N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

Include chiropractic’s, acupuncture, therapeutic touch,

and massage.

Alternative or complementary treatments:

©2017 Achieve Test Prep Page 114 of 160 5.9 Joints Range of Motions (ROM) Active ROM exercises: Isotonic exercises in which the client moves each joint in the body through its complete range of movement, maximally stretching all muscle groups within each plane over the joint. Active ROM is used to maintain or increase muscle strength and endurance and help to maintain cardio and respiratory function in an immobilized client. Active ROM is used to prevent deterioration of joint capsules, ankyloses, and contractures. Passive ROM exercises: Another person moves each of the client’s joints through its complete range of movement. Passive ROM should be done for each movement of arms, legs and neck that the client is unable to achieve actively. Active-assistive ROM exercises: The client uses a stronger, opposite arm or leg to move each of the joints of a limb incapable of active motion. Perform each ROM exercise to the point of slight resistance, 5.8 Interventions • Nutrition: (appropriate nutritional and fluid pattern) Monitor the client’s weight, tissue turgor, fluid intake and output, and serum protein values. • Normal respiratory function: Assess breath sounds and chest expansion at least every 8 hours. Teach clients to take five deep breaths and to cough every waking hour. • Maintain skin integrity: This is evidenced by clean, intact, well-hydrated skin and absence of pressure signs (pallor, redness, or increased tenderness over pressure areas). • Maintain normal elimination patterns: Monitor color, clarity, amount, acidity, and specific gravity of urine. Monitor the color and characteristics of feces and frequency of defecation. Assess for pain during urination. • Prevent contractures: (maintain normal musculoskeletal function) Implement appropriate exercise programs (active, isotonic, or passive ROM) at least every 4 hours to arms, legs, and neck as indicated. Encourage active participation in self-care activities. Compare muscle size and strength to baseline data daily. Position clients in good body alignment. • Provide psychosocial stimulation: Explore diversional activities of interest to client. Assist client to develop a daily activity plan. • Foster independence: Encourage the client to make as many decisions as possible (placement of personal items, daily plan of activities, clothes to wear, etc).

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