Term
| Effects of Impaired Physical Mobility |
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Definition
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Term
| Structure of the musculoskeletal system |
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Definition
*Bones-206 bones in body,osteoblastic; osteoclastic(cells detroys bone).
*Joints-freey moveable-synovial joint
*Skeletal muscles-voluntary control
*Soft tissues-tendons & legiments, atrophy(loss muscle mass). |
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Term
| Function of the musculoskeletal system |
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Definition
*Regulation of movement
*Proprioception-awareness of body position.
*Body Mechanics
*Body Alignment |
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Term
| Factors Affecting Mobility |
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Definition
*Lifestyle Factors
*Environmental Factors
*Developmental Factors
*Physiological Factors |
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Term
| Developing factors that can alter Mobility in: Older Adults |
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Definition
*muscle weakness
*Atrophy
*Osteoarthritis |
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Term
| Physiological Factors Affecting Mobility |
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Definition
Musculoskeletal Problems:
*Inflammatory-rheumatoid arthritis.
*Degenerative-osteoarthritis.
*Traumatic-fractures and dislocations.
*Congenital-occur at birth.
Neurological Problems:
*Quadriplegia-all four limbs.
*Quadriparesis-numbness.
*Paraplegia-lower or upper limbs paralyzed.
*Paraparesis
*Hemiplegia
*Hemiparesis |
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Term
| General Assessment of Physical Mobility |
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Definition
Health History:
*Chief Complaints-pain(acute, chronic), muscle weakness (age, personal history, environment, lifestyle), inflammation.
*Risk for musculoskeletal health problems |
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Term
| Use the R.I.C.E. System- for intial muscoloskeletal injuries |
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Definition
*Rest-immobilize the injury for 2-3days.
*Ice- reduces bleeding & infammation, promotes pain relief & reduces swelling, apply immediately 1st.
*Compression-helps decrease bleeding & swelling.
*Elevation(heat)-also reduces bleeding & swelling; heat may be applied after 72 hours to promote futher healing. |
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Term
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Definition
*Flexion-decreasing the angle of the joint(bending the elbow)
*Extendion-increasing the angle of the joint(straightening the arm at the elbow).
*Hyperextension-further extension or straightening of a joint(bending the head backward)
*Rotation-movement of the bone around the central axis.
*Abduction-movement of the bone away from the midline of the body.
*Adduction-movement of the bone toward the midline of the body.
Circumduction-movement of the distal part of the bone in a circle while the proximal end remians fixed.
*Supination-moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body.
*Eversion-turning the sole of the foot outward by moving the ankle joint.
*Inversion-turning the sole of the foot inward by moving the ankle joint. |
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Term
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Definition
*Radiographic (x-rays)-bone density
*Computed Tomography (CT)-soft tissues
*Magnetic Resonance Imaging (MRI)-brain
*Arthrogram-pic of joints
*Myelogram-pic of spinal columne rupture
*Arthrocentesis-pullinf fluid off joint |
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Term
| Nursing diagnosis related to immobility |
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Definition
*Activity Intolerance
*Impaired physical mobility |
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Term
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Definition
| A state in which an individual is at risk for deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity. |
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Term
| Psychosocial Effects of Inactivity and Immobility |
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Definition
*Loss of motivation or interest in participating in daily living.
*Lost contact with friends & work can result in loneliness & social isolation.
*Feelings of powerlessness.
*Loss of self-esteem.
Behavior changes.
*Acting out.
*Sleep pattern distrubances. |
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Term
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Definition
is the type & amount of exercise or daily living activities an individual is able to perform without experiencing adverse effects.
(Oygen issues, SOB, breathing issueswith activity). |
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Term
| Musculoskeletal Effects of Inactivity & Immbolity |
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Definition
*Atrophy
*Ankylosis
*Contracture
*Footdrop
Wristdrop
*Osteoporosis |
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Term
| Damage to the skin from Prlonoged Pressure on bony prominences- |
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Definition
| is the major complication of immobolity |
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Term
| Integumentary Effects of Inactivity & Immobilty |
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Definition
*Pressure ulcer-damage to underlying tissues.
*Interface pressure-tissues compressed between bones and a support surface.
*Shear-damage from sliding down.
*Friction Injury-skin rubbed off.
*Excoriation-abrasions, wound drainage, feces, urine, chemicals.
*Maceration-contract with moisture(white 7 cheesy look). |
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Term
| Additional Factors that Increases the Risk of developing a Pressure Ulcer |
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Definition
*Inability to move independently in bed; cognitive limitations, musculoskeletal limitations.
*Chronic illness, such as: renal failure(lots of skin in breakdown), diabetes(poor nutrtion),anemia(low blood count & oxygen, doesn't feel well), frail or edematous skin, dehydration & hypoproteinemia. |
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Term
| Other system affected by inactivity & immobilty |
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Definition
*Cardiovascular:
orthostatic hyotension, deep vein thrombosis, pulmonary embolism.
*Respiratory: Hypostatic, pneumonia.
*Gastrointestinal: Hypomobility.
*Genitourinary: renal calculi, urinary tract infection. |
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Term
| Two Purpose in Assessing the Immobile Client |
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Definition
1.To detect the risk of complication fo immobilty.
2. To determine how much assistance the client will need to manage the activities of daily & prevent complications. |
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Term
| Assessment for Imobility includes: |
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Definition
*Health history
*Physical history
*Assess risk for disuse syndrome
*Related Factors: age, body weight, chronic illness, discomfort, environment. |
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Term
| Nursing Diagnosis for Imobility |
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Definition
*Risk for disuse syndrome
*Impaired Physical Mobility
*Activity Intolerance |
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Term
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Definition
*The client will participate in decision-making about his care.
*Have intact skin.
*Have ROM of joints.
*Maintain optimum respiratory 7 bowel fuction. |
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Term
| Interventions for Imobility |
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Definition
*Keep the client as active & mobile as possible.
*Position the client in bed maximum function of joints, circulation & respiration & to prevent skin breakdown. |
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Term
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Definition
*A slowly progessive noninflammatory disorder of the diarthrodial (synovial) joints.
*The most common form of joint disease.
*After age 50, twice as many women as men are affected.
*Maybe due to estrogen reduction after menopause. |
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Term
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Definition
*Trauma
*Mechanical stress
*Inflammation
*Joint instability
*Neurologic disorders
*Skeletal deformities
*Hematologic/endoctrine disorders
*Use of selected drugs. |
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Term
| Symptoms of Osteoarthritis |
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Definition
*Joint pain, not associated with fatigue or fever.
*Generally worsens with joint use.
*Pain increases as OA progresses. |
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Term
| Skeletal Muscle Relaxants |
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Definition
| are used to decrease muscle spasm or spasticity that occura in certain neurologic & musculoskeletal disorders. |
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Term
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Definition
*centrally acting muscle relaxant
* used to treat muscle spasm
*Side effects include dizziness & drowsiness
*Contraindicated in renal or lover disease.
*Instruct client to avoid operating machinery. |
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Term
| Skeletal muscle Relaxants Mechanism of Action |
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Definition
*Contraly acting
*General depression of the CNS |
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Term
| Skeletal Muscle Relaxants Side Effects |
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Definition
*drowsiness
*dizziness
*lightheadedness
*headaches
*occasional nausea
*vomiting
*diarrhea & abdominal distress |
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Term
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Definition
*Assess for muscle spasm & spasticity
*Assess for pain, Determine location, intensity, duration, & precipitating factors
*Assess for impaired functional ability in self-care or impaired ability to participate therapy. |
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Term
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Definition
Flesion-bring each lower arm forward & upward so that the hand is at the shoulder. 150-degree (ex. eating, bathing, shaving).
Extension-bring wach lower arm foward and downward, straightening arm. 150-degree (ex. eating, bathing, shaving).
Rotation for supination- turn each hand and forearm so that the palm is facing upward. 70-90-degrees.
Rotation for pronation-turn each hand and forearm so that the palm is facing downward. 70-90-degrees. |
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Term
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Definition
Flexion-move the head from upright midline position toward, so that the chin rest on the chest. 45-degree from midline(ex.nodding head "yes").
Hyperextension-move the head from the upright position back as far as possible. 45-degree frommidline.
Lateral flexion-move the head laterally to the right & left shoulders. 40-degree from midline.
Rotation-turn the face as far as possible to the right & left. 70-degree from midline(ex. shacking head "no").
Extension-moves head from the flexed position to the upright position. 45-degree from midline (ex.nodding head "yes"). |
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Term
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Definition
Flexion-move the head from upright midline position toward, so that the chin rest on the chest. 45-degree from midline(ex.nodding head "yes").
Hyperextension-move the head from the upright position back as far as possible. 45-degree frommidline.
Lateral flexion-move the head laterally to the right & left shoulders. 40-degree from midline.
Rotation-turn the face as far as possible to the right & left. 70-degree from midline(ex. shacking head "no").
Extension-moves head from the flexed position to the upright position. 45-degree from midline (ex.nodding head "yes"). |
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Term
| Shoulder-Ball & Socket Joint |
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Definition
Flexion-raise each arm from a position by the side forward & upward to a position beside the head. 180-degree from the side.(ex.reaching to turn on overhead light).
Extention-move each arm froma vertical position beside the head forward & down to a resting position at the side of the body. 180-degree from vertical position beside the head.
Hyperextension-move each arm from a resting side position to behind the body. 50-degree from side position.
Abduction-move each arm laterally from the resting position of the sides to a side position above the head, palm of the hand either toward or away from the head. 180-degree(ex.reaching to bedside stand on same side of bed as arm).
Adduction(anterior)-move each arm from a position at the sides accross the front of the body as far as possible. The elbow may be straight or bent. 50-degree (ex. reaching across body toward opposite side of bed).
Circumduction-move each arm forward, up, back, & down in a full circle. 360-degree
External rotation-with each arm held out to the side at shoulder level & the elbow bent to a right angle, fingers pointing down, move arm upward so that the fingers point up. 90-degree(ex.reaching over opposite shoulder to scratch upper back)
Internal rotation-with each arm held out to the side at shoulder level & the elbow bent to a right angle, fingers pointing up, move arm forward and down so that the fingers point down. 90-degree(ex.reaching to scratch same side lower back) |
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Term
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Definition
Fexion-move each leg forward & upward, the knee may be extended or flexed. Knee extended 90-degree; knee flexed 120-degree(ex. walking, leg lifts in front of the body).
Extension-move ech leg back beside the other. 90-120-degree(ex.walking, lining the leg up with the body)
Hyperextension-move each leg behind the body. 30-50-degrees (ex. walking, lying on side, reach the leg behind the body.
Abduction-move each leg out to the side. 45-50-degrees(ex.moving leg away from body).
Adduction-moving each leg back to the other leg and beyond in front of it. 20-30-degrees(ex.moving leg over the other leg toward the middle of the body).
Circumduction-move each leg backward, up, to the side, & down in a circle. 360-degree (ex. leg circles clockwise & counterclockwise).
Internal rotation-flex knee & hip to 90-degree. Place the foot away from the midline. Move the thigh & knee toward the midline. 40-degree.
External rotation-flex knee & hip to 90-degree. Place the foot toward the midline. Move the thigh & knee away from the midline. 45-degree. |
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Term
Isometric exercise
(static or setting) |
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Definition
| exercise for the knees & legs, muscle contration without moving the joint (muscle length does not change),exerting pressure against a solid objects & are useful for strengthening abdominal, gluteal, & quadriceps muscles used in ambulation; for maintaining strength in immobilized muscles in casts or traction; & for endurance training. (bed exercises-squeeze a towel between legs at same time tighten muscles in thighs by pressing knees backwards & holding for a several seconds). |
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Term
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Definition
| is another goal of exercise & as the ability of the body to perform work |
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Term
Isotonic exercises
(dynamic) |
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Definition
the muscle shortens to produce muscle contraction & active movement.(ex. of bed isotonic exercises-pushing, pulling against a stationary object, using a trapeze to lift the body off the bed, lifting buttocks off the bed by pushing with hands agaisnt mattress, & pushing the body to a sitting position.
-increases muscle tone, mass, & strength, & maintain joint flexibility & circulations. During isotonic exercise- both heart rate & cardiac output quicken to increase blood flow to all parts of the body. |
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Term
Isokinetic exercise
(resistive) |
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Definition
| involves muscle contraction or tension against resistance. During isokinetic exercises- the person tenses (isometric) against resistance. An increase in blood pressure, & blood flow to muscles occurs with resistance training. |
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Term
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Definition
| is activity during which the amount of oxygen taken into the body is greater than that used to perform the activity. Uses large muscle groups that move repetitively, & improve cardiovascular conditioning & physical fitness. |
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Term
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Definition
| is activity during which the amount of oxygen taken into the body is greater than that used to perform the activity. Uses large muscle groups that move repetitively, & improve cardiovascular conditioning & physical fitness. |
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Term
Skeletal Muscle Relaxants
Goals: |
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Definition
The client will:
*Experience relief of pain & spasm
*Experience improved motor function
*Increase self-care abilities in activities of daily living
*Take medications as intructed
*Use nondrug measures appropriately
*Be safeguarded when sedated from drug therapy |
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Term
| Nursing Diagnosis for muscle spasms |
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Definition
*Pain
*Impaired Physical Mobility
*Self care deficit
*Knowledge deficit |
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Term
| Muscle Spasms Interventions: |
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Definition
Use adjunctive measures for muscle spasms & elasticity:
*Physical therapy (massage, moist heat, exercises)
*Relaxation techniques
*Correct posture & lifting techniques
*Regular exercise |
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Term
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Definition
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Term
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Definition
*A response to tissue injury & infection
*Fluid, elements of blood, leuocytes (WBCs), chemical mediators accumulate at the site.
*A protective mechanism, the body attempts to detroy harmful agents & promote healing at the site. |
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Term
5 cardinal signs of
Inflammation: |
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Definition
*redness
*swelling(edema0
*heat
*pain
*loss of function |
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Term
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Definition
*chemicl mediators rleased during the inflammatory process
*causes vasodilation
*relax smooth muscle
*increase capillary permeability
*sensitive nerve cells to pain |
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Term
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Definition
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Term
| Nonsteroidal anti-inflammatory drugs (NSAIDS) |
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Definition
*Analgesic
*Antipyretic
*Anti-inflammatory
*Inhibits the COX enzyme
*Acetylsalicyclic Acid (ASA, Aspirin)
*often used for musculoskeletal disorders such as arthritis |
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Term
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Definition
*Anti-inflammatory agent
*Inhibits Prostaglandin
*Relieves Pain (Analgesic)
*Reduces Temperature (Antipyretic)
*Inhibits Platelet Aggregation (Anticoaugulant) |
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Term
Acetylsalicylinc Acid
(ASPIRIN) |
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Definition
Also used to inhibit platelet formation which slows blood coaulation:
-Prescribed for clients at risk for myocardial infarction (MI) or stroke. |
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Term
| Aspirin Contraindications: |
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Definition
*Peptic ulcer disease
*Gastrointestinal (GI) bleeding disorders
*Other bleeding disorders
*Hypersensitivity reaction
*Impaired renal function
*in children with viral infections b/c of Reye's syndrome |
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Term
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Definition
*Motrin
*Nuprin
*Advil
*Medipren
*Aleve |
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Term
Acetaminophen (TYLENOL)
not a NSAID |
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Definition
*Tylenol is not a NSAID b/c is does not have anti-inflammatory effects
*Used extensively as an analgesic & an anti-pyretic |
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Term
| NSAIDS in Older Adults Treat the pain: |
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Definition
*Osteoarthritis
*Rheumatoid Arthritis
*Neuromuscular-skeletal disorders
*Possible complications include:
-GI distress (ulceration)
-Bleeding tendency |
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Term
1. The nurse delegates repositioning the older adult client at risk for pressure ulcers to the unlicensed
assistive personnel (UAP). The nurse provides instructions that include: |
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Definition
| b. “Inform me if you see any changes in the client’s skin.” |
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Term
The nurse plans to position the client’s arm with slight abduction. Using the table shown, how should
the nurse position the arm? |
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Definition
| Away from the midline of the body |
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Term
| The nurse positions the immobilized client to maintain the ability for normal movement and stability by: |
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Definition
| c. Performing range of motion with every position change to keep joints flexible. |
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Term
| The nurse positions the immobilized client to maintain the ability for normal movement and stability by: |
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Definition
| c. Performing range of motion with every position change to keep joints flexible. |
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Term
A nurse who is assisting a postoperative client to ambulate, promotes normal movement to include:
(Select all that apply.) |
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Definition
*Posture
*Balance
*Flexibility |
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Term
| The nurse is assessing the client’s gait and determines that gait is normal when: |
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Definition
| c. The client strikes the ground with the heel during the stance phase. |
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Term
While repositioning a client in bed, the nurse sustains an injury. What actions does the nurse take?
(Select all that apply.) |
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Definition
Seeks medical care
Completes an incident report
Notifies the supervisor |
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Term
The nurse teaches the spouse how to perform passive range of motion on the client and determines
that further teaching is needed when the spouse: |
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Definition
| uses rapid, jerky movements |
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Term
The nurse teaches the spouse how to perform passive range of motion on the client and determines
that further teaching is needed when the spouse: |
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Definition
| uses rapid, jerky movements |
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Term
When developing an exercise plan for a healthy client who wants to improve fitness, the nurse
recommends the client choose between: |
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Definition
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Term
During discharge planning, the nurse is evaluating the client’s understanding of wheelchair safety.
Using the box shown, the nurse determines that further teaching is needed when the caregiver says: |
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Definition
| *lower the footplates before transferring the client into the wheelchair |
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Term
While reviewing the client’s medical record in preparation for providing care, the nurse reads that the
client’s primary nursing diagnosis is Activity Intolerance. The nurse anticipates finding that this client: |
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Definition
| Tires quickly with minimal activity. |
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Term
While reviewing the client’s medical record in preparation for providing care, the nurse reads that the
client’s primary nursing diagnosis is Activity Intolerance. The nurse anticipates finding that this client: |
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Definition
| Tires quickly with minimal activity. |
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Term
The nurse is conducting preoperative teaching with a client who will be in bed for an extended period
after surgery. The nurse recommends that the client increase fluid and fiber intake while on bed rest in
order to: |
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Definition
| Limit the risk of constipation |
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Term
The nurse assesses the client who requires maximum support and determines that the client is using
the walker appropriately when: |
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Definition
| *The client moves the walker forward while the body holds weight on the legs. |
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Term
The nurse assesses the client who requires maximum support and determines that the client is using
the walker appropriately when: |
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Definition
| *The client moves the walker forward while the body holds weight on the legs. |
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Term
A client is concerned about her children developing healthy activity and exercise habits. The nurse tells
the client that her children’s patterns will be most influenced by: |
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Definition
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Term
The nurse is developing an exercise plan for a client. If the client is to maintain the plan, the nurse
takes into consideration: |
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Definition
b. Attitudes about fitness.
c. Goals for fitness.
d. Where the client lives.
e. Desire for socialization. |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
The nurse is developing an exercise plan for a client. If the client is to maintain the plan, the nurse
takes into consideration: |
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Definition
b. Attitudes about fitness.
c. Goals for fitness.
d. Where the client lives.
e. Desire for socialization. |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
| Explain each procedure to client before starting ech part of the assessment & ask concerning questions that pertain to that part of the assessment: |
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Definition
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Term
*Call for patient in waiting area(w/ chart):
*Introduce self:
*Have client follow me to room & ask client to have a seat on the bed:
*Wash my hands:
*General survey: safety concerns, gait, balance, posture, mood,affect, speech, odors, appearance, body type,dress, grooming,personal hygiene.
*Identify client name/dob w/ arm band:
*Orient client person, place,place, time, event:
*Explain Procedure:
**Raise bed to my waist level**
*Provide Privacy:
*Ask questions about pain level 0-10
*Explain that are going to take his vitals:
*Ask which arm client prefers for BP and average BP:
*Start Vitals:T,BP,P,R (watch)ask about HT & Weight: |
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Definition
-Jason? (wait for response)
-My name is Jennifer Largent & I will be your student nurse today.
-Could you follow me and have a seat on this side of the bed please.
-wash my hands
-floor clean & dry, no trip hazards, no clutter & no invasive devices, the bed is at it's lowest lock position; all safety concerns are met.
-hispanic male, average build,a smooth & steady gait, posture erect, no deficits,weight evenly distributed, toes pointed forward, cheerful bright affect, with speech clear & logical,cloths are appropriate for assessment, well groomed & free from breath & bodt odors.
-Could you tell me your full name & DOB? Do you know where you are and why you are here? Could you tell me todays date & year?
-Today I will be doing a head-to-toe assessment on you.
-let jason know I am going to raise the bed & raise the bed to my waist level.
-close curtian & get BP cuff & thermometer to bring over to bed.
-Jason do you have any pain today on a scale of 0 being no pain and 10 being the worst pain ever?
-I will now be taking you vitals do you have specific arm you would like me to take your BP on and do you know your average BP?
-Jason chart states your wight is 175 & your hieght is 5"6 is this correct?
-alright, could you hold this thermometer in your mouth for me, thank you
-Take BP & say it out loud(Blood pressure is 122/78)
-check pulse & respirations at same time (67 bpm pulse and 14 bpm respiration) |
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Term
Head-to-Toe Assessment:
***(State out loud findings)*** |
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Definition
Questions about vision, hearing, and headaches, dizziness:
*Head
*Neck
*Trachea (any tenderness when palpating or bulge?)
*Vision
*Mouth
*Facial features
*Head & neck lymph nodes( occipital, postauricle, preauricle,submandibular, submental, post auricle chains, preauricle chains, (shoulder shrug)-infra & ___? lymph nodes).
*ROM of neck
Questions about skin lesions, tenderness, ..
*Inspect, palpate Arms & Hands (skin color, lessions, warmth)
*Nails(capilaary refill)
*Radial pulses both
*squeeze hands for grip (cross my hands)
*Check for edema on arms
*Turgor on chest (remove shirt, pinch)
*Note clients tatoos on back & chest.
Question about tenderness, weakness
*Arms ROM
Question about lungs:breathing, SOB,dyspnea, ....
*Inspect skin on back & temp
*Ausculate(listen with stethoscope)back in all quads,
-(have client put hands on head)-then back-n-forth at arm pits(state out loud findings)- then ask client to drop hands from head.
*move back around to front of client)-Listen with stethoscope heart(5 points, Aortic, pulmonic, Erbs point, tricuspid & mitral) S1-louder,S1-louder, ERBs-equal or mumur,S2-louder, S2-louder)
*5th Mitral heart sound at the same time listen to heart, feel radial pulse.
Question about abdominal problems(tenderness, costipation, pain, diarrhea)& explain procedure( listen to abdomin & touch): (look, listen, & then feel)
(Have client remove socks & shoes and lie down on bed)
*Inspect skin on abdomin and legs(state out loud skin tone even, no lesions)
*Watch abdomin first, then Palpate
*Palpate abdominal all four quadrients (state out loud each sound).
*while palpating abdomin ask if any pain?
*Tap each abd. quad. percusion (state out loud sounds)
Explain to client that I will be touching their toes & legs:
*Toes capillary refill
*Feet Resistance
*Toes & ankle pulses
*Leg check for edema
*Legs temperature warm
*Leg ROM
(Tell the client to sit up on the bed) & (explain next procedure- reflexes)
*lower bed back down
*check clients knee reflexes
*Thank the client for coming in & let the client know he may put his shirt & shoes back on.
*wash hands
* |
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