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115 Cards in this Set
- Front
- Back
Coordinated movement involves integrated functioning of what systems?
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-Skeletal system
-skeletal muscle -nervous system |
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Postural abnormalities can cause?
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-pain
-impair alignment or mobility |
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Impaired muscle development is caused by?
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-injury
-diseases |
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Name a disorder that causes degeneration of skeletal muscle fibers?
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Muscular distrophies
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What are the characteristics of muscular dystrophies?
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-progressive
-symmetrical weakness -wasting of skeletal muscles -increasing disability & deformity |
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What injury can damage the motor strip in the cerebral cortex?
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-trauma from head injury
-CVA(ischemia from a stroke or brain attack) -bacterial infection (meningitis) |
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A person with a right-sided cerebral hemorrhage with complete necrosis,what body part will be affected?
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-destruction of right motor strip
-left-sided hemiplegia |
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What results from direct trauma to the musculoskeletal system?
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-bruises
-contusions -sprains -fractures |
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Disruption of bone tissue continuity?
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Fracture
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what can cause fractures?
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-direct external trauma
-deformities of the bone (osteoporosis, pagets disease |
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What is the treatment for fractures?
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-proper alignment
-immobilization (promotes healing and restores function? |
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loss of tone and joint stiffness?
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muscle atrophy
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the inability to move about freely?
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immobility
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terms frequently used when discussing clients on the mobility immobility continuum are?
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-bed rest
-impaired physical mobility |
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an intervention that restricts clients to bed for therapeutic reasons?
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Bed rest
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a state in which the individual experiences or is at risk of experiencing limitation of physical movement?
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Impaired physical mobility
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Name some prescribed restrictions of movement that can alter the level of physical mobility?
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-Bed rest
-Physical restriction(cast) -voluntary restriction -impairment fo motor or skeletal function |
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the pathological reduction in normal size of muscle fibers after prolonged inactivity from bed rest, trauma, casting, or local nerve damage?
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disuse atrophy
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immobility disrupts normal metabolic function, name 3 changes?
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-altered endocrine metabolism
-calcium resorption (loss of bones) -disrupt GI system |
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What is the function of the endocrine system?
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maintains and regulate vital functions
-response to stress and injury -growth and development -reproduction -ionic homeostasis -energy metabolism |
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How does the endocrine system maintain homeostasis in the body?
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through maintaince of Na,K,water and acid-base balance
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How does the endocrine system regulate energy metabolism?
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-BMR in increased by thyroid Hormone
-energy made available to cells through GI and Pancreatic Hormones |
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What results from the disruption of normal metabolic function due to immobility?
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-decrease metabolic rate
-alters metabolism of carbs,fats, proteins -F/E and calcium imbalances -GI disturbance(low appetite) |
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If an immobilized client experiencing an infectious process such as fever, or is in the process of wound healing what will happen to his BMR and Why?
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-Increases, due to increase in cellular oxygen requirement.
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Clients with decrease appetite secondary to immobility have what defiency
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-calories
-protein |
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When more nitrogen is excreted than is ingested in protein the body is said to have?
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Negative nitrogen balance
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What causes tissue breakdown (catabolism)?
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-weight loss
-decreased muscle mass -weakness -protein loss |
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What is a common symptom seen due to impairment of GI function?
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constipation
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Most common respiratory complication seen in post-operative and immobile clients are?
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-Atelectasis(collapse of alveoli)
-hypostatic pneumonia (inflammation of lung from stasis or pooling of secretions) |
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Immobilization causes what 3 major cardiovascular changes?
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-orthostatic hypotension
-increase cardiac workload -thrombus formation |
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Name 3 factors that contribute to venous thrombus formation?
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-loss of integrity of the vessel wall(injury)
-abnormalities of blood flow -change in clotting factors |
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Name an effect of the muscles due to immobilization?
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-Protein breakdown
-muscle weakness |
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What puts a client at risk for falls related to muscle effects?
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-loss of endurance
-decreased muscle mass and strenght -joint instability |
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Name 2 skeletal effects immobilization cause?
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-impaired calcium resorption(bone resorption,
tissue less dense, atrophied(osteoporosis) |
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What is the client with disuse osteoporosis at risk for ?
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Pathological Fractures
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An abnormal and possibly permanent condition characterized by fixation of the joint?
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joint contracture
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What causes joint contractures?
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disuse atrophy
shortening of muscle fibers |
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Name a common contracture where the foot is permanently fixed in the plantar flexion, ambulation is difficult due to inability to dorsiflex the foot?
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Foot Drop
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What clients are susceptible to footdrop?
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-Hx CVA or brain attacks
-left or right sided hemiplegia |
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The clients urinary elimination is altered by immobility, when a patient is in a recumbent or flat position, insufficient peristalltic contractions cannot overcome gravity therefor the renal pelvis may fill before urine enters the ureters this condition is known as?
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Urinary stasis
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Calcium stones that lodge in the renal pelvis and pass through the ureters cause hypercalcemia?
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Renal calculi
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As immobility continues how is urinary elimination effected?
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-fluid intake diminish
-fever,causes dehydration -high concentration of urine cause calculi formation and infectin -high risk of e.coli in women |
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Major risk of the integumentary system seen with immobility?
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pressure ulcers
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Tissue metabolism depends on the body's receipt of ?
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-oxygen,nutrients, blood and elimination of wastes
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Common emotional changes seen with immobility
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-depression
-behavioral changes -sleep-wake disturbances -impaired coping |
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Prolong immobility can delay gross motor skills, intellectual and musculoskeletal development this is mostly seen in what age group?
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infants, toddler preschoolers
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Alter growth spurt, decrease independence and increase isolation in what age group?
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Adolescent
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Immobility affects self-confidence and affects adult role regarding family or social structure?
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Adults
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Immobility increases physical dependence and accelerate functional losses, cna be gradual or sudden?
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Older Adults
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Assessment of client mobility focuse on 5 factors?
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-ROM
-Gait -Exercise- -Activity intolerance -Body alignment |
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The maximum amount of movement available at a joint?
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ROM
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Aline that passes through the body from front to back?
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Sagittal plane
(divides the body into left and right side) |
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Passes through the body from side to side and divides the body in front and back?
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Frontal plane
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a horizontal line that divides the body into upper and lower portions?
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transverse plane
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Name the joint movements in the sagittal plane?
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-flexion and extension(fingers and elbows)
-dorsiflexion and plantar flexion (feet) -extension ( hip) |
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Name the joint movements in the frontal plane?
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-abduction and adduction(arms and legs)
-eversion, inversion (feet) |
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Name the joint movements in the transverse plane?
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-pronation and supination (hands)
-internal and external rotation(hips) |
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When assessing ROM, physical examination consist of ?
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-stiffness
-swelling -pain -limited/unequal movement |
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The client is able to move all joints through their ROM unassisted?
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Active ROM
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The client is unable to move independently and nurse moves each joint through its ROM?
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Passive ROM
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A particular manner or style of walking?
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gait
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Assessment of gait allow the nurse to draw conclusions about?
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-balance
-posture -safety -ability to walk w/o assist |
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How does the gait cycle begin?
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-with the heel strike of one lef and continues to the heel strike of the other leg
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Physical activity for conditioning the body, improving healt and maintaining fitness?
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exercise
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The type and amount of exercise or work that a person is able to perform?
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activiy tolerance
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Assement for activity tolerance is necessary when planning what kind of activities/
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-walking
-ROM exercises -ADL's |
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The nurse should monitor pt during activity for what symptoms?
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-dyspnea
-fatigue -chest pain -change of vital signs |
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The assessment of body alignment has what objective?
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-determines normal physiological changes
-Id deviation in body cause by posture -Learning for clients to maintain alignment -id trauma,muscle damage,or nerve dysfuntio |
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What position do you assess body alignment?
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-standin
-sitting -lying |
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What mesurement is used when assessing metabolic system?
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-Ht, Wt, skinfold thickness
-I & O -Dehydration,edema -lab data -lytes,serim protein(albumin),total protein levels, BUN, wound healing |
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Metabolic system: Interventions for the immobilized client involves:
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-High protein,high-calorie diet
-May require Parenteral or enteral feedings |
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TPN, a central line or IV site is Known as what type of feeding?
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-Parenteral
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NGT, GT, jejunostomy tube with high protein feeding is known as what type of feeding?
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-Enteral
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Respiratory system: Name hazards of immobility?
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-Assess full insp and exp cycle.
-chest movement may be aymmetrical -Assess for crackles or wheezez |
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Interventions for a immobile pt at risk for respiratory disfunction?
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-change position every 2hrs
-deep breath and cough q 2hrs -min.2000ml of fluid/day -CPT if needed -Suction PRN |
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Cardiovascular system: What are some hazards due to immobility?
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-edema, poor wound healing
-DVT, Thrombus....Homan signs -Embolus -Recumbant position,increases cardiac workload, increases HR |
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Cardiovascular system: Name NSG Interventions?
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-Prevent orthostatic BP:pedangle
-Increase mobility to decrease cardiac workload -avoid valsalva maneuvar(encourage pt to breath out while moving or positioning -Prevent DVT(IPC/SCDs,Meds,TED,ROM) |
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Name interventions to reduce orthostatic hypotension?
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-dangling at bedside(to increase venous return)
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Name interventions to reduce cardiac workload?
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-avoid valsalva maneuvar
-teach client breathing exercises when moving or repositioning |
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Define valsalva maneuvar?
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-used during straining of defecation or moving up in bed
-decreases venous return,C.O -when strain is release, increase in BP due to increase in venous return -produces reflex bradycardia, low BP |
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Name interventions to prevent thrombus formation?
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-leg exercises
-encourage fluids -position changes -teaching begins when client becomes immobile |
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Name NSG intervention to prevent thrombus formation that require a physicians order?
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-Meds(heparin,LMWH(lovenox)
-Intermittent pneumatic compression(IPC) -Sequential compression devices(SCDs) |
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What is common dosage for heparin therapy?
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-5000 units subq 2hrs before surgery
-repeated every 8 to 12 hrs until client is fully mobile or discharged. |
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Clients on Heparin assess for ?
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-bleeding
-increase bruising -guaiac-positive stools -bleeding gums |
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Common dosage or lovenox(lMWH)in the prophylaxics of DVT?
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-30 to 40 mg subq 2hrs before surgery
-and continue throughout post-op period |
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What are SCD/IPCs? What's a typycal cycle?
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-sleeves or stockings
-wrap around legs, secure with velcro -sleeves connected to pump -inflation 10-15 sec(40mmhg) -deflation 45-60 sec |
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What's the purpose of the use of SCDs/IPCs?
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-decreases venous stasis
-increases venous return through deep veins of legs |
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Define TED Hose?
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-Thromboembolic device hose
-elastic stockings |
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Name position techniques to aid in reducing compression of the leg veins?
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-prevent pressure on posterior knee and deep veins in lower extremities
- |
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What do you teach a client regarding position techniques to aid in reducing compression of the leg veins?
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-avoid crossing legs
-avoid sitting for prolong period of time -avoid wearing clothing that constricts the legs and waist -avoid putting pillows under the knees -avoid massaging the legs |
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Name specific exercises that help prevent thrombophlebitis?
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--anle pumps(alternate plantar flexion and dorsiflexion)
-foot circles(rotate ankle,make letters with feet every 2hrs) -knee flexion(extend and flex knee |
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Name hazards of immobility seen in the musculoskeletal system?
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-decrease muscle tone and strength
-loss of muscle mass -contractures -muscle atrophy due to lack of weight bearing -osteoporosis |
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Whose at greater risk for bone demineralization?
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-Clients on prolonged bedrest
-postmenopausal women -clients taking steroids -clients with increase serum and urine calcium levels |
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NSG interventions for the immobilized client to improve musculoskeletal system?
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-ROM, during hygiene care
-passive ROM or CPM -commonly used in POst knee surgery -may need pt consult |
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Hazard of immobility in the integumentary system?
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-assess skin for pallor or redness
-assess every 2hrs -assess during hygiene care |
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hazard or immobility seen in the elimination system?
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-dehydration(increases risk for skin breakdown, thrombus formation,respiratory infections, constipation)
-inadequate I&O |
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NSG interventions for maintaining optimal elimation sytem function?
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-hydrate(2000-3000ml fl/day
-prevent urinary stasis -assess I & O -assess bowels |
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Diet adequate to facilitate peristalsis movement?
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-veggies -stool softener
-fluids -cathartics -fruits -enemas -fiber |
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Abrupt changes in personality may be due to what physiological causes?
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-surgery
-medication reaction -pulmonary embolus -acute infection |
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Primary symptom seen in older adults when experiencing pulmonary emboli or an acute infection?
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-confusion
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Common reactions to immobilization include?
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-boredom
-feelings of isolation -depression -anger |
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Name some possible NSG DX related to psychological assessment?
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-social isolation
-disturbed sleep pattern -ineffective individual coping |
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What's procedure to transfer from bed to chair?
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-Chair is placed next to bed with chair back in the same direction as the head of bed
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What's procedure to transfer from bed to strecher?
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-place beds side to side
-client fold arms over chest -three-person carry -lift sheet or transfer pad -back board if spinal injury |
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What does the nurse assess when a client is getting ready to walk?
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-activity tolerance
-strength -coordination -balance -orientation |
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Methods used when assisting a client to ambulate?
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-place both hands on waist
-use of a gait belt |
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Name assistive devices for walking
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-walkers
-canes -crutches |
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Causes mucle contraction and change in muscle length
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isotonic contraction
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Walking,swimming,dance aerobics,jogging,bicycling,moving arms and legs with light resistance these exercises are called?
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-Isotonic exercises
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what are the benefits of doing isotonic exercises?
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-increases,
circulation and respiratory function osteoblastic activity(bone forming cells) muscle tone, mass and strength |
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tightening or tensing of muscles without moving body parts
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isometric contraction
|
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quadriceps sets and contraction of gluteal muscles, for pts who are unable to tolerate an increase in activity expected during isotonic exercises.
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Isometric exercises
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What are the benefits of isometric exercises?
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-increase muscle mass,tone,strengh
-decreases potential for muscle wasting -increases circulation to involved body part -increases osteoblastic activity |
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Name pathological influences on body mechanics?
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-congenital defects
-disorders of bones,joints, muscles -CNS damage -musculoskeletal trauma |
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Congenital defects affect what on the body?
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-body alignment
-balance -appearance |