W8 : Complications with immobility part B Flashcards
1
Q
Urinary System
Pathophysiology
A
- Supine position impedes normal kidney contraction and emptying of bladder resulting in urinary stasis
- Increase in microorganism growth
- Increase in calcium excretion (associated with demineralisation of
bones); high amounts leads to formation of crystals (process of precipitation) - Bladder sensitivity decreased due to higher levels of calcium in urine impacting on ability to void
- loss in muscle tone
2
Q
Urinary calculi
A
- Kidney stones associated with precipitation of calcium
- Assessment data - extreme pain, dysuria, haematuria, urinary spasm/colic,
infection
3
Q
Urinary retention
A
- Inability to effective empty the bladder; extreme cases may even lead to
reflux back up ureter to kidney (hydronephrosis) - Assessment data – discomfort, abdominal distention, palpate and percuss
bladder above the symphysis pubis, retention with ‘overflow’ (incontinence)
4
Q
Urinary System
Nursing Interventions
A
- Avoid bed rest and immobility
- Promote activity and weight bearing exercises to ‘stress’
the bones and reduce likelihood of demineralisation and excessive calcium production - Push fluids (3 litres) to flush out the calcium and small stones;
adequate fluid intake to fill the bladder (2 litres) - Privacy; call bell; facilitate correct upright position to pass urine
- Monitor fluid balance, 1mL/kg/hour; or approximately
200-300 mL 6 times a day
5
Q
Skeleton : Musculoskeletal System
Pathophysiology
A
- Lack of exercise / weight bearing
(stress on the bone) results in impaired
osteoblast activity and demineralisation
(loss of calcium and phosphorus) of
bones; evident after 1 week of immobility - Progressive loss of bone mass and
deterioration of bone tissue;
size & strength of bone reduced
6
Q
Muscles: Musculoskeletal System
Pathophysiology
A
- Become weak and stiff; lose 7-10% of
strength weekly - Atrophy and shortening of muscle begins
in 3-7 days; deconditioning - Progressive loss of range of motion over
2 weeks - Tendons become resistant to movement
7
Q
Musculoskeletal System
Complications
A
- Joint stiffness & pain
- Muscle atrophy
- Pain on movement
- Unsteadiness, balance problems, falls
- Foot drop – unable to maintain foot in correct
position, shortening of tendons/muscles,
trouble walking, drag toes on floor
8
Q
Contractures
A
- A permanent contraction of a muscle group caused by shortening and fibrosis of
the muscle fibres, leading to loss of/alteration in function - Contractures complicate care, and cause pain & capillary occlusion
at bony prominences, contributing to pressure injury
9
Q
Contractures
A
Assessment data – permanent shortening
of muscle, deformity of a joint, reduced range of motion
10
Q
Osteoporosis
A
Loss of bony tissue resulting in bones that are brittle and liable to fracture
11
Q
Assessment data Osteoporosis
A
Assessment data – ‘silent disease’,
fractures (hip, vertebrae), back pain, loss of
height, spinal deformities (kyphosis)
12
Q
Musculoskeletal Nursing Interventions
A
- Mobilise or stand the patient; promote low impact weight bearing exercises –
walking, weights - Correct positioning and body alignment; splinting
- Support, cushioning, avoid weight on feet (bed cradle, bed sheet ‘tuck’
- Active and passive exercises; ROM; isometric (tense muscle) exercises
- Vitamin D and calcium supplements; calcium rich diets – milk, yogurt,
cottage cheese, seafood (sardines), green vegetables (spinach”, almonds - Exposure to sunlight (15 min, 4-6 times a week)
- Hip protectors; avoid smoking and excessive alcohol consumption
13
Q
Neurological System
A
- Lack of activity results in lower levels of endorphins, mood elevating
substances - Boredom; lack of stimulation; communication patterns altered
- Self concept and esteem impacted upon reduced ability to carry out
previous functions and roles; may lead to depression, withdrawal; ‘pyjama
paralysis’ - Exaggerated responses and behaviours associated with frustration
14
Q
Nursing interventions Neurological System
A
Nursing interventions
* Holistic nursing care – person-centred approached; active participate in
plan of care and decision making
* Spend time; active listening; promote social interaction, stimulate with
purposeful activities – interests, hobbies, sunshine, outdoors, visitors
15
Q
Gastrointestinal System
Pathophysiology
A
- Peristalsis impaired due to immobility
- Poor digestion, gastric reflux, indigestion
- Nausea, gas
- Constipation – weakening of muscles of skeletal and abdomen,
peristalsis is aided by standing - Other contributing factors - disturbed bowel regimes (environmental
and psychological factors), dietary changes (anorexia, fasting),
dehydration
16
Q
Gastrointestinal Signs and
Symptoms…
A
- Abdominal discomfort
- Abdominal pain
- Bloating
- Stomach cramps
- Painful bowel movements
- Rectal bleeding
- Incomplete bowel movement
- Bowel movement too small
or hard - Straining or squeezing
17
Q
Faecal Impaction
A
- Accumulation of hardened faeces in the rectum or sigmoid
colon that cannot be expelled - May result in faecal incontinence – overflow diarrhoea
18
Q
Faecal Impaction Nursing Interventions
A
- Removal of hard faeces – manually with lubricated glove and caution as to
not damage rectal wall (scope of practice!) - Cleansing enemas; regular aperient
- High fibre diet (bulk) – caution not to ‘dry out’ faeces
- Hydration; promote exercise
- Bowel regime (what is normal for that patient), privacy and toilet rather than
bedpan, positioning (squat, sitting, feet supported)
19
Q
Integumentary System
A
- Risk assessment using recognised tool
- Skin assessment
- Education of patient & family
- Regular repositioning – 2 hours
- Pressure reducing mattresses; support cushions
- High nutrition diet, protein rich
- Skin protection – pH neutral soaps; continence management; avoid
moisture & dryness; prevent friction and shearing; do not vigorously rub skin
