N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

©2017 Achieve Test Prep Page 110 of 160 Immobility can cause impaired social and motor development in young children. Development of numerous cognitive and behavioral changes (apathy, withdrawal, anger, aggressiveness, inability to problem-solve or make decisions, hallucinations) in an immobile client is due to a decrease in meaningful stimuli or the inability to process or manage the amount or intensity of sensory stimuli. 5.5 Nursing Procedures Detailed history should include specific nature of the problem, onset, frequency, causes if known, effect on ADL, coping strategies, and their effectiveness. Focused physical examination, body alignment (good posture) and the geometric arrangement of body parts in relation to each other should be assessed. Good body alignment promotes optimal balance without undue strain on the joints, muscles, tendons, or ligaments and maximal body function in any position. The purpose of assessment is to identify the following: normal developmental variations in posture, poor posture and leaning needs to maintain posture, factors contributing to poor posture, fatigue, low self-esteem, muscle weakness, or motor impairments. Observe whether shoulders are level and toes point forward. Check that the spine is straight, not curved to either side. • Gait: Assess gait to determine mobility and risk for injury related to falling. • Stance phase: The heel of the right foot strikes the ground and the body weight is spread over the ball of the right foot while the left heel pushes off and leaves the ground. • Swing phase: The leg from behind moves in front of the body, when one leg is in swing phase the other is in stance phase. Have the patient walk a distance of 10 feet down a hallway and observe for the following: head is erect, gaze is straight, vertebral column is upright, heel strikes the ground before the toe, feet are dorsiflexed in the swing phase, arm opposite the swing through foot moves forward at the same time, gait is smooth and coordinated with even weight on each foot. Check that the pace is normal, which is roughly 70-100 steps per minute (the elderly may decrease to 40 steps per minute). Appearance and movement of joints: Assess for joint swelling or redness which can indicate illness or injury, deformity or bony enlargement, or contracture and symmetry of involvement. Asses muscle development, along with relative size and symmetry. Assess reported or palpable tenderness, crepitation, increased temperature over a joint, and the degree of joint movement. Capabilities and limitations for movement: How does illness influence the ability to move? Is the client’s movement encumbered? Is the client alert and does he/she have the ability to follow directions? Assess the client’s balance and coordination, orthostatic hypotension, degree of comfort, vision, and amount of assistance needed to move in bed, rising from a lying position and rising from chair to standing. Check the range of motion, coordination, and balance. problem-solving and decision-making abilities occurs as well. Anxiety over the loss of control and increased dependence on others also lowers self-esteem. • Sensory deprivation or overload: