Implementation

Question 1

Metabolic System

Answer 1

Because the body needs protein to repair injured tissue and rebuild depleted
protein stores, give the immobilized patient a high-protein, high-calorie diet. A
high-calorie intake provides sufficient fuel to meet metabolic needs and replace
subcutaneous tissue. Also ensure that the patient is taking vitamin B and C
supplements when necessary. Supplementation with vitamin C is needed for
skin integrity and wound healing; vitamin B complex assists in energy
metabolism.
If the patient is unable to eat, nutrition must be provided parenterally or
enterally. Total parenteral nutrition refers to delivery of nutritional
supplements through a central or peripheral intravenous catheter. Enteral
feedings include delivery through a nasogastric, gastrostomy, or jejunostomy
tube of high-protein, high-calorie solutions with complete requirements of
vitamins, minerals, and electrolytes

Question 2

Reducing Orthostatic Hypotension

Answer 2

When patients who are on bed rest or have been immobile move to a si􀄴ing or
standing position, they often experience orthostatic hypotension. They have an
increased pulse rate, a decreased pulse pressure, and a drop in blood pressure.
If symptoms become severe enough, the patient can faint (McCance and
Huether, 2017). To prevent injury, implement interventions that reduce or
eliminate the effects of orthostatic hypotension. It occurs when a normotensive
person develops symptoms and a drop in systolic pressure by at least 20 mm
Hg or a drop in diastolic pressure by at least 10 mm Hg within 3 minutes of
rising to an upright position (Shibao et al., 2013). Mobilize the patient as soon
as the physical condition allows, even if this only involves dangling at the
bedside or moving to a chair. This activity maintains muscle tone and increases
venous return. Isometric exercises (i.e., activities that involve muscle tension
without muscle shortening) have no beneficial effect on preventing orthostatic
hypotension, but they improve activity tolerance. When ge􀄴ing an immobile
patient up for the first time, assess the situation using a safe patient-handling
algorithm (US Department of Veterans Affairs, 2018) or another appropriate
mobility assessment/screening/scoring system. This is a precautionary step that
protects you and the patient from injury and also allows the patient to do as
much of the transfer as possible.

Question 3

Reducing Cardiac Workload

Answer 3

A nursing intervention that reduces cardiac workload involves instructing
patients to avoid using a Valsalva maneuver when moving up in bed,
defecating, or lifting household objects. During a Valsalva maneuver a patient
holds his or her breath and strains, which increases intrathoracic pressure and
in turn decreases venous return and cardiac output. When the strain is
released, venous return and cardiac output immediately increase, and systolic
blood pressure and pulse pressure rise. These pressure changes produce a
reflex bradycardia and possible decrease in blood pressure that can result in
sudden cardiac death in patients with heart disease. Teach patients to breathe
out while defecating, lifting, or moving side-to-side or up in bed and to not
hold their breath and strain

Question 4

Preventing Thrombus Formation

Answer 4

Deep vein thrombosis (DVT) is one of these Never
Events. The most cost-effective way to address DVT is through an aggressive
program of prophylaxis. Prevention of DVT is critical to reduce the risk of fatal
and nonfatal pulmonary embolism.Early ambulation; leg, foot, and ankle exercises;
regularly provided fluids; frequent position changes; and patient teaching need
to begin when a patient becomes immobile. Prophylaxis also includes anticoagulation, mechanical prevention with
graduated compression stockings, intermi􀄴ent pneumatic compression
devices, and foot pumps. Anticoagulation may include the use of aspirin,
although this is somewhat controversial. Anticoagulants most often used
include unfractionated heparin (UFH) (usually given as 5000 units two or three
times daily), low-molecular-weight heparins (LMWHs) (e.g., enoxaparin or
dalteparin), vitamin K antagonists (e.g., warfarin, but also acenocoumarol,
phenindione, and dicoumarol), and fondaparinux (a selective factor Xa
inhibitor) (Cave et al., 2018). Because bleeding is a potential side effect of
anticoagulants, continually assess the patient for signs of bleeding, such as
hematuria, bruising, coffee ground–like vomitus or GI aspirate, guaiac-positive
stools, and bleeding gums. Sequential compression devices (SCDs) and intermi􀄴ent pneumatic
compression (IPC) are used to prevent blood clots in the lower extremities. The SCD and IPC consist of sleeves or
stockings made of fabric or plastic that are wrapped around the leg and
secured with Velcro. Use of SCD/IPC on the legs decreases
venous stasis by increasing venous return through the deep veins of the legs.Elastic stockings (sometimes called antiembolitic stockings) also aid in
maintaining external pressure on the muscles of the lower extremities and thus
promote venous return. Another device for preventing DVT is the venous
plexus foot pump. It promotes circulation by mimicking the natural action of
walking.Proper positioning reduces a patient’s risk of thrombus formation because
compression of the leg veins is minimized. Therefore, when positioning
patients, use caution to prevent pressure on the posterior knee and deep veins
in the lower extremities. Teach patients to avoid the following: crossing the
legs, si􀄴ing for prolonged periods of time, wearing clothing that constricts the
legs or waist, and massaging the legs.

Question 5

Maintaining Musculoskeletal Function

Answer 5

ROM exercises…Passive ROM exercises begin as soon as a patient’s ability to move an
extremity or joint is lost. Carry out movements slowly and smoothly, through a
prescribed range, just to the point of resistance. ROM exercises should not
cause pain. Never force a joint beyond the point of resistance. Each joint
movement needs to be repeated 5 times during a session, with sessions
performed 2 to 3 times a day.

Question 6

Preventing Injury To the Integumentary System

Answer 6

Usually the time that a patient sits uninterrupted in a chair is limited to 1
hour. This interval is shortened in patients who are at very high risk for skin
breakdown. Reposition patients frequently because uninterrupted pressure
causes skin breakdown. Teach patients to shift their weight in a chair every 15
minutes. Chair-bound patients may benefit from a pressure-relief cushion such
as an air, viscous fluid/foam, or gel/foam cushion that reduces pressure.

Question 7

Elimination System

Answer 7

The nursing interventions for maintaining optimal urinary functioning are
directed at keeping the patient well hydrated and preventing urinary stasis,
calculi, and infections without causing bladder distention. Normal hydration
(e.g., 800 to 2000 mL of noncaffeinated fluids daily) helps prevent renal calculi
and UTIs. The well-hydrated patient needs to void large amounts of dilute
urine that is approximately equal to fluid intake. Also record the frequency and
consistency of bowel movements. Provide a diet rich in fluids, fruits,
vegetables, and fiber to facilitate normal peristalsis. If a patient is unable to
maintain regular bowel pa􀄴erns, stool softeners, cathartics, or enemas are
sometimes necessary. If the patient is incontinent, modify the care plan to
include toileting aids and a hygiene schedule so that the increased urinary
output does not cause skin breakdown.