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Nursing II > concept: mobility > Flashcards

concept: mobility Flashcards

1
Q

alkaline phosphatase (ALP)

A

-increased in bone cancer, healing fractures, rheumatoid arthritis, and osteoporosis

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2
Q

Calcium (Ca)

A
  • increased in bone cancer and multiple fractures

- monitor Ca levels and detect imbalances

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3
Q

Phosphorus (P)

A

-increased with bone tumors and phosphate healing fractures

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4
Q

Rheumatoid factor (RF)

A

-diagnose RA; also increased in lupus and scleroedema

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5
Q

Uric acid

A

-diagnosis and monitor treatment of gout

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6
Q

Creatine kinase (CK)

A
  • diagnose muscle trauma or disease

- increased in muscular dystrophy and traumatic injuries

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7
Q

Sedimentation rate (ESR)

A

-measures inflammation in the body

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8
Q

What do you assess when assessing pain?

A

-descriptors, location and nature

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9
Q

Strength - muscle grading scale 1-5

A 
0- paralysis; no visible contraction 
1- can feel contraction; no movement of limb
2- movement with gravity eliminated 
3- full ROM against gravity 
4- full ROM with some resistance 
5- full ROM with full resistance
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10
Q

Morse fall scale

A

0-24 (no risk)
25-50 (low risk)
>50 (high risk)

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11
Q

Radiologic examinations

A

X-rays
CT scan
MRI
bone scans

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12
Q

Bone density tests

A

DXA or DEXA gold standard

-evaluates degree of osteoporosis

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13
Q

Arthroscopy

A
  • fiber-optic endoscope to examine joint interior, to diagnose diseases, and to perform surgery
  • arthrocentesis- withdraws fluid from a joint by needle aspiration
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14
Q

Electromyogram (EMG) and somatosensory evoked potential (SSEP)

A

-tests of the electrical activity of skeletal muscle

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15
Q

Conditions that effect mobility

A
  • Cardiovascular
  • neurological
  • respiratory
  • musculoskeletal
  • infection
  • peri operative
  • psychological
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16
Q

Short term mobility goals

A
  • prevent further injury
  • control pain
  • prevent falls
  • ROM
  • safe mobility
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17
Q

Long term mobility goals

A
  • Optimal function

- restore normal function

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18
Q

Caring interventions

A

-rehabilitative nursing-process of restoring a persons ability to live and work in as normal a manner as possible; involves the prevention and correction of alterations in the musculoskeletal system

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19
Q

preservative methods

A
  • interventions needed to maintain normal mobility
  • exercises and assisted ambulation
  • used with EVERY client
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20
Q

Restorative methods

A
  • interventions to achieve level of mobility prior to illness
  • crutch walking and splinting
  • used with clients who have decreased mobility caused by factors such as debilitating illness or major surgery
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21
Q

Client education for mobility

A
  • encourage participation
  • instruct on importance of movement/ambulation/exercise
  • proper nutrition
  • maintain proper body alignment
  • safety related to mobility, environment, and use of devices
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22
Q

Potential complications with mobility issues

A
  • tissue integrity
  • DVT/blood clotting
  • falls/fractures
  • functional decline
  • pneumonia
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23
Q

Manifestations of back pain

A
  • lower back pain that radiates across the buttocks and down the posterior leg
  • SCIATICA-lumbar back pain that radiates down the posterior leg to the ankle and is increased by sneezing or coughing
  • posterior deformity
  • motor deficits
  • sensory deficits
  • changes in reflexes
  • pain in shoulder neck and arm
  • paresthesia
  • muscle spasms
  • stiff neck
  • decreased or absent arm reflexes
  • lower extremity weakness
  • unsteady gait
  • urinary elimination problems
  • altered sexual function
  • hyperactive lower extremity reflexes
24
Q

Diagnostics to diagnose back pain

A
  • X rays and CT scans of lumbosacral and cervical area
  • electromyography (EMG)- measures electrical activity of skeletal muscle at rest and during voluntary contractions. May be done to specify which muscles are affected
  • myelogram- illustrates area of hernias
25
Q

CONSERVATIVE Treatment of back pain

A
  • goals of treatment are to relieve pain and healing the involved disk by fibrosis
  • usually prescribed by for 2-6 weeks
  • client is advised to continue with normal activities while taking prescribed meds for pain
  • meds include nonnarcotic analgesics, anti-inflammatory drugs (NSAIDS), muscle relaxants, sedatives
26
Q

SURGERY treatment for back pain (LAMINECTOMY)

A
  • removal of part of the vertebral lamina
  • relieves pressure on the nerves
  • often combined with removal of the protruding nucleus pulposus
27
Q

Diskectomy surgery treatment for back pain

A

-removal of nucleus pulposes of an intervertebral disk

28
Q

Spinal fusion surgery for back pain

A
  • insertion of a wedge-shaped piece of bone or bone chips between the vertebrae to stabilize them
  • bone usually taken from iliac crest of client
29
Q

Foraminotomy surgery for back pain

A

-enlargement of the opening between the disk and the facet joint to remove bony overgrowth compressing the nerve

30
Q

Intradiscal electrothermal therapy (IDET) surgery treatment for back pain

A
  • thermal energy used to treat pain from bulging spinal disk
  • special needle inserted into the disk and heated to high temperature.
  • heat thickens and seals the disk wall and decreases bulging of the disk
31
Q

Microdiskectomy surgery treatment for back pain

A

-microsurgical techniques are used and performed through very small incision

32
Q

Complimentary and Alternative therapies for treatment of back pain

A
  • chiropractic therapy
  • massage therapy
  • acupuncture
33
Q

Nursing implementations for acute pain (back pain)

A
  • assess degree of pain and identify contributing and relieving factors
  • use a firm mattress or place a board under the mattress
  • teach client to avoid turning or twisting the spinal column and to assume positions that decrease stress on the vertebral column
  • provide analgesic meds around the clock
34
Q

Nursing implementations for chronic pain (back pain)

A
  • treat clients reports of pain with respect
  • do not refer to client as being addicted to pain meds
  • monitor client carefully for any changes in condition
  • maintain individualized written plans of care for pain management and ensure continuity of care
  • teach the client alternative methods of pain management
  • develop effective methods of improving rest and sleep
  • refer client to PT for exercise program
  • assess need for referrals for client who is depressed or anxious
35
Q

Nursing implementations for constipation (R/T back pain)

A
  • assess clients usual bowel routine, including diet, fluid intake, and the use of laxatives or enemas
  • encourage fluid intake of 2500-3000 mL/day
  • increase fiber and bulk in the diet
36
Q

Manifestations of hip fracture

A
  • unable to walk, stand, or bear weight on effected side
  • acute pain
  • extreme pain prevents any movement
  • force of gravity and pull of muscles cause affected leg to appear shortened and externally rotated
37
Q

Diagnosis of hip fracture

A
  • bone mineral density test
  • bone and joint radiography and CT
  • magnetic resonance imaging
  • bone and joint scanning
38
Q

treatment for nondisplaced subcapital and femoral neck fractures

A

-internal fixation with multiple pins

39
Q

Treatment for displaced fractures of subcapital and femoral neck

A

-ORIF with rod, pins, prosthesis, or fixed sliding plate

40
Q

Total hip replacement is done only when…

A

Severe arthritis is present

41
Q

Implementations for acute pain

A
  • monitor vitals
  • ask client to rate pain
  • apply bucks traction
  • administer pain meds
42
Q

Implementations for peripheral neurovascular dysfunction (R/T hip fracture)

A
  • assess 5 p’s every 1-2 hours (pain,pallor, pulses, paresthesia, paresis)
  • monitor the extremity for edema and swelling
  • assess for deep, throbbing, unrelenting pain
  • administer anticoagulant
43
Q

Implementations for risk of infection (R/T hip fracture)

A
  • monitor vitals and lab reports of WBCs
  • use sterile technique for dressing changes
  • assess wound for size, color, and presence of drainage
  • administer antibiotics
44
Q

Implementations for impaired physical mobility (R/T hip fracture)

A
  • teach or assist client with ROM exercises of unaffected limbs
  • teach isometric exercises and encourage client to perform every 4 hours
  • encourage ambulation when client is able
  • teach and observe clients use of assistance devices
  • turn client on bed rest every 2 hours
45
Q

Implementations for risk of disturbed sensory perception: tactile (R/T hip fracture)

A
  • assess every 1-2 hours ability to differentiate between sharp and dull touch and presence of paresthesia and paralysis
  • support injured extremity above and below fracture site when moving client
46
Q

Manifestations of osteoarthritis

A
  • pain and stiffness in one or more joints
  • deep ache
  • aggravated by motion of joint and relieved by rest
  • ROM decreases
  • crepitus during movement
  • joint enlargement
  • flexion contractures
  • bony hard, cool on palpation
47
Q

Diagnostics for osteoarthritis

A
  • x-rays of joints
  • synovial fluid from joints can help identify type of arthritis
  • blood level of hyaluronic acid (lubricating substance in cartilage and joint synovial fluid) indicates presence and severity of OA
48
Q

Treatment of osteoarthritis (pharmacological)

A
  • topical medications; counterirritants, salicylates, and capsaicin
  • analgesics and anti-inflammatories; NSAIDs, TYLENOL, Celebrex
  • lidocaine injections (do NOT use more frequently than every 4-6 months)
49
Q

Nonpharmacological therapies for OA

A
  • weight loss
  • exercise- stretching muscles, active ROM for all joints, low intensity isometric exercises, resistive exercises twice a week, aerobic exercises, isotonic exercises
  • rest- adequate sleep at night and frequent, short rest periods, use of assistive devices
  • apply heat to painful joints- moist heat
  • cold applications to reduce pain and swelling- mild cold; swelling, deeper cold; pain
  • canes, crutches, walkers
  • assistive technology- better compliance when adequately taught
50
Q

Surgical treatment for OA (arthroscopy)

A
  • arthroscope is inserted into a joint
  • smoothing rough cartilage and flushing out the joint to remove debris
  • not proven effective in knee OA
51
Q

Surgical treatment of OA (osteotomy)

A
  • incision into or transaction of the bone
  • realigns affected joint
  • shifts joint toward areas of less severely damaged cartilage
52
Q

Surgical treatment of OA (arthroplasty)

A
  • total joint replacement

- pain is virtually eliminated

53
Q

Treatment for OA- physical therapy and rehabilitation

A

-builds strength and regains joint flexibility

54
Q

Complementary and alternative therapies for OA

A
  • bio magnetic therapy
  • acupuncture
  • elimination of nightshade foods such as potatoes, tomatoes, peppers, eggplant, and tobacco
  • nutritional supplements
  • herbal therapy
  • massage therapy
  • osteopathic manipulation
  • vitamin therapy
  • yoga
55
Q

Nursing interventions for chronic pain (R/T OA)

A
  • monitor level of pain (intensity, location, quality, aggravating and relieving factors)
  • take prescribed analgesic or anti inflammatory meds as needed
  • encourage rest of painful joints
  • suggest applying heat to painful joints
  • emphasize importance of proper posture and good body mechanics for walking, sitting, lifting, moving
  • lose weight
  • use nonpharmalogic pain relief
56
Q

Nursing interventions for impaired physical mobility (R/T OA)

A
  • assess ROM of affected joints
  • perform functional mobility assessment
  • teach active and passive ROM exercises as well as isometric, progressive resistance, and low-impact aerobic exercises
57
Q

nursing interventions for self-care deficit (R/T OA)

A
  • perform a functional assessment of the upper and lower extremities
  • assess the home setting to determine the need for assistive devices such as handrails, grab bars, a walk-in shower stall, or a shower chair and handheld showerhead
  • assist in obtaining other assistive devices such as long handled shoehorns, zipper grabbers, long-handled tongs or grippers, jar openers, and special eating utensils

Nursing II (6 decks)

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