Potter and Perry chapter 38, 43, 47, 48, 44, 45, 46 – Flashcards

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

Involves positioning so no excessive strain is placed on a person's joints, tendons, ligaments, or muscles which maintains adequate muscle tone and contributes to balance

reduce the risk of injury to musculoskeletal sys. & facilitate body mvmts., allowing physical mobility w/out muscle strain & excessive use of muscle energy

the principle of proper body mechanics when lifting or carrying objects

equilibrium of an object

face the direction of mvmt.

divide balanced activity between arms and legs

Leverage, rolling, turning, or pivoting

decrease the force required to move an object

Skeletal system:Provides attachments for muscles and ligaments /Provides leverage for movement Skeletal muscles: Help movement of bones and joints Nervous system:Regulates movement and posture

Postural abnormalities- congenital or acquired abnormalities Impaired muscle development-muscular dystrophies Damage to central nervous system (CNS)-trauma from head injury, CVA, meningitis Musculoskeletal trauma-Fractures, sprains, from direct trauma & can come from other problems like osteoporosis

Control your weight Reduce your risk of cardiovascular disease Reduce your risk for type 2 diabetes and metabolic syndrome Reduce your risk of some cancers Strengthen your bones and muscles Improve your mental health and mood Improve your ability to do daily activities and prevent falls, if you're an older adult Increase your chances of living longer

Developmental changes Behavioral aspects Environmental issues cultural and ethnic influences Family and social support

Pt.'s knowledge of exercise and activity barriers to a program of exercise and physical activity current exercise habits what motivates them what they see as appropriate and enjoyable know which specific disease entities are associated with different cultural and ethnic origins pt.'s expectations concerning activity and exercise individual perceptions of what is normal or acceptable

1. Activity intolerance 2. ineffective coping 3. impaired gas exchange 4. Risk for injury 5. impaired physical mobility 6. imbalanced nutrition: more than body requirements 7. Acute or chronic pain

disorders of the bone, scoliosis, birth defects with muscles, ligaments

osteoporosis, decreased joint mobility, inflammatory joint disease, degenerative joint disease

hostility, giddiness, fear, anxiety; sleep-wake alterations; depression, sadness, dejection

increased cardiac output, decreased resting heart rate, increased RR and depth, decreased work of breathing, increased BMR, increased gastric motility, increased joint mobility, reduced bone loss, improved activity tolerance, decreased fatigue, improved tolerance to stress

Immobility disrupts normal metabolic rate and can cause a "stress" reaction within the endocrine system. *Prolonged bed rest increases the heart's workload, producing an increase in oxygen demand which in turn stresses the respiratory system. Pneumonia can occur as secretions lay dormant from bedrest. *When the client is immobile, the body often excretes more nitrogen than it ingests protein, which causes a negative nitrogen balance leading to weight loss, decreased muscle mass, and weakness resulting from tissue breakdown (catabolism). *According to evidence-based studies, calcium metabolism changes by the 2nd day of bedrest. This calcium loss continues for over 2 months, leading to bone fragility and increased risk for fractures in patients who are immobilized for long periods of time. *Immobility can lead to joint contracture, which is characterized by abnormal fixation of a joint which limits range of motion. *Urinary status and increased risk for kidney stones secondary to hypercalcemia can occu. *The risk for skin breakdown over pressure areas is a combination of the metabolic changes that occur from prolonged bedrest. Even just 3 hours of immobility can cause a pressure area with potential skin breakdown. Add to that the effects of gravity, poor nutrition, chronic disease, or impaired fluid intake and you have the perfect set-up for pressure ulcers.

delayed gross motor skills/ intellectual development/musculoskeletal development

Coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment used during lifting, bending, moving, and performing activities of daily living. Balance is achieved when a relatively low center of gravity is balanced over a wide base of support

Equilibrium maintained as long as center of gravity aligns with base of support Facing direction of movement prevents abnormal twisting of the spine Balanced use of arms & legs reduced risk of back injury. Leverage, rolling. Turning & pivoting requires less work than lifting Less friction = less force needed to move object. Alternating period of rest & activity helps to reduce fatigue and injury

Range of joint motion, Gait, body alignment, pain association with activity.

Musculoskeletal system, Skin integrity, Elimination system, Psychosocial problems, Developmental changes.

enhance their feelings of well-being, as well as their endurance, strength, and health.

Tighten stomach muscles, tuck pelvis Bend at the knees Keep weight lifted close to the body Maintain trunk erect and knees bent Avoid twisting Maintain a center of gravity.

the use of range-of-motion exercises.

information regarding the patient's ability to stand, sit, and lie down, as well as degree of mobility, ROM, gait, ability to exercise and activity tolerance.

contributes to the high incidence of work related musculoskeletal problems & back injuries in nurses and other healthcare staff.

delay in gaining independence/accomplishing skills/social isolation can occur

Physiological systems are at risk for changes in family and social structures.

Decrease in physical activity; Hormonal changes; Bone reabsorption

Immobility occurs when one is able to move but restricted by some event or condition. Activity intolerance occurs when movement is NOT impaired, but causes excessive cardiac, resp, or psychological distress.

the pt is relaxed and in a "natural" position. Good alignment should be your goal when repositioning clients in bed, chairs, or while ambulating.

Metabolic assessment includes anthropometric measurements (Ht, Wt, Skinfold Thickness) and analysis of intake and output to assess for dehydration. *The respiratory assessment (performed q2h for pts on bedrest) includes inspecting the chest for wall movement auscultating the lungs for decreased breath sounds, crackles, and wheezes. *The cardiovascular assessment includes measurement of vital signs, peripheral pulses, apical pulse, orthostatic hypotension, DVT, and edema. *The musculoskeletal assessment includes assessing muscle strength and tone, loss of muscle mass, incidence of contractures, and ROM. ID pts at risk for osteoporosis. *The skin needs to be assessed for integrity or early changes in skin condition. The Braden Scale is a tool used to ID high risk clients and is assessed every shift. Skin assessment should occur at least q2h and documented. When assessing the elimination system, intake and output, bowel sounds, and bowel and bladder habits need to be checked. Dehydration increases the risk for thrombus formation, electrolyte imbalances, skin breakdown, infections and impaired elimination. During the psychosocial assessment you will focus on the client's emotional state, behavior, and sleep-wake cycle. How does the pt seem to be handling the immobility? Acute confusion (known as delirium) must be further analyzed for cause and treated appropriately. The developmental assessment looks at how immobility affects the normal development of clients across the lifespan. Altered family roles and response to the pt can be significant

Impaired physical mobility Risk for disuse syndrome Risk for injury Impaired skin integrity Social isolation

correct body alignment permits optimal musculoskeletal balance and operation and premotes good physiological functioning; good alignment consist of The head is held erect. The face is in the forward position, in the same direction as the feet. The chest is held upward and forward The spinal colum is upright, and the curves of the spine are within normal limits The abs muscles are held upward and buttocks downward

Hospitals want to ensure that its patients/residents are cared for safely, while maintaining a safe work environment for employees. To accomplish this, direct care staff on high risk patient/resident care areas should assess high risk patient handling tasks in advance to determine the safest way to accomplish them. Additionally, mechanical lifting equipment and/or other approved patient handling aids should be used to prevent the lifting and handling of patients/residents except when absolutely necessary, such as in a medical emergency. 1. Avoid hazardous patient handling and movement tasks whenever possible. If unavoidable, assess them carefully prior to completion. 2. Use mechanical lifting devices and other approved patient handling aids for high-risk patient handling and movement tasks except when absolutely necessary, such as in a medical emergency. 3. Use mechanical lifting devices and other approved patient handling aids in accordance with instructions and training

Equipment used to lift, transfer, reposition, and move patients. Examples include portable base and ceiling track mounted full body sling lifts, stand assist lifts, and mechanized lateral transfer aids.

Equipment used to assist in the lift or transfer process. Examples include gait belts with handles, stand assist aids, sliding boards, and surface friction-reducing devices

•Pain can always be controlled / improved -( it cannot). •Doctors can always find a cause for pain - (they often cannot but this usually means the cause is not sinister.) •It is unsafe to use analgesia to maintain activity for fear of masking damage - (this is not true.) •Rest is good for pain until I 'heal up' -( you may never 'heal' and exercise is positively beneficial for many reasons.) •Many people become convinced that "hurt must equal harm". (In chronic pain, this is wrong and it is important to understand that "Hurt does not equal harm!")

a. age b. fatigue c. genes d. neurological function

In its simplest form, the pain circuit in the body can be described as follows: pain stimulates pain receptors, and this stimulus is transferred via specialised nerves to the spinal cord and from there to the brain.

The experience of pain has at least two different components. The two main ones are what we call a 'sensory component' and an 'emotional component'

a. Characteristics of pain (PQRST) (1) Palliative / Provocative factors of pain (a) Aggravating factors 1) Question the patient on what makes the pain increase 2) Example - "Does your pain become worse upon exertion?" (b) Alleviating factors 1) Ask patient to describe what makes pain go away or lessen. 2) Determine what pain relief methods have worked in the past. For how long these pain relief methods used? (2) Quality of pain (a) Encourage the patient to describe his/her pain (b) Examples - sharp, stabbing, pressure, dull, aching (3) Radiation (Location) of pain (a) Instruct the patient to point the area of pain. Patients with chronic or visceral pain might have difficulty localizing specific area. (b) Clearly document areas of pain. Utilize a diagram of the body to be more specific if needed. (4) Severity of pain (a) Since pain is subjective, it is very important to have patients rate the pain they are experiencing. This becomes extremely important when assessing the effectiveness of pain medications. (b) Various scales may be used. One example is a 0-10 scale 0 No Pain 1 2 Mild Pain 3 4 5 Moderate Pain 6 7 Severe Pain 8 9 10 As bad as it can be Pain (c) Ask patient to rate pain at various stages 1) At its worse 2) At its least 3) After pain medication (5) Time of pain (a) Duration 1) Ask how long the patient has been experiencing the pain 2) If pain is intermittent, ask how long the pain lasts and how often does pain occur (b) Chronology 1) Have the patient describe how the pain first began 2) Question if the pain has change since the onset 3) Identify if the pain is worsening or improving 4) Is the pain intermittent or constant? (6) Associated phenomena (a) Identify if there were any factors that seem to relate consistently to the pain (b) Examples - Increased anxiety before pain begins B.. Physiological responses (1) Sympathetic stimulation - occur with acute pain (2) Parasympathetic stimulation - with prolonged severe pain (3) Responses to watch - Vital signs, skin color, perspiration, pupil size, nausea, muscle tension, anxiety C. Behavioral Responses (1) Posture, gross motor activities (a) Assess if the patient guards an area (b) Does the patient make frequent position changes? (c) Posture and gross motor activities increased in acute pain, might be absent with chronic pain (2) Facial features - Does the patient have a pinched look? Are there facial grimaces? Look of fatigue? (3) Verbal expression - Does patient sigh, moan, scream, cry, repeat same words?

a. Pain is the body's defense mechanism that indicates the person is experiencing a problem. b. Classic definition of pain: Pain is an abstract concept which refers to a personal, private sensation of hurt, a harmful stimulus which signals current or impending tissue damage, and a pattern of responses which operate to protect the organism. c. Leading nursing definition: Pain is whatever the experiencing person says it is, existing whenever he/she says it does.

Cultures vary in what is an acceptable response to pain Different ethnicities may have different beliefs as to the meaning of the pain

Developmental considerations, food and fluid intake, disease conditions, sociocultural factors, psychological factors, activity and muscle tone, pathological conditions, medications, surgical procedures, diagnostic examination

urinary retention, urinary tract infection, urinary incontinence, urinary diversions

C) Staying with him while voiding Mr. Bales will probably be embarrassed if the nurse remains with him as he attempts to void and is more likely to have difficulty voiding

Social isolation, disturbed body image, urinary incontinence, pain, risk for infection, toileting self-care deficit, impaired skin integrity, impaired urinary elimination, constipation, urinary retention

Color: pale to amber, depending on concentration. Dark red if bleeding from kidneys or ureters. Bright red if bleeding from bladder or urethra. Dark amber is caused by liver dysfunction. Medications and foods can also cause alterations in color.

Normal: transparent at voiding. Renal disease patients: cloudy or foamy. Result of bacteria and WBCs: thick and cloudy.

More concentrated: stronger the odor. Stagnant urine, common in incontinent pt: ammonia odor. Diabetes mellitus or starvation: sweet or fruity odor. Possible infection: foul odor. Also, some food and medications can affect odor of urine.

Determines the size, shape, symmetry, and location of the kidneys.

Obtains detailed images of structures within the abdomen. The computer reconstructs a cross-sectional image of the abdomen and thus allows the health care provider to view pathological conditions such as tumors and obstructions.

Views the collecting ducts and renal pelvis and outline ureters, bladder, and urethra.

Identifies gross renal structures and structural abnormalities in the kidney using high-frequency, inaudible sound waves.

Identifies structural abnormalities of bladder or lower urinary tract. It is also used to estimate the volume of urine in the bladder.

Determines bladder muscle function and evaluates cause of incontinence.

Provides direct visualization, specimen collection, and/or treatment of the interior of the bladder and urethra.

Visualizes the renal arteries and/or their branches to detect narrowing or occlusion.

Patient education, maintaining elimination habits, maintaining adequate fluid intake, promoting complete bladder emptying, preventing infection, medications.

Perineal hygiene, catheter care, adequate fluid intake, avoid the routine use of catheters, collaborate with health care providers to remove catheters when medical indications no longer exist.

absorption, secretion, elimination

Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out.

Age, diet, fluid intake, physical activity, emotional stress, depression, personal habits, position during defecation, pain, pregnancy, surgery and anesthesia, medications, diagnostic tests(colonoscopy)

Constipation, impaction, diarrhea, incontinence, flatulence, hemorrhoids.

Obtain diet and medication history; Identify signs and symptoms associated with altered elimination patterns; Determine impact of underlying illness, activity patterns, and diagnostic tests on bowel elimination patterns.

Bowel incontinence, constipation, risk for constipation, perceived constipation, diarrhea, toileting self-care deficit

X-ray of abdomen

An X-ray film examination using an opaque contrast medium(barium). Examines the structure and motility of the upper gastrointestinal(GI) tract, including pharynx, esophagus, and stomach.

An endoscopic examination of the upper GI tract allows more direct visualization through a lighted fiber-optic tube that contains a lens, forceps, and brushes for biopsy.

An X-ray film examination uses an opaque medium and air that outlines the colon and rectum to examine the lower GI tract.

This technique uses high-frequency sound waves to echo off body organs, creating a picture.

An endoscopic examination of the entire colon uses a colonoscope inserted into the rectum.

An examination of the interior of the sigmoid colon with a flexible or rigid lighted tube.

An X-ray film examination of the body from many angles uses a scanner analyzed by a computer.

A noninvasive examination uses magnet and radio waves to produce a picture of the inside of the body.

Contrast material is introduced to jejunum, allowing entire small intestine to be studied.

Encouraging adequate fluid intake and nutrition, providing privacy, properly positioning on bedpan, encourage physical activity, patient education,

Choosing a time of day, giving stool softeners, a hot drink or fruit juice, helping patient to toilet, avoiding medications that increase constipation, providing privacy, instruct patient to lean forward while sitting on toilet, not criticizing or conveying frustration if the patient is unable to defecate, maintaining normal exercise within the patient's physical ability.

Nurses are legally and ethically responsible for managing pain and relieving suffering.

causes of pain

Description, Intensity, location, aggravating and relieving factors

The meaning that a person associates with pain effects the experience of pain and how one adapts to it. This is often closely associated with cultural background. Cultural beliefs and values effect how individuals cope with pain. Individuals learn what is expected and accepted by their culture, including how to react to pain. (health care providers often mistakenly assume everybody responds to pain in the same way.) Some cultures believe it is natural to demonstrative about pain. Others tend to be more introverted. As a nurse, explore the impact of cultural differences on pain and make adjustments on plan of care.

Not all pain is treated the same. One would treat an acute pain differently than a chronic pain.

Description (sharp, dull, aching, radiating), Intensity (pain scale), location (patient points to, describes), aggravating (things that make it worse) and relieving factors (things that make it better)

Age Fatigue Genetics Neurological function (diabetes) Attention Previous experience Family and social support Spirituality Anxiety Coping style Cultural factors

PCA infusion pumps Analgesics Paraneural local anesthetic infusion Topical analgesics Local analgesics regional analgesics Epidural analgesics

e.g.: not taking medications as prescribed tolerance economic reasons cultural reasons severity of pain anxiety not reporting pain

30-60 minutes after administering, assess vital signs, ask patient pain level. Assess sedation level.

Energy intake > output = obesity, risk for diabetes, risk for hypertension, risk for hyperlipidemia Energy intake < output = nutritional deficit, malnutrition, electrolyte imbalance, poor skin integrity, decreased immune function, osteoporosis, anemia, etc.

Loss of appetite? Data from patients regarding nutritional practices Determine patient's nutritional energy needs Obtain patient's dietary history Assess effects that illness is having on ability to prepare meals at home

...

Cancer of the head, neck, and upper GI Critical illness/trauma Neurological and muscular disorders Stroke Dementia Parkinsons Myopathy Gastrointestinal disorders Enterocutaneous fistula Inflammatory bowel disease Mild pancreatitis Respiratory failure with prolonged intubation Inadequate oral intake from anorexia nervosa, difficulty chewing and swallowing, severe depression

Non-functional GI tract Massive small bowel resection GI surgery GI bleed Paralytic Ileus Intestinal obstruction Trauma to abdomen, head, or neck Severe malabsorption Intolerance to enteral feeding Chemotherapy radiation Bone marrow transplant Extended bowel rest Enterocutaneous fistula Inflammatory bowel disease exacerbation SEvere Diarrhea Moderate to severe pancreatitis Preoperative Total parenteral nutrition Preoperative bowel rest Treatment for comorbid malnutrition in patients with nonfunctional GI tracts Severely catabolic patients when GI tract is nonusable for more than 4-5 days

...

When 75% of nutritional needs are being met by enteral feedings or reliable dietary intake, PN therapy is usually discontinued.

Hand Hygiene Dip tube with surface lubricant into glass of water Insert tube into nostril to back of throat aiming back and down toward ear Have patient flex head toward chest after tube has passed through the nasopharynx Encourage patient to swallow by giving small sips of water or ice chips as possible. Advance tube as patient swallows. Emphasize need to mouth breathe and swallow during procedure. When tip of tube reaches the carina (~10 inches), stop and hold tube near ear and listen for air exchange from distal portion of the tube. Advance tube each time patient swallows until tube has been passed. Check for position of tube in the back of the throat with penlight and tongue blade. Keep tube secure as you measure pH to verify placement of tube and XRAY. Apply tape. Irrigate with 30 mL of water before and after each medication per tube.

Shear, friction, decreased mobility, decreased sensory perception, fecal or urinary incontinence, poor nutrition

pressure intensity, pressure duration, tissue tolerance

method of classifying pressure ulcer based on depth of tissue destroyed

intact skin with nonblanchable redness of a localized area usually over a bony prominence. Area may be painful, firm, soft, warmer, or cooler than adjacent tissue. Harder to notice in darker skinned patients

Partial thickness loss of dermis. Shiny or dry shallow ulcer without slough or bruising. Not to be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration (softening or breaking down of skin from prolonged exposure to moisture), excoriation (injury to surface of skin due to abrasion)

Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, and muscle is not exposed

Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling

Base of wound cannot be visualized and depth of tissue injury is unknown. Full thickness tissue loss in which actual depth is obscured by slough(yellow, tan, gray, green, brown) and/or eschar(tan, brown, black)

purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear

Integrated physiological processes. Tissue layers involved and capacity for regeneration

Those with tissue loss and those without

3 componets: inflammatory response, epithelial proliferation(reproduction), migration and reestablishment of the epidermal layers. inflammatory response in the first 24 hours (redness, swelling, serous exudate), new cells form and cover wound bed (scabs), bleeding stops and healing begins within 4-7 days

4 phases: hemostasis (injured blood vessels constrict and platelets gather to stop bleeding), inflammatory (damaged tissue and mast cells secrete histamine, surrounding capillaries and exudation of serum and white blood cells into damaged tissues this results in edema), proliferative (appearance of new blood vessels as reconstruction begins, begins and lasts 3-24 days, wound fills with granulation tissue, contraction of wound and resurfacing), and remodeling (maturation, final stage. Depending on depth and extent of wound, collagen scar continues to reorganize and gain strength over several months)

healing takes place when wound margins are neatly approximated as in surgical incision or paper cut, occurs by connective tissue deposition

wound edges not approximated, healing occurs by granulation tissue formation and contraction of wound edges

Hemorrhage (bleeding from wound site), infection (wound is infected if purulent material drains from it), dehiscence (partial or total separation of wound layers, fails to heal properly), evisceration (total separation, protrusion of visceral organs through wound opening)

poor nutrition, poor sensory perception, moisture, degree of activity, mobility, friction or shear, tissue perfusion, infection, age

Good nutrition, good sensory perception, degree of activity, mobility, tissue perfusion, age

?????Easily cleaned and repaired, edges are clean and intact

?????Treatment is lengthy and costly

risk for infection, imbalanced nutrition: less than body requirements, acute or chronic pain, impaired physical mobility, impaired skin integrity, risk for impaired skin integrity, ineffective peripheral tissue perfusion, impaired tissue integrity

identify underlying condition or pathology involved, note general debilitation, determine nutritional status, review lab results, note skin color, texture, turgor, odor, inspect surrounding skin, keep clean and dry, assist with debridement

participate in prevention measures and treatment program, verbalize feelings of increased self esteem and ability to manage situation, maintain optimal nutrition and physical well being, display timely healing of skin lesions, wounds, or pressure sores without complication

1. damage to skin caused by scraping; 2. process of scraping or rubbing

Cleansing of or removal of dead tissue from a wound

separation of edges of wound, revealing underlying tissues

Convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage.

A thick layer of dead tissue and tissue fluid that develops over a pressure ulcer or thermal burn.

protrusion of visceral organs through a surgical wound

Fluid, cells, or other substances that have been slowly discharged, from cells or blood vessels slowly through small pores or breaks in cell membranes.

SOFT, PINK, FLESHY PROJECTION OF TISSUE THAT FORMS DURING THE HEALING PROCESS IN A WOUND NOT HEALING BY PRIMARY INTENTION

Collection of blood trapped in tissues of the skin or an organ

termination of bleeding by mechanical or chemical means or the coagulation process of the body

hardening of a tissue, particularly the skin, because of edema or inflammation

torn, jagged wound

inflammation, sore, or ulcer in the skin over a bony prominence

primary union of the edges of a wound, progressing to complete scar formation without granulation

wound closure in which edges are separated; granulation tissue forms to fill gap; and finally, epithelium grows in over the granulation, producing a larger scar than results with primary intention

point at which tissues receive insufficient oxygen and perfusion