Test 2

Cards (156)

  • Atelectasis
    Incomplete expansion or collapse of a part of the lungs, happens with immobility
  • Foot drop
    Complication of extended plantar flexion, irreversible only with surgery
  • Flaccid
    Decrease muscle tone
  • Pressure Injury
    Injury in skin, caused by pressure
  • Atrophy
    Happens from no muscle use, wasted away
  • Venous Thrombus
    Blood clot
  • Spastic
    Increased muscle tone, tightness
  • Joint Movements
    • Abduction: movement away from midline of body
    • Adduction: movement towards the midline of body
    • Circumduction: turning in circular motion
    • Flexion: state of being bent
    • Extension: straight line
    • Hyperextension: looking toward the ceiling
    • Dorsiflexion: foot toward ceiling
    • Plantar flexion: think pointing down like ballerina
  • Range of Motion
    • Active- patient performs by themselves, under supervision of nurse (increases strength/ muscle mass)
    • Passive- performed by the nurse (allows for prevention of contraction)
  • Benefits of Exercise (Cardiovascular System)
    • Increased heart efficiency, decreased heart rate/blood pressure, increase blood flow, improved venous return
  • Effects of Immobility (Cardiovascular System)
    • Increased cardiac workload, increased resting heart rate, risk for orthostatic hypotension, increased risk for venous thrombosis, edema, DVT, pooling [esp. in Legs]
  • Interventions (Cardiovascular System)
    • Reposition every 2 hours, compression stockings, SCD, assess pedal pulses, capillary refill (less than 3 seconds)
  • Benefits of Exercise (Respiratory System)
    • Improved alveolar ventilation, decreased work of breathing, improved rise and fall
  • Effects of Immobility (Respiratory System)
    • Decrease in respiration depth and rate, risk for respiratory secretion pooling and congestion, increased risk for impaired gas exchange [ causes Atelectasis]
  • Interventions (Respiratory System)
    • Assess pulse Ox/ breath sounds, fowlers position (or high fowlers if tolerated), deep breathing/ coughing exercises
  • Benefits of Exercise (Musculoskeletal System)
    • Increase muscle efficiency and flexibility, increased coordination, reduce bone loss, prevents contractions
  • Effects of Immobility (Musculoskeletal System)
    • Decrease muscle size, tone and strength, balance and coordination, decrease in joint mobility and flexibility, bone demineralization, increased risk for contractions, foot drop, atrophy
  • Interventions (Musculoskeletal System)
    • Assess muscle tone, gait, [ ROM prevents contraction and atrophy ] , ambulate, [ prevention of foot drop: foot board, high top sneakers, multipodis boot, dorsiflexion, plantar flexion exercises ]
  • More Joint Movements
    • Rotation: turning of movement of part around its axis
    • Internal Rotation: turning inward, toward center
    • External Rotation: turning outward, away from center
    • Supination: on back
    • Pronation: on tummy
    • Inversion: movement that turns sole of foot inward
    • Eversion: movement that turns sole of foot outward
  • Lordosis
    Exaggerated anterior convex curvature of spine
  • Kyphosis
    Increase convexity in curvature of thoracic spine
  • Scoliosis
    Curvature of spine
  • Benefits of Exercise (Gastrointestinal System)
    • Increase in appetite, increase in intestinal tone, aides in digestion and elimination
  • Effects of Immobility (Gastrointestinal System)
    • Disturbance in appetite, decrease in peristalsis, risk for constipation, risk for weight gain/ acid reflux
  • Interventions (Gastrointestinal System)
    • Assess bowel sounds/ last bowel movement, increased fluid, ROM, fowlers to help acid reflux, ambulate out of bed to chair
  • Benefits of Exercise (Renal/Urinary System)
    • Increased blood flow to kidneys, aides in fluid and acid bases balance, increase efficiency in excreting body waste
  • Effects of Immobility (Renal/Urinary System)
    • Increase urinary stasis- reflux, increased risk for kidney stones, decreased bladder tone which causes incontinence
  • Interventions (Renal/Urinary System)
    • Assess intake/ outtake (fluids), kegal exercise = increased bladder tone, ambulate to the bathroom, if not enough fluids, then increase fluids
  • Benefits of Exercise (Integument System)
    • Improves circulation, increased tone, color and turgor
  • Effects of Immobility (Integument System)
    • Increased risk for skin breakdown and pressure injuries (on bony prominence), poor hygiene, skin rashes/tears
  • Interventions (Integument System)
    • Braden scale, turn/position q2h, dietary to increase protein, ROM - to improve circulation, skin barrier cream to help skin breakdown
  • To prevent venous pooling / venous stasis
    • Compression stockings: should be put on before patient gets out of bed, should have no wrinkles, opening should be on the top, they should come off every shift, should assess skin
    • SCD- compression device as well (can use both SCD/ compression stockings together)
  • Contractures
    Shortening of the muscle and tendon that leads to deformity and limits joint mobility
  • Braden Scale
    Pressure injury risk prediction. The HIGHER the score the BETTER (highest score = 23)
  • Trochanter Rolls
    Prevent hip rolling; hip rotation; prevents legs rotating outward. Placement? alongside of the ilium to mid thigh
  • Activity Orders

    • BR: bedrest
    • BRP: bedrest privilege
    • OOB ad lib: out of bed, whenever
    • OOB to chair: out of bed to chair
    • NWP- non weight baring
    • T&P- turn and position
    • RLE- right lower extremity
    • LLE- left lower extremity
  • Pressure Ulcer Stages
    • Stage 1: skin is intact
    • Stage 2: tissue damage is superficial, partial thickness loss [abrasion, blister, shallow crater]
    • Stage3: full thickness skin loss, damage to the subcut tissue may or may not have undermining [deep crater]
    • Stage 4: eschar is present, full thickness loss, extensive destruction, tissue necrosis, damage to muscle, bone or supporting structures
  • Undermining
    Tissue destruction underneath intact skin along with wound margins
  • Orthopenic position
    Facilitates breathing
  • Eschar
    Thick, leather-like, necrotic tissue. must be removed surgically or enzymatically in order for wound healing to occur "debridement of wound"