time?

Back 184

every 8 hours for 30 minutes, inspect the skin and perform skin care during this time

Front 185

(def)

portion of the antiembolic hose where the material is looser; should be positioned over the interior thigh

Back 185

gusset

Front 186

What are 3 things that you should do to prevent falling in a patient who's peripheral vasoconstriction reflex has been impaired by immobility?

Back 186

- assist the client when changing positions
- teach the client to move slowly when changing positions
- have the client dangle before standing

Front 187

What should you do if you are assisting a client to stand and you notice that they appear pale suddenly and have begun to sweat?

Back 187

Return that patient to a lying position immediately. Dizziness, pallor, sweating, drops in BP, and complaints of feeling faint all may indicate orthostatic hypotension.

Front 188

In regards to the cardiovascular system, we know that we should encourage and assist clients with exercise. What part of the body and what type of exercise do you think we would focus on?

Back 188

For cardiovascular, we would focus on the lower half of the body to stimulate circulation and venous return. ROM, isometric, and isotonic exercises would all be beneficial.

Front 189

What 3 things can we do as a nurse to prevent a patient from using the valsalva maneuver?

Back 189

- prevent constipation (decreases chances of the patient straining)
- teach client to avoid taking a deep breath and holding it while turning, moving or lifting (suggest they sing or count aloud to prevent the glottis from closing)
- teach client to use the overhead trapeze or their legs when moving, not their arms or trunk

Front 190

What patients are definitely at risk when using the valsalva maneuver?

Back 190

those with cardiac disease or a weakened heart

Front 191

Describe the sequence of events that precedes the development of dependent edema. (4)

Back 191

1. skeletal muscles don't contract sufficiently and the muscle atrophy
2. blood pools in veins, causing vasodilation and engorgement
3. veins no longer work effectively to prevent backward flow of blood and pooling. (incomplete valves)
4. venous pressure is so great that some of the serous portion of blood is forced out of the blood vessel into the interstitial spaces

Front 192

Where is dependent edema more likely to occur?

Back 192

in parts of the body positioned below heart level and maintained in that position

Front 193

True/False:

Edematous tissue is more susceptible to damage, and is uncomfortable.

Back 193

True

Front 194

(def)

clot loosely attached to a vein

Back 194

thrombus

Front 195

(def)

clot loosely attached to an inflamed vein

Back 195

thrombophlebitis

Front 196

(def)

clot that has moved from one part of the body to another part

Back 196

embolus

Front 197

What 3 factors must be present for thrombus to occur? What are these three factors called?

Back 197

1. stasis of venous flow
2. hypercoagulability of blood
3. damage to the endothelium

These 3 factors are called Virchow's Triad.

Front 198

Stasis of venous flow is more common in which patients? (6)

Back 198

- elderly
- those with heart disease
- obese clients
- immobilized clients
- pregnant women
- women in postpartum period

Front 199

Hypercoagulability of blood is most likely to occur in which type of patients?

Back 199

- those with hematological disorders
- dehydrated patients
- malnutritioned patients

Front 200

What are factors that contribute to the damage of the endothelium?

Back 200

- presence of an IV in the same site for more than 48 hours
- fracture that causes damage
- diabetes
- blood pooling
- burns
- external trauma or pressure

Front 201

Damaged endothelium has ___________ (decreased/increased) fibrinolytic properties. Describe what fibrinolytic property is.

Back 201

decreased firbrinolytic properties, which is the ability of the endothelium to break down a clot

Front 202

What are ways to prevent thrombus formation?

Back 202

- encourage movement (active & passive ROM, isotonic, and isometric)
- encourage client to move ASAP
- position client properly
- avoid crossing of legs and do not place pillows behind the knee
- elevate foot of bed 10-15 degrees to promote venous return
- increase fluid intake
- wear anti-embolic hose, use sequential compression device (need drs orders for these)
- do not massage or rub legs vigorously
- anti-coagulant therapy (heparin, coumadin, lovenox)

Front 203

What are 3 leg exercises that may prevent DVTs?

Back 203

- alternate dorsiflexion and plantar flexion of the feet (calf pumping)
- flex and extend the knees into the bed while dorsiflexing the foot
- bend one knee and place foot on bed to serve as the stable leg, extend knee of the other leg and lift

(see page 947 for pics)

Front 204

A palpabe, firm, subcutaneous cordlike vein is called what?

Back 204

superficial clot

Front 205

The area surround a superficial clot may be effected how?

Back 205

- tender, red and warm
- edema may form in the extremity

Front 206

What type of systemic effect might you see when a person has a superficial clot?

Back 206

increased WBC, mild increase in temperature

Front 207

What are 5 possible indications of a deep vein thrombosis?

Back 207

1. unilateral leg edema
2. pain in the leg
3. warm skin surrounding the area of the clot
4. increased temperature
5. positive Homan's sign

Front 208

What are 4 treatment measures for a superficial clot?

Back 208

1. bedrest with elevation of affected extremity
2. warm, moist heat used to relieve pain and inflammation
3. mild oral analgesic for pain
4. NSAIDS for inflammatory process (motrin, asprin)

Front 209

What are 2 treatment measures for deep vein thrombosis?

Back 209

1. anticoagulant therapy
2. surgical intervention

Front 210

What are some defining characteristics of Pulmonary Embolus (PE)?

Back 210

- sudden onset of unexplained dyspnea, tachypnea, or tachycardia
- cough
- chest pain
- hemoptysis
- crackles, fever

Front 211

True/False:

Deep vein thrombosis will always present some, if not all, possible symptoms.

Back 211

False - a person could have a DVT and be completely asymptomatic

Front 212

Would a sudden change in the mental status of a client be a result of an early stage of PE or a late stage?

Back 212

late stage of PE

Front 213

A massive emboli or progressive disease may result in what symptoms?

Back 213

- cyanosis
- shock
- pallor
- severe dyspnea
- crushing chest pain
- cardiac arrest

Front 214

What percent of client's afflicted with DVT will have a positive Homan's sign?

Back 214

only 20%

Front 215

Treatment of PE varies according to the severity of the problem. What are some examples of supportive therapy and treatment? (4)

Back 215

- oxygen
- anticoagulant therapy
- surgical intervention
- thrombolytic agents

Front 216

(Def)

joint is moved to a right angle

(source: ROM video)

Back 216

flexion

Front 217

(def)

joint is straightened

(source: ROM video)

Back 217

extension

Front 218

(def)

joint is bent backwards

(source: ROM video)

Back 218

hyperextension

Front 219

(def)

moving a joint so that the appendage is moved away from it's normal resting place

(source: ROM video)

Back 219

abduction

Front 220

(def)

the return of an abducted appendage to it's normal resting position

(source: ROM video)

Back 220

adduction

Front 221

(def)

the circular movement of a joint

(source: ROM video)

Back 221

circumduction

Front 222

(def)

the turning of a joint on an axis

(source: ROM video)

Back 222

rotation

Front 223

Contractures usually occur in what position?

(source: ROM video)

Back 223

flexed

Front 224

Passive ROM is usually performed in what position?

(source: ROM video)

Back 224

Supine with the palms up

Front 225

What are 2 purposes of ROM exercises

(source: ROM video)

Back 225

1. maintain joint mobility
2. prevent complications such as decreased peripheral circulation, skin breakdown, and contractures

Front 226

True/False:

Contractures are usually reversible.

(source: ROM video)

Back 226

False - most are irreversible

Front 227

What causes contractures?

(source: ROM video)

Back 227

Limitations of joint motion results in a permanent shortening of muscles and tendons

Front 228

What are 5 causes of contractures?

(source: ROM video)

Back 228

1. lack of exercise
2. muscle spasticity
3. prolonged joint immobilization
4. edema
5. pain or swelling

Front 229

Connective tissues can show changes in as little as ____ days.

(source: ROM video)

Back 229

4

Front 230

What are 5 benefits of ROM exercises?

(source: ROM video)

Back 230

1. prevents contractures
2. maintains joint mobility and function of tendons and muscle fibers
3. enhances circulation
4. stimulates sensory nerve endings
5. restores loss of joint function

Front 231

When implementing ROM exercises, what 3 specific client factors must you consider.

(source: ROM video)

Back 231

1. age
2. sex (men less flexible than women)
3. muscle mass and fat

Front 232

(def)

type of ROM performed solely by the client; prevents muscle atrophy, encourages independence

(source: ROM video)

Back 232

active ROM

Front 233

(def)

a type of ROM where the client uses a stronger hand or leg to move a weaker limb

(source: ROM video)

Back 233

self-assisted ROM

Front 234

(def)

a type of ROM done by another person

(source: ROM video)

Back 234

passive ROM

Front 235

True/False:

All major joints should be exercised when doing ROM.

(source: ROM video)

Back 235

True

Front 236

When can ROM exercises cause injury?

(source: ROM video)

Back 236

When a joint is forced beyond it's natural ROM or when it is forced to elongate during a muscle spasm

Front 237

Should you ever stop ROM exercises early?

(source: ROM video)

Back 237

Yes, if resistance, fatigue, or pain is experienced

Front 238

In addition to preventing complications from immobility, what is another benefit of ROM exercises?

(source: ROM video)

Back 238

psychologically beneficial

Front 239

What information can you supply the family members regarding ROM?

(source: ROM video)

Back 239

- information on joint injury
- proper joint positioning
- importance of client participation