Immobility Lecture Quiz

Question 0

What two Meds are given to break up clots?

What three meds prevent the formation of clots?

Answer 0

Activase or Retivase

Heparin, Lovenox, and Coumadin

Question 1

What are some immobility related respiratory complications for patients that are on bed rest?
What can be the result?

Answer 1

Decreased Lung Capacity leads to
Decreased circulation and oxygenation
Results in ischemia to the body tissues.

Question 2

What would you assess for a suspected blood clot related to immobility ?

Answer 2

Pulses
Pain Level
B/P
Capillary Refill

Question 3

Doppler Studies are used to evaluate __________.

Answer 3

Deep Vein Thrombosis

Question 4

Immobility leads to swelling in what three common locations?

Answer 4

Hands
Feet
Scrotum (Men)

Question 5

How long does it take a pressure ulcer to form ______?

What are 4 common locations of pressure ulcers?

Answer 5

30 Minutes

Elbows, Buttocks, Heels, and Knees

Question 6

What 3 types of patients are at the highest risk for pressure ulcers and why?

If sitting in a chair the patient needs to be moved how often?

Answer 6

Trauma patient with spinal injuries, paraplegic, and quadriplegic is at the high risk for pressure ulcers because they cannot feel the pain or assess their pain level due to lack of sensation.

Every 20 minutes.

Question 7

Clots can cause what 3 localized symptoms?

Answer 7

pain
swelling
redness

Question 8

How does immobility affect the kidneys and urinary tract?

Answer 8

If patient lays flat gravity cannot work on the ureters and pull urine down into the bladder.

Question 9

How would you assess a patient for urinary complications related to immobility?

Answer 9

Intake and Output

Assess frequency of urination

Question 10

What interventions would you implement to prevent your patient from having urinary complications related to immobility?

Answer 10

Adequate Hydration

Create Toileting Schedule

Question 11

What are 5 high risk immobility related psychological issues?

Answer 11

High Risk for:

Depression
Sadness
Dejection 
Helplessness
Hopelessness

Question 12

How would you assess a patient for immobility related psychological issues?

Answer 12

Screen for Depression

Observed mood changes or mood swings

Talk with patient and family members about changes noticed.

Question 13

Name 1 intervention and 1 referral you would recommend for a patient with psychological problems related to immobility and why?

Answer 13

Intervention
Encourage participation in care activities to promote independence.

Referral
PT/OT to encourage and promote independence.

Question 14

What three factors should nurses always consider that can lead to pressure ulcers?

How often should the patient be
repositioned to prevent pressure ulcers?

Answer 14

Sweat
Wrinkles in Sheets
Incontinence

Q2hrs

Question 15

After surgery patients remain on blood thinners in bed until when?

Answer 15

The blood is fully anti-coagulated.

Question 16

Name 4 nursing interventions to prevent Deep Vein Thrombosis? Which would you do first?

Answer 16

1. Sequential Compression Devices (usually done immediately following post-op)
2. Positioning
3. Passive Range of Motion Exercises
4. Compression Stockings

You put SCDs on before Compression Stockings because they are difficult to remove.

Question 17

What happens to a patients muscles who is immobile and placed on bed rest ?

List 3 major complications?

Answer 17

Muscles get weak leading to atrophy.

Decreased muscle strength
Decreased muscle endurance
Decreased muscle volume

Question 18

What are the 3 most common skeletal complications of immobility related to best rest?

How would you describe their effects on the patient?

Answer 18

Contracture (bones won’t move)

Foot drop (permanent muscle atrophy in the calf)

Osteoporosis (decreased bone density)

Question 19

How do you assess for musculoskeletal changes caused by immobility ?

Answer 19

1. Symmetry (common in patients that wear a cast)
2. Pain Level of swelling, muscle, skin, and nerve endings (bones don’t hurt)
   (Muscle contraction from atrophy is painful)
3. Monitor muscle to fat ratio.
   Look for increase in body fat. Decrease in muscle.

Question 20

What test can tell If your patient is burning muscle protein?

Answer 20

Urine dip.

Checks for protein levels in urine which shows you are burning muscle instead of fat.

Question 21

Immobility can cause skin breakdown.

What are the 2 main related factors of this type of skin breakdown?

Answer 21

Pressure

Friction

Question 22

Name 6 common locations for skin breakdown?

Answer 22

Sacrum, 
Coccyx, 
Heels, 
Elbows, 
Shoulder Blades, 
Back of the Head.

Question 23

How would you prevent skin breakdown related to immobility?

Answer 23

Turn patient Q2Hours

Question 24

What are two other factors that contribute to pressure ulcer formation?

Answer 24

Decreased nutrition status

Increased pressure results in ischemia

Question 25

Patients that are immobile are at a high risk for what urinary complications?

Answer 25

High Risk for UTIs, Kidney Stones and Kidney Failure.

Question 26

______ can cause Emboli
Emboli go to the lungs causing
_________ _____________.
Emboli can also cause __________.

Answer 26

DVT

Pulmonary Embolism

Stroke

Question 27

During pressure ulcer formation it is important to remember:
If the tissue is _______ it can be saved.
If the tissue is _______ it is dead.

Answer 27

Red

White