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35 Cards in this Set
- Front
- Back
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What is "mobility"? |
The ability to move about freely, easily and purposefully in the environment. |
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What is "immobility"? |
Refers to a person's inability to move about freely (restricted or decreased mobility). Prescribed or unavoidable restriction of movement in any area of a person's life. So there are degrees of immobility. |
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What is the deconditioning/disuse phenomena? |
the physical and psychological changes usually degenerative, that result from the lack of use of a body part or system ~Mosby, 2013, 549-550 |
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What are the hazards of immobility under the need, ACTIVITY, of the JAC NEED FRAMEWORK? |
-loss of muscle strength and mass (disuse atrophy/disuse phenomena) -stiffness and pain in joints: loss of joint mobility, demineralization of bones, excess calcium depositing in joints, collagen tissue at the joint becomes anklosed (permanently immobile) -Fibrosis: connective tissue fibers laid down continually in joints and muscles, normal ROM keeps this fibrous network loose. -Contractures: permanent shortening of muscle (clawed hand) -Changes in bone: demineralization, osteoporosis -loss in neurosensory function: foot drop (ft allowed to assume an unsupported position and the achilles tendon shorten, stronger muscle dominates the opposite muscle |
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What are the hazards of immobility under the need, OXYGENATION, of the JAC NEED FRAMEWORK? |
-Increased cardiac workload -Increased risk for orthostatic hypotension -Increased risk for venous thrombosis (DVT, pulmonary embolus) -Decreased depth and rate of respirations, position of pt in bed -Pooling of secretions, because of gravity -Impaired gas exchange, accumulation and stasis of secretions, O2 and CO2 imbalances -Pooled secretions (good for growth of bacteria -Hypostatic pneumonia: inflammation of the lung tissue from stasis or pooling of secretions -Atelectasis: collapse of alveoli |
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What are the hazards of immobility under the need, NUTRITION, of the JAC NEED FRAMEWORK? |
GI SYSTEM -Appetite changes -Anorexia -Decreased intake -Digestive upsets -Altered protein metabolism -Altered digestion and use of nutrients -Negative nitrogen balance - catabolism exceeds anabolism METABOLIC SYSTEM -Increased risk of electrolyte imbalance -Negative calcium balance -> Ca in bone moves -Altered exchange of nutrients and gases -Decreased metabolic rate -Decreased temperature -Decreased hormone levels |
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What are the hazards of immobility under the need, ELIMINATION, of the JAC NEED FRAMEWORK? |
URINARY SYSTEM -Urinary stasis -Bladder distension -Overflow incontinence -Urinary infection (UTI) -Urine retention -Increased risk for renal calculi (stones) GI SYSTEM: -constipation (muscle weakness, uncomfortable, unnatural position and reluctance to use the bedpan. -repeated postponement of BM suppresses urge and weakens the reflex |
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What are the hazards of immobility under the need, SAFETY, of the JAC NEED FRAMEWORK? |
INTEGUMENT SYSTEM -increased risk for skin breakdown and decubitus ulcers - decreased circulation, encreased pressure -Decreased skin turgor - fluid shifts |
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What are the hazards of immobility under the need, SLEEP, of the JAC NEED FRAMEWORK? |
Altered sleep-awake patterns |
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What are the hazards of immobility under the need, SELF ESTEEM (and social interaction), of the JAC NEED FRAMEWORK? |
-increased sense of powerlessness -Decreased self concept -Decreased social interaction -Decreased sensory stimulation -Increased risk for depression -Changes in behaviour -exaggerated emotions -Changes in roles - loss of control -Changes in body images -Deterioration of psychomotor and intellectual skills. |
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What are some nursing interventions to prevent the different hazards of immobility of each need? |
-Early detection -Exercises for loss of muscle strength and mass -Passive exercises for joint mobility -Exercises to prevent contractures -Participation in self-care activities -Ambulate as tolerated as weight-bearing decreases osteoporosis. -Proper body alighment and positioning, use of splints -Turn and position q2h -Assess extremities -Turning clock at head of bed |
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Nursing interventions to prevent the need of oxygenation? |
CV SYSTEM -Monitor vital signs (detect any alterations) -Instruct how and when to avoid the Valsalva maneuver (which increases stress on heart) -TED anti-embolism stockings (TED=thrombo embolic deterrent) -Elevate legs several times a day -Measures to prevent postural hypotension -Inspect lower limbs RESPIRATORY SYSTEM -Assess lung sounds and chest expansion q4h -Deep breathing and coughing q1h encourage to expectorate secretions -Inspirometer -repositioning patient q2h, ambulate as possible |
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Nursing interventions to prevent the need of nutrition? |
Monitor: -weight -tissue turgor -fluid intake and output -serum protein values -drinks between meals -ENSURE (high protein drink) -family to bring in favorite foods -consult to dietician -water at bedside METABOLIC SYSTEM: -monitor serum electrolyte levels (K, Ca, Na, Cl) |
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Nursing interventions to prevent the need of elimination? |
URINARY SYSTEM: -Monitor color, clarity, amount, frequency, acidity, SG of urine -Ask about pain on urination -Toileting schedule -Increased fluid intake according to patient condition -Privacy -Running warm tap water over perineum -Teach pt to wipe from front to back -Ensure adequate fluids to dilute urine -Check urine output GI SYSTEM: -Monitor the color, characteristics and frequency of stools -increased fiber and fluid in diet -Toileting schedule -To prevent constipation (encourage fluids, high fiber diet, roughage) -Offer bedpan |
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Nursing interventions to prevent the need of safety? |
-position q2h -massage. lubricate (especially dry skin) -position for maximum comfort and prevention of problems -keep skin dry and clean -encourage activity -devices: sheepskin, heel protector, food board -keep sheets wrinkle free -special alternating mattress |
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Nursing intervention to prevent the need of sleep? |
-allow for uninterrupted periods of sleep -lights out at night when possible, use night lights in BR -try to keep the client awake during the day -warm milk qhs |
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Nursing intervention to prevent the needs of self-esteem and social interaction? |
-sensory stimulation -allow patient to make decisions (ex: placement of personal items, daily plan of care) -Plan periods of time to spend with the client that don't involve tasks -Diversional activities (radio, TV) |
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What are the COMPLICATIONS of immobility? |
Contractures Osteoporosis Muscle atrophy Psychological deterioration Limited Mobility Insomnia Calculi Atelectasis Thrombosis Impaction Orthostatic hypotension Nutritional intake and decrease Skin breakdown |
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What is a pressure ulcer? |
Any lesion caused by unrelieved pressure that results in damage to the underlying tissue. |
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A localized area of tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissues |
pressure ulcer |
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What is the etiology of pressure ulcers? |
-Due to localized ischemia or decreased blood flow to tissue -The tissue is caught between two hard surfaces (the bed and a bony prominence) -Blood can't reach the tissue. No O2 or nutrients to the cell and waste products accumulate and cells die |
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What is the term used to describe the process where skin has a bright red flush? It is a defense mechanism to prevent ulcers (it's vasodilation that gives it extra blood flow to the area that has had impeded blood flow). This flush lasts from half to 3/4 the time of the impeded blood flow. Once the redness disappears, there is no tissue damage If the redness does not disappear, there is tissue damage |
reactive hyperemia |
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Two surfaces rubbing against each other (ex: skin and sheets) |
friction |
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combination of friction and pressure (eg: pt in fowler's position and slides down in the bad) |
Shearing force (deeper tissue damage, damaging both the blood vessels and tissues) |
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What are the risk factors for pressure ulcer formation? |
-Excessive moisture -Immobility/inactivity -presence of contractures -Inadequte nutrition -Incontinence - urinary and fecal -decreased mental status ( unconscious, sedated) -decreased sensation (neurological disorders, diabetes) -excessive body heat -advanced age -impaired circulation -prolonged surgery -poor lifting techniques -incorrect positioning, incorrect application of pressure relieving devices |
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When a pt has reddened/discolored skin or non-blanchable skin, what level of pressure ulcer does this involve? |
stage 1 |
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When there is partial thickness of the skin loss, formation of a shallow crater or shallow blister, what level of pressure ulcer does this involve? |
stage 2 |
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When there is full thickness of skin loss, damage to subcutaneous tissue and looks like a deep crater, what level of pressure ulcer does this involve? |
stage 3 |
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When the full thickness of skin is loss and there is loss of muscle and bone, what level of pressure ulcer does this involve? |
stage 4 |
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When the base of the ulcer is covered with slough (yellow, tan, gray, green, brown) or eschar (tan, brown, black), what level of pressure ulcer does this involve? |
Unstageable |
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when an area of the skin is purple or marron, what does this involve? |
suspected deep tissue injury |
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What tool would you use to assess the risk of a client that may get pressure ulcers? what are the 6 subscales? |
The Braden scale total score of 23 1-sensory perception 2-moisture 3-activity 4-mobility 5-nutrition 6-friction and shear |
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What score does an adult need to get on the braden scale to be at risk for pressure ulcers? Elderly? |
Adult: 16 Elderly: 17 or 18 |
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What are some nursing interventions for pressure ulcers? |
-Pressure relieving devices- alternating pressure mattresses, foam mattresses, wheelchair cushions, foam boats, lifting sheets -Frequent repositioning (most important) Acute intervention when the pressure ulcer already formed -measure and document (size, photo) -document wound healing -DRSG and cleaning method -Avoid positioning pt on ulcer -Debridement if there is necrotic tissue -NURITION (protein, minerals and vitamins) -Educate the pt and caregivers on pressure ulcers |
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