Chapter 16 Flashcards
What are the potential effects of Immobility?
-Inability to meet own needs
-Depression
-Anxiety
-Hostility
-Fear
What affect does immobility have on the musculoskeletal system?
Decreased muscle strength and muscle mass
shortening and tightening of connective tissue
calcium leaves the bones, resulting in weakness and brittleness
Atrophy
for something to waste away
Osteoporosis
Condition that occurs because of loss of bone minerals; leads to increased risk of skeletal fractures
Foot Drop
Permanent plantar flexion
Contractures
Shortening and tightening of the muscles because of disuse
How does the nurse help prevent musculoskeletal complications?
Help maintain proper body alignment
Do range of motion exercises
What is the difference between AROM and PROM?
Active Range of Motion
Passive Range of Motion
What affect does immobility have on the cardiovascular system?
Decreased cardiac output
Pooling of blood in the extremities
Increased cardiac workload
Orthostatic Hypotension
Postural Hypotension - decrease in blood pressure that occurs when a PT changes from reclining/flat position to upright (sitting/standing)
Embolus/Emboli
Blood Clot that dislodges and enters circulation
How does the nurse help prevent cardiovascular complications?
Encourage movement of extremities
Apply ordered devices to prevent pooling of blood in legs
Change PT position frequently
Remain with PT the first few times they get out of bed
ROM
Range of motion exercises -
series of activities designed to move each joint through all of its natural actions
Venous Stasis
pooling of blood in the veins of the lower legs
DVT
Clot that develops in the deep veins of the legs
Syncope
Fainting
What affect does immobility have on the respiratory system
Decreased respiratory muscle strength and decreased lung expansion
Impaired oxygen and carbon dioxide exchange
Pooling of respiratory secretions
Atelectasis
The collapse of lung tissue affecting part or all of a lung
Hypoxemia
Lowered oxygen in the blood
Hypostatic Pneumonia
Type of lung infection that occurs when a patient is immobile.
Secretions pool in the lungs and the warm dark moist environment is ideal for bacterial growth.
How does the nurse help prevent respiratory system complications?
Turn PT side to side every 2 hours
Elevate the head of the bed45 degrees or more to promote lung expansion
Encourage cough and deep breathing exercises every hour awake
Encourage PT to use incentive spirometer
What affect does immobility have on the gastrointestinal system?
Decreased peristalsis
Decreased appetite
Increased intestinal gas
Constipation
Difficulty voiding bowels
Flatulence
Passing gas
Distension
Swelling
How does the nurse help prevent gastrointestinal system complications?
Ambulate as soon as DR says okay
Reposition every 2 hr on bedrest
Place in sitting position to deficate on bedpan to allow gravity to assist
Encourage fluid intake
Give laxative if not BM in 3 days
What affect does immobility have on the urinary system?
Pooling of urine in the renal pelvis
Incomplete emptying of the bladder
Increased calcium in the blood to be filtered by the kidneys
Urinary Tract Infection
Infection in the urinary tract
Renal Calculi (Nephrolithiasis)
kidney stones
How does the nurse help prevent urinary system complications?
Provide fluids to prevent concentrated urine
Assist PT sitting position for urination
Assess PT output; should void at least once every 8 hours
What affect does immobility have on the integumentary system?
Decreased oxygen and nutrients to tissues
Skin and capillaries compressed between bed and bony proinences
Pressure Injuries
Constant pressure to the same area of the body it prevents blood flow and the tissue dies. Can also be called skin breakdown or decubitus ulcer
Shearing
Occurs when skin layer is pulled across muscle and bone in one direction while the skin slides over another surface in an opposite direction
How does the nurse help prevent integumentary system injuries?
Provide adequate nutrition
Reposition every 2 hours
Inspect bony prominences for redness at least every 2 hours
Use mild soaps to clean skin
Apply lotion to dry skin after bathing
What affect does immobility have on the neurological system?
Decreased oxygenated blood circulating to nerves trapped between the bed and bone
Decrease in normal cues and activities
Decreased balance when initially out of bed
Compression Neuropathy
Impaired nerve function
Decreased level of consciousness
Confusion
