Week 3 Flashcards

Question

what is concept mapping ?

Answer 1

A concept map is a visual representation that show the connections between a client’s health problems.

It fosters a holistic view of the client and identifies linkages between the multiple variables affecting the

client’s health.

Constructing concept maps demonstrates and promotes critical thinking through the use of reflection, creativity, and insight

Answer 2

is is the identification of a disease condition on the basis of a specific evaluation of physical signs, symptoms, the client’s medical history, and the results of diagnostic tests and procedures.

Answer 3

determines health problems within the domain of nursing. The term diagnose means “distinguish” or “know.”

A nursing diagnosis is a clinical judgement about individual, family, or community responses to actual and potential health problems or life processes that is within the domain of nursing

Answer 4

is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a client’s status.

When collaborative problems develop, nurses intervene in collaboration with personnel from other health care disciplines. Nurses manage collaborative problems such as hemorrhage, infection, and cardiac dysrhythmia by
using both physician-prescribed and nursing-prescribed interventions to minimize complications

Answer 5

is a process of using assessment data about a client to logically explain a clinical judgement—in this case, a nursing diagnosis. The diagnostic includes decision-making steps. These steps include data clustering, identifying client needs, and formulating the diagnosis or problem

Answer 6

are objective or subjective
signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion. A specific set of defining characteristics helps confirm identification of each NANDA International– approved nursing diagnosis

Answer 7

1. Actual nursing diagnosis: describes responses to health conditions or life processes that exist in an individual, family, or community. Defining characteristics (manifestations, signs, and symptoms) that cluster in patterns of related cues or inferences support this diagnostic judgement 2. Risk nursing diagnosis: describes human responses to health conditions or life processes that will possibly develop in a vulnerable individual, family, or community. ( ex physiological factors that can increase the clients vulnerability to develop a condition) 3. health promotion: to increase well-being and actualize human health potential, as expressed in their readiness to enhance specific health behaviours, such as those related to nutrition and exercise. 4. Wellness nursing diagnosis: describes levels of wellness in an individual, family, or community that can be enhanced

Answer 8

The nursing diagnosis results from the assessment and diagnostic process.

It is this two-part format that provides a diagnosis meaning and relevance for a particular client.

Answer 9

is the name of the nursing diagnosis as approved by NANDA International.

It describes the essence of a client’s response to health conditions in as few words as possible.

Diagnostic labels include descriptors used to give additional meaning to the diagnosis. For example, the diagnosis impaired physical mobility includes the descriptor impaired to describe the nature or change in mobility that best describes the client’s response

Answer 10

is a condition or etiology (cause/ origin) identified from the client’s assessment data It is associated with the client’s actual or potential response to the health problem and can be changed through the use of nursing interventions.

Answer 11

Risk factors are environmental, physiological,
psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community to an unhealthful event

Answer 12

1. errors in data collection: its vital to check for inaccurate or missing data and to collect data in an organized way. 2. errors in interpretation and analysis of data: Data are reviewed to confirm that measurable objective physical findings support subjective data. (ex trouble breathing, matching finding on x-ray or listening to sound) 3. Errors in data clustering: Errors in data clustering occur when data are clustered prematurely or incorrectly or are not clustered at all. (Premature closure of clustering occurs when nurses make the nursing diagnosis before, grouping all data, incorrect clustering, occurs when nurses try to make the nursing diagnosis fit the signs and symptoms obtained)

Answer 13

Planning requires critical thinking, applied through deliberate decision making and problem solving, to set priorities for a client. Successful planning requires the nurse to collaborate with the client and family, consult with other members of the health care team, and review related literature

Answer 14

is the ranking of nursing diagnoses or client problems, through the use of principles such as urgency or importance, to establish a preferential order for nursing actions< highest priorities: conditionals that when left untreated could result in hard to the client or others. Intermediate priorities: y nursing diagnoses involve the nonemergency, non–life-threatening needs of the client low priorities: y nursing diagnoses are not always directly related to a specific illness or prognosis but affect the client’s future well-being. Many low-priority diagnoses focus on the client’s long-term health care needs.

Answer 15

initial > ongoing > discharge.

initial planning: involves the development of preliminary plan of after assessment and diagnosis.

ongoing: continuous update of clients plan of care

discharge: involves the anticipation and preparation for meeting the client’s needs after discharge.

Answer 16

are specific client behaviour or physiological responses that nurses set to achieve through nursing diagnosis or collaborative problem resolution

Answer 17

is a specific and measurable behavioural response
that reflects a client’s highest possible level of wellness and independence in function

Answer 18

is an objective behaviour or response that a client is expected to achieve in a short time, usually less than a week.

In an acute care setting, goals are set for over a course of just a few hours

Answer 19

is an objective behaviour or response that a client is expected to achieve over a longer period, usually over several days, weeks, or months: for example, “Client will be tobacco-free
within 60 days.”

Answer 20

a specific measurable change in a client’s status
that is expected in response to nursing care.

Expected outcomes provide a focus or direction for nursing care because they are the desired physiological, psychological, social, developmental, or spiritual

Derived from both short- and long-term goals, outcomes determine when a specific client-centred goal has been met.

Answer 21

1. client goal or outcome: the nurse should write a goal to reflect client behaviour not to reflect goals or intervention. 2. singular goal or outcome: should be precise in evaluating a clients response to nursing action. 3. observable goal or outcome: need to be able to observe whether change in a client’s status occurs. Changes in physiological findings and in the client’s knowledge, perceptions, and behaviour are observable. 4. measurable goal or outcome: It is imperative to learn to write goals and expected outcomes that set standards against which to measure the client’s response to nursing care. Examples such as “Body temperature will remain between the normal range of 36.5 and 37.5°C” 5. time limited goal or outcome: The time frame for each goal and expected outcome indicates when the expected response should ccur. Time frames assist in determining progress toward goals and outcomes. 6. mutual goal outcome: Mutually set goals and expected outcomes ensure that the client and nurse agree on the direction and time limits of care. Mutual goal setting increases clients’ motivation and cooperation. 7. realistic goal or outcome: It is important to set goals and expected outcomes that are achievable. Clients are then more likely to have a sense of empowerment that increases motivation and cooperation. In order to establish realistic goals, the nurse needs to assess the resources of the client, the family, the health care facility, and the community

Answer 22

allows quick reference to the needs of the client for
certain aspects of nursing care

Answer 23

a majority of health care facilities now have some type of electronic record (EHR).

In many facilities, the format is for
standardized care plans that list generalized nursing diagnoses, goals,
outcome criteria, and interventions for specific clients. The nurse adds
or deletes information by making selections from menus on the standardized form to individualize it for a client’s need

Answer 24

treatment plans that outline treatments or interventions that clients may require for treatment of a condition. Most pathways are based on medical rather than nursing diagnoses, but they incorporate related nursing diagnoses and associated nursing interventions. A critical pathway maps out, day to day or even hour to hour, the recommended interventions and expected outcomes

Answer 25

initiates or completes
planned actions or nursing interventions.

This may include organizing and managing planned care, aiding with activities of daily living.

Answer 26

is any treatment, based on clinical judgement and knowledge, to enhance client outcomes

Ideally, interventions are evidence informed providing the most current up to date and effective approaches addressing the clients problems, this includes direct/indirect care

Answer 27

are treatments performed through interactions with clients.

Answer 28

are treatments performed away from the client but on behalf of the client

ex. environment safety and infection control

Answer 29

1. nurse initiated
2. physician initiated
3. collaborative

Answer 30

nurse initiated interventions are a type of independent nursing intervention

these dont require directions from other health care providers

these actions must be evidence informed decision

Answer 31

physician initiated interventions are a type of dependent nursing intervention

These require direct orders or directions from the physician

this intervention is directed towards treating or managing a medical diagnosis

Answer 32

Interdependent nursing interventions, or collaborative interventions, are therapies that require the combined knowledge, skill, and expertise of numerous health care providers.

Typically, when a nurse plans care for a client, the nurse reviews the necessary interventions
and determines whether the collaboration is necessary

Answer 33

1. the nursing diagnosis
2. goal and expected outcomes
3. evidence base
4. feasibility
5. acceptability to the client
6. the nurse competence

Answer 34

developed a set of nursing interventions that provide a level of standardization, which enhance communication of nursing care across all health care settings and enable health care providers to compare outcomes.

Answer 35

is a document that guides decisions and interventions for specific health care problems.

Answer 36

is a statement of orders for the conduct of routine therapies, monitoring guidelines, or diagnostic procedures of a combination of these for a specific client with a problem

Answer 37

Preparation for implementation ensures efficient, safe, and effective nursing care.

Preparatory activities include reassessing the client, reviewing and revising the existing nursing care plan, organizing resources and care delivery, anticipating and preventing complications, and implementing nursing interventions.

Answer 38

Assessment is a continuous process that occurs each time the nurse interacts with a client. As new data are collected and client needs change or resolve, nurses modify the plan of care.

Reassessment helps the nurse decide whether the proposed nursing action continues to be appropriate for the client’s level of wellness

Answer 39

After reassessing a client, the nurse reviews the care plan, compares assessment data in order to validate the nursing diagnoses, and determines whether the nursing interventions remain the most appropriate ones for the client’s situation.

if the clients status has changed and the current intervention is not appropriate, then the nursing care plan is modified.

Answer 40

1. equipment: Most nursing procedures require some equipment or supplies. Nurses must identify which
supplies are required for an intervention, determine whether they are available, and ensure that equipment is in working order

2. personal: Nurses are responsible for determining whether to perform an intervention or to delegate it to another member of the nursing team.

3. environment: Nurses must anticipate circumstances that place clients at risk and must create a culture of client safety

4. Client: Before providing care, the nurse needs to ensure that the client is as physically and psychologically comfortable as possible.

Answer 41

concerns how certain interventions (e.g., pressure-relief devices, repositioning, or wound care) prevent or minimize complications, helps the nurse select the most useful preventive measures

Answer 42

a branch of of indirect care

which is collaborative with a team of health care providers

Answer 43

1. cognitive skill: involves the application of critical thinking in the nursing process (to perform any intervention, nurse must use good judgments) 2. Interpersonal skill: the nurse must develop a trusting relationship. 3. psychomotor skills: require the integration of cognitive and motor activities. For example, when giving an injection, nurses need to understand anatomy, physiology, and pharmacology (cognitive skills) and use good coordination and precision to administer the injection correctly (motor skills)

Answer 44

are activities usually performed in the course of a normal day, including ambulation, eating, dressing, bathing, brushing the teeth, and grooming

A client’s need for assistance with ADLs is
temporary, permanent, or rehabilitative.

Answer 45

Direct care

Illness or disability sometimes alters a client’s ability to be independent in society.

IADLs include such skills as shopping, preparing meals, writing cheques, and taking medications. Nurses within the home care and community health care settings frequently assist clients in finding ways to accomplish IADLs.

Answer 46

Direct care

Nurses routinely perform a variety of physical care techniques when caring for a client. Examples include turning and positioning, changing dressings, administering medications, and providing comfort measures.

Answer 47

Direct care is a harmful effect of a medication, diagnostic test, or therapeutic intervention. Nurses are responsible for knowing the potential adverse reactions associated with nursing interventions as they provide client care

Answer 48

Direct care

is a direct care method that helps the client use a
problem-solving process to recognize and manage stress and to facilitate interpersonal relationships.

Nurses may engage in emotional, intellectual, spiritual, and psychological support for the client.

Answer 49

direct care

Teaching is an important nursing responsibility and is related to counselling.

However, in counselling, the focus is on the development of new attitudes and feelings, whereas in teaching, the focus is on intellectual growth or the acquisition of new knowledge or psychomotor
skills

Answer 50

direct care

promote health and prevent illness in
order to avoid the need for acute or rehabilitative health care. Prevention includes assessment and promotion of the client’s health potential, carrying out prescribed measures (e.g., immunizations), health teaching, and identification of risk factors for illness, trauma, or both

Answer 51

Nursing care is implemented to meet client-centred goals and outcomes.

Answer 52

valuation is the final step of the nursing process. Evaluation involves two components:
1) an examination of a condition or situation and
2) a judgement as to whether change has occurred.

Answer 53

1. identifying evaluative criteria and standards
2. collecting data to determine whether the criteria or standards are met
3. interoperating and summarizing findings
4. documenting findings and any clinical judgments
5. terminating, continuing or revising the care plan

Answer 54

is the minimum level of care acceptable to ensure high quality of care

Answer 55

are statements of progressive, step-by-step responses or behaviours that must be achieved in order to accomplish the goals of care

Answer 56

are assessment skills and techniques (e.g., auscultation of lung sounds, observation of a client’s skill performance, discussion of the client’s feelings, and inspection of the skin)

Answer 57

Nurses evaluate expected outcomes and determine whether the goals of care have been met. They then decide whether the plan of care needs to be adjusted. If goals are successfully met, that portion of the care
plan can be discontinued. If goals are unmet or partially met, the intervention continues.

Answer 58

After a nurse determines that expected outcomes and goals have been met, he or she confirms this finding with the client, when possible. If the nurse and the client agree, that portion of the care plan is discontinued.

Answer 59

When nurses evaluate the effect of interventions, they are essentially performing another nursing assessment whereby they learn to recognize relevant evidence about a client’s condition.

Answer 60

When goals are not met, nurses identify the factors that interfere with goal achievement. A change in the client’s condition, needs, or abilities usually necessitates alteration of the care plan.

Answer 61

refers to the relationship of one body part to another body part along a horizontal or vertical line.

Correct alignment involves positioning in such a way that no excessive strain is placed on a person’s joints, tendons, ligaments, or muscles, thereby maintaining adequate muscle tone and contributing to balance.

Answer 62

is the internal state of muscle tension within an individual muscle or muscle groups.

Answer 63

Body balance is achieved when a centre of gravity
is balanced over a stable base of support and is enhanced using proper posture.

Answer 64

is a force that occurs in a direction to oppose
movement. It increases a patient’s risk for skin and tissue damage and potential pressure injuries

Answer 65

is physical activity for the purpose of conditioning the body, improving health, and maintaining fitness, or it may be used as a therapeutic measure

Answer 66

the amount of exercise or activity that the individual is able to perform

Answer 67

muscle contraction and changes in muscle length (Walking, swimming, dance aerobics, jogging, bicycling, and moving arms and legs with light resistance are examples of isotonic exercises

Answer 68

involve tightening or tensing muscles without
moving body parts

An example is quadriceps set exercises

Answer 69

are those in which the individual contracts the muscle while pushing against a stationary object or resisting
the movement of an object

plank (for abdominal strengthening) and the wall push-up (for chest, triceps, and shoulder strengthening).

Answer 70

The skeletal system or bones perform five functions in the body:

support, protection, movement, mineral storage, and hematopoiesis (blood cell formation).

Answer 71

caused by weakened bone tissue

patients with lowered decreased Ca regulation and metabolism are at risk for developing osteoporosis

Answer 72

permit strength and flexibility of the skeleton.

Strength enables the skeletal system to support
the body

Answer 73

Joints or articulations are the connections between bones.

A person’s flexibility is demonstrated through range of motion (ROM), which is the range of normal movement for a joint.

Answer 74

bones are jointed by bones. No movement is associated with this type of joint, and the bony tissue that forms between the bones provides strength and stability.

The classic example of this type of joint is the sacrum, in which vertebrae are joined

Answer 75

or synchondrodial joint, has little movement but is elastic and uses cartilage to unite body surfaces.

Cartilaginous joints are found when bones are exposed to constant pressure, such as the costosternal joints between the sternum and ribs

Answer 76

or syndesmodial joint, is a joint in which two bony surfaces are united by a ligament or membrane. The fibres of ligaments are flexible and stretch, permitting a limited amount of movement. For example, the paired bones of the lower leg (tibia and fibula) are fibrous joints

Answer 77

is a freely movable joint in which contiguous bony surfaces are covered by articular cartilage and connected by ligaments lined with a synovial membrane.

Joining of the humeral radius and ulna by cartilage and ligaments forms a pivotal joint.

Answer 78

are white, shiny, flexible bands of fibrous tissue that support the skeletal system. Ligaments bind joints together and connect bones and cartilage, Ligaments are elastic and aid joint flexibility and support, also have protective function

Answer 79

are white, glistening, fibrous bands of tissue that connect muscle to bone.

Tendons are strong, flexible, and inelastic

Answer 80

is nonvascular, supporting connective tissue with flexibility similar to that of firm plastic

permits it to sustain weight

it is a shock absorber

Answer 81

Muscles are made of fibres that contract when
stimulated by an electrochemical impulse

Contraction of skeletal muscles allows people to walk, talk, run, breathe, and participate in physical activity.

Answer 82

antagonistic, synergistic, and antigravity muscle groups are coordinated by the nervous system and maintain
posture and initiate movement

Answer 83

movement at the joint.

For example, during flexion of the arm, the active mover (the biceps brachii) contracts and its antagonist (the triceps brachii) relaxes

Answer 84

are two or more muscles that contract to accomplish the same movement. When the arm is flexed, the strength of the contraction of the biceps brachii is increased by contraction of the synergistic muscle, the brachialis

Answer 85

work to stabilize joints.

These muscles continuously oppose the effect of gravity on the body and permit a person to maintain an upright or sitting posture

In an adult, the antigravity muscles are the extensors of the leg—the gluteus maximus, the quadriceps femoris, and the soleus muscles—and the muscles of the back.

Answer 86

Movement and posture are regulated by the nervous system

Answer 87

n is the awareness of the position of
the body and its parts.

Answer 88

nervous system and requires proprioception and balance

Answer 89

Damage to any part of the central nervous system that regulates voluntary movement causes impaired body alignment and immobility

Answer 90

Musculoskeletal trauma often results in bruises, contusions, sprains, and fractures.

Answer 91

Osteoporosis, a well-publicized disorder of aging, results in the reduction of bone density or mass.

The cause is uncertain, and theories vary from hormonal imbalances to insufficient intake of nutrients

Answer 92

1. infants through school ages children:

2. adolescence: Adolescent growth is often sporadic and uneven. As a result, the adolescent may appear awkward and uncoordinated. Adolescent girls usually grow and develop earlier than boys do. In girls,
hips widen and fat is deposited in the upper arms, thighs, and buttocks. The adolescent boy’s changes in shape are usually a result of long-bone
growth and increased muscle mass

3. young to middle age adults: A healthy adult also has the necessary musculoskeletal development and coordination to carry out ADLs

4. older people: In older persons, a progressive loss of bone mass
occurs as a result of decreased physical activity, hormonal changes, and increased osteoclastic activity (activity by cells responsible for bone
tissue absorption).

Answer 93

is the manner or style of walking

Answer 94

ROM exercises

In active ROM exercises, patients are able to move their joints independently.

With passive ROM exercises, the nurse moves each joint in patients who are unable to perform these exercises themselves

Walking also increases joint mobility

Answer 95

1. walkers
2. canes
3. crutches

Answer 96

are the coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing activities of daily living (ADLs).

Answer 97

congenital and acquired impairments, degenerative and episodic conditions, and diseases affecting virtually every body system

Answer 98

Congenital or acquired postural abnormalities affect the efficiency of the musculoskeletal system, as well as
body alignment, balance, and appearance.

during assessment nurse has to observe the ROM

Answer 99

Injury and disease can lead to numerous alterations in musculoskeletal function.

For example, the muscular dystrophies are a group of familial disorders that cause degeneration of skeletal muscle fibres. They are the most prevalent of
the muscle diseases in childhood

Answer 100

impaired body mobility.

Trauma from a head injury, ischemia from a stroke or cerebrovascular accident (CVA), hemorrhage, tumour, or bacterial infection such as meningitis can damage
the cerebellum or the motor strip in the cerebral cortex

this causes problems with balance

Answer 101

muscle paralysis

Answer 102

muscle weakness

Answer 103

two limb paralysis

Answer 104

injury above the first thoracic vertebra

Answer 105

bruises,
contusions,
sprains
fractures

Answer 106

is a disruption of bone tissue continuity.

Fractures most commonly result from direct external trauma but can also occur as a consequence of some deformity of the bone

Answer 107

refers to the inability to move about freely

Answer 108

is an intervention that restricts patients to bed for therapeutic reasons. Although it is much less commonly used, health care providers often prescribe this intervention.

the duration of the best rest depends on a variety of conditions

Answer 109

describes the tendency of cells and issue to reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting of a body part, or local nerve damage

Answer 110

can cause major physiological, psychological, and social effects.

The greater the extent and the longer the duration of immobility, the more pronounced are the consequences.

Answer 111

endocrine metabolism, calcium resorption, and functioning of the gastrointestinal system.

The endocrine system, made up of hormone-secreting glands, maintains and regulates vital functions such as

(1) response to stress and injury;
(2) growth and development;
(3) reproduction;
(4) maintenance of the internal environment; and
(5) energy production, use, and storage

Answer 112

the endocrine system triggers a series of responses aimed at maintaining blood pressure and preserving life.

The endocrine system is important in maintaining homeostasis.

Answer 113

Immobility disrupts normal metabolic functioning, decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis

Answer 114

lack of movement and exercise places patients at higher risk for respiratory complications.

Patients who are immobile are at a high risk of developing pulmonary complications such as atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions).

Answer 115

results in orthostatic hypotension, increased cardiac workload, and thrombus formation.

Answer 116

is a drop of blood pressure greater than 20 mm Hg in systolic blood pressure and of 10 mm Hg in diastolic
blood pressure.

Symptoms include dizziness, light-headedness, nausea, tachycardia, pallor, or fainting when the patient changes from a lying or sitting position to a standing position

Answer 117

Patients who are immobile are also at risk for thrombus formation. A thrombusis an accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery, sometimes occluding the lumen of the vessel

Answer 118

a dislodged venous thrombus

Answer 119

Immobility affects the musculoskeletal system by causing temporary or permanent impairment or permanent disability.

Restricted mobility may result in loss of endurance, strength, and muscle mass as well as decreased stability and balance

Answer 120

immobility can lead to joint contractures, in which jointed are fixed with one another

ex of this is foot drop ( the foot is permanently fixed in a planter flexion)

Answer 121

immobility forces people to be in positioned in a flat position (harder for urine to move down due to gravitational forces)

this cases urinary stasis which is an increase risk for infection and renal calculi (stones)

Answer 122

immobility a major risk factor for pressure injuries

Answer 123

is localized damage to the skin and/or underlying
soft tissue as a result of prolonged ischemia (decreased blood supply in the tissues).

Answer 124

can contribute to decreased social interaction, social isolation, sensory deprivation, loss of independence, and role changes.

Answer 125

is the maximum amount of movement available at a joint in one of the four planes of the body:

medial, sagittal, frontal, or transverse.

Answer 126

focuses on ROM, gait, exercise and activity tolerance, and body alignment.

Answer 127

Flexion is decreasing the angle between two
adjoining bones (bending of the joint);

extension is increasing the angle between two adjoining bones (extending the joint).

Answer 128

This is movement of a body part beyond its normal
resting extended position.

Answer 129

Abduction is movement of an extremity away from the midline of the body;

adduction is movement of an extremity towards the midline of the body

Answer 130

Eversion is the turning of a body part away from the midline;

inversion is the turning of a body part toward the midline (e.g., feet).

Answer 131

Pronation is movement of a body part so that the front or ventral surface faces downward;

supination is movement of a body part so that the front or ventral surface faces upward (e.g., hands, forearm).

Answer 132

Internal rotation is rotation of the joint inward; external rotation is rotation of the joint outward

Answer 133

This is the circular movement of a limb in a
cone-shaped manner (e.g., shoulder).

Answer 134

to set a baseline measurment to determine the patients mobility status and later compare and evaluate whether loss in joint mobility has occured as a result of clinical changes and treatment

Answer 135

is the type and amount of exercise or work that a person can perform without injury

Answer 136

is done with the patient lying, sitting, or standing. This assessment has the
following objectives:
• Determining normal physiological changes in body alignment resulting from growth and development for each individual patient
• Identifying deviations in body alignment caused by incorrect posture
• Providing opportunities for patients to observe their posture
• Identifying learning needs of patients for maintaining correct body alignment
• Identifying trauma, muscle damage, or nerve dysfunction
• Obtaining information about other factors contributing to poor alignment, such as fatigue, malnutrition, and psychological problem

Answer 137

When assessing metabolic functioning, nurses
use anthropometric measurements (measures of height, weight, and skin fold thickness) to evaluate muscle atrophy)

Answer 138

A respiratory assessment is performed at least
every 2 hours for patients with restricted activity. The nurse needs to inspect chest wall movements during the full inspiratory–expiratory cycle.

Answer 139

Cardiovascular assessment of the patient who is immobile includes blood pressure monitoring, evaluation of apical and peripheral pulses, and observation for signs of venous stasis (e.g., edema and poor wound healing)

Answer 140

Major musculoskeletal abnormalities to identify during nursing assessment include decreased muscle tone and strength, loss of muscle mass, reduced ROM, and contractures.

Answer 141

The patient’s skin must be continually assessed for breakdown and colour changes, such as pallor or redness.

Answer 142

To determine the effects of immobility on elimination, the patient’s total intake and output needs to be assessed each shift and every 24 hours.

Answer 143

Nurses should know proper positioning and transferring techniques to safely move patients

Answer 144

Patients with impaired function of the nervous, skeletal, or muscular system and with general weakness often require help to attain proper body alignment while in bed or sitting.

Answer 145

1. pillows: Provide support, elevate body parts, and can splint incisional areas, reducing postoperative pain during activity or coughing and deep breathing. 2. wedge: : This is a triangular-shaped pillow made of heavy foam used to maintain the legs in abduction after total hip replacement surgery 3. foot boot: Prevents footdrop by maintaining the feet in dorsiflexion 4. trochanter roll: Prevents external rotation of the hips when the patient is in a supine position 5. sand bag: These are sand-filled plastic tubes or bags that can be shaped to body contours. Sandbags can be used in place of or in addition to trochanter rolls. They immobilize an extremity or maintain body alignment. 6. hand wrist splints: These are individually moulded for the patient to maintain proper alignment of the thumb (slight adduction) and the wrist (slight extension). 7. trapeze bar: This is a triangular device that descends from a securely fastened overhead bar attached to the bed frame. A trapeze bar allows the patient to use his or her upper extremities to raise the trunk off the bed, to assist in transfer from the bed to a wheelchair, or to perform arm exercises

Week 3 Flashcards

(169 cards)