Editing Anatomy and Physiology – LPN Flashcards (section)

== Nervous, Musculoskeletal, and Mobility ==

;What is the earliest sign of a worsening neurologic problem?
:A change in level of consciousness, such as new drowsiness, confusion, restlessness, or difficulty being aroused. Report any change from the patient's baseline right away.

;What are the neurovascular checks performed distal to a cast or an injured limb?
:Color, temperature, capillary refill, pulses, movement, sensation, and pain. Report coolness, pallor or bluish color, capillary refill longer than 3 seconds, numbness or tingling, inability to move the fingers or toes, or pain that increases with movement.

;Name three complications of immobility and one prevention measure for each.
:Pressure injury, prevented by repositioning at least every 2 hours; pneumonia and atelectasis, prevented by deep breathing and incentive spirometry; muscle atrophy and contractures, prevented by range-of-motion exercises. Immobility also causes constipation, blood clots, and bone calcium loss.

;What is the difference between active and passive range of motion?
:In active range of motion the patient moves the joint independently. In passive range of motion the nurse moves the joint for a patient who cannot move it. Move joints slowly and stop at the point of resistance or pain.

;How do you stage a pressure injury with intact skin and nonblanchable redness?
:Stage 1. The redness does not fade when pressed. Relieve pressure immediately and report the finding so a treatment plan can be started before skin breakdown occurs.