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Ch 34 Mobility

Mobility and Body Mechanics

What are the rules of body mechanics? assess situation, use leg muscles, appropriate height, use supportive devices
Active ROM Pt. does ROM themselves.
Passive ROM Nurse or physical therapist does ROM
Contractures Joint freezes in an abnormal position.
Ataxic gait Staggering and unsteadiness
Spastic gait Walking appears stiff and toes appear to catch and drag.
Waddling gait Walking with feet wide apart in a duck like fashion.
Hemiplegic gait Occurs when one leg is paralyzed or neurologically damaged, so the leg is dragged or swung around to propel forward
Festinating gait Walking on the toes as if being pushed.
Orthostatic hypotension Decreased ability to maintain systemic blood pressure when changing from a supine to an upright position.
Thrombus blood clot, composed of platelets, fibrin, and cellular elements that attach to the wall of an artery or vein.
Gross motor activities riding a bike, walking backwards, dancing..
Fine motor skills catching a ball, brushing teeth, washing hands
At what age does physical growth slow? between 6 and 12 y/o
Adequate intake of what vitamins is important to prevent ambormal skin changes? Vitamins A,B6, C, K, niacin and riboflavin
Name the three types of wound healing Primary Intention, Seconday and Tertiary intention
primary intention Wounds with minimal tissue loss heal with primary intention. The edges of the wound are approximated (lightly pulled together)
secondary intention wounds with full-thickness tissue loss like burns, deep lacerations and pressure ulcers have edges that do not readily approximate. scarring is more prevalent.
tertiary intention occurs when a delay ensues between injury and wound closure. aka delayed primary closure. may happen when a deep wound is not sutured immediately. a deeper wider scar occurs.
sequential compression device (912) promotes venous return from legs to decrease the risk of dvt and pe in clients with reduced mobility
types of dressings transparent films, foams, hydrocolloids, hydrogels, alginate, collagens, composites, contact layers, silver dressings
alginate dressing used for absorption in a deep or moderately draining wound
contact layer dressing nonadherent dressing minimizes disruption of new cells
silver dressings antimicrobial dressings used for infected wounds
methods of securing dressing tape, montgomery straps (used when dressing requires frequent changes, eliminate the need to remove tape with every dressing change), ace wraps, stretch nets, binders.
types of debridement mechanical, surgical, enzymatic (placing chemical products in the wound), autolytic (using bodys own fluid and cells)
jackson-pratt drain permits drainage to collect in a bulblike device that can be compressed to create suction.
nursing dx for skin integrity and wound healing impaired sking integrity, risk for infection, altered nutrition, impaired tissue integrity, altered self-concept, risk for impaired skin integrity
outcome identification for skin integrity and wound healing wound will demonstrate evidence of healing in specific time period. client will verbalize understanding of preventive skin care
how many mL are in an oz 30
normal urinary output w/ a catheter 30-50mL per hour
oliguria less than 30ml may indicate inadequate blood flow to the kidneys
average amount of urine per void 250-400mL
newborn-2 urine output daily 500-600mL
2-5 daily urine output 500-800mL
5-8 daily urine output 600-1200mL
8-14 daily urine output 1000-1500mL
14 and over daily urine output 1500mL
ADH secreted by thy hypothalamus and released by the posterior pituitary in the brain. causes the kidney to reabsorb water.
diuresis water excretion
urinary incontinence involuntary loss of urine
urge incontinence involuntary loss of urine after a strong feeling of the need to urinate
reflex incontinence involuntary loss of urine that occurs at somewhat predictable intervals when a specific bladder volume is reached
enuresis involuntary voiding whith no underlying pathophysiologic origin
stress incontinence a person experiences a loss of less than 50mL of urine with increased abdominal pressure.
maceration process of skin softening caused by continuous moisture or soaking
intermittent catheterization straight catheterization
indications for catheterization monitoring acutely ill patients, assessment of urinary output is necessary, surgical clients, comfort measure for terminally or severely ill patients.
how much feces is produced daily 150-300g
what amount of fluid intake is necessary to meet cellular needs and have enough left over to promote soft stool 2000mL
Created by: briannatapia