Hazards of Immobility

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Author:
tatekj
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235684
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Hazards of Immobility
Updated:
2013-09-19 22:02:16
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exam
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Nursing
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  1. Hazards of Immobility
    Body system: Cardiovascular
    Explain the effects and nursing interventions for the following:
    1) High cardiac workload 2) High risk orthostatic hypotension 3) High of venous thrombosis
    • 1) Less resistance in the blood vessels causes heart to work more while at rest              
    • ⇨Discourage straining while making a bowel movement  
    • 2) With sudden position changes it can lead to high blood pressure
    • ⇨Avoid them laying supine for too long.
    • ⇨Take b/p while in fowler’s position.
    • ⇨Try taking b/p in different to make sure they don’t have that problem.
    • 3) D/T pooling of blood, high fluids lead to edema, clots. Overall an error in the distribution of blood
    • ⇨ROM
    • ⇨Elevate the legs
    • ⇨Asses and follow health care plan
    • ⇨Feel and compare both legs for heat (can be blood clot)
  2. Hazards of Immobility
    Body System: Respiratory
    Explain the effects and nursing intervention of each of the following:
    1)Low depth of respiration 2)Low rate of respiration 3)Pooling of secretions impaired gas exchange
    • Rigid bed, pressure from abd organs. Low blood flow to lungs, high mucous which becomes thick and sticky and low ability to cough leas to shallow respirations. Risk for hypostatic pneumonia impaired exchange of co2 and O2 common cause of death.
    • ⇨Monitor respiratory rate
    • ⇨Listen to respiratory sound
    • ⇨Monitor cough to see if its productive 
    • ⇨Monitor spuedom (color, thickness and quantity) 
    • ⇨Does it hurt when you breath? (asses pain)⇨Monitor temperature 
    • ⇨Cough & deep breathing 
    • ⇨Make sure they are drinking a lot fluids (break up mucous)
    • ⇨Reposition to move mucous (document every time)
    • ⇨Pulse oxsemitry
  3. Hazards of Immobility
    Body System: Gastrointestinal
    Explain the effects and nursing intervention of each of the following:
    1)Disturbance in appetite 2)Altered protein metabolism 3)altered digestion and utilization of nutrients
    • Low peristalsis, muscle weakness in abdomen and perineal muscle and stool becomes hard
    • ⇨Listen for bowel sounds
    • ⇨Record how often or how long ago they had a bowel movement.
    • ⇨Encourage them to drink more fluids
    • ⇨Sit them up to make a bowel movement
    • ⇨(Last resort) Laxative
  4. Hazards of Immobility
    Body system: Urinary
    Explain the effects and nursing intervention of each of the following:
    1) High urinary stasis 2) High Risk of renal calculi 3) Low bladder muscle tone
    • Lack of gravity plays a role in stasis. Bacterial growth leads to UTI’s and stasis leads to kidney stone formation
    • Fluids (for flushing)
    • Sit them up to void and bowel movement Suggest a bed side commode
    • (For females) back to front pericare
    • High vitamin c to make pee more acidic
    • Food to make them go ex: whole grains, prunes, plums
  5. Hazards of Immobility
    Body system: Integumentary
    Explain the effects and nursing intervention of each of the following:
    1) high risk of skin breakdown and formation of decubitus ulcers
    • Friction-acts parallel to the skin ex: pulling up in the bed. Shearing-friction and pressure-in fowlers position body slides down. Can damage blood vessels
    • Make sure nothing is left in the bed.
    • Keep them as cool as possible
    • When transferring them make sure you follow the care plan
    • Dry beds (change sheets as soon as they are wet)
    • Watch for wrinkles
    • Skin assessments
    • Have them use their legs when sliding them up or ask for assistance (use bed pads)
    • Be aware of the side railing.
    • Make sure we are using with the care plan says
    • Make sure your applying your lotion
  6. Hazards of Immobility
    Body system: Psychological
    Explain the effects and nursing intervention of each of the following:
    1)high sense of powerlessness 2)low self-concept 3)low social interaction 4)low sensory stimulation altered sleep-wake pattern 5)high risk of depression
    • Clients feels dependent, deformed, pain and withdraw
    • ⇨Find activities to do with them
    • ⇨Promote independent activities
    • ⇨Challenge them intellectually
    • ⇨Council family
    • ⇨Give them a sense of power
  7. Hazards of Immobility
    Body system: Metabolic
    Explain the effects and nursing intervention of each of the following:
    1) High risk of electrolyte imbalance 2) altered exchange of nutrients and gases
    •  Low metabolic rate, catabolism > anabolism, low wound healing, low appetite
    • ⇨(Doctor order) vitamins
    • ⇨Lots of protein,
    • ⇨high calories and fibers
    • ⇨Small frequent feeding
  8. Hazards of Immobility
    Body system: Musculoskeletal
    Explain the effects and nursing intervention of each of the following:
    1)Low muscle size, tone and strength  2) Low joint mobility, flexibility, bone demineralization 3) endurance, stability 4) high of contracture formation
    • 20% loss of strength for every week on bed rest, disuse osteoporosis, bone loss. Joint most effected-hips, knees, and ankles
    • Correct alignment
    • ⇨ROM passive and active
    • ⇨Any weight bearing activities (even if it is just walking)
    • ⇨Make sure they are comfortable in bed

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