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52 Cards in this Set
- Front
- Back
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Review the positive
effects of mobility on the body |
Mobility serves many
purposes; expression, self defense, performance of ADL's, health/basic needs, exercise |
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Differentiate between
the consequences of immobility in young adults vs geriatric adults |
Children: can have temporary
set back, resillient, recover better. Adults: physical recovery is better, not as resillient as kids Elderly: systems at risk, not performing optimally |
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Discuss the benefits
of bed rest |
Reduces physical activity
Decreases injury Promotes healing Reduces O2 req. of body Reduces pain Regain strength Safety |
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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. |
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Reasons why patients
may be on bed rest |
Medical conditions
Physical impairment Cognitive impairment Temporary vs. permanent Progressive Prescribed Restrictive devices |
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Common types of
bed rest |
strict bed rest, can't get
OOB at all Bed rest with ADL in bed with BRP with BSC |
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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 |
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Thromboembolitic
device hose (TED 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 |
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Sequential
compression device (SCD) |
apply pressure to calf to
increase venous return in an immobile patient. Can cycle on and off. Decreases risk of DVT |
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Continuous
passivie ROM machine |
typically after knee related
surgeries, mechanical machine rotates knee back and forth. Progressively increases ROM. Decreases risk of DVT |
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Blood clots:
Thrombus |
blood clot, stuck to wall
not going anywhere, attached. With immobile patients and post op patients (ortho) they are more prone to blood clots |
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Embolus
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A blood clot that has
detached and is flowing through blood stream |
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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, cancer Vascular trauma: surgery, IV, massivie trauma/infection, hip fx, ortho surgery |
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Dislodged clot
can go _______? |
To the brain: CVA
To the lungs: PE To deep veins of legs: DVT |
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Veins in leg
effected by DVT's |
Greater saphenous
Posterior tibial Popliteal Femoral |
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What are signs and
symptoms of DVT |
usually unilateral
edema, swelling painful red, erythemia warm to touch skin breakdown maybe with advanced DVT. looks like cellulitis but without fever, elev WBC, defined border |
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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, Pressure/friction/shearing forse on skin, Cognitive rxn or response |
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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 |
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Pathological
influences on mobility |
1. Musuloskeletal system - fx
2. CNA - compromise, MVA, quadrapalegic 3. Muscle development - muscular dystrophy 4. Postural - ability to stand, scoliosis, kyphosis |
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What requires
bed rest? |
Activity and O2 - activity
limitations, COPD with exac Pain Debilitated/ill - cancer Exhausted - post partum mom |
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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 good Pulmonary embolism All this can lead to hypostatic (not moving) pna |
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Common response to
immobility by cardiovascular system |
Deconditiong (atrophy) of
muscle. Postural hypotension orthostatic 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 |
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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 board. Pathologic Fx - fell because bone broke |
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Common response to
immobility by skin (integument) system |
Moisture/friction/shear
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 |
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Common response to
immobility by gastrointestinal system |
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 |
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Common response to
immobility by genitourinary system |
Don't have gravity working
with us. UTI Renal calculi - stones Urinary incontinence Urinary retention don't empty bladder completely muscle atrophy - decrease in sphincter control/muscle tone |
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Common response to
immobility by psycho-social condition |
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 |
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Common response to
immobility by sensory |
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 |
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orthostatic BP and HR
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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 |
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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
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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 |
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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
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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) |
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how can you prevent
DVT in the immobile client? |
give medication
SCDS TED hose pedal feet while in bed |
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what kind of medication
would you use and why? |
Anticoagulant treatments
which reduce risk of DVT formation or pts with decreased mobility. |
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Most common
anti-coag meds? |
Heparin - parenteral, iv or sq
Lovenox - parenteral, sq Warfarin (coumadin) - enteral po |
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Heparin: MOA
Route 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 |
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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 |
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Heparing: S+S of
overdose Treatment of toxicity |
Hematuria, melena, petechiae,
ecchymosis, oral mucosal bleed Treatment: stop med, call doc, order lab. protamine sulfate will reverse it quickly |
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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 |
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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 |
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Warfarin (coumadin)
MOA 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 |
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Warfarin (coumadin)
treatament for tox |
Stop drug, slow admin of
IV vit K |
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Respiratory physiological
risks of immobility Role of nurse |
Prevent atelectasis
prevent hypostatic pna implement use of: incentive spirometer turn cough deep breath adequate hydration |
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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 |
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Integument
physiological risks of immobility role of nurse |
prevent pressure
ulcer - reposition, assess skin thoroughly |
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Metabolic/endocrine
physiological risks of immobility role of nurse |
prevent osteoporosis - move
pt around |
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GI
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 |
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Sensory
risks of immobility role of nurse |
orient pt
interact with pt touch pt decrease noise level encourage day/night cycle |
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Psychosocial
risks of immobility role of nurse |
Engage in activities, encourage
visits from family/friends, personal care, familiar items, express feelings, involve support staff 1:1 |
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Developmental
risks of immobility role of nurse |
Assess and monitor pt
plan appropriate interventions prepare for regression/delays identify temporary changes promote self care stimulate interest |
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The nursing
care plan is designed to: |
improve/promote/maintain
pts functional capabilities self care psychological well being |
