Movement and Mobility - Immobility Danger
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| Long bones | contributes to height (femur, fibula, & tibia) & length (e.g., phalanges of fingers & toes)
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| Short bones | (e.g., carpal bones & patella the knee) occur in clusters & when combined w/ligaments & cartilage, permit movement of extremities.
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| flat bones | bones in skull & ribs, provide structural contour.”
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| irregular bones | make up vertebral column & mandible
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| Synostotic joints | bones jointed by bones - no movement - bony tissue between bones provides strength & stability - skull, where fusion of joint occurs later in life
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| Cartilaginous joints or synchondrosis joint | cartilage unites bony components - allows for bone growth while providing stability - when bone growth is complete, joints ossify – 1st sternocostal
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| Fibrous joints or syndesmosis joint | ligament or membrane unites 2 bony surfaces - fibers of ligaments flexible & stretch, permitting limited movement - paired bones of lower leg (tibia and fibula)
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| Synovial joints or true joint | a freely movable joint - contiguous bony surfaces covered w/articular cartilage & connected by ligaments lined w/synovial membrane - joining of humeral radius & ulna by cartilage & ligaments forms pivotal joint
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| Other types of synovial joints are | ball-and-socket joints, such as the hip joint, and the hinge joints such as the interphalangeal joints of the fingers
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| Ligaments | bind joints & connect bones and cartilage
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| Tendons | connect muscle to bone – Achilles tendon (tendo calcaneus) is thickest and strongest in body.
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| Cartilage | nonvascular, supporting connective tissue located mainly in joints, thorax, trachea, larynx, nose & ears
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| Skeletal muscle | helps us move and holds us together
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| How nervous system regulates movement and posture | During voluntary movement, impulses descend from motor strip to spinal cord - exits through efferent motor nerves & travels through the nerves,
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| P | Pattern - onset, duration, what relieves or exacerbates – do anti-inflammatory agents help?
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| A | Area - Location of pain
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| I | Intensity - 0-10 scale, smiley faces, or terms pt. can understand
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| N | Nature - throbbing, burning, aching, crushing, pressure
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| Gait | Conformity, Symmetry, Rhythm of gait & arm swing - begins w/heel strike of one leg & continues to heel strike of the other leg.
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| Assessing a client's gait allows you to draw conclusions about | balance, posture, safety, and ability to walk without assistance.
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| Body alignment & symmetry | 2 arms, 2 legs, etc.
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| Posture | sitting, standing - Muscles associated primarily with maintaining posture are short and - converge obliquely at a common tendon.
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| Which muscles primarily associated with posture? | Muscles of the lower extremities, trunk, neck, and back are concerned primarily
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| Posture | the position of the body in relation to the surrounding space
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| Torticollis | Inclining of head to affected side, in which sternocleidomastoid muscle is contracted
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| Footdrop | Inability to dorsiflex & invert foot - nerve damage – foot fixed in plantar flexion - ambulation difficult - unable to lift toes off ground
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| Pigeon toes | Internal rotation of forefoot or entire foot, common in infants
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| Contractures | can begin to form after only 8 hours of immobility in the older adult client
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| Range of motion joints | flexion, extension, rotation
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| Fasciculation | Localized muscle twitching of a single muscle group
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| Spasms | neuralized involuntary muscle contractions
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| Ecchymosis | bruise
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| The individual of average weight and height and without a chronic illness on bed rest loses muscle strength | from baseline levels at a rate of 3% a day.
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| Immobility disrupts normal metabolic functioning: decreasing | metabolic rate; altering met of carb, fats, & proteins; causing fluid, electrolyte, & Ca imbalances; GI disturbances - decreased appetite & slow peristalsis
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| When the client is immobile, client's body often excretes more | nitrogen (end product of amino acid breakdown) than it ingests in proteins, resulting in neg nitrogen balance
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| Immobility causes release of Ca into circulation | if kidneys unable to respond appropriately, hypercalcemia results - Pathological fractures occur if Ca reabsorption continues
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| The heart therefore works __ during periods of prolonged rest | harder and less efficiently
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| Immobilization causes two skeletal changes | impaired calcium metabolism and joint abnormalities.
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| When disuse osteoporosis occurs | client is at risk for pathological fractures
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| Renal calculi occurs often because immobilized clients | frequently have hypercalcemia.
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| metabolic effects of immobility | Altered endocrine, calcium absorption, and GI function
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| Cardiovascular effects of immobility | Increases Cardiac workload, Orthostatic hypotension, Thrombus
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| GI Effects of immobility | Decreases appetite, stress ulcers, Decreases peristalsis, constipation
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| Urinary elimination effects of immobility | Urinary stasis, UTI, Renal calculi
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| Respiratory effects of immobility | Increase resp. effort, altered gas exchange, Atelectasis and hypostatic pneumonia
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| Musculoskeletal changes in immobility | Decrease endurance, stability, balance, Muscle atrophy, joint abnormalities, Dec. bone density, risk of fx & fall
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| Integumentary effects of immobility | Pressure ulcers, Ischemia, shearing
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| Psych effects of immobility | Anxiety, depression, helplessness, hopelessness, dependency
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| Lordosis | anterior flexion of neck, slumping of shoulders – pregnant women and toddlers
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| Kyphosis | hunchback – elderly
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| Crepitus | grating sound/feel) breakdown of joint when the bones grate together
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| Tenderness Grading Scale | 0 No Tenderness; 1+ Client says it is tender, 2+Client complains of pain & winces;3+Client complains of pain, winces and pulls back; 4+Client will not allow palpation
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| Assess CMS (Circulation, Motion, Sensation) to extremities | routine assessment for knee replacements, fractures, - Circulation – Color, temperature, cap refill, pulses; Motion – ROM; Sensation – numbness or tingling to hands or feet
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| Because people are not geometrically perfect, their centers of gravity are | usually at 55% to 57% of standing height and are located in the midline
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| Face direction of movement to | avoid twisting
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| Metabolic interventions for immobility | high-protein, high-caloric diet with vitamin B and C supplements - Dehydration and edema increase the rate of skin breakdown - monitor lab electrolytes, serum protein (albumin and total protein), and (BUN)
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| Turn, cough and deep breathe every | 1 to 2 hours
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| If a client has an atelectatic area, chest movement | is often asymmetrical
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| SCDs | sequential compression devices
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| signs of venous stasis | edema and delayed wound healing
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| Lying down increases heart rate and can create | 3rd heart sound indicating CHF
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| Measure bilateral calf circumference, and record it daily as an alternative assessment | for DVT
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| Unilateral increases in calf circumference are an early indication of | thrombosis
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| CPM = continuous passive motion | machines used after joint surgeries to provide passive range of motion to avoid stiffening
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| Continually assess the client's skin for breakdown and color changes such as | pallor or redness
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| Complete | through the bone
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| Incomplete | partially through the bone
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| Simple | (closed): fracture of bone with no skin break
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| Compound | (open): fracture causes break in skin
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| Pathological | sight pressure or minimal trauma fractures bone. Bone is weak r/t osteoporosis, bone cancer, osteomyelitis
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| Greenstick | splinters on the top, but the bottom just bends – common in children.
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| Stress fracture | r/t prolonged or repeated low-level stress. Also called fatigue fractures
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| Displaced | fragment is over-riding other bone fragment
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| Spiral | the line of the fracture extends in a spiral direction along the shaft of a bone
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| Transverse | a fracture in which the line of the break extends across the bone shaft at a right angle to the longitudinal axis
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| Longitudinal or oblique fracture | Parallel or at an angle to longitudinal axis
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| Signs & Sx Fracture | Pain, Swelling, Ecchymosis, Impaired mobility, Unnatural position (deformity), Impaired sensation, numbness, tingling, Loss of distal pulse indicates vascular complication, Crepitus
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| fracture hematoma | Fibrin clot forms at break
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| Order of events of bone healing | Bone cells die, inflammation, fracture hematoma, osteoblastic activity forms immature bone called callus, true bone replaces callus in 4-6 weeks
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| Reduction | Realignment of bones - can be open (surgery) or closed - Allows recovery of normal position and range of motion (ROM).
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| Open Reduction - Internal Fixation (ORIF) | open the skin and re-aline the bone
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| The two diagnoses most directly related to mobility problems are | impaired physical mobility & risk for disuse syndrome.
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| The diagnosis of impaired physical mobility | applies to the client who has some limitation but is not completely immobile.
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| The diagnosis of risk for disuse syndrome | applies to the client who is immobile and at risk for multisystem problems because of inactivity
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| Delayed union | not as fast as normal – healing will occur, though
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| Non-union | fracture fails to heal even though appropriate interventions – usually an underlying pathology
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| mal-union | bones don’t heal right and so bone must be broken again and replaced
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| Fat Embolus | Can travel to lungs and cause a PE or travel to heart and cause MI
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| Complications of Fractures – Compartmental Syndrome | Nerve and blood vessel damage or destruction from swelling and edema in a confined space - in arms/leg where expansion limited by fascia - Risk greater if muscle damage occurred w/fracture
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| 5 Ps | Pain, pallor, parasthesia, paralysis, decreased perfusion - Neurovascular deterioration manifested by this
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| Treatment of Hip Fractures | Immobilization in Buck’s traction until surgery can be performed - 24-48 hr. max - Relieves muscle spasm, Surgery is tx of choice - ORIF – open reduction, internal fixation - Permits early mobilization
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| Endoprosthesis | fracture is on the ball of the bone
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| Intracapsular repaired with | endoprosthesis
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| Extracapsular repaired with | nail plates or prosthesis
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| Abductor pillow between legs | abducts the legs – keeps the legs apart and so they can’t cross legs
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| Osteoarthritis – OA - formerly Degenerative Joint Disease (DJD) | Slowly progressive, non-inflammatory disorder of the synovial joints
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| HA injections | into joint (hyaluronic acid)
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| Osteoporosis | Chronic progressive loss of bone tissue, low bone mass, structural deterioration of bone tissue - S/S: Bone loss occurs without symptoms - Bones become weak/fracture easily with strain, bump or fall
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| Common sites of osteoporosis | hip, vertebrae, and wrist - Collapsed vertebrae leads to back pain, loss of height, spinal deformities such as Kyphosis.
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| Bone mineral density | assesses bone mass
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| DEXA | BMD test measures bone density of spine, hips and forearm
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| Interventions for osteoporosis | Proper nutrition, exercise, weight bearing, prevention of fractures, drugs, Calcium 1000-1500 mg/day and Vitamin D 400-800 Units, Estrogen replacement, Fosmax or Evista
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| Osteoporosis | 8x more common in women - lower Ca intake, less bone mass because of smaller frame, Resoprtion begins @ earlier age - accelerated @ menopause – Pregnancy/breast feeding deplete skeletal reserve
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| Pallor | temperature changes
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| C-reactive protein | inflammation, infections, wide spread malignancy. Normal-negative – if positive, we know there is an infection, but don’t know where.
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| Rheumatoid Factor | Presence of autoantibody in serum. Not specific for RA, seen in other connective disorders. Normal is negative or titer <1:20 – tests for autoimmune disorders.
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| ESR: Erythrocyte Sedimentation Rate Sed Rate | Non-specific index for inflammation. Number of RBC’s that settle in 1 hour - Seen w/inflammatory response. Normal: <20 mm/hr - not specific to disease, but general
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| Serum Protein Electrophoresis | infection, neoplasm, rheumatoid-collagen disorders, inflammatory disorders
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| Radiography | density of bone, changes in bones and joints
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| Nuclear medicine | Use of radioactive isotopes to evaluate muscles bones, joints
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| Bone Scan | Injection of radioisotopes so evaluate perfusion of blood through bones.
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| Avascular necrosis | when you have decreased blood supply and RBCs break down.
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| MRI: Radio waves and magnetic fields used to view | soft tissue & cartilage. Useful in DX avascular necrosis, disk disease, tumors, osteomyelitis, ligament tears, cartilage tears
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| Flexion | toward body
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| Abduction | away
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| Adduction | toward
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| Pronation | palm down
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| Supination | palm up
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| Circumduction | arm around in circle
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| Inversion | ankle in – a lot with club feet
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| Eversion | ankle out
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| Rotation | head
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| Protraction | forward& =
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| Retraction | back & =
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| Fosamax | bone reabsorption inhibitor – prevents and treats Osteoporosis
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| NURSING IMPLICATIONS of Fosamax | Take with full glass of water & remain upright 30 minutes to avoid esophageal damage
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| Force exerted on body by gravity | weight
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| Froce that opposes movement | friction
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| Type of joint that is freely moveable | synovial
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| Normal state of balanced muscle tension | tonus
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| Motor strip located in the cerebral cortex | precentral gyrus
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| Lateral S curvature of the spine | scoliosis
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| Internal rotation of the foot | pigeon toe
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| Measures of attributes such as height, weight, and skinfold thickness | antropometric measurements
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| Max amount of movement at a joint | range of motion
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| Which of the following laboratory values would the nurse expect to see for a client experiencing prolonged immobility?Calcium 11.5 mg/dl |
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| Having the client __ can help prevent Orthostatic hypotension. | sit for 2 minutes before standing
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| Hematuria is a sign that the client | is possibly bleeding out.
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| Nurse caring for pt w/r-sided weakness - What should nurse do while walking w.pt? | Put a gait belt on the client and provide support on the right side - should always stand on pt affected side to support pt
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| Ligaments are elastic and | provide joint flexibility and support.
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| Tendons are fibrous bands of tissue that | connect muscle to bone.
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| Cartilaginous tissue is | nonvascular supporting connective tissue located in the joints, thorax, trachea, larynx, nose, and ear.
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| When a client is immobilized, which position is preferred to prevent skin breakdown? | Semi-Fowler's - head of bed elevated 30 degrees, Side-lying w/knees flexed puts press on greater trochanter area, supine = pressure on the scapula, buttocks, calf, & heels, prone puts pressure on anterior pelvis, knees, and elbows.
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| The most significant hazard of restricted mobility is | Deep vein thrombosis
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| most important for preventing deep vein thrombosis in an immobilized client? | Ensuring that compression devices are fitted correctly and pumping
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| The immobilized client should be instructed to | Take in a minimum of 2000 ml of water per day
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