Immobility Fundamentals Of Nursing Potter Perry

Front 1

Anthropometric measurements

Back 1

indicate loss of muscle tone and mass

Front 2

Atelactasis

Back 2

collapse of alveoli. Can occur when secretions block a bronchiole or broncus and distal tissue collapses as air is absorbed. May cause hypoventilation

Front 3

CPT

Back 3

Chest Physiotherapy. Includes percussino and positioning to prevent pneumonia

Front 4

Concentric tension

Back 4

muscles contract, shorten and movement results

Front 5

Eccentric tension

Back 5

helps control speed and direction of movement such as slowly lowering from a chin-up

Front 6

Embolus

Back 6

a dislodged thrombus that can move to critical areas such as lungs or brain and create a blockage that could be life threatening

Front 7

foot drop

Back 7

a common debilitating contracture. Ankle is fixed in plantar flexion

Front 8

hypostatic pneumonia

Back 8

inflamation of the lung from stasis or pooling of secretions. Lowers O2 and increases recovery time from underlying cause of immobility

Front 9

Immobility

Back 9

refers to an inability to move about freely

Front 10

Joint contracture

Back 10

abnormal and possibly permanent condition characterized by fixation of the joint. Caused by disuse atrophy and shortening of muscle fibers

Front 11

pathological fractures

Back 11

those caused by weakened bone tissue

Front 12

Renal calculi

Back 12

"kidney stones" calcium crystals that lodge in the renal pelvis or pass through ureters

Front 13

Synostoic joint

Back 13

bones fused together with no movement at all e.g. plates of the skull

Front 14

Thrombus

Back 14

static clot

Front 15

3 Factors leading to thrombus

Back 15

Damage to vessel wall, alterations of blood flow, alterations in blood constituents (Virchow's triad)

Front 16

Long bones

Back 16

contribute to height (eg - femur, fibula, tibia) and length (eg - phalanges of fingers and toes)

Front 17

How changes in bone reflect use at various developmental stages

Back 17

Infant - max flexibility and cartilage but not weight bearing. Toddler withstands falls but not as stable, adult has strength/stability but may be brittle.

Front 18

tonus

Back 18

muscle tone - normal state of balanced muscle tension

Front 19

An immobile client with no known digestive issues is showing signs of inadequate calorie and protein intake. This is likely due to _________. If left untreated, the client may excrete more nitrogen than ingested leading to ___________

Back 19

decreased appetite secondary to immobility
negative nitrogen balance

Front 20

3 major effects on cardovascular system due to imobilization -

Back 20

Orthostatic hypotension, increased cardiac workload, thrombus formation

Front 21

What factors lead to increased cardiac work load and other cardiac issues during immobility?

Back 21

Decreased circulating fluid volume, pooling of blood in extremeties, decreased autonomic response, These lead to decreased venous return and decreased cardiac output

Front 22

2 primary skeletal effects of immobility

Back 22

impaired calcium metabolism, joint abnormalities

Front 23

Older adults may begin to develop contractures after only ____ hours of immobility.

Back 23

8

Front 24

pressure ulcer

Back 24

is an impairment of the skin as a result of prolonged ischmia (decreased blood supply) in tissues. Usually forms over bony prominence. If P on skin is greater than P in small peripheral blood vessels.

Front 25

An older adult immobilized on a back board can develop skin breakdown and pressure ulcer within ___ hrs

Back 25

3

Front 26

In the saggital plane, movements are described as

Back 26

Flexion and extension for fingers/elbows. Dorsiflexion and plantar flexion for feet. Extension for hip

Front 27

In the frontal plane, movements are described as

Back 27

abduction and adduction for arms and legs. Eversion and inversion for feet

Front 28

In the transverse plane movements are described as

Back 28

pronation and supination for hands, internal and external rotation for hips

Front 29

Monitoring what lab values are particularly high priority for assessing metabolic function of an immobile client

Back 29

Electrolytes, serum protein, blood urea nitrogen (BUN)

Front 30

perform a respiratory assessment at least every ____ hours for clients with restricted activity

Back 30

2

Front 31

When assessing respiratory function of an immobile client, observe chest wall movements during a full inspiratory - expiratory cycle. Asymetrical movement may indicate ______________

Back 31

an atelectactic area

Front 32

When assessing lungs of an immobile client, auscultate entire lung region for __________, _________, ___________ . Focus on depenent lung fields because _______________

Back 32

diminished breath sounds, crackles, wheezes
pulmonary secretions tend to collect in these lower regions

Front 33

Cardiovascular assesment of an immobile client includes monitoring __________, evaluation of ______ and ______ and observing for signs of _________ (eg - edema, delayed wound healing)

Back 33

BP
apical and peripheral pulses
venous stasis

Front 34

Lying down causes __________(increased/decreased) pulse rate.

Back 34

increased

Front 35

When and how should you assess for DVT?

Back 35

Assess for Deep Vein Thrombosis by removing elastic stockings or SCD every 8 hrs and observe for redness, warmth, tenderness, pain in calf if client initiated dorsiflexion of foot (Homans' Sign - may dislodge thrombus). Measure bilateral calf circumference daily @ 10cm inferior to midpatella. Monitor for any unilateral changes

Front 36

Early assessment of ROM

Back 36

Provides a baseline for comparison - to determine if any range of motion has been lost during immobilization

Front 37

A tool to measure ROM

Back 37

Goniometer

Front 38

What factors, other than immobility, may cause an increased risk for disuse osteoporosis?

Back 38

postmenopausal female, steroid use, increased serum and urine calcium levels

Front 39

Skin assessment should be done at least every ____ hrs

Back 39

2

Front 40

Dehydration increased risks for what 4 conditions common to immobile clients?

Back 40

skin breakdown, thrombus formation, respiratory infections, constipation

Front 41

2 nursing diagnoses most directly related to mobility problems are

Back 41

Impaired physical mobility
Risk for disuse syndrome
These can be qualified i.e. impaired physical mobility related to reluctance to initiate movement

Front 42

Which 2 vitamin supplements are particularly helpful for immobilized clients?

Back 42

C - to help replace protein stores
B - promotes skin integrity and wound healing

Front 43

Parenteral nutrition is delivered _____

Back 43

through a central or peripheral IV catheter

Front 44

Enteral nutrition is delivered __________

Back 44

through nasogastric, gastrostomy, or jejunostomy tube

Front 45

Encourage immobilized clients to deep breathe and cough every _____ to ____ hrs. Teach alert clients to deep breath, _______, cough, and/or use an incentive _____ every hour.

Back 45

1 to 2 hours
yawn
spirometer

Front 46

Unless contraindicated, ensure immobile clients take in at least _______ mL of fluid per day

Back 46

2000

Front 47

Steps when repositioning a client

Back 47

1 - Assess client's comfort, ability, limitations, restrictions, etc. to determine best approach/goal

2 - if patient can provide some assistance and is less than 200lbs, use a friction-reducing device and 2-3 caregivers (use 3+ caregivers for client over 200lbs). If unable to assist, use full body lift and 2+ caregivers

3 - evaluate outcome, patient comfort, check devices, etc