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Nursing The Hospitalized Adult > Immobility 1 > Flashcards

Immobility 1 Flashcards

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1
Q

What is immobility?

A


Individuals who have inactive lifestyles or who are faced with inactivity because of illness or injury are at risk for many problems that can affect major body systems.

inability to move about freely

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2
Q

Mobility?

A

a person’s ability to move about freely

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3
Q

Deconditioning?

A

out of shape

muscle wasting and progressive loss of function

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4
Q

Alterations in the level of physical mobility can result from?

A

prescribed restriction of movement in the form of bed rest

physical restriction of movement because of external devices( cast)

voluntary restriction of movement

impairment of motor or skeletal function.

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5
Q

Total immobility as in bed rest and can produce complications including ?

A

bedsores, pneumonia, or contractures

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6
Q

common complication of partial immobility or impaired physical mobility?

A

edema, thrombus

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7
Q

Bed Rest?

A

Pt is restricted to bed rest for therapeutic reasons

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8
Q

The general objectives of bed rest?

A

To reduce physical activity and the oxygen needs of the body

To reduce pain, including post op pain , and the need for large doses of analgesics

To promote safety for pts recovering from the effects of anaesthetics or who are sedated

To allow pts who are ill or debilitated to rest

To allow pts who are exhausted the opportunity for uninterrupted rest

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9
Q

Pathological influences on Mobility?

A

Impaired muscle development: eg. muscular dystrophy

Direct trauma to the musculoskeletal system : eg. fractures

Damage to the Central nervous system: eg. head injury, stroke

Postural Abnormalities: eg. scoliosis

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10
Q

Causes of Immobility?

A 
Bone surgery (Knee replacements, Hip replacements)
Abdominal Surgery
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11
Q

Common Joint Surgical Procedures indications?

A

Relieving chronic pain
Improving joint motion
Correcting deformities & malalignment
Removing intra- articular causes of erosion
Movement of a painful joint is often avoided , and if not corrected contraction with permanent limitation of motion often occurs ( contractures)

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12
Q

Types of joint surgeries?

A

Synovectomy
Debridement
Arthroplasty

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13
Q

Synovectomy?

A

removal of the synovial membrane for pt with Rheumatoid arthritis

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14
Q

Debridement?

A

removal of degenerative debris such as loose bodies, osteophytes, joint debris, and degenerative menisci from a joint. Also termed arthroscopy.

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15
Q

Arthroplasty?

A

reconstruction or replacement of a joint to relieve pain, improve or maintain range of motion and correct deformities.

Most commonly in pts with Osteoarthritis, Rheumatoid arthritis.

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16
Q

Nursing intervention for impaired physical mobility?

A

Exercise therapy for joint mobility and ambulation

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17
Q

impaired mobility after THA/TKA

A

related to pain , stiffness, and physical deconditioning as evidenced by limited joint movement, difficulty ambulating, inability to participate in physical rehabilitation, and guarded movement.

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18
Q

Why are elderly more at risk?

A

With the longer life expectancy, the incidence of disease and disability continues to grow (i.e. strokes, leg fracture, trauma, morbid obesity, multiple sclerosis)

Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, joints becoming stiffer and less mobile, and gait changes affecting balance can significantly compromise the mobility of elder patients.

Related Factors:
Activity intolerance (pneumonia)
Perceptual or cognitive impairment 
Musculoskeletal impairment 
Neuromuscular impairment 
Medical restrictions 
Prolonged bed rest 
Limited strength 
Pain or discomfort 
Depression or severe anxiety
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19
Q

Effects on Mobility 
: Any disorder which impairs?

A 
Respiratory System (pneumonia)
Musculoskeletal System (sprain, turning the wrong way)
Cardiovascular System(low BP, high BP, complete heart block)
Metabolic System (thyroid)
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20
Q

Effects on Musculoskeletal System?

A

Disuse osteoporosis: bones demineralize (osteoporosis) Loss of Calcium

Disuse atrophy: unused muscles atrophy

Contractures: a shortening of the muscle

Stiffness and pain of the joint: collagen
tissue “ankyloses” -> as bone demineralizes, excess Calcium becomes deposited in the joint

21
Q

Assessments/Interventions: 
Musculoskeletal System ?

A

Check muscle tone (Health assessment)
Assessment of ROM (Health assessment)
Falls Risk (Morse Scale)
Range of Motion=ROM (passive and active)

22
Q

Types of dance of motion exercises?

A 
passive
active passive
active
resistive
isometric/isotonic
23
Q

passive exercises?

A

keeps ROM for joint so it won’t be lost

exercises are carried out by the nurse, without assistance from the patient.

Passive exercises will not preserve muscle mass or bone mineralization because there is no voluntary contraction, lengthening of muscle, or tension on bones.

24
Q

active passive?

A

performed by the patient with assistance from the nurse.

Active assistive exercises encourage normal muscle function while the nurse supports the distal joint.

25
Q

active?

A

performed by the patient, without assistance, to increase muscle strength.

26
Q

resistive?

A

active exercises
performed by the patient by
pulling or pushing against an opposing force

27
Q

isometric/isotonic?

A

performed by the patient by contracting and relaxing muscles while keeping the part in a fixed position

maintain muscle strength when joint is immobilized

28
Q

USCR REST & ACTIVITY?

A

Rest:
altered sleep wake pattern

Activity:
↓ muscle size, tone and strength
↓ joint mobility, flexibility, bone demineralization
↓ endurance, stability
↑ risk of contracture formation
29
Q

Assessments/Interventions: Musculoskeletal System 


Nursing intervention?

A

Exercise therapy for joint mobility and ambulation by:

Early ambulation
Encourage ROM exercises
Work with the medical team to ensure best possible mobility
Use appropriate aids for safe ambulation

30
Q

Examples of Nursing Directives for USCR Rest and Activity Musculoskeletal System (TNP)?

A 
Out of bed up in chair for all meals
Walk three times a day
Teach isotonic exercises
Assist with ROM exercises twice a day
Walk with high walker 20 m daily
31
Q

Effects on Cardiovascular System?

A

Tachycardia: (less blood flow to the coronary arteries)

Increased used of Valsalva manoeuvre: (contraction of chest muscles on a closed glottis with simultaneous contraction of abd muscles =increases intra-abdominal pressure)

Orthostatic hypotension: (blood pooling of the blood in lower extremities) associated with a drop of 20 mm Hg or more in the systolic Bp.

Venous dilation (blood pooling results in damage to the valves in the lower extremities)


32
Q

Valsalva Manoeuvre? *

A

Occurs during straining to pass a hardened stool

May cause serious problems in patients with congestive heart failure, cerebral edema, hypertension, and coronary artery disease.

During straining the pt takes a deep inspiration, the breathe is held, & the glottis closes and traps the air.

Simultaneously with the contraction of the chest muscles against the closed airway , the abd muscles contract and try to push against the colon. Increases in intra abdominal pressure & intrathoracic pressure occur, reducing venous return to the heart.

There is bradycardia, cardiac output decreases, & a transient drop in BP.

When the pt relaxes there is a sudden flow of blood to the heart causing distension & an increase in heart rate.
Fatal for pt who cannot compensate for the sudden return of blood flow to the heart.

33
Q

Effects on Cardiovascular System cont.

Pooling of blood?

A

Dependent edema: (increased venous pressure) - noted in sacrum and heels; feet; feet and ankles when up in chair

Thrombus formation: -abnormalities in blood flow such as slow blood flow in calf veins . Hypercoagulation as a response to stress.

34
Q

Assessments/Interventions: Cardiovascular System ?

A

BP monitoring orthostatic hypotension
a drop in systolic blood pressure of 20 mmHg upon moving to an upright position (sitting or standing)
Associated with dizziness, fainting, pale, sweating, fast heart beat

Evaluate peripheral pulses

Check for venous stasis and edema

Education regarding Valsalva manoeuvre (encourage to breathe thru mouth)

Prevent Deep Vein Thrombus: Use of Pneumatic stockings or Ted Stockings

diuretic= relieve interstitial fluid

35
Q

Assessments/Interventions: Cardiovascular System?

A

Fall prevention for orthostatic hypertension

Teaching measures to reduce edema (extremities elevation)

Promote venous return (Teds, pneumatic stockings, elevate extremities, no leg crossing…)

Give anticoagulant as prescribed

36
Q

ORTHOSTATIC HYPOTENSION? *

A

drop of 20 mmHg or more in systolic and of 10 mmHg in diastolic BP within 3 minutes of when the pt rises from a lying or sitting position to a standing position.

Decreased circulating fluid volume , pooling of blood in the lower extremities and decreased autonomic response occurs when a pt is immobile.

These factors result in a decrease in venous return, followed by a decrease in cardiac output, which is reflected by a decrease in BP.

GI bleeding/meds can contribute to orthostatic hypotension

37
Q

ASSESSMENT OF ORTHOSTATIC HYPOTENSION?

A

Take the BP and pulse in the supine position to determine a baseline.

Request that the pt sit on the side of the bed for 3 minutes, take BP and pulse again. Monitor for dizziness or lightheadedness.

If no drop in BP > than 20 mmHg systolic, and no dizziness, assist the pt to the standing position.

Take the BP immediately and then 3 minutes after the pt is standing. Continue to monitor for dizziness.

38
Q

DVT prevention?

A

ted stockings

pneumatic stockings

39
Q

USCR AIR?

circulation?

A

↑ risk of orthostatic hypotension

↑ risk of venous thrombosis

40
Q

Examples of Nursing Directives for USCR Air Cardiovascular System (TNP)?

A

Monitor for orthostatic hypertension
Teach positions that promote venous return (elevate legs)

Antiembolic ( Ted) stockings at all times
Monitor for DVT.
Administer anticoagulant

41
Q

Effects on Respiratory System ?

A

Decreased respiratory movement
(shallow breathing and client rarely
sighs)

Pooling of secretions (rarely sighs, lack of coughing)

Atelectasis or secretions pool in one area of lung (collapse of lobe or lung)

Hypostatic Pneumonia (pooled secretions = excellent medium for bacterial growth)

42
Q

Assessments/Interventions: Respiratory System 
?

A 
Auscultate the lungs
Monitor O2 saturation
Ambulate ASAP
Turn and Position (T&P) if ambulation is not possible
Encourage deep breathing and coughing
Use incentive spirometer
43
Q

USCR AIR:

Lungs?

A

↓ depth of respiration
↓ rate of respirations
pooling of secretions
impairing gas exchange

44
Q

Examples of Nursing Directives for USCR Air Respiratory System (TNP)?

A

Teach deep breathing & coughing exercises
Assist with incentive spirometer every hour
Monitor for respiratory infection
Change position frequently

45
Q

Effects on the Urinary System

A

*Urinary Stasis (incomplete emptying of kidneys and bladder) resulting in

Urinary Retention (bladder doesn’t empty completely, decreased muscle tone) can be caused by meds

Urinary Infection (increased alkalinity of the urine = excellent medium for bacterial growth)

46
Q

Assessments/Interventions: Urinary System ?

A 
Monitor I & O, turn & position
Check bladder for extension
Ask patient about S&S of UTI
Monitor temperature
Offer BR frequently
Hydration (increase to 2liter a day)
47
Q

Effects on the Urinary System: Renal Calculi

A

excess amount of calcium -> calcium salts precipitate to form renal stones

48
Q

USCR ELIMINATION: Urine?

A

↑ urinary stasis
↑ risk of renal calculi
↓ bladder muscle tone

49
Q

Examples of Nursing Directives for USCR Elimination GU System (TNP)?

A

Offer use of bathroom for urination q3 hrs
Monitor I&O
Up to commode to void
Increase fluid intake to 2 liter per day (increases renal blood flow)

Nursing The Hospitalized Adult (11 decks)

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