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NP Ch 39 CCC 105
NP Ch 39 CCC PN105
| Question | Answer |
|---|---|
| conditions that may require bedrest | stroke, trauma, neuromuscular disorder, chronic debilitating illness |
| complications caused by immobilization | pressure injuries, pneumonia, bone loss, loss of function in immobilized part |
| immobilization effect - cardiovascular | venous stasis, increased cardia workload, blood pressure alterations |
| cardiovascular problems from immobilization | thrombus, thrombophlebitis, pulmondary embolus, orthostatis hytptension, increased pulse rate |
| immobilization effect - respiratory | stasis of secretions, decreased elastic recoil, decreased vital capacity |
| respiratory problems from immobilization | hypostatic pneumonia, bacterial pneumonia, atelectasis, decreased gas exchange |
| immobilization effect - GI | anorexia, metabolic change to catabolism and negative nitrogen balance, decreased peristalsis |
| GI problems from immobilization | weight loss, protein deficiency, abdominal distention, constipation |
| immobilization effect - musculoskeletal | decreased muscle mass and tension, shortening of muscles, loss of calcium from bone matrix, decrease in bone weight |
| musculoskeletal problems from immobilization | fibrosis of connective tissue, atrophy, weakness, joint contracture, osteoporosis, bone pain |
| immobilization effect - urinary | stasis of urine, UTI, renal stones |
| urinary problems from immobilization | precipitation of calcium salts, frequency of urination, dysuria |
| immobiliation effect - skin | decreased circulation from pressure, ischemia, necrosis of tissue |
| skin problems from immobilization | skin breakdown, pressure ulcers |
| immobilization effect - psychological/brain | decreased mental activity, decreased sensory input, decreased socialization, decreased independence |
| psychological/brain problems from immobilization | disorientation, confusion, boredom, anxiety, depression, lonliness |
| prevention of immobilization complications (physical) | increase fluid intake to 3L/day; adequate nutrition; increased fiber; stool softeners/laxatives; passive/active ROM; isometric exercises; turn q2h; keep skin clean and dry; use pressure-relief devices |
| types of immobilization | splints, traction, traction, cast, external fixators |
| types of splints | molded, immobilizers, inflatable, cervical collars, traction |
| splint | protects injured parts by immobilizing them; can be used prior to cast application |
| splint to control bleeding | inflatable splint |
| amount to inflate inflatable splint | until can be indented 1.2" by fingertips |
| splints are made of _________ | cloth, foam, velcro |
| types of traction | skin and skeletal |
| how traction works | pulling force is used to maintain body alignment, maintain fracture alignment, and relieve pain and muscle spasm |
| considerations for patients in traction | should have overhead frame and trapeze bar; weights should seing freely without touching bed or floor |
| skin traction is made of ___________ | velcro boots, belts, halters, slings |
| purpose of skin traction | decrease spasm accompanying fractures |
| skin traction is applied _________ | snugly to the skin |
| considerations of skin traction | skin pain must be reported; weight is limited to 5-10 lbs |
| skeletal traction | requires surgical placement of pins, tongs, screws, or wires anchored to the bone |
| which supports more weight, skeletal or skin traction | skeletal traction |
| considerations of skeletal traction | clear fluid drainage around pins; sign of infection immediately reported; circulation checks q1h for first 24h, then q4h |
| for skeletal traction, the nurse is responsible for maintaining _______ | correct weight, alignment, and balance |
| cast | used to immobilize and extremity following a fracture or orthopedic procedure |
| cast protects by _____________ | layer of stockinette followed by layer of padding; plaster or fiberglass cast then applied |
| cast considerations | protection during drying to prevent dents and uneven pressure which can cause circulatory impairment and pressure injuries |
| how to handle a cast | use palm of hands and plat part of fingers |
| problems with cast | swelling is common anc can cause circulatory impairment and pressure injury |
| to fix a tight cast | can be bivalved |
| hip spica cast should not_____ | be used for turning or lifting |
| external fixators | pins, screws, or tongs inserted through one or more bones to stabilize fragments during healing; metal inserts are attached to external frame |
| considerations for external fixators | allows for more activity; device needs to be checked for stability q4h; pine care required to prevent infection |
| pressure relief devices | aid in reducing skin trauma from pressure for patients in standard hospital beds |
| types of pressure relief devices | foam and gel pads; sheepskin pads; heel and elbow protectors; pulsating air pads; water mattresses on top of regular mattress |
| types of devices to prevent immobility problems | pressure relief devices; continuous passive motion machine; therapeutic exercise |
| continuous passive motion machine | ordered to restore joint function after orthopedic surgery to replace joint |
| how continuous passive motion machine works | exercises extremity and joint thus preventing contracture, muscle atrophy, venous stasis, and thrombus formation |
| therapeutic exercise | physical therapy ordered for patient who is immobilized for extended period of time |
| ROM exercises | full ROM exercises shoudl be performed either actively or passively several times a day |
| to prevent injury during passive ROM _________ | support limb to be exercised above and below the joint |
| assessing immobilized patient | circulatory impairment; respiratory impairment; which ADL can perform; neurovascular assessment for cast/traction; cultural beliefs/customs; pulleys/ropes function properly; ambulation aids; patient gait |
| how to apply bandage | elevate and support limb; wrap from distal to prosimal using even pressure; overlap turns equally; smooth wrinkles; secure end with safety pin/tape/clips; check neurovascular status; remove and rewrap at least 2x daily |
| bandage wrapping techniques | circular turn; spiral turn; spiral reverse turn; figure 8 turn |
| circular turn | used to anchor bandage and terminate the wrap |
| spiral turn | used to bandage parts of body uniform in circumference |
| spiral reverse turn | used to bandage body partgs not uniform in circumference |
| figure 8 turn | used to bandage and stabilize elbow, knee, ankle, or fractured clavicle |
| aids to mobilization | walkers, crutches, canes, wheelchairs, braces, splints, prostheses, rehabilitation |
| walkers | first mechanical aid used when training individual to walk following loss of function |
| crutches | follow use of walker or first aid to ambulation |
| canes | standard (one point) and quad (four point) |
| wheelchairs | for patients who are not able to ambulate independently or with aids |
| braces and splints | used to strengthen and support areas affected by weakness or paralysis |
| prostheses | used to replace missing body parts |
| rehabilitation | prescribed exercise to improve muscle tone, joint flexibility, or cardio fitness |
| rehabilitation parameters | determined by target heart rate during activity based upon age and condition |
| neurovascular assessment | use dorsum of hand to check temp; movement distal to injury; sensation bilaterally; pulses distal and bilaterally; capillary refill; pain level |
| advantage of quad cane | will stand by itself |
| guidelines for cane use | intact rubber tip; use on unaffected side; not bear full weight on affected side; walk beside patient; elbow bend 15-30 degrees when weight bearing; tip is 6-10" to side and 6" from front on near foot; patient looks straight ahead |
| how continuous passive motion machine works | extends extremity to prescribed angle for specific period of time and then releases joint, flexing it again |
| pain and continuous passive motion machine | assess pain and medicate prior to use; closely monitor pain level during; pain is best controlled before it becomes severe |
| prior to using continuous passive motion ____ | check dressing for need of reinforcement; check function of machine; check electrical safety of machine |
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