TBRQ Ch: 28 - Immobility Flashcards
An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.)
- B/P = 128/84
- Respirations 26/min on room air
- HR 114
- Crackles over lower lobes heard on auscultation
- Pain reported as 3 on scale of 0 to 10 after medication
Answer: 2, 3, 4.
Patients who are immobile are at high risk for developing pulmonary complications. The most common respiratory complications are atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Ultimately the distribution of mucus in the bronchi increases, particularly when the patient is in the supine, prone, or lateral position.
A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility:
- Decreased peristalsis
- Decreased heart rate
- Increased blood pressure
- Increased urinary output
Answer: 1.
Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.
The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to __________________________.
Answer:
Promote venous return to the heart. Elastic stockings (sometimes called antiembolitic stockings) aid in maintaining external pressure on the muscles of the lower extremities and thus promote venous return. Increase in venous return helps reduce the stasis of blood thereby, reducing the risk for deep vein thrombosis in the lower extremities.
A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply.)
- “I usually go swimming with my family at the YMCA 3 times a week.”
- “I need to ask my doctor if I should have a bone mineral density check this year.”
- “If I don’t drink milk at dinner, I’ll eat broccoli or cabbage to get the calcium that I need in my diet.”
- “I’ll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill.”
- “My lactose intolerance should not be a concern when considering my calcium intake.”
Answer: 1, 2, 3.
Patients at risk for or diagnosed with osteoporosis have special health promotion needs. Encourage patients at risk to be screened for osteoporosis and assess their diets for calcium and vitamin D intake. Multivitamins do not always have the needed amount of calcium for every individual. A patient needs to know his or her requirement and make a decision based on that.
A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient?
- Encouraging use of an overhead trapeze for positioning and transfer
- Frequent family visits
- Assisting the patient to a wheelchair once per day
- Ensuring that there is an order for physical therapy
Answer: 1.
The trapeze bar allows the patient to pull with the upper extremities to raise the trunk off the bed, aid in transfer from bed to wheelchair, or perform upper-arm exercises. It increases independence and maintains upper body strength to help in performing activities of daily living.
An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? 1. Loss of appetite 2. Gum soreness 440 3. Difficulty swallowing 4. Left ankle joint stiffness
Answer: 4.
Patients whose mobility is restricted require range-ofmotion (ROM) exercises daily to reduce the hazards of immobility. Temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Two weeks of joint immobilization without ROM can quickly result in contractures.
A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply.)
- Bruising
- Pale yellow urine
- Bleeding gums
- Coffee ground–like vomitus
- Light brown stool
Answer: 1, 3, 4.
Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding such as hematuria, bruising, coffee ground–like vomitus or gastrointestinal aspirate, guaiac-positive stools, and bleeding gums.
The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend?
- Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert
- Hot dog on whole wheat bun with a side salad and an apple for dessert
- Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert
- Turkey salad on toast with tomato and lettuce and honey bun for dessert
Answer: 1.
Teach patient and/or caregiver the current recommended dietary allowances for calcium and review foods high in calcium (e.g., milk fortified with vitamin D, leafy green vegetables, yogurt, and cheese).
The nurse evaluates that the NAP has applied a patient’s sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.)
- Initial patient measurement is made around the calves
- Inflation pressure averages 40 mm Hg
- Patient’s leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve.
- Stockings are removed every 2 hours during application.
- Yellow light indicates SCD device is functioning.
Answer: 2, 3.
The most effective way to prevent deep vein thrombosis is through an aggressive program of prophylaxis. A properly functioning SCD inflates with a pressure around 40 mm Hg. Inflation pressure averages 40 mm Hg, and the patient’s leg should be placed in the SCD sleeve with the back of knee aligned with the popliteal opening on the sleeve. Measurement involves length of leg, not calf. A green light indicates the SCD device is functioning.
A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken:
- Myoclonus
- Pathological fractures
- Pressure ulcers
- Pruritus
Answer: 3.
Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative.
The effects of immobility on the cardiac system include which of the following? (Select all that apply.)
- Thrombus formation
- Increased cardiac workload
- Weak peripheral pulses
- Irregular heartbeat
- Orthostatic hypotension
Answer: 1, 2, 5.
The three major changes are orthostatic hypotension, increased cardiac workload, and thrombus formation.
To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery?
- Turn, cough, and deep breathe every 30 minutes while awake
- Ambulate patient to chair in the hall
- Passive range of motion 4 times a day
- Immobility is not a concern the first postoperative day
Answer: 2.
Prevention of complications of immobility begins when the patient becomes immobilized. Every 30 minutes is not necessary and disruptive to the healing process. Active patient participation in exercises is more beneficial to preventing venous stasis.
Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?
- Isometric exercises
- Administration of low-dose heparin
- Suctioning every 4 hours
- Use of incentive spirometer every 2 hours while awake
Answer: 4.
Incentive spirometry opens the airway, preventing atelectasis.
Place the following options in the order in which elastic stockings should be applied.
- Identify patient using two identifiers.
- Smooth any creases or wrinkles.
- Slide the remainder of the stocking over the patient’s heel and up the leg
- Turn the stocking inside out until heel is reached.
- Assess the condition of the patient’s skin and circulation of the legs.
- Place toes into foot of the stocking.
- Use tape measure to measure patient’s legs to determine proper stocking size.
Answer:
1, 5, 7, 4, 6, 3, 2.
Which of the following are physiological outcomes of immobility?
- Increased metabolism
- Reduced cardiac workload
- Decreased lung expansion
- Decreased oxygen demand
Answer: 3.
Physiologic outcomes of immobility include decreased metabolism, increased cardiac workload, decreased lung expansion, and increased oxygen demand.
