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Fundamentals – Exam 1 Chapter 15 – Critical Thinking  

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RN is responsible for making decisions on the basis of clinical information Basic Critical Thinking - Learner trusts that experts have the right answers for every problem. - Thinking is concrete and based on a set of rules or principles Complex Critical Thinking - Separates thinking from experts - Alternative approaches - Examines choices more independently - Each solution has benefits and risks that are weighed before making a final decision - There are options - Thinking is more creative and innovative - Willing to consider different options from routine procedures Commitment - Anticipate when to make choices without assistance from others - Accept accountability for decisions made

Critical Thinking Competencies: 

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Scientific Method - Methodical - Uses reasoning to solve problems - Looks for truth and verifies that a set of facts agrees with reality - 5 steps: 1) Identify the problem 2) Collect Data 3) Formulate a question or hypothesis 4) Test the question or hypothesis 5) Evaluate results of the test or study Problem Solving - Involves evaluating a situation overtime, identifying possible solutions, and trying a solution over time to make sure that it is effective Decision Making

Specific Critical Thinking 

Diagnostic Reasoning and Inference - Analytical process for determining a patient’s health problems - Requires you to assign meaning to behaviors and physical signs and symptoms presented by a patient.

Begins when you interact with a patient or make physical or behavioral observations Clinical inference – the process of drawing conclusions from related pieces of evidence and previous experience with evidence Clinical Decision Making - Requires careful reasoning - Occurs through knowing the patient

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Chapter 28 – Immobility  

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Body mechanics – coordinated efforts of the musculoskeletal and nervous systems Body alignment and posture - Refer to positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. - Body alignment means that an individual’s center of gravity is stable Gravity and Friction - Force of weight is always directed downwards, which is why an unbalanced object falls - Unsteady patients fall if their center of gravity becomes unbalanced because of gravitational pull on their weight Friction – force that occurs in a direction to oppose movement - greater surface area of object that is moved, greater the friction Skeletal System - Provides attachments for muscles and ligaments and the leverage necessary for mobility - Supporting framework of the body is made up of 4 types of bones: long, short, flat, and irregular - Bones are important for mobilization because they are firm, rigid, and elastic Joints – connections between bones Ligaments – white, shiny, flexible bands of fibrous tissue that bind joints together, connects bones and cartilages - Aids joint flexibility and support Tendons – white, glistening, fibrous bands of tissue that connect muscle to bone - Strong, flexible, and inelastic Cartilage – nonvascular supporting connective tissue located chiefly in the joints and thorax, trachea, larynx, nose, and ear -

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Pathological Influences on Mobility 

Postural Abnormalities - Can cause pain, impair alignment or mobility, or both - Some limit ROM -

Nurses intervene to: - maintain max. ROM in unaffected joints - often collaborate with PTs to design interventions to strengthen affected muscles

and joints - improve patient’s posture - adequately use affected and unaffected muscle groups  Muscle abnormalities - Injury and disease leads to numerous alterations in musculoskeletal functions - Muscular dystrophies – group of familial disorders that cause degeneration of skeletal muscle fibers - most prevalent of muscle diseases in childhood - patients experience progressive, symmetrical weakness and wasting of skeletal muscle groups, with increasing disability and deformity  Damage to CNS - Results in impaired body alignment, balance, and mobility - Damage to the cerebellum causes problems with balance - Trauma from a head injury, ischemia from a stroke, or bacterial infection such as meningitis can damage cerebellum or the motor strip in the cerebral cortex  Direct Trauma to the Musculoskeletal System - Results in bruises, contusions, sprains, and fractures - Fracture – disruption of bone tissue continuity; most commonly result from direct external trauma - treatment often includes positioning the fractured bone in proper alignment and alignment and immobilizing it to promote healing and restore function - temp. immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness Nursing Knowledge Base: Factors Influencing Mobility-Immobility    

Mobility – person’s ability to move about freely Immobility – the inability to do so Cluster of symptoms associated with lack of physical activity is often referred to as the “hazards of immobility”. Disuse atrophy – describes tendency of cells and tissue to reduce in size and function in response to prolonged inactivity - Results from bed rest, trauma, casting of a body part, or local nerve damage

Systemic Effects: 

Metabolic Changes: - Alters endocrine metabolism, calcium resorption, and functioning of the GI system - When injury or stress occurs, the endocrine system triggers a series of responses aimed at maintaining BP and preserving life - Important in maintaining homeostasis - Immobility disrupts normal metabolic functioning, decreasing metabolic rate - altering metabolism of carbs, fats, and proteins - causing fluid, electrolyte, and calcium imbalances - causing GI disturbances such as decreased appetite and slowing of peristalsis

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When a patient is immobile, his/her body often excretes more nitrogen (end product of acid breakdown) than it ingests proteins, resulting in negative nitrogen balance - Immobility causes release of calcium into circulation - Impairments of GI functioning - constipation - pseudodiarrhea often results from a fecal impaction (accumulation of hardened feces); abnormal finding; liquid stool passing around the area of impaction - Distended intestines and increased intraluminal pressure Respiratory Changes: - Immobile patients at risk for developing pulmonary complications such as atelectasis (collapse of alveoli) and hypostatic pneumonia ** Hypostatic pneumonia – inflammation of the lung from stasis or pooling of secretions - Proportional decline in the patient’s ability to cough productively Cardiovascular Changes: - Orthostatic hypertension – drop of BP greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure - symptoms: lightheadedness, dizziness, nausea, tachycardia, pallor, or fainting when patient changes from supine to standing position - Increased cardiac workload - Thrombus formation As the workload of the heart increases, so does oxygen consumption - heart works harder and less efficiently during periods of prolonged rest - 3 factors contribute to venous thrombus formation: 1) damage to the vessel wall (e,g., injury during surgical procedures) 2) alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest) 3) alterations in blood constituents (e.g. change in clotting factors or increased platelet activity) ** These 3 factors are often referred to as Virchow’s triad Musculoskeletal Changes: - Muscle Effects: - patient loses lean body mass - reduced muscle mass makes it difficult for patients to sustain activity without increased fatigue - prolonged immobility often leads to disuse atrophy - loss of endurance, decreased muscle mass and strength, and joint instability place patients at risk for falls - Skeletal Effects: - immobilization causes 2 skeleton changes: 1) impaired calcium metabolism 2) joint abnormalities -

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- because immobilization results in bone resorption, the bone tissue is less dense or atrophied, and disuse osteoporosis results - with disuse osteoporosis, patient is at risk for pathological fractures - Joint contracture – an abnormal and possibly permanent condition characterized by fixation of a joint ** foot drop – foot is permanently fixed in plantar flexion; patient is unable to lift toes off the ground  Urinary Elimination Changes: - When patient is recumbent or flat, the kidney and ureters move toward a more level plane - Because the peristaltic contractions of the ureters are insufficient to overcome gravity, the renal pelvis fills before urine enters the ureters. This condition is called urinary stasis. - Increases the risk of UTI and renal calculi - Immobilized patients are at risk for calculi because they frequently have hypercalcemia. - Fluid intake diminishes - risk for dehydration increases; urinary output declines - Concentrated urine increases risk for calculi formation and infection  Integumentary Changes: - Pressure ulcers – an impairment of the skin as a result of prolonged ischemia in tissues - usually form over a bony prominence - ischemia develops when the pressure on the skin is greater than the pressure inside the small peripheral vessels supplying blood to the skin ** Older adults are at greater risk Developmental Changes:  Infants, Toddlers, and Preschooler - Prolonged immobilization delays a child’s gross motor skills, intellectual development, and musculoskeletal development.  Adolescents - Behind peers in gaining independence and accomplishing certain skills - Social isolation is a concern  Adults - Role of adult changes with regards to the family or social structure - Self-concept can be affected  Older Adults - Immobilization increases their physical dependence and accelerates functional loss - Progressive loss of total bone mass - Decreased physical activity, hormone changes, and bone resorption - Walk more slowly, take smaller steps, and appear less coordinated - Prescribed meds alter their sense of balance or affect their BP - Increased risk for falls and injuries Nursing Process

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Assessment: - Consider patient’s normal mobility status, the effects of any disease or condition on mobility, and patient’s risk for mobility alterations - Understand how any limitations in mobility is perceived by patient - Assess patient’s ROM, gait, exercise and activity tolerance, and body alignment - When unsure of a patient’s abilities, begin assessment of mobility with the patient in the most supportive position and move to higher levels according to his/her tolerance. - Assessment starts with patient lying, and proceeds to assessing sitting positions in bed, transfers to chair, and finally walking. - ROM: - maximum amount of movement available at a joint in one of the three planes of the body: sagittal, transverse, or frontal - sagittal plane: a line that passes through the body from front to back, dividing the body into a left and right side - frontal plane: passes through the body from side to side and divides the body into front and back - transverse plane: horizontal line that divides the body into upper and lower portions - Gait: particular manner or style of walking 1) Observe the patient entering the room, and note speed, stride, and balance. 2) Ask the patient to walk across the room, turn, and come back. 3) Ask patient to walk heel-to-toe in a straight line. - Activity tolerance – the type and amount of exercise or work that a person is able to perform without undue exertion or possible injury. - includes data from physiological, emotional, and developmental domains - Body alignment objectives: - determining normal physiological changes resulting from growth and development - identifying deviations in body alignment caused by incorrect posture - providing opportunities for patients to observe their posture - identifying learning needs of patients for maintaining correct body alignment - obtaining info. concerning other factors that contribute to incorrect alignment such as fatigue, malnutrition, and psychological problems - identifying trauma, muscle damage, or nerve dysfunction Immobility Metabolic System - Use anthropometric measurements (measures height, weight, and skinfold thickness) to evaluate muscle atrophy. - Analyze intake and output records for fluid balance - Monitoring lab levels such as levels of electrolytes, serum protein, and blood urea nitrogen (BUN) helps determine metabolic functioning - Monitoring food intake and elimination patterns and assessing wound healing help to determine GI functioning and potential metabolic problems

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Respiratory System - Perform respiratory assessment at least every 2 hours for patients with restricted activity - Inspect chest wall movements during the full inspiratory-expiratory cycle  Cardiovascular System - Assessment includes BP monitoring, evaluation of apical and peripheral pulses, and observation for signs of venous stasis - Monitor for orthostatic hypotension - Edema - DVT  Musculoskeletal System - Identify decreased muscle tone and strength, loss of muscle mass, reduced ROM, and contractures  Integumentary System - Assess skin for breakdown and color changes such as pallor or redness - Observe often during routine care  Elimination System - Assess the patient’s input and output each shift and every 24 hours - Assessment of bowel elimination status includes adequacy of a patient’s dietary choices, bowel sounds, and frequency and consistency of bowel movement Nursing Diagnosis  2 diagnoses most directly related to mobility problems are Impaired Physical Mobility and Risk for Disuse Syndrome  Impaired Physical Mobility – applies to the patient who has some limitation but is not completely immobile  Risk for Disuse Syndrome – applies to patient who is immobile and at risk for multisystem problems because of inactivity  Other possible diagnoses include: - Ineffective Airway Clearance - Ineffective Coping - Impaired Urinary Elimination - Risk for Impaired Skin Integrity - Social Isolation Planning  Develop goals and expected outcomes to help patients achieve their highest level of mobility and reduce hazards of immobility  Ensure immediate needs are met first  Do not overlook potential complications  Collaborate with other health care team members such as PT or occupational therapists when it is essential to consider mobility needs Implementation  Prevention of work-related musculoskeletal injuries - Overexertion

- Back injuries – often a result of improper lifting and bending - Strain on lumbar muscle group (most common back injury)  Exercise  Bone health in patients with Osteoporosis - Encourage patients at risk to be screened for osteoporosis - Assess their diets for calcium and vit. D intake Acute Care  Metabolic System - High-calorie intake provides sufficient fuel to meet metabolic needs - Ensure patient is taking vit. B and C supplements when necessary - Vit C is needed for skin integrity and wound healing - Vit B complex assists in energy metabolism  Respiratory System - Deep breathing exercise - Incentive spirometry - Controlled coughing - Chest physiotherapy – prevents pneumonia and keeps airway clear - Encourage immobile patient to deep breathe and cough every 1-2 hours  Cardiovascular System - Reducing orthostatic hypotension - Reducing cardiac workload (avoid Valsalva maneuver – patient holds breath and strains) - Prevent thrombus formation - SCDs and pneumatic compression (IPC) are used to prevent blood clots in lower extremities - elastic stockings (sometimes called antiembolitic stocking) also aid in maintaining external pressure on muscles of lower extremities - leg exercises  Musculoskeletal System - Exercises to prevent excessive muscle atrophy and joint contractures  Integumentary System - Turning and repositioning every 1-2 hours - Regular skin care (cleansing of soiled areas and use of moisturizers) - Never massage areas of redness  Elimination System - Keep patient well hydrated - Prevent urinary stasis, calculi, and infections without causing bladder distention - Provide a diet rich in fluids, fruits, vegetables, and fiber to facilitate normal peristalsis - If patient is unable to maintain regular bowel patterns, stool softeners, cathartics, or enemas are sometimes necessary Positioning Techniques  Trochanter Roll - Prevents external rotation of the hips when a patient is in a supine position

To form trochanter roll, fold a cotton bath blanket lengthwise to a width that extends from the greater trochanter of the femur and the lower border or popliteal space  Trapeze Bar - a triangular device that hangs down from a securely fastened head bar that is attached to the bedframe - allows patient to pull with upper extremities to raise the trunk off the bed, assist in transfer from bed to wheelchair, or perform upper arm exercises  Hand Rolls - Most often used with patients whose arms are paralyzed or who are unconscious  Supported Fowler’s Position - Patient is in a semi-seated position - Head of the bed is elevated 45 to 60 degrees - Patient’s knees are slightly elevated without pressure to restrict circulation in the lower legs  Supine position - Patients rest on their backs  Prone position - Patient lies face or chest down  Side-lying Position - Patient rests on side with the major portion of body weight on the dependent hip and shoulder - A 30-degree lateral position is recommended for patients at risk for pressure ulcers  Sim’s Position - Differs from side-lying in the distribution of weight - Patient places weight on the anterior ileum, humerus, and clavicle Restorative and Continuing Care - Focus is not only on ADLs that relate to physical self-care, but also on instrumental activities of daily living (IADLs) - IADLs – activities that are necessary to be independent in society beyond eating, grooming, transferring, and toileting - include skills as shopping, preparing meals, banking, and taking medications -

Chapter 30 – Vital Signs  Body temperature = heat produced – heat lost  Body tissues and cells function efficiently within a narrow range, from 36º to 38 ºC (96.8º - 100.4ºF)  In the elderly population, the average core temp. ranges from 35º - 36.1ºC (95º - 94ºF) as a result of decreased immunity  Heat Loss: - Radiation – transfer of heat from the surface of one object to the surface of another without direct contact between the two - increases as the temp difference between the objects increases

- can be considerable during surgery when the patient’s skin is exposed to a cool environment - however, if the environment is warmer than the skin, the body absorbs heat through radiation - Conduction – transfer or hear from one object to another with direct contact - when the warm skin touches a cooler object, heat is lost - accounts for small amount of heat loss - applying an ice pack or bathing patient with a cool cloth increases conductive heat loss - applying several layers of clothing reduces conductive heat loss Convection – transfer of heat away by air movement - rate of heat loss increases when moistened skin comes into contact with slightly moving air Evaporation – transfer of heat when a liquid is changed to gas - body continuously loses heat by evaporation - perspiration Neural and Vascular Control  Hypothalamus controls body temp.  Mechanisms of heat loss include sweating and vasodilation of blood vessels - Body redistributes blood to surface vessels to produce heat loss  Vasoconstriction reduces blood flow to skin and extremities - Compensatory heat production is stimulated through voluntary muscle contraction and muscle shivering. Factors Affecting Body Temp. 1) Age - A newborn loses 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss - Newborn’s body temp is usually within 35.5º - 37.5ºC (95.9º - 99.9ºF) - Older adults are particularly sensitive to temp extremes because of deterioration in control mechanisms, particularly poor vasomotor control (vaso constriction/dilation), reduced amou...