Immobility Flashcards
Body aligment:
Individual’s center of gravity is stable
Relationship of one body part to another while in different positions
Body mechanics:
Coordinated efforts of musculoskeletal and nervous system
Passive ROM:
Exercises performed by the nurse, just to the point of resistance
Prevention of atelectasis:
Deep breathing and coughing using an incentive spirometer
Repositioning immobile patient
Nurse duty:
AP duty:
Level of comfort, hazards of immobility, assessing circulation
Positioning pt
To prevent injury from orthostatic hypotension…
Dangle pt at bedside or move to a chair
A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor
for in this patient?
Altered nutrient metabolism
Body alignment in standing position:
- Laterally, spinal curves align in a reversed “S” pattern
- Posteriorly, shoulder and hips are straight and parallel
- Arms hang comfortably at side
- Feet slightly apart to achieve base of support
- Toes pointed forward
Body alignment in sitting position:
-Feet on the floor with ankles flexed
-Weight evenly distributed on butt and thighs
1-2 in space between edge of seat and popliteal artery or nerve
-Forearms supported by armrest
The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use?
Lateral position
Actions by the nurse when assessing respiratory system on an immobile pt:
- Auscultate entire lung region
- Assess respiratory every 2 hrs for restricted pts
- Focus assessment on dependent lung fields
SCD to be removed:
Every 8 hrs
Precaution when assessing for DVT:
Do not massage area due to danger of moving thrombus
Braden scale: (3)
- Tests skin integrity and pressure ulcers
- Lower number= higher risk
- Less than 17= risk for pressure ulcers
Discharge planning begins:
When a pt enters the health care system upon admission
The most widely used drugs in the prophylaxis of DVT:
Heparin and low-molecular-weight heparin
The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one?
- Position one nurse at each side of the bed.
- Place the drawsheet under the patient from shoulder to thigh.
- Grasp the drawsheet firmly near the patient.
- Place your feet apart with a forward-backward stance.
- Flex knees and hips and on count of three shift weight from the front to back leg.
- Move the patient and drawsheet to the desired position.
Trochanter roll:
Prevents external rotation of hips when pt is in supine position
Hand rolls:
Maintain the thumb in slight adduction and opposition to the fingers
Foot cradle:
Used for pt’s with poor peripheral circulation to reduce pressure on the tips of pt’s toes
Logrolling provides care to what kind of pt?
Pt who has suffered a spinal cord injury or are recovering from neck, back, or spinal surgery
Sims position pressure pts:
Ileum, humerus, clavicle, knees, ankle
Lateral position pressure pts:
Ear, shoulder, anterior iliac spine, ankles
Prone position pressure pts:
Chin, elbows, female breasts, hips, knees, toes
Supine position pressure pts:
Occipital, vertebrae, coccyx, elbow, heels
Logrolling technique requires:
3-4 people
Lordosis:
Exaggeration of anterior convex curve of lumbar spine
Kyphosis:
Increased convexity in curvature of thoracic spine
Scoliosis:
Lateral-S- or C-shaped spinal column with vertebral rotation
Genu valgum
Legs curved inward so knees come together as person walks
Genu varum:
One or both legs bent outward at knee
Torticollis:
Inclining of head to affected side
Morse fall scale:
Six-item fall risk assessment tool
nursing diagnosis for immobility:
impaired physical mobility risk for disuse symdrome ineffective airway clearance ineffective coping impaired urinary emliniation impaired skin integrety social isolation
Positioning techniques:
- Trochanter roll
- Hand roll
- Trapeze bar
- Supported Fowler’s-head 45-60 degrees
- Supine
- Prone
- Side-lying
- Sims’
