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Funds Ch.16
| Question | Answer |
|---|---|
| Contractures | Shortening and tightening of muscles due to disuse |
| Dorsiflexion | Bending the foot in an upward position |
| Plantar flexion | Bending the foot in a downward direction |
| Log roll | Turning a patient in the same way as one unit |
| Trochanter roll | Tightly rolled sheet or blanket placed against the lateral side of the thigh to prevent outward motion of the hip and leg |
| Hazards of Immobility include.... | Blood clots Pneumonia Kidney stones Constipation Pressure ulcers Urinary retention Depression |
| Body Systems affected by immobility include.. | Musculoskeletal, Cardiovascular, Resp, GI, Urinary, Integumentary, Neuro, Psychological effects |
| How to prevent musculoskeletal complications | Maintain proper body alignment, Prevent the legs from rotating in the hip socket medically or laterally, Maintain arms in correct alignment with the shoulders |
| Nursing actions to prevent Contractures and Osteoporosis | ROM every 8hrs, Support the weight of the extremity at the joints, Apply supportive or therapeutic devices for maintains body alignment, assist with ambulation |
| Effects of immobility on CV System | Venous Thromboembolism, Orthostatic Hypotension, Syncope |
| Nursing measures to prevent CV complications | Encourage extremity movement, Apply ordered devices to prevent blood from pooling in the legs, Gradually move pt from lying to sitting or to a standing position, Change pts position frequently, remain with the pt the first few times they are getting out o |
| Nursing measures to prevent resp complications | Turn pt from side to side every 2hrs, Elevate head of the bed to 45 degrees, Encourage coughing and deep breathing, Encourage use of incentive spirometer |
| Nursing measures to prevent GI complications | Assist w/early ambulation, reposition pt every 3 hours, Encourage ROM, Place pt in a sitting position when on the bed pan, Inquire about food likes & dislikes, Encourage fiber & fluid intake, Admin. Laxative or stool softener PRN |
| Nursing measures to prevent Urinary Complications | Encourage Fluids to prevent concentrated urine, Assist female pts to urinate in a sitting position, Assess the pts output |
| Nursing Measures to Prevent Integumentary (skin) complication | Provide adequate nutrition, reposition pt every 2hrs, Inspect bony prominences for redness every 2hrs and massage the areas around the redness, Use mild soaps for cleansing skin, Provide appropriate surface for the pt |
| Nursing Measures to prevent Neuro Complications | Determine pts LOC by asking specific questions relating to person, place, and time, Use foot board to keep feet in a natural position, Perform Neuro checks, provide clues in the room to the correct date and time |
| Psychological effects of immobility | Depression, anxiety, hostility, fear, isolation, Restriction of self-image and independence, sensory deprivation, diff sleeping |
| Nursing measures to prevent Psychological Complications | Minimize sensory deprivation, involve pts sense with the pt, Encourage the pt to remain awake during the day and do as much for self as possible, allow pt to express concerns, Encourage visits from family & friends |
| Position of function | Places the extremities in alignment, maintains the potential for their use and movement, helps prevent undue pressure on the nerves, helps prevent discomfort, pain, and nerve damage, Uses devices including pillows, hand rolls, arm boards and foot boards |
| Supine | Lying on back, arms at side |
| Dorsal Recumbent | Lying on back, arms at side, legs apart, knees bent, feet flat |
| Trendelenberg | Lying on back, arms at side, feet higher than head |
| Reverse trendelenburg | Lying on back, arms at side, head higher than feet |
| Lateral | Lying on back or R side, supported by pillows |
| Left sims | Left side semi-prone, right leg drawn up to chest, left arm along patients back |
| Right Sims | Right sided semi-prone, left leg drawn to chest, right arm along pt back |
| Low, Semi and High Fowlerâs | Semi-sitting w/ various degrees of head elevations |
| Orthopneic | Sitting upright, leaning slightly forward, arms supported on overbed |
| Prone | On stomach with head to side |
| Lithotomy | On back, legs in stirrups |
| Devices used to transfer pts | Transfer (gait) belts, nylon friction reducing devices, slide boards, partial or full weight bearing assist devices, overhead ceiling lift devices |
| Support surfaces | Mattress overlays, specialized mattresses, speciality beds |
| Types of specialty beds | Air-fluidized bed, Low air-loss bed, Combination air-fluidized and low air-loss bed, Continuous lateral rotation bed |
Created by:
grdrgz92
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