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Fundamentals of Nursing, 9th Ed., Potter, Perry, Stockert & Hall, 2017
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28 - Immobility

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Fundamentals of Nursing, 9th Ed., Potter, Perry, Stockert & Hall, 2017 | Registered Nurse (RN) School Study Aid

28 - Immobility
34 Picmonics to Learn | 1 hr 4 mins
Scoliosis
Assessment
S Shaped Lateral Spinal Rotation
Unequal Shoulder and Scapula Height
Uneven Gait
Impaired Oxygenation
Hump when Bending Forward
Interventions
Body Braces
Worn 23 Hours/Day
Surgery
Considerations
Adolescent Screening
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3 mins
Developmental Dysplasia of the Hip
Cause
Abnormal Femoral Head in Acetabulum
Newborn Assessment
Positive Barlow Sign
Clicking with Adduction
Positive Ortolani Sign
Clicking with Abduction
Asymmetrical Limb Lengths and Folds (Gluteal and Thigh)
Older Child Assessment
Trendelenburg Sign
Interventions
Abduction Device
Pavlik Harness
Closed Reduction
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3 mins
Osteoporosis Assessment
Highest Risk
Postmenopausal Women
Long Term Corticosteroids
Assessment
Kyphosis
Dowager's Hump
Loss of Height
Back Pain
Pathologic Fractures
Spinal Compression Fracture
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1 min
Clubfoot
Cause/Mechanism
Multifactorial Congenital Anomalies
Fetal Position
Assessment
Deformed Foot and Ankle Position
Talipes Equinovarus
Interventions
Serial Casting
Ponseti Method
Early Surgery
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2 mins
Immobility
Assessment
Mobility Continuum
Complications
Cardiovascular
Respiratory
Musculoskeletal
Integumentary
Gastrointestinal
Urinary
Considerations
Turn, Cough, Deep Breathe (TCDB)
Range of Motion (ROM)
Skin Care
Fluids
Balanced Diet
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2 mins
Venous Thromboembolism (DVT) Assessment
Mechanism
Venous Wall Inflammation caused by Thrombus
Assessment
Tenderness
Edema
Warmth
Asymmetry
Considerations
Could be Asymptomatic
Monitor for Pulmonary Embolism
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58 secs
Supine Hypotension (Vena Cava Syndrome)
Mechanism
Compression of the Vena Cava and Descending Aorta
Signs and Symptoms
Hypotension
Dizziness
Tachycardia
Decreased Renal Perfusion
Decreased Uteroplacental Perfusion
Intervention
Side-lying Position
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2 mins
Renal Calculi Assessment
Cause/Mechanism
Hypercalcemia (Most Commonly)
Signs and Symptoms
Flank Pain
Radiates Toward Bladder
Renal Colic
Urinary Tract Infection
Urinary Retention
Hematuria
Considerations
Stone Recurrence
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2 mins
Pressure Ulcers
Risk Factors
Prolonged Immobilization
Neurologic Disease
Decreased Level of Consciousness
Classification
Stage 1: Intact Skin with Non-blanchable Erythema
Stage 2: Partial Thickness Skin Loss
Stage 3: Full-thickness Skin Loss without Fascial Involvement
Stage 4: Full-thickness Skin Loss with Fascial Involvement
Management
Wound Care
Surgery
Considerations
Septicemia
Osteomyelitis
Prevention
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3 mins
Age 18 Months - Developmental Milestones
Gross Motor
Walks Independently
Climbs On/Off Furniture Without Help
Fine Motor
Drinks from Open Cup Independently
Scribbles
Eats with Fingers
Tries to Use a Spoon
Stacks Three Blocks
Language/Communication
Attempts Three-word Phrases
Follows One-step Commands
Social / Cognitive
Checks While Moving Away
Points to Objects
Engages With Toys Simply
Copies Parent Doing Chores
Extends Hands for Washing
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2 mins
Age 5 Years - Developmental Milestones
Gross Motor
Buttons Some Buttons
Hops on One Foot
Fine Motor
Prints Letters
Language / Communication
Counts to 10
Uses Simple Rhymes
>3 Back-and-forth Exchanges
Answers Simple Questions
Tells a Story
Social / Cognitive
Names Some Letters When Pointed
Follows Rules
Sings, Dances, Acts
Does Simple Chores
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2 mins
Age 2 Months - Developmental Milestones
Gross Motor
Holds Head Up, But Unsteady
Moves Both Arms and Both Legs
Fine Motor
Opens Hands Briefly
Tracks Objects to the Midline
Language/Communication
Produces Sounds Aside from Crying
Reacts to Loud Noise
Social / Cognitive
Social Smile
Recognizes Parents
Soothed When Spoken to or Picked Up
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2 mins
Age 4 Months - Developmental Milestones
Gross Motor
Keeps Head Steady Without Support
Pushes Up on Elbows While on Tummy
Fine Motor
Holds a Toy in Hands
Moves Hands Towards Mouth
Language/Communication
Cooing
Turns to Voice
Social / Cognitive
Chuckles
Enjoys Looking Around
Looks at Hands With Interest
Opens Mouth When Hungry
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2 mins
Age 6 Months - Developmental Milestones
Gross Motor
Sits Propped Up On Hands
Rolls
Fine Motor
Raking Grasp
Language/Communication
Makes Squealing Noises
Blows "Raspberries"
Turn-Taking in Sounds
Social / Cognitive
Laughs
Enjoys Looking at Self in a Mirror
Recognizes Familiar People
Closes Lips to Signal Fullness
Puts Objects in Mouth
Reaches for Desired Toys
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2 mins
Age 9 Months - Developmental Milestones
Gross Motor
Sits Up Independently
Fine Motor
Transfers Objects Between Hands
Uses Fingers to Pull Food Toward Self
Language/Communication
Produces Various Sounds Like "mamamama" and "bababababa"
Raises Arms to be Lifted Up
Social / Cognitive
Separation Anxiety
Shows Facial Expressions
Looks When Calling Name
Smiles or Laughs at Peek-a-boo
Looks for Dropped Objects Out of Sight
Bangs Two Items Together
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2 mins
Age 1 Year - Developmental Milestones
Gross Motor
Pulls Up to Stand
First Steps
Fine Motor
Drinks From an Open Cup with Assistance
Two-Finger Pincer Grasp
Language/Communication
Understands “No”
Waves "Bye-Bye"
"Mama & Dada"
Social / Cognitive
Plays Pat-A-Cake
Puts Block in Cup
Searches for Hidden Toys
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2 mins
Age 2 Years - Developmental Milestones
Gross Motor
Kicks a Ball
Runs
Walks Up Stairs With Help
Fine Motor
Stacks Six Blocks
Feeds Self With a Spoon
Language / Communication
Two-Word Phrases
Points to Book Items as Prompted
Demonstrates Varied Gestures
Identifies Body Parts When Prompted
Social / Cognitive
Shows Empathy
Holds and Manipulates Objects Simultaneously
Engages With Multiple Toys
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2 mins
Age 3 Years - Developmental Milestones
Gross Motor
Starts Dressing Independently
Rides Tricycle
Fine Motor
Stack Nine Block Tower
Threads Items Together
Copies Circle
Uses Fork
Language / Communication
Engages in Two-way Conversation
75% Speech Understood by Stranger
Says First Name
Social / Cognitive
Avoids Hot Objects When Warned
Joins Other Kids in Play
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2 mins
Age 4 Years - Developmental Milestones
Gross Motor
Unbuttons Some Buttons
Catches a Large Ball
Serves Food or Pours Water With Help
Fine Motor
Copies Line, Circle, Stick Figure
Language / Communication
100% Speech Understandable
Identifies Colors
Social/ Cognitive
Cooperative Play
Imaginary Friends
Likes Being a “Helper”
Avoids Danger
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2 mins
Anterior Thorax Muscles
Characteristics
Pectoralis Minor
Pectoralis Major
Serratus Anterior
Intercostals (External, Internal, Innermost)
Subcostales
Transversus Thoracis
Diaphragm
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2 mins
Neck and Shoulder Muscles
Superficial
Splenius Capitis
Trapezius
Rhomboid Minor
Rhomboid Major
Deltoid
Latissimus Dorsi
Levator Scapulae
Deep
Supraspinatus
Infraspinatus
Teres Minor
Teres Major
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2 mins
Hand Muscles
Characteristics
Opponens Pollicis
Abductor Pollicis Brevis
Flexor Pollicis Brevis
Flexor Digiti Minimi Brevis
Abductor Digiti Minimi Brevis
Opponens Digiti Minimi
Lumbricals
Interossei (Palmar and Dorsal)
Palmaris Brevis
Adductor Pollicis
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2 mins
Back Muscles
Superficial
Latissimus Dorsi
External Oblique
Internal Oblique
Gluteus Medius
Gluteus Maximus
Deep
Erector Spinae
Serratus Anterior
Serratus Posterior
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2 mins
Posterior Thigh Muscles
Innervation
Sciatic Nerve
Muscles
Biceps Femoris
Long and Short Head
Flex Knee
Extend Hip
Laterally Rotate Hip
Semitendinosus and Semimembranosus
Flex Knee
Extend Thigh
Medially Rotate Thigh and Leg
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1 min
Muscle Types
Characteristics
Skeletal Muscle
Somatic Nervous System
Striated
Multinucleate
Cardiac Muscle
Autonomic Nervous System
Myogenic
Gap Junctions
Uninucleate
Smooth Muscle
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2 mins
Anterior Thigh Muscles
Innervation
Femoral Nerve
Muscles
Iliopsoas
Psoas Innervated by L1-3
Sartorius
Pectineus
Quadriceps Femoris
Vastus Lateralis
Vastus Intermedius
Vastus Medialis
Rectus Femoris
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2 mins
Medial Thigh Muscles
Action
Adduct the Thigh
Innervation
Obturator Nerve
Muscles
Adductor Magnus
Tibial Nerve
Adductor Longus
Adductor Brevis
Gracilis
Obturator Externus
Laterally Rotates Thigh
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1 min
Deep Gluteal Muscles
General Action
Lateral Rotation and Abduction
Muscles
Gluteus Minimus
Medially Rotates Leg
Piriformis
Superior Gemellus
Obturator Internus
Inferior Gemellus
Quadratus Femoris
Other Structures
Sacrotuberous Ligament
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1 min
Pulmonary Embolism Assessment
Assessment
Shortness of Breath (SOB)
Pleuritic Chest Pain
Tachypnea
Hemoptysis
Hypoxemia
Considerations
Sudden Death
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52 secs
Pulmonary Embolism Causes
Causes
FAT BAT Mnemonic
Fat
Air
Deep Vein Thrombosis (DVT)
Bacteria
Amniotic Fluid
Tumor
Risk Factors
Hypercoagulable
Central Venous Lines
Immobilized
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1 min
Braden Scale
Characteristics
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
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2 mins
Osteoporosis Interventions
Increased Calcium Intake
Vitamin D Supplements
Bisphosphonates
Raloxifene
Denosumab
Calcitonin
Teriparatide
Bone Densitometry (DEXA) Scan
Weight Bearing Exercises
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2 mins
Venous Thromboembolism (DVT) Interventions
Anticoagulants
Prevention Education
Frequent Ambulation
Leg Exercises
Compression Stockings or SCD's
Avoid Nicotine and Oral Contraceptives
Surgery
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1 min
Patient Position Overview
Position Techniques
Trochanter Roll
Trapeze Bar
Ankle-Foot Orthotic (AFO) Devices
Positions
Fowlers Position
Supine Position
Trendelenburg
Side-Lying Position
Prone Position
Sims' Position
Nursing Considerations
Reposition q2 Hours/Prevent Skin Breakdown
Confirm Body Alignment
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2 mins

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