Nursing 3134 Acute & Chronic Module 1 – Flashcards
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Give some examples of patients who need bed rest.
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-myocardial infarction, helps to decrease the workload of the heart -pregnant women, to slow down or prevent delivery -pts with fractures, to promote healing of bones -pts in respiratory distress, to decrease oxygen need
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What are some benefits of bed rest?
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-provide uninterrupted sleep -help regain strength -promote pain reduction -decrease o2 need (decreasing physical activity)
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What are some hazards of bed rest?
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-Disuse syndrome -atelectasis -hypostatic pneumonia -dvt's -orthostatic hypotension -increased workload of the heart -thrombus formation -renal calculi -urinary tract infection -negative nitrogen balance
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Name some reasons why people are immobilized.
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-prescribed intervention -restricted (traction/external fixation device) -loss of ability (injury, CVA) -voluntary (depressed, pain)
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Patients who are weak from prolonged bedrest or surgery cannot cough up secretions effectively, so mucous accumulates, air is trapped in alveoli, and is reabsorbed, leaving collapsed alveoli or lung segments, what can this lead to?
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Atelectasis, when a person is in a recumbent position, mucous accumulates in the airways and pools.
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This is one of the most common and preventable hazards of immobility.
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Atelectasis
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This results when mucous accumulates in the alveoli because of the recumbent position and causes a gas exchange barrier.
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Hypostatic Pneumonia
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If someone is diagnosed with decreased O2-CO2 exchange, what can we do to increase respiration?
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-Turn, cough, and deep breathe -Perform chest PT and postural drainage -Provide humidification -Provide pain relief -Suction if patient is too weak to cough -Ambulate early, if possible -Semi-Fowlers, Fowlers position
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What are some ways to position a patient to prevent hazards of immobility?
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-Maintain body alignment. -Keep head and neck straight. -Pillows to support back and legs. -Trochanter roll; footboard; hand rolls.
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Orthostatic hypotension is a hazard of immobility related to the cardiovascular system, it is a result of decreased circulating blood volume, pooling of blood and a decreased vasomotor response. How can you prevent orthostatic hypotension?
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Dangle legs on the side of the bed prior to walking
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Deconditioning leads to what?
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increased workload of the heart
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Decreased rate of blood flow, pooling of blood and change in constituents of blood lead to what?
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Thrombus formation
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A patient has a nursing diagnosis of alteration in tissue perfusion as evidenced by dizziness, what are some nursing interventions?
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-change position gradually -monitor VS -avoid Valsalva -prevent thrombus formation
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What are some ways to prevent thrombus?
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-identify patients at risk -elastic stockings/compression devices -heparin -range of motion/leg exercises -place in proper position -elevate extremity/reduces edema
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Urine must move against gravity and when we are immobilized what can develop?
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-urinary stasis -urinary tract infection -renal calculi -urinary retention -Nursing Diagnosis: Risk for Infection
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A patient has a nursing diagnosis of altered urinary functioning as evidenced by UTI or kidney stone or pain, what are some useful interventions?
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-encourage fluids (2000-3000 cc/day) -if incontinent (watch skin integrity) -encourage voiding
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In regards to the endocrine system what do hormone secreting glands do?
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-Mediate stress response -Promote growth and development -Manage reproduction -Maintain fluid & electrolyte balance -Regulate metabolism -MAINTAIN HOMEOSTASIS
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Stress increases blood sugar due to the increased release of cortisol which causes what?
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Temporary diabetes
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Immobility can effect the endocrine system by decreasing adrenocortical functioning, name some dysfunctions.
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-decreased metabolism of fats, CHO, protein -Fluid and electrolyte imbalance increased urine output; edema -Decreased stress response -Slowed wound healing
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How can immobility effect your nutritional status?
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-decreased appetite -negative nitrogen balance -decreased GI muscle mass/function -GI system does not function as well as usual
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Increase in nitrogen in the blood can do what to your appetite?
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decrease
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Muscles atrophy from disuse and protein is lost from them, less protein is ingested and then what happens as a result?
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negative nitrogen balance
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Having decreased muscle mass in the heart, lung, liver, GI tract, immune system because of disuse means that a person is more vulnerable to what?
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infection
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Decreased motility of the GI system leads to this.
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constipation
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A patient has a nursing diagnosis of altered nutrition as evidenced by decreased appetite or constipation, what are some useful nursing interventions?
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-high protein -high calorie -vitamin supplements -fluids -tube feedings -TPN (IV)
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How does immobility effect the musculoskeletal system?
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-loss of muscle strength -loss of muscle mass -decreased stability (at high risk for falls)
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What happens to muscles during extended periods of immobility?
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-Protein breakdown causes loss of mass -Disuse causes atrophy -Muscles cannot work without fatigue -Loss of endurance and -Actual joint instability cause decreased stability
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What happens to bones during extended periods of immobility?
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-Impaired calcium metabolism (bone resorption hypercalcemia) -Joint abnormalities (calcium deposits in joints flexion and fixation from disuse footdrop)
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Bone resorption (loss of bone) leads to less dense bone leads to this condition which leads to fractures. Also calcium is released in the blood (hypercalcemia) and causes renal stones.
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osteoporosis
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What is foot drop?
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its when the foot is positioned in a permanent plantar flexion, makes it difficult to walk
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A patient has a nursing diagnosis of risk for injury; activity intolerance as evidenced by falls or fractures, what are some useful nursing interventions?
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-Determine baseline level of activity -Provide frequent rest periods -Encourage active ROM -Provide passive ROM -Encourage isometric exercises -Show energy-saving techniques -Monitor response and modify
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How could you assess immobility and its effect on the integumentary system?
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-rapid and visible response -redness, edema, tissue breakdown -braden scale
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Describe the stages of pressure ulcers.
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-STAGE 1- REDNESS NON-BLANCHABLE, TOPICAL ZINC OXIDE FOR TX -STAGE 2 - LITTLE OPEN AREA, ZINC OXIDE & DUODERM -STAGE 3- DEEPER INTO DERMIS, DUODERM -STAGE 4 - VISUALIZE MUSCLE AND BONE -UNSTAGEABLE- BLACK OR TAN IN COLOR
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A patient has a nursing diagnosis of alterations in skin integrity, what are some useful nursing interventions?
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-Watch for signs of impaired circulation -Turn frequently 1-2 hours -Special order mattresses -Meticulous skin care
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What are psychosocial aspects that result from immobility?
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-DEPENDENCE -DISORIENTATION -REGRESSION -DECREASED LEVEL OF MOTIVATION -EXAGGERATED REACTIONS -CHANGES IN BODY IMAGE
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A patient has a nursing diagnosis of ineffective coping; anxiety as evidenced by impaired social interactions, what are some useful nursing interventions?
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-encourage expression of feelings -provide opportunities for contact -provide stimulation -encourage use of glasses, dentures, makeup -hearing aids -encourage participation in care -cluster care -monitor coping ability -modify plan as needed -consult as needed
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Immobilized patients don't cough up secretions effectively because it is hard to cough when they are ___ ___ (they have to work against gravity).
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Lying down
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Remember that oxygen must diffuse from the alveoli into the capillary and carbon dioxide must diffuse from the capillary into the alveoli. If there are extra secretions in this area, that thickens the gas exchange barrier and we have decreased what?
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O2-CO2 exchange
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What are some effects of immobility on the Gastrointestinal system?
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-Slowed basal metabolic rate, slowed motility, delayed gastric emptying -Anorexia -Constipation -Increased storage of fat and carbohydrates -Negative nitrogen balance
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What are some possible nursing diagnoses for ineffective GI functioning?
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-Risk for imbalanced nutrition -Constipation -Risk for deficient volume
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What is atrophy?
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decrease in size of tissue as a result of decreased use
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What is Ankylosis/contractures?
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permanent fixation usually in a flexed position
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What is osteoporosis?
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Porous condition of the bone
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What are some ways to maintain skin integrity?
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-Skin assessment -Skin care and hygiene -Skin temperature comfortable to improve circulation -Prevent skin irritation and infection -Control moisture -Reduce friction/excoriation -Proper nutrition -Positioning- prevention of shear, reduction of pressure. Pressure reducing devices
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These problems can be fatal if not treated properly and is the nurses responsibility.
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Respiratory problems
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The physician orders bed rest for a client after surgery. The nurse is aware that the most beneficial method of preventing skin break-down while the client is confined to bed is to?
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Encourage independent movement
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The physician orders bed rest for a client with cellulitis of the leg. The nurse understands that the primary purpose of bed rest for this client is to?
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Limit muscle contractions that would force causative organisms into the bloodstream.
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Negative nitrogen balance results when?
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More protein is excreted than consumed.
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What symptoms most clearly relate to kidney stones in the immobilized patient?
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Hematuria and flank pain
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Again what is orthostatic hypotension?
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A drop of 20 mmHg systolic and 10 mm Hg diastolic when rising
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Avoiding valsalva helps reduce the workload of the heart, why?
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Valsalva causes a rise in intrathoracic pressure and this increased pr essure prevents good venous return to the right side of the heart. Then suddenly when the pressure is relieved (the person released their breath) blood rushes to the heart and makes it work harder to pump it out.
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What is an appropriate Nursing Diagnosis for psychosocial effects of immobility?
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Powerlessness
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What are some appropriate Nursing Diagnoses for Musculoskeletal effects of immobility?
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-Risk for disuse syndrome -Impaired physical mobility
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A patient presents with pressure ulcers, shear, friction injury, excoriation and maceration, what is an appropriate Nursing Diagnosis?
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Impaired skin integrity
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Often times this age group believes that immobilization is a justified punishment for misbehavior. They often react with to immobility with active protest, anger, & aggressive behavior, or they may become quiet, passive, & submissive.
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Children
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Behavioral changes occur when children experience prolonged sensory deprivation, name some of the behaviors that are indications of a higher-than-normal level of anxiety.
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-restlessness -difficulty with problem solving -inability to concentrate on activities -depression -regression -egocentrism
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Monotony in immobilized children leads to.
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-sluggish intellectual responses -sluggish psychomotor -decreased communication skills -increased fantasizing -hallucination -disorientation -dependence -acting-out behavior -depression
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Describe the effects of immobilization on the family of the patient who is immobilized.
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-financial strains may decrease or eliminate the family's funds -attention is focused on the affected member & siblings may feel neglected -family may have difficulty accepting the child's altered body condition -family may have difficulty expressing feelings & coping with the crisis -parents experience guilt, feelings of failing to protect the child
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Children need materials to stimulate activity, who are some interdisciplinary team members who can assist with that?
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-physical therapist for help with passive excercise and movement -occupational therapist and child life specialist may plan activities to decrease boredom and regain lost skills (self-feeding) -child psychologist to discuss issues such as depression, anger management and effects of illness on the family
