Chapter 47 mobility and immobility Flashcards Preview

NUR 151 > Chapter 47 mobility and immobility > Flashcards

Flashcards in Chapter 47 mobility and immobility Deck (105):
1

Visible aspect and contributes to self-worth and well-being

Movement

2

Used to show self-defense, perform activities of daily living (ADLs) and recreational activities

Mobility

3

Coordinated efforts of the musculoskeletal and nervous system

Body mechanics

4

Reduces strain, maintains muscle tone, comfort, conserves energy

Body alignment

5

Required to maintain a static position

Balance

6

Force that occurs in a direction to oppose movement

Friction

7

Contribute to height

Long bones

8

Occur in clusters (carpal bones in the foot)

Short bones

9

Provide structural contour (skull)

Flat bones

10

Make up the vertebral column and some bones of the skull

Irregular bones

11

Caused by weakened bone tissue

Pathological fractures

12

Bones jointed by bones with no movement

Synostosis joint

13

Unites bony components

Cartilaginous joint

14

joint in which a ligament unites two bony surfaces (paired bones of the lower leg)

Fibrous joint

15

Ball and Socket Joint (hip)

Synovial joint

16

Fibrous tissue that connect ones an cartilages

Ligaments

17

Connect muscle to bone

Tendons

18

Nonvascular, supporting tissue (joints and thorax)

Cartilage

19

Increased muscle contraction causes muscle shortening resulting in movement

concentric tension

20

Helps control the speed and direction of movement

Eccentric tension

21

Active movement between concentric and eccentric muscle actions

Isotonic contraction

22

Causes an increase in muscle tension or muscle work but no shortening or active movement

Isometric contraction

23

Inducing or compelling force

Leverage

24

Position of the body in relation to the surrounding space

Posture

25

Normal state of balanced muscle tension

Muscle tone

26

Inclining of head to affected side, in which sternocleidomastoid muscle is contracted

Torticollis

27

Exaggeration of anterior convex curve of lumbar spine

Lordosis

28

Increased convexity in curvature of thoracic spine

Kyphosis

29

Lateral S- or C-shaped spinal column with vertebral rotation, unequal heights of hips and shoulders

scoliosis

30

Hip instability with limited abduction of hips and, occasionally, adduction contractures (head of femur does not articulate with acetabulum because of abnormal shallowness of acetabulum)

Congential hip dysplasia

31

Legs curved inward so that knees come together as person walks

knock-knee

32

One or both legs bent outward at knee, which is normal until 2 to 3 years of age

Bowlegs

33

95%: medial deviation and plantar flexion of foot (equinovarus) 5%: lateral deviation and dorsiflexion (calcaneovalgus)

Clubfoot

34

Inability to dorsiflex and invert foot because of peroneal nerve damage

Footdrop

35

Internal rotation of forefoot or entire foot; common in infants

Pigeon Toes

36

Damage to component of the central nervous system that regulates voluntary movement results in

impaired body alignment, balance, and mobility

37

Direct trauma to the musculoskeletal system results in

bruises, contusions, sprains, and fractures

38

inability to move freely

Immobility

39

Identify the objectives of bed rest.

a. Reducing physical activity and the oxygen needs of the body
b. Reducing pain, including postoperative pain or after acute injury, to the lower back
c. Allowing ill or debilitated clients to rest
d. Allowing exhausted clients the opportunity for uninterrupted rest

40

Identify the complications of immobility in relation to the metabolic functioning of the body

decreases the metabolic rate; alters the metabolism of CHO, fats, and proteins; causes fluid and electrolyte and calcium imbalances; and causes GI disturbances

41

collapse of alveoli

Atelectasis

42

inflammation of the lung from stasis or pooling of secretions

Hydrostatic pneumonia

43

increase in heart rate of more than 15% and a drop of 15 mm Hg or more in SBP

Orthostatic hypotension

44

accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery that occludes the lumen of the vessel

Thrombus

45

Identify the complications of immobility in , relation to the musculoskeletal system

a. loss of endurance, strength, and muscle mass and decreased stability and balance
b. impaired calcium metabolism
c. impaired joint mobility
d. osteoporosis
e. joint contractures
f. footdrop

46

Identify the complications of immobility in relation to the urinary system.

a. urinary stasis (renal pelvis fills before urine enters the ureters)
b. renal calculi (calcium stones that lodge in the renal pelvis)

47

Identify the psychosocial effects that occur with immobilization

a. emotional and behavioral responses
b. sensory alterations
c. changes in coping

48

39. is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, or transverse

Range of Motion (ROM)

49

particular manner or style of walking

Gait

50

physical activity for conditioning the body, improving health, and maintaining fitness

Exercise and activity tolerance

51

identifies deviations, learning needs, identifies trauma, risk factors

Body alignment

52

Which nursing diagnoses is related to an immobilized or partially immobilized client.

1 ineffective airway clearance
2. ineffective individual coping
3. risk for injury
4. impaired skin integrity
5. disturbed sleep pattern
6. social isolation
7. impaired urinary elimination

53

List the expected outcomes for the goal "client skin remains intact"

a. skin color and temperature return to normal baseline within 20 minutes of position change
b. changes position at least every 2 hours

54

Identify some examples of health promotion activities that address mobility and immobility

a. prevention of work-related injury
b. fall prevention measures
c. exercise
d. early detection of scoliosis

55

Identify the nursing interventions that will reduce the impact of immobility on Metabolic Systems

a. a high caloric diet
b. vitamin B and C supplements

56

Identify the nursing interventions that will reduce the impact of immobility on Respiratory system

a. deep breathe and cough every 1-2 hours
b. CPT
c. ensure intake of 2000 mL of fluid per day

57

Identify the nursing interventions that will reduce the impact of immobility on Cardiovascular system

a. deep breathe and cough every 1-2 hours
b. CPT
c. ensure intake of 2000 mL of fluid per day

58

Identify the nursing interventions that will reduce the impact of immobility on Musculoskeletal system

a. perform active and passive ROM exercises
b. CPM machines

59

Identify the nursing interventions that will reduce the impact of immobility on Integumentary system

a. positioning and skin care
b. use of therapeutic devices to relieve pressure

60

Identify the nursing interventions that will reduce the impact of immobility on Elimination system

a. well-hydrated
b. prevent urinary stasis and calculi and infections

61

Identify the nursing interventions that will reduce the impact of immobility on Psychosocial

a. anticipate change in the client's status and provide routine and informal socialization
b. stimuli to maintain client's orientation

62

prevents external rotation of the hips when the client is in supine position

Trochanter roll

63

maintain the thumb in slight adduction and in opposition to the fingers

Hand rolls

64

allows the client to pull with the upper extremities to raise the trunk off the bed, assist in transfer, or to perform exercises

Trapeze bar

65

HOB elevated 45-60 degrees and the knees are slightly elevated

Fowlers

66

rest on their backs; all the body parts are in relation to each other

Supine

67

lies face or chest down

Prone

68

the client rests on the side with body weight on the dependent hip and shoulder

Side-lying

69

client places the weight on the anterior ileum humerus and clavicle

Sims

70

Are activities beyond ADLs that are necessary to be independent in society

Instrumental activities of daily living (IADLs)

71

Describe how you would assist clients with hemiplegia or hemiparesis

Always stand on the client's affected side and support the client by using a gait belt.

72

Identify the evaluative measures in mobility

the client's ability to maintain or improve body alignment, improve mobility; protect the client from the hazards of immobility

73

What is a potential hazard that you should assess when the client is in a prone position

footdrop

74

Abnormal and usually permanent condition of a joint, characterized by flexion and fixation and caused by disuse, atrophy, and shortening of muscle fibers.

joint contracture

75

Measures of height, weight, and skinfold thickness to evaluate muscle atrophy.

anthropometric measurements

76

A decline is bone density that is associated with impaired mobility or immobilization of an extremity because of fracture, paralysis, or bone or joint inflammation.

disuse osteoporosis

77

A foreign object, a quantity of air or gas, a bit of tissue or tumor, or a piece of thrombus that circulates in the bloodstream until it becomes lodged in a vessel.

embolus

78

Leather belt that encircles the waist and has handles attached for the nurse to hold.

gait belt

79

Loss of muscle tissue.

muscle atrophy

80

Condition occurring when the body excretes more nitrogen than it takes in.

negative nitrogen balance

81

Not hardened, soft.

unossified

82

Group of therapies used to mobilize pulmonary secretions.

chest physiotherapy (CPT)

83

Paralysis of one side of the body.

hemiplegia

84

Muscular weakness of one half of the body

hemiparesis

85

the coordinated efforts of the musculoskeletal and nervous systems as the person moves, lifts, bends, stands, sits, lies down, and completes daily activities

body mechanics

86

safe patient handling prevents

injuries to nurses and clients when moving and transferring clients

87

The skeletal system provides bony support structure for

movement, attachment of ligaments and muscles, protection of vital organs, some of the regulation of calcium, and production of red blood cells.

88

initiation and voluntary control of movement

nervous system

89

Coordination and regulation of muscle groups depend on

muscle tone; activity of antagonistic, synergistic, and antigravity muscles; and neural input to muscles

90

Body alignment is the condition of

joints, tendons, ligaments, and muscles in various body positions.

91

Balance occurs when there is a wide base of

support, the center of gravity falls within the base of support, and a vertical line falls from the center of gravity through the base of support.

92

Developmental stages influence

body alignment and mobility; the greatest impact of physiological changes on the musculoskeletal system is observed in children and older adults.

93

The risk of disabilities related to immobilization depends on

on the extent and duration of immobilization and the client's overall level of health.

94

illness or trauma or is prescribed for therapeutic reasons.

Immobility sometimes results from

95

Immobility presents hazards in

the physiological, psychological, and developmental dimensions.

96

The nursing process and critical thinking assist in providing

care for clients who are experiencing or are at risk for the adverse effects of impaired body alignment and immobility.

97

Clients with impaired body alignment require nursing interventions to

maintain them in the supported Fowler's, supine, prone, side-lying, and Sims' positions.

98

Client movement algorithms serve as

assessment tools and guide safe client handling and movement.

99

Appropriate friction-reducing assistive devices and mechanical lifts need to be used for

client transfers when applicable.

100

No-lift policies benefit

all members of the health care system: clients, nurses, and administration.

101

Intervention that restrict patients to bed for therapeutic reasons.

Bed rest

102

It is an increase in heart rate or more than 15%, a drop 15mm in systolic Bp, drop 10mm or more in diastolic. when the pt change from supine to standing position

Orthostatic hypotension

103

factors that contribute to venous thrombus formation

damage on the vessel wall.(injury)
alteration in blood flow
alteration in blood constitute(change in clotting factors)

104

impairment of the skin as a result of prolonged ischemia (decrease blood supplies in tissues)

Pressure ulcer

105

head of the bed is elevated 45-60 degrees. Pt knees are slightly elevated without pressure to restrict circulation in the lower legs.

Supported Folwer's Position