Nursing Diagnosis r/t Immobility – Flashcards
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What are the four parts of a Nursing Diagnosis r/t Immobility?
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-Body System Affected -Etiologies -Assessment Interventions -Nursing Priorities
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Name 3 different Nursing Diagnoses r/t Immobility affecting the Cardiovascular System
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-Activity Intolerance: Increased Cardiac workload -Ineffective Tissue Perfusion: Thrombus Formation -Risk for Injury: Orthostatic Hypotension
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Name 3 different Nursing Diagnoses r/t Immobility affecting the Respiratory System
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-Respiratory: Ineffective Breathing -Ineffective Airway Clearance -Impaired Gas Exchange: O2 / CO2 ratio
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Name 3 different Nursing Diagnoses r/t Immobility affecting the Musculoskeletal System
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- Risk for Activity Intolerance - self care deficits -Impaired Mobility -Risk for Injury: Pathologic Fractures
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Name 6 different Nursing Diagnoses r/t Immobility affecting the Metabolic processes in the body
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-Imbalanced Nutrition: -Less Than Body Requirements -Imbalanced Nutrition: -More than Body Requirements -Fluid Volume Excess: -Dependent Edema
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Name 1 different Nursing Diagnoses r/t Immobility affecting the Gastrointestinal System
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-Constipation
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Name 4 different Nursing Diagnoses r/t Immobility affecting the Urinary System
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-Altered Urinary Elimination -Urinary Retention -Risk for Infection: -Urinary Tract
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Name a different Nursing Diagnoses r/t Immobility affecting the Integementary System or Skin
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Impaired Skin Integrity pressure ulcer
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Name 8 different Nursing Diagnoses r/t Immobility affecting the Psychological and Social aspects of a patient
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-Chronic or Situational Low self-esteem -Powerless -Impaired social interaction -Disturbed thought process -Deficient knowledge -Ineffective coping -Ineffective family coping -Disturbed sleep pattern
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What is the etiology of Activity Intolerance related to?
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Supine position contribute to greater volume of circulating blood, which must be pumped by the heart; decreased vascular resistance
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What is the etiology of Ineffective Tissue Perfusion related to?
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Venous stasis due to lack of muscle contraction in the legs. Increased blood coagulation because calcium moves from bones into circulation. External pressure on the veins (e.g. From knee gatch on bed)
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What is the etiology of Risk for Injury related to?
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Skeletal muscle weakness and decreased vessel tone. Hypovolemia
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What is the etiology of Ineffective Breathing Pattern related to?
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Limited chest expansion. Prolonged sitting or lying. Muscle disuse or atrophy. Loss of muscle coordination. Medications that decrease respiratory effort.
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What is the etiology of Ineffective Airway Clearance related to?
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Altered function of mucous membranes and cilia. Decreased position changes. Ineffective coughing due to weakness, pain Dehydration
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What is the etiology of Impaired Gas Exchange related to?
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Decreased respiratory movement Pooling of secretions
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What is the etiology of Risk for Activity intolerance / Self Care Deficits related to?
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Decreased muscle mass, tone and strength (atrophy) Contractures Stiffness and pain in the joints. Limited range of motion. Decreased endurance
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What is the etiology of Risk for Injury: Pathologic Fractures related to?
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Excessive bone demineralization disuse osteoporosis
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What is the etiology of Imbalanced Nutrition: Less Than / More Than Body Requirements related to?
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Negative nitrogen balance Anorexia Imbalance between calories ingested and burned off Fluid shifts because of negative nitrogen balance
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What is the etiology of Fluid Volume Excess: Dependent Edema related to?
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Negative nitrogen balance Anorexia Imbalance between calories ingested and burned off Fluid shifts because of negative nitrogen balance
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What is the etiology of Constipation related to?
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Decreased gastric motility and muscle tone Decreased fluid intake
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What is the etiology of Altered Urinary Elimination, Urinary Retention, Risk for Infection UTI related to?
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Renal Calculi Urinary stasis Alkalinized urine in the bladder leads to infection
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What is the etiology of Impaired Skin Integrity related to?
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Decreased local blood circulation to the tissues. Prolonged pressure on skin.
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What is the etiology of Impaired Psychological & Social Imbalance related to? Including: Chronic / Situational Low self-esteem Powerless Impaired social interaction Disturbed thought process Deficient knowledge Ineffective coping Ineffective family coping Disturbed sleep pattern
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Inability to move voluntarily Dependency on others. Inability to fulfill role expectations. Pain experience Skeletal deformities Exaggerated emotional and behavioral responses. Decreased ability to learn and retain information. Increase need for sleep and napping.
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What are the Assessment Interventions for Activity Intolerance ?
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Assess apical and peripheral pulses. Note increased heart rate, weakened peripheral pulses. Note presence of edema
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What are the Assessment Interventions for Ineffective Tissue Perfusion r/t Immobility
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Assess for complaints of pain, especially calf pain, and signs of inflammation. Compare one extremity to the other. Measure calf or thigh circumference daily, mark place to measure.
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What are the Assessment Interventions for Risk for Injury due to Orthostatic Hypotension ?
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Assess for complaints of dizziness or fainting. Compare BP before position change with BP after position change.
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What are the Assessment Interventions for Ineffective Breathing Pattern ?
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Assess rate, rhythm, quality of respirations. Assess symmetry of chest wall movements.
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What are the Assessment Interventions for Ineffective Airway Clearance r/t Immobility ?
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Assess breath sounds over the entire lung region. Note any adventitious breath sounds. Assess sputum C & S may be ordered. Percuss chest
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What are the Assessment Interventions for Impaired Gas Exchange ?
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Note any changes in behavior or mental status. Compare clinical picture with changes in ABG's pulse oximetry, PFT's
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What are the Assessment Interventions for Risk for Activity Intolerance r/t Immobility ?
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Assess for weakness, fatigue, muscle, or joint pain or tenderness. Assess for decreased muscle mass, decreased muscle tone and strength. Note contractures of ankylosis.
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What are the Assessment Interventions for Risk for Injury ?
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Bone demineralization is not detectable through physical assessment. Relate clinical picture to blood chemistries. note elevated serum calcium and phosphorous levels.
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What are the Assessment Interventions for Impaired Nutrition Less / More than Body Requirements ?
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Assess diet history Monitor intake and output Compare clinical picture to laboratory studies that evaluate fluid and electrolyte status. Evaluate muscle atrophy. Assess skin turgor and wound healing
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What are the Assessment Interventions for Fluid Volume Excess: Dependent Edema r/t Immobility ?
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Assess diet history Monitor intake and output Compare clinical picture to laboratory studies that evaluate fluid and electrolyte status. Evaluate muscle atrophy. Assess skin turgor and wound healing
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What are the Assessment Interventions for Constipation r/t Immobility ?
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Assess frequency and consistency of bowel movements. Examine for bowel sounds, abdominal tone and anal sphincter tone.
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What are the Assessment Interventions for Altered Urinary Elimination, Urinary Retention Risk for UTI r/t Immobility ?
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Assess voiding patterns-time and amount. Question about urgency, dysuria, pain. Monitor fluid output. Examine for bladder distention. Examine urine for cloudiness or odor. culture if indicated
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What are the Assessment Interventions for Impaired Skin Integrity ?
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Examine skin, especially pressure points, for beginning stages of breakdown with each position change at least every 2 hours Assess for factors that place patient at high risk for breakdown e.g. Malnutrition and incontinence
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What are the Assessment Interventions for Impaired Psychological and Social Behaviors r/t Immobility ?
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Assess patient for changes in behavior, emotional status and mental abilities. Assess adequacy of the patient's and family coping. Assess sleep-wake patterns. Explore with patients and family possible reasons for these changes
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What are the Nursing Priorities for Activity Intolerance r/t Immobility ?
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Encourage patient to sit in Fowler's position. Avoid activities that increase intrathoracic pressure.e.g. Valsalva maneuver.
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What are the Nursing Priorities for Ineffective Tissue Perfusion
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Encourage active exercise of legs three to four times daily. Elevate legs periodically. Avoid prolonged knee and hip flexion. Apply TEDS if ordered. Never rub or massage the legs- especially if patient complains of pain.
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What are the Nursing Priorities for Risk for Injury due to Orthostatic Hypotension r/t Immobility ?
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Have patient sleep sitting up or in an elevated position if not contraindicated. Change position gradually. Encourage leg exercises. Avoid Valsalva maneuver
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What are the Nursing Priorities for Ineffective Breathing Pattern ?
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Change position every 2 hours. Encourage deep breathing and coughing every 1-2 hours. Remove abdominal binders every 2 hours to allow for deep breathing
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What are the Nursing Priorities for Ineffective Airway Clearance r/t Immobility ?
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Change position every 2 hours. Encourage deep breathing and coughing every 1-2 hours. Remove abdominal binders every 2 hours to allow for deep breathing. Keep patient well hydrated. Initiate chest physiotherapy. Suction if needed
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What are the Nursing Priorities for Impaired Gas Exchange ?
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Change position every 2 hours. Encourage deep breathing and coughing every 1-2 hours. Remove abdominal binders every 2 hours to allow for deep breathing. Keep patient well hydrated. Initiate chest physiotherapy. Suction if needed
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What are the Nursing Priorities for Risk for Activity Intolerance / Impaired Mobility ?
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Incorporate ROM exercises and isometric setting exercises into daily routine - at least three times daily.
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What are the Nursing Priorities for Risk for Injury r/t Immobility ?
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Utilize proper ergonomics in lifting and transferring
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What are the Nursing Priorities for Imbalanced Nutrition Less / More than Body Requirements ?
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Provide patient with high-protein, high calorie diet. Explore parenteral and enteral alternatives if patient is unable to eat. Serve small, frequent feeding in pleasant environment. Monitor intake and output. Monitor weight
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What are the Nursing Priorities for Fluid Volume Excess / Dependent Edema ?
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Monitor intake and output. Monitor weight.
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What are the Nursing Priorities for Constipation r/t Immobility ?
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Respect usual elimination schedule. Offer assistance with bedpan or commode and privacy. Increase fluid intake and roughage
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What are the Nursing Priorities for Altered Urinary Elimination or UTI r/t Immobility ?
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Keep patient well hydrated. Maintain usual voiding pattern/ If needed, provide assistance with bedpan or urinal-respect patient's privacy
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What are the Nursing Priorities for Impaired Skin Integrity - pressure ulcer ?
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Reposition patient in correct alignment at least every 1-2 hours. Protect pressure points e.g. Heel and elbow protectors Decrease effects of shearing force. Keep skin clean and dry. Keep bed linens dry and free of wrinkles.
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What are the Nursing Priorities for Impaired Psychological and Social Behaviors r/t Immobility ?
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Explore immobility effects on mental status and behavior. Explore means to meet needs for socialization. Increase stimuli to maintain orientation. Encourage patients to be as independent as possible. Challenge patient intellectually. Explore impact of patient's illness on family and counsel appropriately
