ATI: chapters 53-55

  1. What is the definition of mobility?
    • The ability to be free and independent in purposeful movement
    • Refers to adapting and having self-awareness of the environment
  2. What systems of the body are essential to mobility?
    • Musculoskeletal
    • Nervous
  3. What is the definition of immobility?
    Not being able to move on one's own volition
  4. What does immobility cause?
    Increased risk of complications the greater the amount of immobility and the longer the immobilization
  5. Immobility may be
    • Temporary
    • Permanent
    • Sudden onset
    • Slow onset
  6. What are the principles of body mechanics based on?
    • Alignment
    • Balance
    • Gravity
    • Friction
  7. What is movement dependent on?
    • Intact skeletal system
    • Skeletal muscles
    • Nervous system
  8. What does assessment of a client's mobility/immobility focus on?
    • Mobility
    • ROM
    • Gait
    • Exercise status
    • Activity tolerance
    • Body alignment in respect to sitting, standing and lying
  9. What are nursing interventions designed for with mobility/immobility?
    To maintain mobility and prevent or minimize the complications of immobility
  10. What factors affect mobility?
    • Alteration in muscles
    • Injury to the musculoskeletal system
    • Abnormal posture
    • Impaired CNS
    • Client's health status and age
  11. Changes that occur in the integumentary system with decreased mobility are?
    • Increased pressure on skin, which is aggravated by metabolic changes
    • Decreased circulation to tissue causing ischemia
  12. Changes that occur in the respiratory system with decreased mobility are?
    • Decreased respiratory movement resulting in decreased oxygenation and carbon dioxide exchange
    • Stasis of secretions and decreased and weakened respiratory muscles resulting in atelectasis and pneumonia
    • Decreased cough response
  13. What changes occur in the cardiovascular in relation to decreased mobility?
    • Orthostatic hypotension
    • Less fluid volume
    • Stasis of blood in the legs
    • Less autonomic response
    • Decreased cardiac output leading to poor cardiac effectiveness
    • Increased workload on the heart
    • Increased oxygenation requirement
    • Increased risk of thrombus development
  14. What changes occur in the metabolic system in relation to decreased mobility?
    • altered endocrine system
    • decreased basal metabolic rate
    • change in protein, carbohydrate and fat metabolism
    • decreased appetite with altered nutritional state
    • negative nitrogen balance
    • decreased protein resulting in loss of muscle
    • loss of weight
    • alteration of calcium, fluid and electrolytes
    • resorption of calcium from bones
    • decreased urinary elimination of calcium resulting in hypercalcemia
  15. What changes occur in the elimination system in relation to decreased mobility?
    • Change in calcium metabolism with hypercalcemia resulting in renal calculi
    • Decreased fluid intake, poor perineal care and indwelling Foley resulting in UTI
    • Decreased peristalsis
    • Decreased fluid intake
    • Constipation, then fecal impaction, then diarrhea
  16. What changes occur in the musculoskeletal system in relation to decreased mobility?
    • Decreased muscle endurance
    • Decreased balance
    • Atrophy of muscles
    • Decreased stability
    • Altered calcium metabolism
    • Osteoporosis
    • Contractures
    • Foot drop
    • Altered joint mobility
  17. What changes occur psychosocially with decreased mobility?
    • Changes in emotional status - depression, alteration in self-concept, anxiety
    • Behavioral changes - withdrawal, altered sleep/wake patterns, hostility, inappropriate laughter, and passivity
    • Altered sensory perception
    • Ineffective coping
  18. What changes are seen developmentally in infants, toddlers, and preschoolers with decreased mobility?
    • Slower progression in gross motor skill, intellectual and musculoskeletal development
    • Body aligned with line of gravity, resulting in unbalanced posture
  19. What changes are seen developmentally in adolescents in relation to decreased mobility?
    • Growth spurt that is imbalanced and possibly altered with immobility
    • Delayed development of independence
    • Social isolation
  20. What changes are seen developmentally in adults in relation to decreased mobility?
    • Alterations in every physical system
    • Alterations in family and social systems
    • Alterations in job identity
  21. What changes are seen developmentally in older adults with decreased mobility?
    • Alteration in balance resulting in major risk for falls and injuries
    • Steady loss of bone mass resulting in weakened bones
    • Decreased coordination
    • Walking more slowly
    • Taking tiny steps
    • Alteration in functional status
    • Increased dependence on staff, family and significant others
  22. What are some nursing diagnoses related to mobility/immobility?
    • Activity intolerance
    • risk for constipation
    • ineffective airway clearance
    • risk for disuse syndrome
    • bathing/hygiene self-care deficit
    • disturbed sleep pattern
    • social isolation
    • impaired tissue integrity
  23. What is the primary goal for the integumentary system for clients with decreased mobility?
    Maintaining intact skin
  24. What are the primary goals for the respiratory system for clients with decreased mobility?
    Maintaining a patent airway, achieving optimal lung expansion and gas exchange and mobilizing airway secretions
  25. What are the primary goals for the cardiovascular system for clients with decreased mobility?
    Maintaining cardiovascular function, increasing activity tolerance and preventing thrombus formation
  26. What are the primary goals for the metabolic system for clients with decreased mobility?
    Decreasing injuries to the skin and maintaining metabolism within normal functioning
  27. What are the primary goals for the elimination system for clients with decreased mobility?
    Maintaining or achieving normal urinary and bowel elimination patterns
  28. What are the primary goals for the musculoskeletal system for clients with decreased mobility?
    Maintaining or regaining body alignment and stability, decreasing skin and musculoskeletal system changes, achieving full or optimal ROM and preventing contractures
  29. What instructions are given to a client using a cane?
    • - Maintain two points of support on the ground at all times
    • - Keep the cane on the stronger side of the body
    • - Support body weight on both leg, move cane forward 6 to 10 inches, then move the weaker leg forward toward the cane
    • - Next, advance the stronger leg
    • - Repeat
  30. What instructions are given to the client using crutches?
    • - Do not alter crutches after proper fit has been determined
    • - Follow crutch gait prescribed by physical therapy
    • - Support body weight at hand grips with elbows flexed 30 degrees
    • - Position crutches on unaffected side when sitting or rising from chair
  31. What are the primary goals for psychosocial health in clients with decreased mobility?
    Maintaining normal sleep/wake patterns, achieving socialization, and independent completion of self-care
  32. What are the primary goals developmentally for clients with decreased mobility?
    Continuing normal development and achieving physical and mental stimulation
  33. A client has been sitting in a chair for 2 hr. What is the client most at risk for developing?

    B. pressure ulcer
  34. Which of the following nursing interventions should be implemented to maintain a patent airway in a client on bedrest?

    A. teach to use an incentive spirometer while awake
  35. Which of the following findings should be reported to the PCP for a client on bedrest?

    C. orthostatic hypotension
  36. Which of the following nursing interventions will reduce the risk of thrombus development? (select all that apply)
    - teach the client not to use the Valsalva maneuver
    - apply elastic stockings
    - review lab values for total protein level
    - place pillows under the client's knees and lower extremities
    - assist the client to change position often
    • - apply elastic stockings
    • - assist the client to change position often
  37. What does a sleep cycle consist of?
    • Nonrapid eye movement (NREM)
    • Rapid eye movement (REM)
  38. During the course of the night, how many sleep cycles does a person normally experience?
    After a person experiences stage 1 of NREM, he cycles 4 to 6 times through the other stages of sleep
  39. Very light sleep
    Only a few minutes long
    Vital signs and metabolism beginning to diminish
    Can be awakened easily
    Feels relaxed and drowsy
    These are the characteristics of what stage of sleep?
    Stage 1 NREM
  40. Deeper sleep
    10 to 20 minutes in length
    Vital signs and metabolism continuing to diminish
    Can still be awakened easily
    Increased relaxation
    These are the characteristics of what stage of sleep?
    Stage 2 NREM
  41. Deep sleep
    15 to 30 minutes in length
    Vital signs continuing to decrease
    Difficult to awaken
    Relaxation such that the person seldom moves
    These are the characteristics of what stage of sleep?
    Stage 3 NREM
  42. Deepest sleep
    15 to 30 minutes in length
    Vital signs very low as compared to when awake
    Very difficult to awaken
    Stage at which the body achieves physical rest and restoration
    Stage at which enuresis and talking and walking in one's sleep occur
    These are the characteristics of what stage of sleep?
    Stage 4 NREM
  43. Occurrence of dreams
    20 minutes long and starts about 50 to 90 minutes after falling asleep
    Varying vital signs
    Very difficult to awaken
    Stage at which mental rest and restoration occur
    These are the characteristics of what stage of sleep?
  44. Match the sleep averages with the ages (one option may be used twice)
    1. 16 hr a day
    2. 12 hr a day with some of the sleep coming during a daytime nap
    3. 12 hr a night with less napping during the day
    4. 8 to 10 hr a night with two to three naps during the day
    5. 7.5 hr a night
    6. 11 to 12 hr a night for younger children with 9 to 10 hr a night for older ones
    7. 6 to 8.5 hr per a night with daytime naps possibly accounting for some of the hours
    8. 6 to 8.5 hr a night

    A. Birth to 3 months
    B. Infants (3 months to 1 year)
    C. Toddlers
    D. Preschoolers
    E. School-age
    F. Adolescents
    G. Young adults
    H. Middle adults
    I. Older adults
    • 1 - A
    • 2 - C
    • 3 - D
    • 4 - B
    • 5 - F
    • 6 - E
    • 7 - I
    • 8 - G and H
  45. What are three common sleep disorders?
    • Insomnia
    • Sleep apnea
    • Narcolepsy
  46. Which sleep disorder consists of difficulty falling asleep or the inability to receive restorative sleep, is more common in women and causes may include stress, illness, and work-related issues?
  47. Which sleep disorder is a disorder caused by the lack of airflow to the nose and mouth for > 10 sec or longer during sleep?
    Sleep apnea
  48. Which sleep disorder may be caused by a single disorder or a mixture of a CNS dysfunction and obstructive problem?
    Sleep apnea
  49. which sleep disorder is a disorder of the sleep and wake mechanism, which may cause the person to lose the ability to stay awake?
  50. When assessing a client's sleep patterns, history and changes that have occurred what questions would you ask about sleep problems?
    • Type of problem
    • Symptoms
    • Timing
    • Seriousness
    • Related factors
    • How the lack of sleep has impacted the client
  51. What type of scale or visual is used to rate sleep?
    • Linear scale with "best night sleep" on one end and "worst night sleep" on the other
    • or
    • Rate the sleep on a scale of 0 to 10
  52. What are common factors that interfere with sleep?
    • Illness
    • Current life events
    • Emotional stress or mental illness
    • Diet
    • Exercise
    • Sleep environment
    • Medications
  53. What are some nursing diagnoses related to rest and sleep?
    • Sleep deprivation
    • Fatigue
    • Disturbed sleep pattern
  54. What are some nursing interventions to implement for a client with a sleep disorder?
    • Assist the client in establishing and following a bedtime routine
    • Attempt to minimize the number of times the client is awakened during the night while hospitalized
    • Offer to assist the client with personal hygiene needs and/or a back rub prior to sleep to increase comfort
  55. What are some lifestyle changes a client can implement to help with sleep?
    • Exercise regularly at least 2 hr before bedtime
    • Arrange the sleep environment to what is comfortable
    • Limit alcohol, caffeine and nicotine in the late afternoon/evening
    • Limit fluids 2 to 4 hr before bedtime
    • Engage in muscle relaxation if anxious or stressed
  56. What are special instructions that can be given to a patient with narcolepsy in regard to sleep?
    • Participate in regular exercise
    • Eat small meals that high in protein
    • Avoid activities that increase sleepiness
    • Avoid activities that would cause injury should the client fall asleep
    • Take naps when narcoleptic events are likely to occur
    • Take stimulants as prescribed by PCP
  57. What device may be prescribed for a client with sleep apnea?
    Continuous positive airway pressure (CPAP)
  58. A client presents to the clinic reporting fatigue and an inability to sleep at night. Which of the following assessment findings supports the client's statement?

    D. the client's eyes are puffy and red and he is irritable
  59. Which of the following recommendations should be given to a client to promote sleep and rest? (select all that apply)
    - Avoid all caffeinated beverages
    - Participate in regular exercise each morning
    - Take an afternoon nap
    - Practice relaxation exercises before bedtime
    - Limit fluid intake after dinner
    • - Participate in regular exercise each morning
    • - Practice relaxation exercises before bedtime
    • - Limit fluid intake after dinner
  60. A client is diagnosed with obstructive sleep apnea. Which of the following nursing diagnoses should be the highest priority?

    C. ineffective breathing pattern
  61. Since admission to the hospital, a client has bathed in the morning following facility/agency routine; however, at home, she always takes a warm bath just before bed. Now she is having difficulty sleeping. Which of the following interventions is most beneficial to the client at this time?

    B. allow her to take a bath in the evening
  62. Is undertreatment of pain a serious healthcare problem in the US?
  63. What are the physiological and psychological consequences of undertreaatment of pain?
    • Acute/chronic pain can cause anxiety/fear and depression
    • Poorly managed acute pain may lead to chronic pain syndrome
  64. When assessing for pain, in what clients may challenges occur?
    • Cognitively impaired
    • Ventilator dependent
  65. What does proper pain management include?
    Pharmacological and nonpharmacological methods
  66. In the physiology of pain what is the conversion of painful stimuli to an electrical impulse?
  67. In the physiology of pain what occurs as the electrical impulse travels along the nerve fibers and is regulated by neurotransmitters?
  68. In the physiology of pain where does perception or awareness of pain occur?
    In the brain and is influenced by thought and emotional processes
  69. Where does modulation of pain occur and what does it cause?
    • In the spinal cord
    • Causes muscles to reflexively contract, moving the body away from painful stimuli
  70. These factors increase or decrease pain transmission?
    Substance P
  71. These factors increase or decrease pain transmission?
  72. This type of pain is protective, temporary, usually self-limiting and resolves with tissue healing
    Acute pain
  73. With this type of pain the physiological responses (SNS) are fight-or-flight
    Acute pain
  74. What are the fight-or-flight responses to acute pain?
    • Tachycardia
    • Hypertension
    • Anxiety
    • Diaphoresis
    • Muscle tension
  75. What behavioral responses may be seen with acute pain?
    • Grimacing
    • Moaning
    • Flinching
    • Guarding
  76. What are interventions for acute pain?
    Treating the underlying problem
  77. Which type of pain is not protective, is ongoing or reoccurs frequently, lasting > 6 months and persisting beyond tissue healing?
    Chronic pain
  78. What are the physiological responses to chronic pain?
    • Usually no alterations in vital signs
    • Client may experience depression, fatigue, and decreased level of functioning
  79. What can psychosocial implications of chronic pain lead to?
  80. Which type of pain may or may not have a known cause?
    Chronic pain
  81. What type of pain management is aimed at symptomatic relief?
    Chronic pain
  82. For which type of pain is pain rating not useful?
    Chronic pain
  83. Which type of pain can be malignant or nonmalignant?
    Chronic pain
  84. What is nociceptive pain?
    Typical processing of stimuli that has damaged normal tissues - it arises from injured body tissues
  85. This pain is usually throbbing, aching and localized
    Nociceptive pain
  86. What are the three types of nociceptive pain?
    • Somatic
    • Visceral
    • Cutaneous
  87. Which type of pain typically responds to opioids and nonopioid medications - nociceptive or neuropathic?
  88. Where does nociceptive somatic pain come from?
    Bone, muscle, skin or connective tissue
  89. Where does nociceptive visceral pain that may cause referred pain in other body locations come from?
    • Internal organs
    • Usually poorly localized
  90. Where does nociceptive cutaneous pain come from?
    Originates in the skin or subcutaneous tissue
  91. What is neuropathic pain?
    Atypical processing of stimuli by the peripheral or central nervous system
  92. What is neuropathic pain associated with?
    Damaged nerve fibers
  93. Which type of pain (nociceptive or neuropathic) includes phantom limb pain, pain below the level of a spinal cord injury, and diabetic ______?
  94. What are the typical characteristics of neuropathic pain?
    Intense, shooting, burning or "pins and needles"
  95. What does neuropathic pain respond to for treatment?
    Adjuvant medications - antidepressants, antispasmodic agents, skeletal muscle relaxants
  96. What are the risk factors for undertreatment of pain?
    • Cultural and societal attitudes
    • Lack of knowledge
    • Fear of addiction
    • Exaggerated fear of respiratory depression
  97. What populations are at risk for undertreatment of pain?
    • Infants
    • Children
    • Older adults
    • Clients with substance abuse problems
  98. What are some causes of acute and chronic pain?
    • Trauma
    • Surgery
    • Cancer
    • Arthritis
    • Fibromyalgia
    • Neuropathy
    • Treatment procedures
  99. What can impact the pain experience?
    • Age
    • Fatigue
    • Genetic sensitivity
    • Cognitive function
    • Prior experiences
    • Anxiety and fear
    • Support systems
    • Culture
  100. What can cause an increased sensitivity to pain?
  101. What factor can increase or decrease the amount of pain tolerated?
    Genetic sensitivity
  102. What is the most reliable diagnostic measure of pain?
    Client's self report
  103. How often should pain assessment be done?
    Frequently - may be considered the 5th vital sign
  104. What kind of data can be obtained using symptom analysis of pain?
  105. How is location of pain described?
    Using anatomical terminology and landmarks
  106. What does quality of pain refer to?
    How pain feels
  107. What are some ways the quality of pain is described?
    • Sharp
    • Dull
    • Aching
    • Burning
    • Stabbing
    • Pounding
    • Throbbing
    • Shooting
    • Gnawing
    • Tender
    • Heavy
    • Tight
    • Tiring
    • Exhausting
    • Sickening
    • Terrifying
    • Torturing
    • Nagging
    • Annoying
    • Intense
    • Unbearable
  108. How would you ask a client about the location of their pain?
    • Where is your pain?
    • Does it radiate anywhere else?
    • Can you point to the location?
  109. How would you ask a client about the quality of their pain?
    • What does the pain feel like?
    • Is the pain throbbing, burning or stabbing?
  110. What are measures of pain?
    • Intensity
    • Strength
    • Severity
  111. How are intensity, strength and severity of pain measured?
    With visual analog scales
  112. What are visual analog scales used for during pain management?
    • Measuring pain
    • Monitoring pain
    • Evaluating the effectiveness of interventions
  113. How would you ask a client about the intensity of their pain?
    • How much pain do you have now?
    • What is the worst/best the pain has been?
  114. What does the timing of pain consist of?
    • Onset
    • Duration
    • Frequency
  115. How would you ask a client about the timing of their pain?
    • When did it start?
    • How long does it last?
    • How often does it occur?
    • Is it constant or intermittent?
  116. How would you ask a client about the setting of the their pain?
    • Where are you when the symptoms occur?
    • What are you doing when the symptoms occur?
  117. What are associated symptoms of pain?
    • Fatigue
    • Depression
    • Nausea
    • Anxiety
  118. Who would you assess for associated symptoms of pain?
    Ask what other symptoms they experiences when they are feeling the pain
  119. How would you ask a client about aggravating/relieving factors of pain?
    • What makes the pain better?
    • What makes the pain worse?
    • Are you currently taking an prescription or OTC medications?
  120. What are some nursing diagnoses for pain?
    • Acute/chronic pain
    • Disturbed sleep pattern
    • Fatigue
    • Impaired physical mobility
    • Powerlessness
    • Self-care deficit
  121. How long after a pain management intervention should a nurse reassess the client?
    30 - 60 minutes
  122. What are the types of nonpharmacological pain management?
    • Cutaneous stimulation
    • Distraction
    • Imagery
    • Acupuncture
    • Reduction of pain stimuli in the environment
    • Elevation of edematous extremities
  123. What are types of cutaneous stimulation used in nonpharmacological pain management?
    • Transcutaneous electrical nerve stimulation (TENS)
    • Heat
    • Cold
    • Therapeutic touch
    • Massage
  124. What are types of distraction that can be used in nonpharmacological pain management?
    • Ambulation
    • Deep breathing
    • Visitors
    • Television
    • Music
  125. What are used in pharmacological pain management?
  126. What are the different types of analgesics?
    • Nonopioid
    • Opioid
    • Adjuvant
  127. What are nonopioid analgesic appropriate for?
    Treatment of mild to moderate pain
  128. How much acetaminophen should be to a client with a healthy liver?
    No more than 4 g/day
  129. What is salicylism in relation to nonopioid analgesics?
    • Tinnitus
    • Vertigo
    • Decreased hearing acuity
  130. How can gastric upset be prevented when administering nonopioid analgesics?
    Administering the medication with food or antacids
  131. What should be monitored with long-term NSAID use?
  132. What are opioid analgesics appropriate for?
    Treatment of moderate to severe pain
  133. When managing acute severe pain should opioids be given around-the-clock or PRN?
  134. What is the preferred route for immediate, short-term relief of acute pain?
  135. What is the preferred route for treatment of chronic, nonfluctuating pain?
  136. What will provide consistent pain control with opiod administration?
    Consistent dosing and timing
  137. What are some adverse effects of opioid use?
    • Constipation
    • Orthostatic hypotension
    • Urinary retention
    • Nausea/vomiting
    • Sedation
    • Respiratory depression
  138. What usually precedes respiratory depression?
  139. What is administered to reverse opioid effects?
    Naloxone (Narcan)
  140. What are adjuvant analgesics?
    They enhance the effects of nonopioids, help alleviate other symptoms that aggravate pain, and are useful for treatment of neuropathic pain
  141. What medications are included under adjuvant analgesics?
    • Anticonvulants (carbamazepine - Tegretol)
    • Antianxiety agents (diazepam - Valium)
    • Tricyclic antidepressants (amitriptyline - Elavil)
    • Antihistamine (hydroxyzine - Vistaril)
    • Glucocorticoids (dexamethasone - Decadron)
  142. What is a patient controlled anaglesia (PCA) pump?
    Medication delivery system that allows the client to self-administer safe doses of opioid narcotics
  143. What are the advantages of PCAs?
    • Constant plasma levels are maintained by small, frequent doses
    • The client experiences less lag time between identified need and delivery of medication
  144. What does the client need to understand about the use of PCAs?
    He is the only person who should push the PCA button to prevent inadvertent overdosing
  145. What are two commonly used opioids in PCAs?
    Morphine sulfate and hydromorphone
  146. What are some other strategies for effective pain management?
    • Proactively giving analgesics before pain becomes to severe
    • Instructing client to not wait until pain is severe to request medication
    • Educating the client
    • Assisting the client to reduce fear and anxiety
    • Creating a treatment plan that includes both nonpharmacological and pharmacological pain relief measures
  147. Who are the high risk clients for sedation, respiratory depression and coma?
    • Older adults
    • Opioid-naive client
  148. When should the opioid be stopped and Narcan given?
    When respirations are less than 8/min, shallow and the client is difficult to arouse
  149. What other scale should be used along with a pain rating scale when a client is receiving opioids?
    Sedation scale
  150. A nurse is performing a pain assessment on a client who has come to the emergency department with a report of severe abdominal pain. The nurse asks the client if he has experienced nausea and vomiting. The nurse is assessing

    C. presence of associated symptoms
  151. Frequent pain assessment includes assessing the intensity of the pain. The nurse can best assess the intensity of a client's pain by

    A. offering the client a pain scale to measure his pain
  152. Which of the following statements are true regarding pain? (select all that apply)
    - all cultures have the same attitudes regarding pain
    - feelings of anger and guilt may be caused by pain
    - it may be difficult to adequately assess pain in a client with cognitive impairment
    - a client who is sleeping could not be experiencing pain
    - it is best to wait until pain is severe before administering analgesics
    • - feelings of anger and guilt may be caused by pain
    • - it may be difficult to adequately assess pain in a client with cognitive impairment
  153. A nurse is taking a history on a client with pain knows that

    A. pain is whatever the client says that is is
  154. Match the following types of pain with their descriptors: V = visceral, S = somatic, and N = neuropathic
    - Phantom limb pain
    - Poorly localized pain
    - Referred pain
    - Fracture pain
    - Burning "pins and needles" pain
    - Sharp, aching pain
    • V = Poorly localized, referred pain
    • S = Fracture pain, sharp, aching pain
    • N = Phantom limb pain, burning "pins and needles" pain
Card Set
ATI: chapters 53-55
ati flashcards basic nursing care