immobility nursing assessments and interventions

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  1. Cardiovascular System 
    asses for edema discomfort, Homan's sign DVT(positive sign is present when there is pain in the calf on dorsiflexion of the patient's foot at the ankle while the knee is fully extended), warmth and ulceration

    elastic stockings, vascularboots(plastic sleeve)

    Leg movement q 1-2 hours 

    Rom-- active vs. passive q 4 hours 
  2. Cardiovascular System (2) 
    increase fluids intake (8oz every hour) 

    Heparin Therapy/Lovenox--prevent DVT(blood thinners) Hepranin (frequent blood draws) 

    Discourage Balsalva maneuver - pt forcefully exhales while closing mouth--causes venous return to decrease 
  3. Care of the client on anti-coagulants
    • assess for bleeding 
    • guaiac stools(+ blood), ecchymosis(bruises), petechiae(pinpoint purple dots), hematuria(blood in urine or urine cloudiness) , hemoptysis(blood in spit), hematemesis(blood in vomit) 
    • avoid trauma
    • soft toothbrush, no needle sticks, handle gently 
    • monitorPTT (with Heparin) Partial Thromboplastin Time--evaluates coagulation factors 
    • *coffe beans--digested blood
  4. Respiratory Interventions 
    • Assessment: Lung sounds, resp rate, cough, temp, skin color
    • TCDB(turn cough deep breath) prevents pnemonia 
    • Suction prn(the more you do it the more you need it ) 
    • CPT(Chest Physiotherapy): postural drainage, percussion, vibration 
  5. Musculoskeletal Interventions
    • Prevent backaches 
    • prevent contractures( permanent shortening of a muscle or joint) 
    • ROM 
    • Isometric exercise ( with out joint movement, muscle contract)
    • Assistive devices(walking canes, back braces, etc.) 
    • specialty beds
    • physical therapy
  6. Nutrition Interventions 
    • Protein rich foods, fiber(whole grains, pears, greek yogurt, protein shakes) 
    • vitamins B,C, Zinc 
    • Assess appetite, muscle mass, weight 
    • assist with eating 
    • Colorie count(fever, depends on disease process) 
    • monitor lab values(albumin, hgb)(circulating protein-albumin) (hgb make sure they don't become uremic--protein in urine) 
  7. Eliminaition Interventions 
    • asses GI function: bowel sounds, stool patter, flatus(passing gas) 
    • increase fluids
    • stool softeners/laxatives(Miralax, coax, decicate) 
    • measure outputs 
  8. Signs/symptoms of Fecal impaction 
    • *common in elderly/immobile 
    • no stool for days(normal patterns are irregular) 
    • urge to defecate with out results (but can't go)
    • oozing of diarrhea(leak around firm stool) 
    • anorexia-no appetite 
    • abdominal distention 
    • cramping
    • rectal pain 
    • *can result in digital removal
  9. Urinary interventions 
    • increase fluids 
    • measure output(checking for urinary stasis) 
    • assess voiding pattern
    • Signs of Stones: flank pain, low back pain, pink color of urine, painful to void
    • Signs of infection...
  10. Signs/ symptoms of UTI 
    *E.coli, normal floura in colon
    • urgency 
    • frequency 
    • dysuria 
    • cloudy urine
    • fever, chills(kidney infection) 
    • nausea, malaise 
  11. Interventions for UTI 
    • cranberry juice(pure) 
    • push fluids
    • administer antibiotics 
    • get meds to numb pain 
    • have them void frequently 
  12. Signs and symptoms of dehydration 
    • decreased urinary output(UOP) 
    • concentrated urine
    • thirst(mild dehydration state) 
    • poor skin turgor 
    • dry mucous membranes(no tears ) 
    • Inteventions: electroyles , IV fluids, no gatorade 
  13. Integument Interventions
    • position changes (every two hours) 
    • keep skin clean and dry(avoid moisture) 
    • avoid friction and shear 
    • assess skin condition frequently:pallor, redness, red areas that do not return to normal color after pressure removed
    • Interventions: cushions, toe pleat, bed cradles, different matress
  14. Psychosocial Interventions 
    • provide appropriate choices 
    • spend time 
    • create diversions 
    • encourage self care 
    • involve other health team members 
    • Aesthetic(encourage them to bring in pictures blanket)
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immobility nursing assessments and interventions
2013-03-12 05:08:52

nursing assessments
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