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47 Cards in this Set
- Front
- Back
Anthropometric measurements
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indicate loss of muscle tone and mass
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Atelactasis
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collapse of alveoli. Can occur when secretions block a bronchiole or broncus and distal tissue collapses as air is absorbed. May cause hypoventilation
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CPT
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Chest Physiotherapy. Includes percussino and positioning to prevent pneumonia
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Concentric tension
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muscles contract, shorten and movement results
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Eccentric tension
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helps control speed and direction of movement such as slowly lowering from a chin-up
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Embolus
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a dislodged thrombus that can move to critical areas such as lungs or brain and create a blockage that could be life threatening
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foot drop
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a common debilitating contracture. Ankle is fixed in plantar flexion
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hypostatic pneumonia
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inflamation of the lung from stasis or pooling of secretions. Lowers O2 and increases recovery time from underlying cause of immobility
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Immobility
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refers to an inability to move about freely
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Joint contracture
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abnormal and possibly permanent condition characterized by fixation of the joint. Caused by disuse atrophy and shortening of muscle fibers
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pathological fractures
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those caused by weakened bone tissue
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Renal calculi
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"kidney stones" calcium crystals that lodge in the renal pelvis or pass through ureters
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Synostoic joint
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bones fused together with no movement at all e.g. plates of the skull
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Thrombus
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static clot
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3 Factors leading to thrombus
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Damage to vessel wall, alterations of blood flow, alterations in blood constituents (Virchow's triad)
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Long bones
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contribute to height (eg - femur, fibula, tibia) and length (eg - phalanges of fingers and toes)
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How changes in bone reflect use at various developmental stages
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Infant - max flexibility and cartilage but not weight bearing. Toddler withstands falls but not as stable, adult has strength/stability but may be brittle.
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tonus
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muscle tone - normal state of balanced muscle tension
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An immobile client with no known digestive issues is showing signs of inadequate calorie and protein intake. This is likely due to _________. If left untreated, the client may excrete more nitrogen than ingested leading to ___________
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decreased appetite secondary to immobility
negative nitrogen balance |
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3 major effects on cardovascular system due to imobilization -
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Orthostatic hypotension, increased cardiac workload, thrombus formation
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What factors lead to increased cardiac work load and other cardiac issues during immobility?
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Decreased circulating fluid volume, pooling of blood in extremeties, decreased autonomic response, These lead to decreased venous return and decreased cardiac output
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2 primary skeletal effects of immobility
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impaired calcium metabolism, joint abnormalities
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Older adults may begin to develop contractures after only ____ hours of immobility.
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8
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pressure ulcer
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is an impairment of the skin as a result of prolonged ischmia (decreased blood supply) in tissues. Usually forms over bony prominence. If P on skin is greater than P in small peripheral blood vessels.
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An older adult immobilized on a back board can develop skin breakdown and pressure ulcer within ___ hrs
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3
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In the saggital plane, movements are described as
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Flexion and extension for fingers/elbows. Dorsiflexion and plantar flexion for feet. Extension for hip
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In the frontal plane, movements are described as
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abduction and adduction for arms and legs. Eversion and inversion for feet
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In the transverse plane movements are described as
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pronation and supination for hands, internal and external rotation for hips
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Monitoring what lab values are particularly high priority for assessing metabolic function of an immobile client
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Electrolytes, serum protein, blood urea nitrogen (BUN)
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perform a respiratory assessment at least every ____ hours for clients with restricted activity
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2
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When assessing respiratory function of an immobile client, observe chest wall movements during a full inspiratory - expiratory cycle. Asymetrical movement may indicate ______________
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an atelectactic area
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When assessing lungs of an immobile client, auscultate entire lung region for __________, _________, ___________ . Focus on depenent lung fields because _______________
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diminished breath sounds, crackles, wheezes
pulmonary secretions tend to collect in these lower regions |
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Cardiovascular assesment of an immobile client includes monitoring __________, evaluation of ______ and ______ and observing for signs of _________ (eg - edema, delayed wound healing)
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BP
apical and peripheral pulses venous stasis |
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Lying down causes __________(increased/decreased) pulse rate.
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increased
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When and how should you assess for DVT?
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Assess for Deep Vein Thrombosis by removing elastic stockings or SCD every 8 hrs and observe for redness, warmth, tenderness, pain in calf if client initiated dorsiflexion of foot (Homans' Sign - may dislodge thrombus). Measure bilateral calf circumference daily @ 10cm inferior to midpatella. Monitor for any unilateral changes
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Early assessment of ROM
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Provides a baseline for comparison - to determine if any range of motion has been lost during immobilization
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A tool to measure ROM
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Goniometer
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What factors, other than immobility, may cause an increased risk for disuse osteoporosis?
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postmenopausal female, steroid use, increased serum and urine calcium levels
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Skin assessment should be done at least every ____ hrs
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2
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Dehydration increased risks for what 4 conditions common to immobile clients?
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skin breakdown, thrombus formation, respiratory infections, constipation
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2 nursing diagnoses most directly related to mobility problems are
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Impaired physical mobility
Risk for disuse syndrome These can be qualified i.e. impaired physical mobility related to reluctance to initiate movement |
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Which 2 vitamin supplements are particularly helpful for immobilized clients?
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C - to help replace protein stores
B - promotes skin integrity and wound healing |
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Parenteral nutrition is delivered _____
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through a central or peripheral IV catheter
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Enteral nutrition is delivered __________
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through nasogastric, gastrostomy, or jejunostomy tube
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Encourage immobilized clients to deep breathe and cough every _____ to ____ hrs. Teach alert clients to deep breath, _______, cough, and/or use an incentive _____ every hour.
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1 to 2 hours
yawn spirometer |
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Unless contraindicated, ensure immobile clients take in at least _______ mL of fluid per day
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2000
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Steps when repositioning a client
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1 - Assess client's comfort, ability, limitations, restrictions, etc. to determine best approach/goal
2 - if patient can provide some assistance and is less than 200lbs, use a friction-reducing device and 2-3 caregivers (use 3+ caregivers for client over 200lbs). If unable to assist, use full body lift and 2+ caregivers 3 - evaluate outcome, patient comfort, check devices, etc |