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47 Cards in this Set
- Front
- Back
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CBR s =
BR c BRP = BR c BSC = |
Complete bed rest w/out (never gets up for anything)
Bedrest w/ bathroom privleges Bedrest w/ bedside commode |
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What are immobility benefits?
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reduces O2 needs (saves energy)
Energy is directed towards healing (quicker healing) Reduces analgesics |
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What clients are completely immobile?
What clients are partially immobile? |
unconscious
pelvic fracture, broken leg, etc. |
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The longer the bed rest the more complications. Name complications of all the body systems:
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Musculoskeletal:
inadequate tissue perfusion Disuse osteoporosis Contractures: hips, knees, ankles muscle atrophy Systemic Effects: decreased metabolic rate catabolic > anabolic (-) Nitrogen Balance f/e imbalances calcium imbalances GI disturbances (appetite and slowing of peristalsis) constipation Respiratory complications: atelectasis hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions) O2-CO2 Imbalance Cardiovascular System: < SV = < coronary BF results in Valsalva maneuver =(>HR) fixed thorax Sympathetic activity (>HR,< CO, Low BF) orthostatic hypotension (> hr) thrombus formation Urinary System: renal calculi Stasis Reflux (distension from bladder) Retention Incontinence Bowel Elimination: < motility Position Fecal Impaction Constipation Integumentary: pressure ulcers Psychosocial Effects: altered sleep pattern anxiety hostility depression |
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What bed position dilates blood vessels?
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supine
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What are the mechanisms of heat loss pertaining to Immobility?
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radiation and conduction
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What are other factors of impaired skin integrity?
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moisture
hygiene nutrition sensory awareness |
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What occurs in a mobile client that promotes blood return and prevents blood clots and edema?
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vasoconstriction
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In an immobile client what occurs when the blood pools in the lower extremitites?
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edema
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how long does it take an immoblie client on bed rest to lose calcium?
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2 weeks
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Who are the people that are at risk for blood clotting (hypercoagulability) and risk for injury to the veins?
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pregnant woman
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To aid the nurse in determining metabolic functioning what should the nurse monitor?
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dehydration/edema
Labs: elecrolytes serum protein (albumin) BUN |
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Give examples of Negative Nitrogen Balances?
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infection
sepsis burns fevers starvation head injury trauma |
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What kind of diet should the client that is immoblized be given when the body needs protein to repair injured tissue/rebuild depleted protein stores?
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high-protein
high-calorie diet |
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What vitamin is necessary to replace protein stores?
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Vitamin C
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What vitamin is needed for skin integrity and wound healing?
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Vitamin B complex
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Total parenteral nutrition refers to delivery of nutritional supplements through?
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central or peripheral intravenous catheter
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Enteral feedings include delivery through?
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nasogastric
gastrostomy jejunostomy |
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Pulmonary Interventions:
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cough every 1-2 hours
deep breathe every hour (IS) take 3 deep breaths/cough w/ 3rd exhalation |
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What does coughing reduce?
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pulmonary seretions
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Chest physiotherapy (percussion/positioning) helps the client how?
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drain secretions from specific segments of the bronchi and lungs into the trachea so that the client can cough and expel secretions
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How much fluid should an immobile client take in?
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2000 ml/day if not contraindicated to help keep mucociliary clearance normal
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Signs/Symptoms of orthostatic hypotension?
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increased pulse rate
decreased pulse pressure drop in BP Severe cases: client faints |
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An increase in cardiac workload results by immobility. What is a primary nursing intervention?
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discourage the client from using the Valsalva Maneuver
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What happens to the heart when a client uses the Valsalva Maneuver?
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client holds breath
which increases intrathoracic pressure This decreases venous return/cardiac output When strain is released venous return/cardiac output increases and Systolic BP/Pulse rises. These pressure changes produce a reflex bradycardia/possilbe decreae in BP that can result in cardiac death |
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What is the most effective way to prevent DVT?
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prophylaxis
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What is the common drug used in prophylaxis of DVT?
and how is it given? |
Deparin
5000 units subQ 2 hours before surgery/repeated every 8-12 hours |
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What is a nursing intervention for reducing the risk of contractures and aid in preventing thrombi?
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ROM exercises
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Specific exercises that help prevent thrombophlebitis are?
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ankle pumps, foot circles and knee flexion
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What prevents a client from external rotation of the hips when the clent is in supine position?
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trochanter roll
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Joints need to be supported otherwise their alignment is impaired and mobility decreased. How should you position joints?
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slightly flexed position
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What is one-sided paralysis?
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hemiplegia
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What is one-sided weakness?
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hemiparesis
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What are indicators of malnutrition?
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Prealbumin (best)
Serum albumin |
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Tissue perfussion (oxygen) is essential for what process?
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healing (wound)
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Wound infection prolongs the _________ phase, delays collagen synthesis, prevents epithelialization and increases the production of proinflammatory cytokines, which leads to additional tissue destruction.
What indications are present during a wound infection? |
inflammatory
pus, odor, volume, character of drainage, erythema, fever & pain |
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The assessment of mobility has 3 components. What are they?
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ROM, gait, & exercise
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What happens to the Vital Signs to indicate activity intolerance?
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increased pulse and respiration
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how many assists are required for a client <200 lbs
>200 lbs |
2-3
3-4 |
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The term body alignment refers to the conditions of the what parts of the body?
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joints, tendons, ligaments and muscles
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How is body balance acheived?
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wide base of support
center of gravity falls within the base of support vertical line can be drawn from the center of gravity thru the base of support |
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A 65 year old pt who weighs 260lbs is to be transferred from his bed to a chair. This pt is unable to bear full weight on one leg. His upper body strength is good. Which technique is the most appropriate technique to transfer?
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Use of a bariatric transfer device
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What causes an increase rate of skin breakdown?
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dehydration and edema
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Annorexia occurs in what kinds of clients?
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immobilized
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If a patient can partially bear weight and is cooperative, the transfer requires how many caregivers?
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one
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How many caregivers are required for transferring an uncooperative client who can bear partial weight and for clients who cannot bear weight and are either uncooperative or do not have upper body strength?
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2
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When transferring a client from a bed to a chair when the client can not bear weight but is cooperative and has upper body strength to complete the transfer uses what aid?
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seated transfer aid
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