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Ch 34 Mobility
Mobility and Body Mechanics
| Question | Answer |
|---|---|
| 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
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