Nur 122

Card Set Information

Author:
RosieHernandez
ID:
118995
Filename:
Nur 122
Updated:
2011-11-26 16:00:33
Tags:
Immobility
Folders:

Description:
Immobility
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user RosieHernandez on FreezingBlue Flashcards. What would you like to do?


  1. Problems of Immobility
    Benefits
    • Reduces 02 demand
    • directs resourses toward healing
    • may reduce pain
  2. Not a benefit?
    Bedrest can kill your patient!!!!
  3. Physiological response to immobility
    Musculoskeletal
    • ↓Muscle strength
    • ↓Muscle mass
    • disuse osteoporsis- Ca extracted from bone = brittle & break
    • fibrosis → contractions
  4. Musculoskeletal
    How to assess for it
    • Observe for joint stifness
    • coordination
    • ROM
    • Labs: serum: protein, Ca (higher) urine: Ca (spilling out)
  5. Musculoskeletal
    how to manage
    • Aligment: specific turning schedule
    • weight bearing
    • indep ADL's
    • AROM and PROM
    • meds: calcium
    • Diet
  6. Skin should always be?
    Warm and dry
  7. The Valsalva Maneuver is dangerous for two reasons.
    • The increased pressure in the thoracic cavity reduces the amount of blood flowing into the thoracic cavity, especially in the veins leading to the right atrium of the heart.
    • The maneuver can also cause cause blood clots to detach, bleeding, irregular heart rhythms and cardiac arrest.Many of the heart attacks which occur in bathrooms have been linked to the Valsalva Maneuver, which in turn, is closely associated with sitting toilets...
  8. Thrombophlebitis
    is swelling (inflammation) of a vein caused by a blood clot.
  9. Cardiovascular
    • General weakness
    • disrupted ANS ↑heart rate (0.5 bpm/day)
    • ↓diastolic pressure coronary blood flow cardiac ability to respond to demands
    • Basically- tachy and pain with slight exertion
    • Valsalva Maneuver
    • ortho hypotension ( Body does not respond ↓B/P)
    • thrombophlebitis
  10. Cardiovascular
    How to assess for it (Watch for this)
    • Heart rate
    • Narrowed pulse pressure ( not widening)
    • Edema (↓ venous return)
    • Skim temp
    • Clots
    • Chest pain, pressure
    • B/P
  11. Cardiovascular
    How to manage it:
    • Teach not to do the Valsalva Maneuver
    • TEDS (Anti embolism stockings and medical support stockings.)
    • Good leg positioning
    • Meds: anticogulants, stool softners, anti-htpn's
  12. Females sign of heart attack:
    Heart Burn
  13. Always pay attention to pain in
    Arm = MI's or Clot's
  14. Respiratory Response to Immobility:
    • Chest movement impaired→ abdominal organs move↑ →difficult expansion
    • Pt doesn't sigh (pt doesn't get air out since they are laying down to long)
    • Joints get fixed
    • ↓Blood flow to lungs, esp dependant areas + ↓
    • cough+ weak cilia Ô××atelectasis (is the collapse of part or (much less commonly) all of a lung) and pneumonia (cilia don't move like they have to)
  15. Respiratory
    How to assess for it (Watch out for)
    • Listen!!!! Diminshed breath sounds, wheezing (narrowed airway)
    • Cough (good)
    • Temp
    • Pulse ox/ Blood gas (sign of life look at color)
  16. Respiratory
    How to manage it:
    • Deep breathe and cough (you want them to do this)
    • Turn, turn, Turn!!!
    • Meds: expectorants (thin the mucus that blocks the air tubes leading to the lungs), No cough meds! Bronchodialators (is a substance that dilates the bronchi and bronchioles, decreasing resistance in the respiratory airway and increasing airflow to the lungs), ? suctioning
    • Fluids (clear water & tea)
  17. Metabolism & Nutrition responds to Immobility
    • ↓BMR (not moving)
    • ↓GI mobility
    • ↓Digestive scretions and then they're not hungry!
  18. Metabolism & Nutrition responds to Immobility
    How to assess it:
    • Weight loss (little muscle tone)
    • Nutrition
    • Labs:↓serum protein ↑serum Ca↑BUN
    • slow wound healing
  19. Metabolism & Nutrition responds to Immobility
    How to manage it:
    • ↑protein↑calories↑fiber easy to chew and swallo
    • may need enteral or parenteral support
    • Food they like!
    • Meds: appetite stimulants (magaze), supplements, pleasant meal time environment
  20. Urinary system problems with immobility
    • Initial diuresis→↑excretion Na excretion
    • unable to empty bladder →stasis (stopping of the normal flow)
    • stasis compromised by ↓muscle tone
    • ↑serum Ca→urine more alkaline crystals→ calculi (15-30%)
    • Incontinence/retention/ overflow
    • static urine →↑bacterial growth→↑UTI's
  21. Urinary system problems with immobility
    How to assess:
    • I&O
    • urine appearance
    • frequency, urgency, pain
    • Labs: ↑Spe gravity, BUN, Hct, Urine pH, bacateria, WBC's, cultures
  22. Urinary system problems with immobility
    How to manage it:
    • Turn turn turn
    • Push clear fluids-cranberry juice
    • perineal hygiene
    • good environment
    • answer lights
    • cath is a last resort
  23. Intestinal System problems with immobility
    • ↓peristalsis
    • ↓Motility
    • contracted anal sphincter
    • disruption of habits/ bedpan
    • water extracted from stool →hard, dry, impaction
  24. Intestinal System problems with immobility
    How to assess for it:
    • Bowel patterns
    • bowels sounds
    • general malaise (feeling discomfort)
    • temp ( ↑when constipated)
  25. Intestinal System problems with immobility
    How to manage:
    • Exercise
    • turn turn turn
    • position and privacy
    • fluids(caffine, water, prune juice)
    • ↑fiber and fruit
    • meds: only as last resort Laxatives
  26. Pressure ulcer
    If it has eschar can't stage until its debrided.
  27. Integumentary system problems with immobility
    • Skin trophies
    • decreased turgpr
    • basic problem is pressure sores
    • aka decubiti, bedsore
  28. Integumentary system problems with immobility
    def: reddened areas, open sores or ulcers usually occuring over bony prominences

    • caused by: interupton of blood circulation to tissues
    • localized ischemia
    • tissue caught between 2 hard surfaces
    • cells dprived of 02 & nutrients
    • cellular waste accumulates tissue dies
  29. Integumentary system problems with immobility
    Causes:
    • 1. Pressure -perpendicular force (↓↑) highest pressure in sarcrum, buttocks, and heels. Pressure →skin turns white→if relieved→reactive hyperemia last 1/2-3/4 as long as the pressure.
    • If redness disapperas in that time, no damage.
  30. Friction
    2. Forces parallel to skin(↔) abrades the skins, removes superficial layers increase risk of breakdown.
  31. Shearing Force
    3. comination of pressue and friction seen with smi-fowlers seen if sliding rather that lifting.
  32. Staging 1
    • intact reddened
    • non-blanching
  33. Staging 2
    • Break in epidermis
    • blister, abrasion
    • surrounding red
    • serous drainage (clear or bleeding)
  34. Staging 3
    • Break thru dermis and sub q
    • serous or purulent drainage
    • progresses rapidly
  35. Staging 4
    • breaks into: fascia, muscle, bone
    • Drainage, osteo, sepsis
  36. Factors affecting formation of pressure sores:
    • Mositure
    • hygiene
    • nutrition
    • hard support
    • body heat
    • anemia
    • mobility
    • poor lifting
    • poor position
    • injections
    • hard support surfaces
    • incorrect applications of devices
  37. Factors affecting formation of pressure sores:
    What to assess:
    • Skin turgor
    • edema
    • redness
    • labs: H&H
    • temp
  38. Factors affecting formation of pressure sores:
    How to manage:
    • Turn turn turn-all positions every 2 hrs
    • bed making
    • HOB ↑< 30º
    • clean and dry
    • bony prominences
    • better to prevent than to treat
  39. Psychological Responses Problems with Immobility:
    • More gradual and subtle
    • ↑dependance feeling of worthlessness, hopelessness and empitness
    • ↓intellectual abilities, ability to concentrate, coping mechanism.
    • May have financial concerns, work concerns
    • Changes in sexuality and role performance
    • May be evidence by hosility, confusion, belligience, withdrawal, apathy and anxiety
  40. Psychological Responses Problems with Immobility:
    How to assess:
    More gradual and subtle ↑dependance feeling of worthlessness, hopelessness and empitness↓intellectual abilities, ability to concentrate, coping mechanism. May have financial concerns, work concerns Changes in sexuality and role performanceMay be evidence by hosility, confusion, belligience, withdrawal, apathy and anxiety
  41. Psychological Responses Problems with Immobility:
    How to manage:
    • Social stimulation
    • consistency
    • involve significant others
    • encourage ADL's
    • appearance, won clothes
    • Sleep
    • Intellectual stimulation
    • hobbies

What would you like to do?

Home > Flashcards > Print Preview