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MDC 1 Exam 2

Terms in this set (40)

Flexion
bending a joint - bicep curls
Extension
straightening a joint - elbow when throwing a shot put
Abduction
movement away from the center of gravity - jumping jack & move arms and legs out
Adduction
movement towards the center of gravity (you ADD to the body) - return to regular position at end of jumping jack
Circumduction
movement in a circular motion - swinging a tennis racket overhead; spiking a volleyball
Opposition
occurs with your thumb when the tip of the thumb reaches the tip of a finger
Fowler's position
a semi-sitting position; the head of the bed is raised between 45 and 60 degrees
Semi-Fowler
30 degrees, -Promotes respiratory function, Lowers Diagrams allowing better expansion.
High Fowler
45-90, -Helps with cardiac dysfunction
Orthopneic Position
patient leans forward to help with respiration, Used in shortness of breath (SOB)
Lateral Position
side lying position (Left lateral à help with increasing blood flow to the heart if blood pressure is low)
Oblique position
lying semi to the side with leg slightly bent, may be helpful for reducing pain
Prone
lying on the stomach, -Allows better respiration and chest expansion, and it should be use for short periods of time.
-Creates a significant lordosis
-Never use in patients with back surgery or injury. (seen in patients with ARDs to help with lung expansion and reduce atelectasis)
Sims' position
(lying semi lateral and semi on the stomach) -Semi-prone
-Position for suppository, enema administration. Perineal procedures
-Facilitates mouth drainage, limits trochanter and sacrum pressure
Supine Position
(lying on the back)-Dorsal recumbent- shoulders and head are elevated in pillows.
-Alignment should be in a comfortable position
-Usually used with spinal injury patients as the vertebrae needs to be stable.
Trochanter roll
tightly rolled towels placed adjacent to the hip and thighs.
,prevents external rotation of the hip - hip fracture patients to reduce mobility
Hand roll
rolled washcloths to keep wrist and hand in natural position and prevent claw-hand, used in patients with flexion contractures
Abduction pillow
wedge to prevent internal hip rotation. Usually use after hip surgery
Cradle boots
Spongy rubber used to prevent foot-drop, skin breakdown and external hip rotation
Foot board
foot cradles used to secure the foot of the bed but allow free movement.
Dangling
Help the patient to sit upright on the edge of the bed, sit there for a few seconds to a minute, then transition to helping them stand, Reduces risk of orthostatic hypotension - dizziness or fainting - fall
Canes
hold cane on the strong side
advance cane with weak side for a wide base of support
Crutches
about 1-2 inches below your armpits. The handgrips of the crutches should be even with the top of your hip line. Your elbows should be slightly bent when you hold the handgrips.
Purposes for positioning your client
Prevent skin breakdown,
Prevent muscle discomfort,
Prevent damage to superficial nerves and blood vessels,
Prevent contractures
Effect on Musculoskeletal system
•Bed confinement reduces 7 - 10% loss of muscle strength per week.
•Osteoporosis changes calcium metabolism leading to possible formation of renal calculi
•Impaired balance
•Foot drop
•Altered joint mobility
•Pathological fractures
•Decreased stability
Interventions for supporting the musculoskeletal system during impaired mobility
PROM, Reposition, encourage independent activity and assistive devices
Immobility Effect on Respiratory system
decrease all muscle strengths including lungs, increase secretion (aspiration pneumonia), decreased ventilation capacity in response to exercise, respiratory depth decreases affecting ventilation, air passage blocks can lead to atelectasis (collapse of air sacks and alveoli)
Interventions for supporting the respiratory system during impaired mobility include:
turn, cough, and deep breathe every two hours, incentive spirometer every two hours while awake, chest physiotherapy, 2000mL fluids, asses lungs, cough, sputum production every shift
Effect on the Circulatory system
Increases the workload of the heart
Promotes venous stasis
Orthostatic hypotension
Risk of thrombus formation (DVTs or PEs à especially important post surgical
Frequently assess/monitor respiratory and cardiovascular systems
Encourage early mobility, promote adherence to heparin prophylaxis, and use of SCDs (sequential compression devices)
Nursing interventions to support the circulatory system during impaired mobility
increase activity, asses for peripheral, sacral and pedal edema, asses calf's for red, warm, tender, and compare for thrombus formation, TED hose or compression devices, low dose heparin.
Effect on Metabolism
•Drop in the metabolic rate
•Can stimulate a stress response
•Decreased appetite
•Weight loss
•Bone loss from calcium reabsorption
•Muscle mass reduction
Nursing interventions to support the metabolic system during impaired mobility
high calorie and protein diet, vitamins and minerals, I and O, calorie count
Effect on the Integumentary system
Prolonged immobility - compresses the capillaries in that area of the skin - causing tissue ischemia & eventual necrosis (cell death) - pressure injuries
Nursing interventions to prevent pressure ulcer formation during impaired mobility
change positions from skin assessment, pressure ulcer risk, shift weight every 15 min, positioning devices, skin and perineal care
Effect on the gastrointestinal System
slows peristalsis, constipation, paralytic illeus
Nursing interventions to support the gastrointestinal system during impaired mobility include
8-10 glasses of water/day or maintenance IV fluids if needed
Fruits & vegetables are high in essential nutrients and fiber, which provide the body with needed energy and promote proper bowel function
Proper positioning during elimination helps to reduce straining or hemorrhoid formation and promotes full elimination
Effects on the Genitourinary system
Decreased mobility can lead to stasis of urine in the bladder - puts the patient at risk for UTIs and Kidney Stones
Nursing interventions to support the genitourinary system during impaired mobility
fluids, bladder training, use bladder scanner for urinary retention, use warm water on perineum area
Psychological effects of immobility
Isolation
Mood change
Depression
Anxiety
Nursing interventions to support one's psychosocial or emotional state during times of impaired mobility
involve clients in care, provide stimuli, assist with grooming and hygiene, involve client in planning daily routine, provide clock and calendar
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