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52 Cards in this Set

  • Front
  • Back
Review the positive
effects of mobility
on the body
Mobility serves many
purposes; expression,
self defense, performance
of ADL's, health/basic
needs, exercise
Differentiate between
the consequences of
immobility in young adults
vs geriatric adults
Children: can have temporary
set back, resillient, recover
Adults: physical recovery is
better, not as resillient
as kids
Elderly: systems at risk,
not performing optimally
Discuss the benefits
of bed rest
Reduces physical activity
Decreases injury
Promotes healing
Reduces O2 req. of body
Reduces pain
Regain strength
Discuss the hazards
of bed rest
Prolonged bed rest can
lead to systemic effects.
Muscle atrophy, decreased
ROM, effects mental state.
Essentially it can effect
every system of the body.
Reasons why patients
may be on bed rest
Medical conditions
Physical impairment
Cognitive impairment
Temporary vs. permanent
Restrictive devices
Common types of
bed rest
strict bed rest, can't get
OOB at all
Bed rest with ADL in bed
with BRP
with BSC
Nursing interventions
to reduce hazards and
risks of bed rest
ROM, re-position, decrease
pressure loads (places on
body with force of gravity
that can cause change in
integument system, body
alignment, nutrition,
hydration, elimination,
pain mgmt, devices,
equipment that limit or
promote changes
device hose
can be knee or thigh high
compress calf/apply pressure
to promote venous return in
an immobile pt. Have to
take off to do a skin
assessment and must be
measured for appropriate fit.
Pt must wear all the time.
Decreases ris of DVT
apply pressure to calf to
increase venous return in an
immobile patient. Can cycle
on and off. Decreases risk
of DVT
passivie ROM
typically after knee related
surgeries, mechanical
machine rotates knee back
and forth. Progressively
increases ROM. Decreases risk
of DVT
Blood clots:
blood clot, stuck to wall
not going anywhere, attached.
With immobile patients and
post op patients (ortho) they
are more prone to blood clots
A blood clot that has
detached and is flowing
through blood stream
Risk factors
for DVT
Venous stasis - blood
not moving: bed rest,
immobility, spinal cord
injury, acute MI, CHF,
shock, venous obstruction
Hyperreactivity of blood
coag: stress, trauma, preg,
childbirth, BCP, dehydration,
Vascular trauma: surgery,
IV, massivie trauma/infection,
hip fx, ortho surgery
Dislodged clot
can go _______?
To the brain: CVA
To the lungs: PE
To deep veins of
legs: DVT
Veins in leg
effected by DVT's
Greater saphenous
Posterior tibial
What are signs and
symptoms of DVT
usually unilateral
edema, swelling
red, erythemia
warm to touch
skin breakdown maybe with
advanced DVT.
looks like cellulitis but
without fever, elev WBC,
defined border
Common response to
immobility by
patient metabolism
Drug metabolism - effects way
and rate of metabolism
F+E imbalance
Anorexia - remind pt to eat
Nitrogen imbalance - start
to metabolize muscle instead
of food/nutrients (anabolic)
Osteoporosis, Immunity,
forse on skin, Cognitive rxn
or response
How does decrease
in mobility effect
Psychosocial and
developmental state?
Psychosocial - change in
role, self image, isolated,
depression, worthlessness
Developmental - with children,
adults, and seniors immobility
can impair progression. Once
treated, usually pts are back
to normal
influences on
1. Musuloskeletal system - fx
2. CNA - compromise, MVA,
3. Muscle development -
muscular dystrophy
4. Postural - ability to
stand, scoliosis, kyphosis
What requires
bed rest?
Activity and O2 - activity
limitations, COPD with exac
Debilitated/ill - cancer
Exhausted - post partum mom
Common response to
immobility by
respiratory system
Lung volume - not taking
big breaths, ventilation
Alveoli collapse - atelectisis
Secretions - build up, not
moved along
Hypoxemia - O2 exchange not
Pulmonary embolism
All this can lead to
hypostatic (not moving) pna
Common response to
immobility by
cardiovascular system
Deconditiong (atrophy) of
Postural hypotension
Cardiac workload
Venous stasis - decreased
venous return leads to
heart thinking blood volume
is decreased so it pumps
harder. Leads to decrease
in BP. Patients are weak,
dizzy, faint
Common response to
immobility by
musculoskeletal system
Disuse atrophy - change in ROM
Contractures - can't reverse
it, result of muscle atrophy
Osteoporosis - change in way
Ca++ is being used. Body
can't adequately use Ca++ when
immobile. Have to be weight
bearing for Ca++ to come on
Pathologic Fx - fell because
bone broke
Common response to
immobility by
skin (integument)
prone to more moisture,
sweating, scraping
Tissue ischemia - no O2
Necrosis - dead tissue
Pressure sores - can effect
skeletal system in long run
osteomyelitis - bone infection
Common response to
immobility by
Defecation - never in position,
no intra-abd pressure
Change in motility - peristalsis
slows down
Constipation - more prone to get
Impaction - solid block in GI
system, oozing water stool
abd distended, firm, pain
digital removal.
Check if it is real
constipation or change in
bowel habit
Common response to
immobility by
genitourinary system
Don't have gravity working
with us.
Renal calculi - stones
Urinary incontinence
Urinary retention
don't empty bladder completely
muscle atrophy - decrease in
sphincter control/muscle tone
Common response to
immobility by
perception is off
cognition - change
hard to remember things
hard to assimilate new info
social isolation
change in role/self esteem/
self concept
coping ability may change
Intervention: use white
erase board to help
Common response to
immobility by
change in quality and quantity
decreased interaction
sensory perception - auditory
stimulus threshold lowers
-get irritated at loudness
visual/auditory hallucinations
vivid dreams
thought processes change
thermal point decreases-cold
sensory monotony
change in mental status
change in loc
orthostatic BP and HR
while pt lies supine take BP
and HR. wait 1-2 min
have pt stand, take BP and HR
if orthostatic: BP decreases
upon standing, HR increases
A client on prolonged
bedrest is assessed by
the nurse for:
a. increase BP
b. decrease HR
c. increase urinary output
d. decreased peristalsis
d. decreased peristalsis
61 yo male is hospitalized
with L sided paralysis
from CVA. In planning the
care for this client, the
RN implements what kind
of intervention?
assess the extremities for
unilateral swelling
and muscle atrophy
A client is getting
up OOB for the first
time after a period of
bed rest. The nurse
should first _______?
obtain a baseline BP and HR
how can you prevent
hypotension in the
immobile client?
Increase fluid intake
Sit pt up - decreases work
load on heart (when lying
supine, heart works harder)
how can you prevent
DVT in the
immobile client?
give medication
TED hose
pedal feet while in bed
what kind of medication
would you use and why?
Anticoagulant treatments
which reduce risk of DVT
formation or pts with
decreased mobility.
Most common
anti-coag meds?
Heparin - parenteral, iv or sq
Lovenox - parenteral, sq
Warfarin (coumadin) - enteral
Heparin: MOA
common dose
Turns off the coagulation
activating pathway, prevents
clots from forming, DOES NOT
breakdown existing clot
Sub-q or IV
5000 units subq daily in
anterio-lateral abd
Heparin: Complication
Labs to monitor
what's expected
Blood: bleeding, bruising
GI: n/v, abd cramping, ulcers,
bleeding gums/mucous membranes
Other: skin necrosis
Labs - APTT, no labs for sub-q
Expected - no dvt, thrombo-
embolitic event
Heparing: S+S of
Treatment of toxicity
Hematuria, melena, petechiae,
ecchymosis, oral mucosal bleed
Treatment: stop med, call doc,
order lab.
protamine sulfate will reverse
it quickly
Lovenox: route
common dose
labs to monitor
derivitive of heparin
sub q in anterio-lateral abd
don't expel air bubble
30 mg bid
no routine labs to monitor
Lovenox - S/E
what's expected
treatment for toxicity
Blood: bleeding, bruising
GI: n/v, abd cramping, ulcers,
bleeding gums/mucous membranes
Other: skin necrosis
Expected - no dvt, thrombo-
embolitic event
Treatment: stop med, call doc,
order lab.
protamine sulfate will reverse
it quickly
Warfarin (coumadin)
Labs to monitor
what's expected
Interferes with vit. K
production. slow acting.
monitor PT/INR (international
normalizing ratio). expect
values to become elevated if
patient is on med
Expected - no dvt, thrombo-
embolitic event
Warfarin (coumadin)
treatament for tox
Stop drug, slow admin of
IV vit K
Respiratory physiological
risks of immobility
Role of nurse
Prevent atelectasis
prevent hypostatic pna
implement use of:
incentive spirometer
turn cough deep breath
adequate hydration
Urinary physiological
risks of immobility
Role of nurse
prevent urinary stasis
prevent urinary retention
implement: have pt sit up
on bed pan or BSC
increase fluid volume
check for S+S of hypovolemia
physiological risks
of immobility
role of nurse
prevent pressure
ulcer - reposition, assess
skin thoroughly
physiological risks
of immobility
role of nurse
prevent osteoporosis - move
pt around
physiological risks
of immobility
role of nurse
prevent constipation
prevent impaction - increase
pt fluids, ambulate, sit pt
up at BSC. give colace and
advance prn
of immobility
role of nurse
orient pt
interact with pt
touch pt
decrease noise level
encourage day/night cycle
of immobility
role of nurse
Engage in activities, encourage
visits from family/friends,
personal care, familiar items,
express feelings, involve
support staff 1:1
of immobility
role of nurse
Assess and monitor pt
plan appropriate interventions
prepare for regression/delays
identify temporary changes
promote self care
stimulate interest
The nursing
care plan is designed
pts functional capabilities
self care
psychological well being