NURS 317 - Final Exam with questions and Answers
What systems does mobility require the function of?
muscle, skeleton, nervous
Osteoarthritis
deterioration of articular cartilage mainly on weight-bearing joints
What are mobility changes seen in older adults?
-increased convexity of thoracic spine (kyphosis) caused by intervertebral disc shrinkage,
decreased height
-loss of muscle tone
-loss of subcutaneous fat
-arthritic joint changes
What do you need to assess in older adult's mobility?
assess muscle mass, tone, strength, joints and their function, alignment, movement and gait
What are the effects of immobility on the cardiovascular system?
risk for orthostatic hypotension and DVT/PE
What are the effects of immobility on the respiratory system?
-decreased resp. rate and depth
-pooling of secretions
-impaired gas exchange
What are the effects of immobility on the gastrointestinal system?
,-decreased apetite, peristalsis
-slower digestion
-altered protein metabolism
What are the effects of immobility on the genitourinary system?
-urinary stasis
-risk for renal calculi
-decreased bladder tone
What are the effects of immobility on the musculoskeletal system?
-decreased muscle size, tone, strength, joint mobility, flexibility, endurance, stability
-bone demineralization
-risk for contractures
What are the effects of immobility on the integumentary system?
risk for skin breakdown and pressure ulcers
What are the effects of immobility on the psychosocial system?
-powerlessness
-decreased socialization, self concept, sensory simulation
-altered sleep
-increased risk for depression
What should nurses promote for mobility?
-preserving, maintaining, and restoring as much mobility and function as possible
-body alignment to prevent injury
,-skin integrity (positioning)
-adequate circulation (compression devices)
-maintenance of muscle mass, tone, strength and joint ROM exercises
What equipment and moving devices can nurses use to care for bedridden patients?
-pillows, wedges, hand rolls, foot boots
-slide boards, draw sheets, hover mats, lifts
How do you care for bedridden patients?
-correct positioning to prevent joint issues
-ensure head of bead is at the appropriate height
-avoid friction/shear while moving
How do you care for ambulatory patients?
-know your patient's history, strengths, and weaknesses before moving
-use assistive devices = gait belts, canes, walkers, wheelchairs, etc.
-get physical therapy involved
IF YOU ARE UNSURE, ALWAYS ASK FOR HELP
Assessing for fall risk
-history of fall/s
-elderly, >70 years old
-impaired mobility
-ALOC
-confusion
, -not following directions
USE NURSING JUDGEMENT
What are nursing interventions to prevent falls?
-bed locked in and in lowest position
-call light in pt's reach and knowing how to use it
-patient in view of nurse's station
-belonging kept close to patient
-room is tidy and well-lit
-patient knows if they need to call for help to use bathroom
-assess patients hourly
-4 P's (position, pain, potty, personal needs)
How do nurses protect their own mobility?
-maintain upright posture
-use longest and strongest muscles
-stay as close as possible to object being lifted
-face the direction of your movement
-use your body weight as force
-push rather than pull
-to lift bend at the knees
Basal Metabolic Rate (BMR)
number of calories required to fuel involuntary activities of the body at rest
-men have a higher BMR based on muscle mass
What systems does mobility require the function of?
muscle, skeleton, nervous
Osteoarthritis
deterioration of articular cartilage mainly on weight-bearing joints
What are mobility changes seen in older adults?
-increased convexity of thoracic spine (kyphosis) caused by intervertebral disc shrinkage,
decreased height
-loss of muscle tone
-loss of subcutaneous fat
-arthritic joint changes
What do you need to assess in older adult's mobility?
assess muscle mass, tone, strength, joints and their function, alignment, movement and gait
What are the effects of immobility on the cardiovascular system?
risk for orthostatic hypotension and DVT/PE
What are the effects of immobility on the respiratory system?
-decreased resp. rate and depth
-pooling of secretions
-impaired gas exchange
What are the effects of immobility on the gastrointestinal system?
,-decreased apetite, peristalsis
-slower digestion
-altered protein metabolism
What are the effects of immobility on the genitourinary system?
-urinary stasis
-risk for renal calculi
-decreased bladder tone
What are the effects of immobility on the musculoskeletal system?
-decreased muscle size, tone, strength, joint mobility, flexibility, endurance, stability
-bone demineralization
-risk for contractures
What are the effects of immobility on the integumentary system?
risk for skin breakdown and pressure ulcers
What are the effects of immobility on the psychosocial system?
-powerlessness
-decreased socialization, self concept, sensory simulation
-altered sleep
-increased risk for depression
What should nurses promote for mobility?
-preserving, maintaining, and restoring as much mobility and function as possible
-body alignment to prevent injury
,-skin integrity (positioning)
-adequate circulation (compression devices)
-maintenance of muscle mass, tone, strength and joint ROM exercises
What equipment and moving devices can nurses use to care for bedridden patients?
-pillows, wedges, hand rolls, foot boots
-slide boards, draw sheets, hover mats, lifts
How do you care for bedridden patients?
-correct positioning to prevent joint issues
-ensure head of bead is at the appropriate height
-avoid friction/shear while moving
How do you care for ambulatory patients?
-know your patient's history, strengths, and weaknesses before moving
-use assistive devices = gait belts, canes, walkers, wheelchairs, etc.
-get physical therapy involved
IF YOU ARE UNSURE, ALWAYS ASK FOR HELP
Assessing for fall risk
-history of fall/s
-elderly, >70 years old
-impaired mobility
-ALOC
-confusion
, -not following directions
USE NURSING JUDGEMENT
What are nursing interventions to prevent falls?
-bed locked in and in lowest position
-call light in pt's reach and knowing how to use it
-patient in view of nurse's station
-belonging kept close to patient
-room is tidy and well-lit
-patient knows if they need to call for help to use bathroom
-assess patients hourly
-4 P's (position, pain, potty, personal needs)
How do nurses protect their own mobility?
-maintain upright posture
-use longest and strongest muscles
-stay as close as possible to object being lifted
-face the direction of your movement
-use your body weight as force
-push rather than pull
-to lift bend at the knees
Basal Metabolic Rate (BMR)
number of calories required to fuel involuntary activities of the body at rest
-men have a higher BMR based on muscle mass
