Nclex Ch06 U01-02: Complications Of Immobility

Front 1

14 complications of immobility.

Back 1

1. decubitus ulcers
2. sensory input changes
3. osteoporosis
4. negative N-balance
5. hypercalcemia
6. increased cardiac workload
7. contractures
8. thrombus formation
9. orthostatic hypotension
10. stasis of respiratory secretions
11. C
12. urinary stasis
13. boredom
14. depression

Front 2

3 sequelae that can follow a DECUBITUS ULCER

Back 2

1. osteomyelitis
2. tissue maceration
3. infection

Front 3

What type of diet should a patient w/ a decubitus ulcer be on?

Back 3

a balanced diet w/ adequate PROTEIN, VITAMINS, & MINERALS

Front 4

Nursing care for a pt w/ a decubitus ulcer

Back 4

1. frequently turn pt
2. provide skin care
3. ambulate as appropriate
4. use draw sheet to avoid shearing force
5. use air mattress, flotation pads, elbow and heel pads, sheepskin
6. use Stryker frame or Circ-O-Lectric bed

Front 5

Sequelae r/t sensory input changes

Back 5

1. confusion
2. disorientation

Front 6

nursing considerations for immobile pt w/ sensory input changes

Back 6

1. orient frequently
2. place clock/calendar in sight

Front 7

Sequelae r/t osteoporosis?

Back 7

1. pathological fractures
2. renal calculi

Front 8

NC (nursing considerations) for an immobile pt w/ osteoporosis

Back 8

1. encourage weight-bearing on long bones
2. provide a balanced diet
3. monitor estrogen therapy, if ordered

Front 9

Sequelae r/t negative nitrogen balance?

Back 9

1. anorexia
2. debilitation
3. weight loss

Front 10

What diet should an immobile pt in negative nitrogen balance be fed?

Back 10

HIGH PROTEIN diet + small, frequent feedings

Front 11

Sequelae r/t hypercalcemia

Back 11

impaired bone growth

Front 12

NC for an immobile pt w/ hypercalcemia

Back 12

1. reduce ca in diet
2. encourage fluids

Front 13

sequelae r/t increased cardiac workload

Back 13

tachycardia

Front 14

NC for immobile pt w/ increased cardiac workload

Back 14

1. use trapeze to decrease Valsalva maneuver when moving in bed
2. teach pt how to move w/o holding breath

Front 15

sequelae r/t contractures?

Back 15

deformities

Front 16

NC for immobile pt w/ contractures?

Back 16

1. frequent change of position
2. use pillows, trochanter rolls, foot board to promote body alignment
3. exercise as appropriate

Front 17

Sequelae r/t thrombus formation

Back 17

pulmonary embolism

Front 18

NC for an immobile pt w/ thrombus formation?

Back 18

1. leg exercises: flexion, extension of toes for 5 min q1h
2. ambulate as appropriate
3. frequent change in position
4. avoid using knee gatch on bed or pillows to support knee flexion
5. use TED or elastic hoes
6. check Homan's sign

Front 19

Sequelae r/t orthostatic hypotension

Back 19

1. weakness
2. faintness
3. dizziness

Front 20

NC for immobile pt at risk for orthostatic hypotension

Back 20

1. teach pt to rise from bed slowly
2. increase activity gradually

Front 21

Sequelae r/t stasis of respiratory secretions?

Back 21

hypostatic pneumonia

Front 22

NC for immobile pt w/ stasis of respiratory secretions

Back 22

1. teach pt the importance of turning, C & DB
2. administer postural drainage as appropriate

Front 23

sequela r/t C

Back 23

fecal impaction

Front 24

NC for immobile pt w/ C

Back 24

1. ambulate as appropriate
2. increase fluid intake & fiber
3. insure privacy for use of bed pan or commode
4. Colace

Front 25

Sequelae of urinary stasis

Back 25

1. urinary retention
2. renal calculi

Front 26

describe the diet an immobile pt w/ urinary stasis should be on

Back 26

LOW CALCIUM diet w/ increased ACID-ASH residue to acidify urine and prevent formation of calcium stones

Front 27

NC for immobile pt w/ urinary stasis

Back 27

1. have pt void in normal position, if possible
2. increase fluid intake

Front 28

Sequelae r/t depression

Back 28

1. insomnia
2. restlessness