Immobility and Nursing Interventions

question

Metabolic
answer

Assessment: Anthropometric Measures and Analysis of input/output to assess dehydration Physiological Effect of immobility: Muscle Atrophy and Negative Nitrogen balance Nursing Care to Minimize Effect: Provide increased protein diet, increased calorie diet with vitamin B & C supplements
question

Respiratory
answer

Assessment: Inspect chest walls for mvmt, Auscultating lungs for decreased breath sounds, crackles & wheezing Physiological Effect of Immobility: Atelectasis (collapse of alveoli) and hypostatic Pneumonia (Congestion due to stagnation of blood in dependent part of lungs due to staying in same position too long) Nursing Care to Minimize Effect: Cough & Deep breathe every 1-2 hours and chest physiotherapy (indirect removal of mucous)
question

Cardiovascular
answer

Assessment: Measurement of VS, Peripheral Pulse, Apical Pulse, Deep Vein Thrombosis (DVT), Edema Physiological Effect of Immobility: Thrombosis Formation, Orthostatic HTN, Increased cardiac workload Nursing Care to Minimize Effect: Progress from bed to chair to ambulation, Leg Exercises, TED Hose (anti-embolism hose), SCD (Sequential Compression Devices)
question

Musculoskeletal
answer

Assessment: Muscle tone/strength/mass, ROM, Incidents of contracture Physiological Effect of Immobility: Loss of lean body mass, Muscle weakness/atrophy, Contracture, Disuse Osteoporosis Nursing Care to Minimize Effect: Passive ROM, Active ROM, CPM (continuous passive motion)
question

Integumentary
answer

Assessment: Skin Integrity (look for early changes in skin condition) Physiological Effect of Immobility: Pressure Ulcers and Ischemia Nursing Care to Minimize Effect: Re-position often and provide skin care
question

Elimination
answer

Assessment: Intake/Output, Bowel Sounds, Bowel/Bladder habits Physiological Effect of Immobility: Renal Calculi (kidney stones) and Urinary Stasis (difficulty) Nursing Care to Minimize Effect: Provide adequate hydration (2000-3000 m/L day) and a diet rich in fluids/fruits/fiber/Vegetables
question

Psychosocial
answer

Assessment: Focus on client’s emotional state, behavior and sleep/wake cycles Physiological Effect of Immobility: Emotional/behavioral (giddiness, fear, hostility, anxiety), Sensory Alterations (altered sleep patterns), changes in coping (depression, sadness, dejection) Nursing Care to Minimize Effect: Provide mental and physical stimulation (especially in young children)
question

Developmental
answer

Assessment will look at how immobility affects normal development of patients across the lifespan.

Get instant access to
all materials

Become a Member