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why bed rest in hospitals?
- - to help manage pathologies
- - but in saying this bed risk increases the risk of other pathologies
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Why are pts on bed rest?
- - prescribed- DVT, back surgery
- - pt decision
- - pt has nothing else to do
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What are the indications of bed rest?
- - critically ill- sedated etc
- - unconscious
- - imediate post op period eg day 0
- - ortho injury
- - immediately following AMI (acute myocardail infarct)
- - unstable cardiac conditions
- - mltiple wounds and fractures
- - hypotension
- - severe peripheral oedema
- - DVT?
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WHat can bed rest include?
- - sitting up or in a special chair
- - rare for someone to lie flat and still- many pts can be positioned or sat into a special chair
- - upright is best
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What are some adverse consequences of bed rest?
- all depends on the prior condition of the pt, level of activity, fitness, strength
- - length of time of the condition
- - amount of reduction of the effects of gravity
- - mm expect and need to move and be activeand they need regular stimulation by motor nerves
- - decrease inactivity - deconditioning
- - mm beome smaller- atrophy
- - reduction in strength
- - postural and ll mm
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What happens to the mm system when someone is on constant bed rest?
- - postural mm strength drops quickly
- - total losses of slow twitchmm mass is greater but the loss of cross sectional area is also very large in fast twitch mms eg quads
- - reported drop in strenght 1- 1.5%/day
- - loss continues for about 130 days
- - 15-20% in quads
- - upper body is less than lower
- - mm endurance is also reduced knee 15-20% about 4 weeks
- - contractile protein lost- not mm fibres
- - O2- insufficient use and increased demand for simple thing
- - changes in mm length
- - loss of mm strength and size can be prevented by pretraining
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what are the clinical implications of mm and bed rest?
- - pts on prolonged bed rest have reduced mm strength and endurance
- - increased difficulty in transferring, standing and walking
- - reduced balance and increased risk of falling
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what are some adverse consequences of bed rest?
- - bone responds to PA- needs mechanical stress to balance the ratio of bone formation to bone absorption
- - bone reflects mechanical stress applied to them
- - bones with increased stress become thicker and heavier
- - inactivity and lack of weight bearing exercise cause changes in the bony skeleton
- - bone use force to get stronger will weak if not used therefore bone is absorbed rather than formed
- - loss of mineral eg calcium from bone- hypercalcaemia- direct result
- - trabecular bone is particularly sensitive to demineralisation due to inactivity. The bone normally protects against stress from diff directions
- - loss of bone density is not uniform
- - more significantwith long term bed rest etc
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what are the clinical effects of bed rest for bones?
- - renal calculi (more calcium in blood)
- - greater risk of # due to reduced bone density
- - development of osteoporosis
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What are the adverse consequences of bed rest on the CVS?
- - changes occur within a few days
- - as well as immediate changes, chronic inactivity is a risk factor for CVS disease eg IHD
- - deconditioning on CVS
- - increased HR at rest and sub max exercise
- - reduced SV
- - reduced VO2 max
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What are the adverse effects of bed rest on blood?
- - fluid loss
- - changes in fluid regulating mechanisms- diresis- pee more, reduce plasma volume
- -hypovolaemia
- - increased blood viscosity
- - increased fibrinogen and platelets- risk of clotting
- - venous statis-lack of mm pump
- - risk of DVT
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What occurs with diuresis from bed rest?
- - occurs quickly
- - 15-20% of body's extracellular fluid may be lost within 3 days
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what are the significant effects of bed rest on CVS?
- - reduced blood volume
- - reduced venous return
- - reduce CVP (central venous pressure)
- - HR need to increase to maintain CO
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What are the adverse effects of bed rest on orthostatic hypotension?
- - reduces BV
- - dysfunction of baroreceptors
- - pooling of blood in lower limbs
- - pt dizzy
- - can start after 3-4 days of bed rest
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what are the clinical implications of bed rest on CVS?
- - heart less able to meet increase demands- SOB, fatigue
- - more O2 consumed for less work
- - orthostatic hypotension- need to assume pt has this
- - increased risk of DVT
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What are the adverse effects of bed rest on neuro system?
- - not much research
- - bed rest has -ve effects on neural firing rate and motor unit recruitment
- - evidence may effect postural control, gait, proprioception
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what are the adverse effects of bed rest on psyc status?
- - depression
- - anxiety
- -fear of activity
- - sensory deprivation
- - clinical implications- reluctant to be active, afraid of further activity, not modified with treatment
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What are the adverse effects of bed rest on the skin?
- - pressure areas/ ulcers/ bed sores
- - ischemic and breakdown
- common on:
- - sacrum
- - ischial tuberosity
- - greater trochanter
- - heels
- - lateral malleolus
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What are the contributing factors to pressure olcers?
- - immobility
- - pressure > arteriolar prevents dlivery of nutrients to the skin
- - accumulation of waste product products
- - greatest over bony prominences
- - shearing forces
- - tissue moving in oposite directions eg dermis in contact with matress
- - occurs when someone is on a incline
- - increase temp
- - increased moisture
- - poor nutrition
- - cirulatory factors- poor circulation, low BP
- - neurological disease
- - surface/ matress quality
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Stage 1 of skin changes
- skin non blancheable erythema of the intact skin
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Stage 2 of skin changes
- - partial thickness skin loss
- - skin surface is broken
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stage 3 of skin changes
- - full thickness skin lss
- - extension into subcutaneous fat
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Stage 4 of skin changes
- extensive destruction involving damage to m, bone or tendon
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What are the consequences of pressure ulcers?
- - infection- wound, bone, sepsis
- - dvelopment of sinus tract- may commnicate with bladder/ bowel
- Less commonly:
- - septic arthritis
- - endocarditis- infection of heart
- - meningitis
Psychological effects
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How can you prevent pressure spots?
- - improve general health
- - relief of pressure- positioning, mattresses- gel, foam, air
- - mobility
- - manage moisture
- - adequate nutrition
- - do not drag pt along bed or chair
- - dressing by specialists
- - topical agents
- - antibiotics
- - surgery
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What are the adverse consequence of bestrest on the resp system?
- - less dramatic consequences to other systems
- - usually worse if combined with pathology eg surgery
- - loss of resp mm strength
- - recumbent position- reduce lung volume, risk of atelectasis
- - not moving around- reduce clearance
- Clinical implications
- - increased risk of collapse, infection
- - increased risk of sputum retention and pneumonia
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What are nosocomial infections?
- nosocomial- pertaining to or originating in hopsital
- - UTI
- - Pneumonia
- - wound infection
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what is Iatrogenic infection?
caused by medical intervention
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What are contributing factors to nococomial infections
- - hospital setting eg ICU
- - health status
- - underlying disease/ comorbidties
- - immune status
- - skin integrity
- - presence of invasive devices eg IDC, IVC
- - antibiotic use and resistance
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Nococomial infections?
- - single celled organisms
- Typing:
- - gram stain (gram negative, gram positive)
- - morphology (cocci, bacilli, spirchetes)
- - metabolic properties (O2 tol)
- - analysis of genetic material
- Aim of a bacteria is to become 2 bacterial
- - very adaptive to diff envts
- staph aureus
- - major human pathogen
- - gram +ve
- - carries- intermittent colonisation- nacophayrnx, skin, 20% prolonged, 60% intermittent, 20% never colonised
- - common in health care workers
- staphylocciMRSA- methicillin resistant staph
- epidemic in health care systems
- - resistant to a variety of antibiotics
- - able to be treated with Vancomycin
- - effects- infection, wound infection
- Enterobacteriacae- gram -ve
- - ecoli
- - common constituents of GI flora
- - can cause infection elsewhere- diarhoea, UTI, sepsis, pneumonia
- VRE- vancomycin resistant enterococcus- vancomycin resistant
- - generally harmless bacteria
- - live in intestines of healthy people
- - difficult to manage
- Pseudomonas
- - isolated fom soil, water, plants, animals and humans
- - likes moist envt
- - reservoirs- resp equ, sinks, shower heads, swimming pools, contact lens solutions
- - opportunistic
- - rarely causes disease in healthy people
- Effects:
- - preumonia
- - ICU
- - bronchiectasis, CF, chronic bronchitis, excessive secretions
- - UTI
- - surgical site infection
- - blood stream infection
- Acinetobacter:- gram -ve
- - soil, human secretions, ventilator equp
- - 25% of healthy adults have cutaneous colonisation
- - common
- - increasing in incidence and resistance
- Effects:
- - pneumonia
- - sepsis
- - wound infection
- - UTI
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WHat is nosocomial pneumonial?
- - pneumonia developing 2 or more days after admission for another reason
- - accounts for 15% of all nosocomial infections 2nd most common, 1st UTI
- - affects 0.5-2% of all hospitalised pts
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What are predisposing factors of nosocomial neumonia?
- - mechanical ventilation > 48 hrs
- - prior AB use and resistance
- - duration of hospital stay
- - other health problems- chronic diseases eg COPD
- - malnutrition
- - ETOH abuse
- - severisty of underlying factos
- - reduces immune defenses- immunocompromise
- - major surgery
- - reduced LOC
- - increased age
- - presence of a NGT
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What are common organisms causing nosocomial pneumonia?
- gram -ve bacterial (50-80%)
- - pseudomona aurugonia
- - enterobacter
- - acinetobacter
- - haemophyillis
- gram +ve bacteria (20-30%)
- - staphylococcus
- - streptococcus
- Other anaerobes, fungi
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Nosocomial pneumonia- where do the bugs come from?
- - other sites in body
- - translocation from GIT
- - cross infection- other pts, staff
- - contam equip
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How can you prevent secondary complications of bed rest and hospitalisation?
- - early and regular activity and mobs even position changes
- - physios help where they can
- - self management- pretraining, optimise mobility, teach bed exercises, resp exercises, group treatment
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Prevention of nosocomial pneumonia
- - must assess if
- - mech ventilation >48 hrs
- - prolonged bed rest
- - post major surgery
- - past history of sig resp diesases
- - those with mob disorders
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