Immobility – Flashcards
Unlock all answers in this set
Unlock answersquestion
What are the effects of immobility on Cardiovascular System?
answer
Increased Cardiac workload Orthostatic hypotension (adjustment mechanism quits) Venous thrombosis R/T venous statis Long term effects: - Increased HR - Decreased Co - Increased SV - Increase clotting
question
What are the effects of immobility on Respiratory system?
answer
Decreased ventilatory effort Increase pooling of secretions Decreased movement of thoracic cage Hpyo static pneumonia R/T secretions
question
What are the effects of immobility on metabolic system?
answer
Decreased or increased metabolic rate depending on factors. Negative nitrogen balance
question
What are four related problems with a nitrogen balance?
answer
Muscle atrophy Weakness Altered F&E (????) GI problems
question
What is a negative nitrogen balance a result of?
answer
Catabolism of muscle tissue - for excessive protein breakdown.
question
What are effects of Immobility on GI system?
answer
Decreased food intake usually Decreased GI peristalsis leading to constipation Atrophy of abdomen, GI, pelvic floor muscles Loss of privacy
question
What are effects of immobility on Musculosketal system?
answer
Decreased muscle size, tone, strength Diminished joint mobility Bone demineralization Contractures (shortened muscle) Ankylosis
question
Define ankylosis
answer
immobilization and consolidation of joint
question
What are the effects of immobility on urinary system?
answer
Urinary statis causing increased risk for UTI Renal Calculi
question
Why do renal calculi form in immobile patients
answer
Calcium is released from bones during immobility.
question
What is effect of immobility on Skin?
answer
Increased risk for skin damage.
question
What nine diagnostic tests are useful for diagnosing mobility issues?
answer
P Pulmonary function studies A Arthrocentesis A Arthroscopy C Computerized Tomography (CT) C Cardiac Function tests H Hematological Studies E Electromyogram (EMG) M Magnetic Resonance Image (MRI) E Exercise Stress Test X X Ray Dexa
question
Arthrocentesis test is for what?
answer
To look at sonovial fluid in joints
question
What is Arthroscopy for
answer
Joint scope
question
What does an EMG look at?
answer
Muscle electrical activity. Uses electrodes and possible needles.
question
What are MRI used for with immobility
answer
To look at joint assessment.
question
What are some MRI cautions
answer
No metal No pacemakers In the tube so anxiety for patient
question
CT scans are used for what immobility related search?
answer
Used for bones primarily
question
List the 9 complication categories for immobility.
answer
PPPP MD DOK Psychological Pressure ulcers Paralytic ileus (low peristalsis of Gi leads to no bm) Pneumonia Muscle atrophy/contractures Disuse osteoporosis Deep Vein thrombosis Orthostatic hypotension Kidney stones
question
Define isometric
answer
Contraction w/o movement
question
Define isotonic
answer
Contraction with movement
question
Define isokinetic
answer
Contraction with resistance
question
What are the five categories of nursing interventions for immobility?
answer
Positioning and turning Joint mobility maintenance Ambulation Client teaching Preventing complications
question
What are three stages of ambulation?
answer
Dangle, Stand, Walk
question
What are primary prevention nursing interventions for immobility?
answer
Education Disease prevention - calcium supplements, stop smoking, stop ETOH Motivation oriented
question
What are secondary prevention nursing interventions for immobility?
answer
Focus on early detection - screening (i.e. dexa scan) Focus on maintenance with a health problem - Lower weight - Protective body mechanics - Fall protection - Diet
question
Assisting with transfers and positioning is what level of care? Primary, Secondary, Teritary?
answer
Teritary
question
What is the goal of evaluation for immobility issues?
answer
To obtain the highest level of functioning for patient. As such evaluation should suggest next step to take for progressive increase in self care in ROM, strength, activity tolerance, and lowering of disuse symptoms.
question
What two things affect bones?
answer
Mineral content Adequate dietary intak
question
What is resiliency?
answer
Mineral content of bones
question
Proper nerve conduction is dependent upon what two things?
answer
Circulation and electrolyte balance
question
What does exercise do to metabolism?
answer
Increases efficiency
question
What are the 4 signs of a negative nitrogen balance?
answer
Muscle atrophy Weakness Altered F&E GI Problems
question
Why do renal calculi form in immobility?
answer
Calcium is released from bones
question
What are main defining characteristics of Nanda Stem "Impaired Physical Mobility"?
answer
Inability to move purposefully Movement restriction
question
What are main defining characteristics of Nanda Stem "Activity intolerance"?
answer
Physical inability due to fatigue, abnormal HR, pain
question
What are the risk factors for "Risk for Disuse Syndrome"?
answer
Paralysis Prescribed immobilization Pain Altered LOC
question
What complication of immobility is about muscles?
answer
Atrophy and contractures
question
What complication of immobility is about bones?
answer
Osteoporosis
question
What complication of immobility is about skin?
answer
Pressure ulcers
question
What complication of immobility is about blood pressure?
answer
Orthostatic hypotension
question
What complication of immobility is about veins?
answer
Deep vein thrombous
question
What complication of immobility is about lungs?
answer
Pneumonia
question
What complication of immobility is about kidneys?
answer
Kidney stones
question
What can be taught to client for immobility?
answer
correct positioning exercises
question
What are some preventions for lung complications?
answer
Deep breathing
question
What are some preventions for muscle complications?
answer
ROM, Activity, nutrition
question
What are some preventions for skin complications?
answer
Positioning, hydration, activity, continence,
question
What are some preventions for BP complications?
answer
Ted hose
question
What is the goal of primary prevention?
answer
Promote health and prevent disease
question
Fall prevention is in what immobility prevention category?
answer
Secondary
question
Recognizing strengths is in what prevention category?
answer
Tertiary
question
Decrease mobility and increasing rehab interventions fall into what prevention category?
answer
Tertiary
question
Evaluation of nursing interventions should focus on what
answer
Next level of care possible
question
Define puresis.
answer
Decreased muscle strength
question
Define atrophy
answer
Decreased muscle size
question
Urinary retention causes increased risk for what common hospital condition?
answer
Increases risk of UTI due to increased alkalosis of blood (book source....am not sure why)
question
Phosphorus and Calcium have what effect on bones?
answer
Are related to bone integrity
question
If a patient has a fracture, what would be expected in phosphorus and calcium serum levels?
answer
Both would be elevated
question
Calcium and phosphorus have what kind of relationship to each other?
answer
Inverse
question
What is a normal serum CA level?
answer
2. 5 -4.5 mg/dL
question
What is a normal phosphorous level?
answer
8.2 - 10.2 mg/dL
question
Which calcium test is more indicative of bone calcium release? Urine or serum?
answer
Urine
question
How do you take a 24 hour urine calcium test?
answer
Keep urine on ice for 24 hours.
question
What happens to serum muscle enzymes during an injury and what is the consequence of that for reading lab tests?
answer
They peak shortly after injury and then decline making any serum muscle enzyme tests time sensitive.
question
CK stands for what
answer
Creatine Kinase
question
What 4 muscle enzymes indicate a muscle injury?
answer
CK LDH AST ALD
question
CK enzymes all come from what?
answer
Muscle
question
Where is LDH enzyme found?
answer
Muscle
question
What does LDH stand for?
answer
Lactic Dehydrogenase
question
ASP stands for what?
answer
Aspartate Transmaminase
question
Where is AST found?
answer
Heart, liver, and muscle tissue
question
Name three drugs for muscle spasms
answer
Damtrolene (damtrium) Baclotem (liaresal) Cyclobenzaprine (Flexril)
question
Which drug decreases synaptic neurotransmission of skeletal muscles?
answer
Damtrium
question
What drugs decrease synaptic transmission at spinal column?
answer
Liaresal Flexeral
question
ALP is a test for what disorder?
answer
Bone deterioration
question
What does ALP stand for?
answer
Alkaline phosphate
