NUR 2356 Multidimensional Care I - Exam 2 Concept Guide | NUR2356 Multidimensional Care I - Concept Guide

NUR 2356 Multidimensional Care I - Exam 2 Concept Guide MDC I Concept Guide Exam_2 – Updated Multidimensional Care I - Exam 2 Concept Guide Extension Straightening the hinge joint to 180 degrees.A straightening movement that increases the angle between body parts. Flexion Bending the hinge joint at 90 degrees.The action of bending or the condition of being bent, especially the bending of a limb or joint. Abduction Movement of a limb away from the midline of the body. Adduction Movement of a limb toward the midline of the body. Active range of motion Patient moves the joint alone. • Movement performed without assistance Passive range of motion Patients move the joint with help. • Joint movement performed by someone other than the patient Fowler’s position (High and standard)/supine positioning High Fowlers: This is when the patient is sitting straight up with the head of the bed (HOB) at 60-90 degrees. Reasons for this position: This position could be used to do a procedure like inserting an NGtube to help facilitate swallowing or if there are swallowing deficits. This positioning also helps to open up the airway especially if the patient is having a hard time breathing. Fowlers: This is a comfortable sitting up in bed position with the HOB at 45-60 degrees. Reasons for this position: Helps facilitate better digestion and respiratory expansion and decrease respiratory effort due to proper airway alignment. It's common for patients with cardiac or respiratory conditions because it helps increase oxygenation. Supine: The patient is lying flat on their back and the HOB is flat. Reasons for this position: This is used commonly following surgical procedures as it helps to normalize the hemodynamics. The patient may also have a neck roll in place to help align the airway a little better. Crepitus Crepitus is a crackling or popping sound that occurs as a result of tissues rubbing together abnormally. The sound results from an abnormal interaction between air, fluid or bone Crepitus is often the result of arthritis or a previous joint injury. Proper body mechanics Moving clients up in bed Transferring clients out of bed Benefits of regular exercise 1. Benefits a. Heart and lung improvement i. Improved cardiac efficiency ii. Improved lung capacity iii. Decrease in hypertension b. Increases strength and mobility i. Improves: 1. Coordination 2. Alignment 3. Balance 4. Endurance c. Burns fat i. Improves body composition d. Cognitive functions i. Improves mood ii. Enhances memory iii. Slows neurodegenerative decline Deep vein thrombosis (DVT)/Venous thromboembolism Assessment HIS Leg Might Fall off • H-History of DVT in the past • I-Immobility • S-Surgery • L-Leg: varicose veins • M-Malignancy • F-Fracture Interventions o Provide comfort o Compression therapy o Positioning & exercise Pulmonary embolism Immobility Assessment • Focused Nursing History • Exercise and activity • Focused Physical Assessment • The Functional Independence Measure • Gait • Activity Tolerance • Psychologic • Complete neurologic assessments as ordered • Observe for changes in mentation or alertness • Observe for signs of delirium or withdrawn affect • Cardiovascular • Observe for changes in blood pressure, and orthostatic hypotension • Assess for new leg pain or difficulty breathing • Pulmonary • Assess lung sounds for adventitious sounds • Watch for any changes in cough, secretions or sputum • Like cardiovascular, watch for changes in breathing • Breathing difficulty and a feeling of “impending doom” could be pulmonary embolism • Renal and gastrointestinal • Complete ins and outs to verify fluid and nutrition status • Ensure regularity of bowel movements • Musculoskeletal and skin • Assess range of motion and strengths daily • Check over bony prominences for skin breakdown Complications and negative effects on the body 1. Pressure Injury 2. Constipation 3. Joint Contracture 4. Muscle Weakness 5. Balance of Problems 6. DVT 7. Pooling in secretions in lower lobes if Immobile for long periods 8. Orthostatic hypertension 9. Risk of mortality increases 1. Psychologic a. Frustration b. Anxiety and depression c. Delirium i. Increases length of stay ii. Decreases compliance 2. Cardiovascular a. Coagulopathies i. Blood pooling ii. Increased risk of deep vein thrombosis 1. Increased risk of pulmonary embolism b. Edema c. Changes in blood pressure 1. Orthostatic hypotension 3. Pulmonary a. Decreased gas exchange .Due to decreased thoracic expansion i.Increased risk of pneumonia b. Weakened cough 0.Inability to clear secretions 4. Renal and gastrointestinal a. Urinary .Urinary stasis 1. Increased risk of UTI i.Risk of urinary incontinence 1. Due to positioning b. Gastrointestinal .Risk of aspiration i.Malnutrition ii. Difficulty with bowel movements 1. Mobility increases peristalsis 5. Musculoskeletal & skin a. Musculoskeletal .Atrophy i.Foot drop ii.Decreased strength b. Skin .Pressure and poor oxygenation 1. Skin breakdown i.Friction and shearing