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the movement of a limb or other part away from the midline of the body
necessary for optimal health
Activities of Daily Living (ADL's)
are activities usually performed in the course of a normal day and include things such as ambulating, eating, dressing, bathing, brushing the teeth and grooming.
to walk or move about
to move a limb or other part of the body toward the midline of the body
partial or complete collapse of the lung
wasting of muscles
confinement to be as part of treatment
an internal "clock" that synchronizes our sleep cycles
exercises designed to improve posture, gait and stamina
sudden muscle weakness during intense emotions such as anger, sadness or laughter
Center of Gravity
a point from which the weight of the body may be considered to act
Central Sleep Apnea
sleep related breathing disorder
the 24h sleep/wake cycle
combination of all movenments for a ball and socket joint
- a deformed foot that is twisted so that the sole cannot be placed flat on the ground
- typically congenital or a result of polio
a condition of shortening and hardening of muscles, tendons or other tissue, often leading to deformity and rigidity of joints
primary sleep disorders which have origins in different body systems
a blood clot, air bubble,or piece of fatty deposit that has been carried in the blood stream to lodge in a vessel and cause an embolism
Excessive Daytime Sleepiness
a disruptions in daily activities because of sleepiness
activity requiring physical effort; carried out to sustain or improve physical health
the action of moving a limb from bent to a straight position
skin that is soft and hanging loosely
the action of bending
plantar flexion contracture
the cracking or breaking of a hard object
the resistance that one surface encounters when moving over another
a persons manner of walking
paralysis of one side of the body
paralysis of one side of the body
to forcefully extend beyond its normal limits
inadequate quantity or quality of sleep
in a state of abnormally high muscle tone
- enlargement of an organ or tissue from the increase in the size of its cells
- excessive growth
not moving, motionless
Impaired Physical Mobility
limitation in independent, purposeful physical movement of the body or of one or more extremities
longer than 24 hrs (period, seasonal)
difficulty falling asleep
muscular action in which tension is developed without contraction of the muscle
muscle action taking place with normal contraction
a structure in the body where 2 parts of the skeleton are fitted together
excessive outward curvature of the spine causing a hunchback
excessive inward curvature of the spine, straightening of the spine
the normal level of firmness or slight contraction in a resting muscle
a dysfunction of the mechanism in the brain which controls sleep and wake states
Nonrapid Eye Movement (NREM)
- 4 stages in a 90 min sleep cycle
- the sleep becomes increasingly deep between 1-4
Obstructive Sleep Apnea
when muscles or structures of the oral cavity/throat relax during sleeping
- brittle bones
- results of hormonal changes or deficiency in vitamin D or calcium
sleep problems that are more common in children than adults
having toes or feet turned inward
flexion of the foot
the position of a persons body when sitting or standing still
is the awareness of the position of the body and its parts
Range of Motion (ROM)
the maximum amount of movement a a joint
Rapid Eye Movement (REM)
the end of each 90 min sleep cycle
when a person feels mentally relaxed, free from anxiety and physically calm
Reticular Activating System (RAS)
located in the upper brain stem, controls alertness and wakefulness
Abnormal lateral curvature of the spine
medications that produce a soothing or calming effect
- a cyclical physiological process that alternated with longer periods of wakefulness
- a state of consciousness in which the individual's perception and reaction to the environment is decreased
results from dyssomnia can be caused by meds, shift work, stress, pain or environmental disturbances
Habits or practices associated with sleep
a condition in which the head becomes persistantly turned to one side, often associated with muscle spasms
occur more frequently than 24 hrs
- straining to have a BM
- interferes with blood return to the heart
- increased intrathoracic pressure which decreases venous blood flow that decrease cardiac output; when the strain is released there is an increase in venous blood flow and an increase in cardiac output.
Describe the assessment of the musculoskeletal system.
- decreased muscle strength/weakness
- decreases endurance
- decreased stability/ balance
- decreased muscle mass/ disuse atrophy
Identify factors that affect mobility.
- Developmental Changes
- Behavioral Changes
- Environmental Issues
- Culture/ Ethnicity
- Family and Social Support
Describe the changes that occur in the older adult which affect their mobility.
- Progressive loss of bone mass
- muscle mass reduced
- posture changes
- cardio respiratory changes
- changes in activity tolerance
List the causes of immobility.
- severe pain
- impaired musculoskeletal system
- generalized weakness
- psychological problems
- infectious processes
- therapeutic restrictions
- unavoidable restrictions
- voluntary restrictions
Identify the physiological and psychosocial effects of immobility.
- orthostatic hypotension
- decrease bp
- hypostatic pneumonia
- thrombus formation
What factors should the nurse consider when assessing activity tolerance.
- Skeletal abnormalities
- muscular impairments
- endocrine or metabolic illnesses (diabetes mellitus, thyroid)
- decreased cardiac fx
- decreased endurance
- impaired physical stability
- sleep pattern disturbance
- poor exercise patterns
- infectious processes and fever
- chemical addiction
Describe the nursing measures that reduce the impact on immobility on body systems on the acute care setting. (List them in the PERSON format.)
- Psychosocial: encourage visitors; re-orient frequently to date, time and place; encourage hearing aides and glasses; talk about the outside world
- Elimination: turn and position, move and exercise; cough and deep breath ; chest physiotherapy; increase hydration; high fiber diet
- Rest & Activity: body positioning; weight bearing activity; promote independence with ADL's; ROM; ambulate; promote exercise
- Safety: assess skin integrity; provide skin care lubricant; avoid trauma or injury to skin; position; side rails; ambulate w assistance; call bell
- Oxygen: encourage deep breathing; incentive spirometry; turn and position; apply TEDS, SCD; elevate legs;encourage movement and ambulation; avoid valsalva; administer prophylactic anticoagulation therapy
- Nutrition: increase protein intake; increase calories; increase fiber; vitamins and minerals; have pt sit up in bed during and after eating; encourage fluids; maintain IV fluid replacement
Indicate four objectives of therapeutic bed rest.
- reducing physical activity and oxygen needs of the body
- reducing pain, including po pain or after acute injury to the lower back
- allowing ill or debilitated pt's to rest
- allowing exhausted pt's the opportunity for uninterrupted rest
Identify possible nursing diagnoses for the patient with impaired mobility and/or improper body mechanics.
- Altered mobility r/t
- Impaired Physical Mobility r/t
- ineffective tissue perfusion r/t
- impaired skin integrity r/t
- ineffective airway clearance r/t
- acute pain or chronic pain r/t
Identify principles of body mechanics that the nurse should use in administering care.
- wide base of support
- lower center of gravity
- divide balanced activity bt arms and legs
- face the direction of movement
- rolling, turning or pivoting is less work than lifting
- remove objects that cause friction
What body functions are affected by circadian rhythms?
- body temp
- heart rate
- blood pressure
- hormone secretion
- sensory acuity
What areas of the brain and chemicals are associated with wakefulness and sleep?
- RAS: reticular activating system is located in the upper brain stem and receives environmental stimuli to stimulate wakefulness, it releases norepinephrine
- BSR: bulbar synchronizing region is located in the pons and medulla and releases serotonin to help you fall asleep
Identify physiological changes that occur during sleep.
- decreased HR;
- decreased BP;
- decreased muscle tone
Describe the stages of a normal sleep cycle.
Stage 1: very light sleep, the person is drowsy and relaxed. The eyes roll from side to side, heart and respiration drop slightly, the person can easily be awakened. This stage lasts for a few minutes.
Stage 2: a sound sleep, but the person can still be awakened easily. Relaxation progresses and the eyes are still. The body processes continue to slow, heart, respirations and temp drop slightly. This stage lasts 10-20 minutes.
Stage 3: the person is difficult to arouse. Skeletal muscles are very relaxed and the person is undisturbed by sensory stimuli. Vital signs decrease but are stable, the person barely moves. Lasts 15-30 mins.
Stage 4: the deepest sleep stage, the person is very difficult to arouse. The heart and respiration rates are 20%-30% below waking rates. The person is extremely relaxed and rarely moves. Last 15-30 mins.
REM sleep begins 90 mins or so after falling asleep. the person has active vivid dreams and is difficult to arouse or wake spontaneously. There is REM, and fluctuation of heart, respirations and BP rates. Gastric secretions and brain metabolism increase.
Pre-sleep sleepiness- NREM1- NREM2- NREM3- NREM4- REM sleep- NREM2- NREM3-----
NREM2 is the door stage because it is the entrance/exit for REM sleep
Explain the functions of sleep.
- healing and restoration
- psychological restoration
- physiological restoration
- conservation of energy
What physiological and psychological symptoms may a person have with sleep deprivation?
- Physiological: ptosis (droopy lids) and blurred vision; fine motor clumsiness; slowed response time; decreased reasoning and judgment; decreased auditory and visual alertness; cardiac arrhythmia's
- Psychological: confusion; disorientation; increased sensitivity to pain; irritability; w/drawn; apathetic; excessive sleepiness; hyperactivity; decreased motivation
What factors affect an older adult's sleep patterns?
- complaints of sleeping difficulties increase with age
- progressive decrease in stage 3 & 4 NREM sleep
- episodes of REM sleep shorten
- increase in the tendency to nap
What effects do the following drugs have on sleep? 1-Hypnotics 2-Alcohol 3-Caffeine 4-Narcotics
Hypnotics: Interfere with reaching deeper sleep stages; provide only temporary increase in quantity of sleep; eventually will cause "hangover" during the day; sometimes worsens sleep apnea in the OA
Alcohol: speeds onset of sleep; reduces REM sleep; awakens person during the night and causes difficulty returning to sleep
Caffeine: prevents person from falling asleep; causes person to awaken during the night; interferes with REM sleep
Narcotics: suppresses REM sleep; causes increased daytime drowsiness
Identify nursing diagnoses appropriate for patients with sleep alterations.
- sleep deprivation r/t
- disturbed sleep pattern r/t
- fatigue r/t
- anxiety r/t
- ineffective coping r/t
Identify some non-pharmacologic methods that may be used to promote sleep.
- regular bedtime schedule
- avoid excessive mental stimulation & emotional stress
- avoid caffeinated beverages
List the components of a sleep history.
- bedtime rituals
- sleep environment
- changes in sleep patterns
What assessment questions may the nurse ask a patient who reports difficulty sleeping?
- what time do you go to bed at night?
- what time do you normally fall asleep?
- do you do anything special to help you fall asleep?
- how many times do you awaken during the night? why?
- what is the average number of hrs you sleep during the night?
Explain why a person on bed rest might not feel rested.
bc there are people who might physically be at rest but may have emotional worries that keep them from completely resting
Define chronic and acute pain.
- Acute Pain: is protective and has an identifiable cause, it is of short duration and has limited tissue damage and emotional response.
- Chronic Pain: is not protective and serves no purpose, it lasts longer than anticipated and does not always have an identifiable cause.
Describe the action, indication and nursing implications (side effects, assessments and patient teaching) for the following medications:
Prototype:Zolpidem tartrate (ambien) CSS IV
Prototype:Temazepam (restoril) CSS IV
- AMBIEN: Zolpidem Tartrate
- Action: it binds to the omega-1 receptor resulting in sedation
- Indication: tx of insomnia
- Side Effects: dizziness, drowsiness, headache, nausea, diarrhea, dyspepsia, URTI, headache
- Assessments: note reasons for therapy; assess respiratory fx; assess for depression; monitor and LFT's; evaluate mental status
- Pt Teaching: take as directed; swallow whole, do not chew or crush; do not perform any activities that require mental or physical alertness; avoid alcohol, caffeine and chocolate after 4pm
- RESTORIL: Temazepam
- Action: involves GABA receptors in the CNS
- Indication: tx of insomnia
- Side Effects: drowsiness, dizziness, lightheadedness, incoordination
- Assessments: note reasons for therapy; assess sleep patterns, diet and lifestyle; determine addiction or depression hx
- Pt Teaching: take only as directed; may cause daytime drowsiness; avoid Etoh and CNS depressants; no daytime napping; for short term use only