Immobility Flashcards
Problems older adults face d/t immobility
- postural abnormalities (kyphosis!!)
- muscle abnormalities
- CNS damage
- joint disease
- musculoskeletal trauma
- increased fall risk
effects of immobility
- decreased basal metabolic rate
- negative nitrogen balance
- dehydration
- increase calcium reabsorption from your bones
examples of nursing diagnoses
- impaired physical mobility
- activity intolerance
- risk for impaired skin integrity
- inneffective airweay clearance
Respiratory Complications
- atelectasis: alevolar collapse
- hypostatic pneumonia: lung inflammation from stasis of mucus secretions
- muscle weakness
- decreased lung expansion
respiratory interventions
- cough/deep breath q 1-2 hours in high fowler’s
- spirometer 10 times q 1hr
- turn q 2hr
cardiovascular complications
- orthostatic hypotension (decrease of SBP >20 or DBP > 10)
- increased cardiac workload (because of decreased fluid volume)
- thrombus formation
cardiovascular interventions
- isometric exercises
- monitor tachycardia, dizziness, faintness, BP, HR, cap refill
- preventing thrombus, DVT prohylaxis (Lovenox injections)
- TEDs for venous return
- SCDs for venous bloodflow to reduce stasis
TED: thromboembolic devise
SCD: sequential compression devise
contraindications for SCDs
patients with DVT’s. SCDs can cause DVT to dislodge and travel to lungs (pulmonary embolism)
GI complications
- decreased appetite
- constipation
- fecal impaction
- hypobowel sounds
- fluid and electrolyte imbalances
- dehydration
GI interventions
- hydration (2-3L/day)
- 1100 - 1400 mL non-caffeinated fluids
- increased fruits, veggies, exercise, fiber
- check bowels, last BM, passing gas, diet choice
Renal complications
- urinary stasis/reflux
- incomplete bladder emptying (more common in males bc prostate)
- urinary retention
- renal calculi (kidney stones)
- low urine output
- UTI/CAUTI
Renal interventions
- hydration/non-caffeinated fluids
- decreased food high in Calcium (if calculi)
- monitor I/O, renal function
musculoskeletal complications
- decreased muscle mass/strength
- atrophy
- disuse osteoporosis
- pathological fracture (bone breaks before fall)
- contractures
- foot drop
musculoskeletal inteventions
- ROM exercises
- education on fall prevention (Teach back!)
- increase bone health
integumentary complications
pressure injuries! (friction and shearing)
infection
tissue maceration
osteomyelitis
Friction: force occurs opposite to movement (superficial)
Shearing: force against stationary skin, but bony structures move (deep tissue death/necrosis)
Maceration: breakdown d/t moisture
integumentary interventions
- reposition q 2hrs
- skin care, balanced diet
- monitor blanchable redness
- air mattress, floating pads, stryker frames etc. (DME)
Psychosocial complications
- behavioral responses (i.e. hostility, anxiety)
- sensory alterations (i.e. altered sleep)
- changes in coping (i.e. depression, withdrawn)
psychosocial interventions
- encourage self care
- treat depression
- encourage family visits
