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Which body sys is immune to immobility? None
How does immobility disrupt normal metabolic functioning? Alters Metabolism of C,P,F. Decreased metabolic rate. BMR descreases bc cell E & Ox demands are reduced. Decreases ability to produce insulin & metabolize glucose
HOw does immobility cause a loss of lean body mass and increases BF%? When body can't metabolize glucose, it breaks down P stores for E. After P is metabolized, Nitrogen is left. Neg Nitrogen Balance exists when excretion of N from P breakdown more than intake of P. Causes loss of lean body mass, increase BF%
What happens to BMR in a pt who's immobile that has an infection? BMR increases as a result of fever or wound healing bc they increase cellular oxygen requirements
What can you do to prevent metabolic changes in immobile pt? Nutritional Assessment. Diet high in cals & P. Added Vit C. Some juice for tissue repair & to prevent further breakdown. Dangle feet. Ambulate to increase E requirements & BMR
How does Diuresis effect fld and electrolyte balances in pt who's immobile? Bc diuresis is the production and excretion of urine, diuresis causes body to lose electrolytes and affect serum calcium levels
Define hypercalcemia Increased calcium in the blood
How does immobility lead to hypercalcemia? Immobility increases calcium resorption (loss) from bones. This cuases a release of more calcium into blood circulation. Hypercalcemia can occur if kidneys can't respond appropriately.
What can you do to prevent fluid and electrolyte imbalances in pt who's immobile? Watch labs for electrolyte imbalances. Strict I/O (nuns cap, tell family not to discard urine, know mL of all containers)
List cardiovascular changes in pt who's immobile. Major shifts in blood vol. Blood shifts from LE up. Diuretic response. HR increases 4-15 bpm (increase cardiac workload). Increase need for O2. Orthostatic Hypotension
Define Orthostatic Hypotension Drop of 20 mmHg or more in SBP or Drop of 10 mmHg or more in DBP when Pt goes from lying or sitting to standing
Thrombus Blood clot
S/S of thrombus formation Legs feel heavy. Redness. Warmth. Fever. Pn
What factors contribute to venous thrombus formation? Loss of integrity of vessel wall (injury). Abnormalities of blood flow (slow blood flow in calf veins assoc with bedrest). Alterations in blood constituents (change in clotting factors or increased platelet activity)
Define Pulmonary Emboli Clots that move to lung and block portion of pulmonary artery which disrupts blood flow to one more more lobes of lung
S/S of Pulmonary Emboli (PE) Pn. SOB. Increased HR. Bloody sputum
What can you do to prevent Pulmonary Emboli's (PE)? Raise HOB. Ambulate. ROME. Ankle circles. Avoid crossing legs or wearing tight clothes. Use TED hose (not stockings). SCD boots. Watch for bleeding if Pt on anticoagulant
Why are pts with DVT at increased risk of developing a pulmonary embolism? Bc DVT's blood clots
List gastrointestinal changes in pt that's immobile. Constipation. Impaction (looks like diarrhea). Descreased Gastric Motility. Loss of Defacation Reflex
Why or How is pt that's immobile at risk for constipation? Lack of activity. Hypercalcemia (greater than normal amt of calcium in blood)
What can you do to reduce gastrointestinal changes in pt that's immobile? Increased fiber (fld, fruits, veges). Allow privacy. Assess Freq & consistency of BM. Weigh daily. Assess for impation. Encourage Pt to go when they feel urge
List Urinary changes in pt that's immobile UTI. Urinary retention. Urinary Stasis. Renal calculi
Define Urinary Stasis Stoppage of flow of urine at any level of urinary tract
Define Renal Canculi Kidney stones that lodge in renal pelvis and pass through ureters
Why are pt's that are immobile at risk for Renal Calculi? Bc Renal Calculi are kidney stones and immobile pts have altered calcium metabolism and resulting in hypercalcemia
What can you do to prevent Urinary changes in immobile pt? Increase fl. I/O. Check for bladder distention. Check fo color or urine. Sit upright. Void q3h. Dash diet
List Psychosocial effects that immobility has on pt Depressed. Changes in behavior. Changes in sleep-wake cycle. Developmental changes. Decreased coping mechanisms.
Why would pt that's immobile be depressed? Normally active, now bedridden. No one visits. Changes in how they view themselves.
What Behavioral changes would you see in a pt that's immobile? Acting out. Hostile. Mean. Withdrawn. Passive.
Developmental changes in pt that's immobile are more common in _ and _. Very young and Very old
What can you do to prevent Psychosocial changes in pt that's immobile? Watch for emotional/behavioral changes. Watch for sleep cycle. Provide stimuli for orientation. Offer books/TV/newspaper. Encourage fam to visit. Place clock/calendar in room.
To reduce Psychosocial effect on pt that's immobile, you should: Promote self care activities. Encourage to attend therapy is scheduled. Encourage to put on own clothes, hair, makeup. Extend environment. Allow control over environment.
List Respiratory changes in pt that's immobile Decreased lung expansion. Generalized muscle weakness. Stasis or pooling of secretions. Atelectasis. Hypostatic Pneumonia
Define Atelectasis Collapse of alveoli from secretions blocking bronchiole or bronchus
Define Hypostatic Pneumonia Inflammation of lung from stasis or pooling of secretions (mucus accumulation)
What can you do to prevent Respiratory changes in pt that's immobile? Assess for O2 deprivation. Assess Resp status q2h. Turn,cough,& deep breathe q2h. Change position q2h. Incentive Spirometer. Increased fld intake to @ least 2,000cc/day to thin secretions.
List Musculoskeletal changes in pt that's immobile Loss of strength & endurance. Muscle atrophy. Bone resorption. Osteoporosis from disuse. Joint contractures. Foot drop.
Hoare are kidney stones caused by osteoporosis? Lose calcium from bones in osteoporosis so body releases calcium into system which causes kidney stones
Immobility affects which muscle the most? Leg muscles which explains the difficulty older pts have getting out of a chair
What can you do to prevent musculoskeletal changes in pt that's immobile? ROME. Splints. Exercise. Ambulate. High top tennis shoes
What can help prevent Foot Drop? Hightop tennis shoes. Foot board
What is the biggest Integumentary concern in pt that's immobile? Pressure Ulcers
Define Ischemia Temporary descrease in blood flow to organ or tissue
How are Pressure Ulcers formed? Pt lies or sits on bony prominence too long, the longer the period of ischemia & greater risk of skin breakdown
Define Blanchable Hyperemia Appears red & warm. Will blanche after fingertip palpation
Define Nonblanchable Hyperemia Redness that persists after palpation, Indicates tissue damage
What are some complications from Pressure Ulcers? Systemic infection. Osteomyelitis. Death
What are the common areas to get Pressure Ulcers? Sacrum/Coccyx. Back of head (occiput). Ears. Scapula. Acromion Process. Cubital. Iliac crest. Perineum. Medial/Lat knee. Ankles. Heels. Toes.
Define Shearing Force Force exerted against skin while skin remains stationary and bony prominences move. (Pt bends legs and push with ft to help move in bed. HOB lower than 30 degrees)
How does Intrinsic Factors contribute to Pressure Ulcers? Age. Decreased muscle mass. Skin elasticity. SQ fat stores. Incontinence. Chemo/Rad. Infection. Nutrition (decreased albumin). Poor nutrition. Edema. Anemia. Impaired Peripheral Circulation. Obesity. Agitation (rubbing due to head trauma).
How does Extrinsic Factors contribute to Pressure Ulcers? Excessive uniaxial pressure. Friction and shear forces. Impact injury. Heat. Moisture. Posture.
Name the layers of the skin Epidermis. Dermis. SQ. Muscle. Bone.
Describe Stage I of a Ducubitus Ulcer Observable PU-related alteration of intact skin. When compared, changes in: Skin T (warm/cool). Tissue consistency (firm/boggy). Sensation (pn, itching).
Interventions for Stage I of a Ducubitus Ulcers Turning. Use pillows/blankets behind & b/t legs. Keep off PU (Float heels off pillows). Daily skin care. Moisture barrier cream.
Describe Stage II of a Ducubitus Ulcer Partial-thickness skin loss involving Epidermis, Dermis or both. Ulser is superficial. Looks like abrasion, blister, or shallow crater.
Describe Stage III of a Ducubitus Ulcer Full-thickness skin loss involving damage to or necrosis of SQ tissue that extends to undderlying fascia. Ulcer looks like deep crater with or without undermining of surrounding tissue.
Describe Stage IV of a Ducubitus Ulcer Full-thickness skin loss. Extensive damage/tissue necrosis to muscle, bone, joints. Undermining and sinus tract can occur.
Define Closed Pressure Ulcer Ulcer that is walled off. Cavity is filled with necrotic debris. ***Be aware if you have Boggy area
What can you do to prevent Pressure Ulcers? Watch for redness (doesn't blanche or go away within 30 min). Turn at least q2h & encourage Pt to move (roll side to side, use trapeze bar). Special mattresses & pillows to protect bony prominences, Treat incontinence. Protect healthy tissue with NS.
During Nursing assessment, you should: Inspect bony prominences. Use skin criteria to determine proper device. Use lifting tech (not drag). Encourage regular bathing. Sheets clean & wrinkle free with seem away from pt.
During Nutritional Assessment, you should: Consult dietician. Keep strict weight logs. Watch for decreased albumin. Provide adequate P, Cals, Fld intake. Provide Vit & liq supplements as ordered. Assess personal preferences or special needs.
How do you treat Pressure Ulcers? Keep wound bed moist, clean, and debrided. Use mild cleanser (NS, never peroxide). Monitor for infection (COCA). Reevaluate wound q day.
What is Debridement? Cleanse wound with NS. Reduce bacterial contamination. Provide an optimal environment for wound healing.
When treating a Pressure Ulcer, you should: Select dressing carefully. Eliminate dead space (clean out). Use very small amt of tape. Use tape that's gentle to skin.
How do you treat a Diabetic Foot Ulcer? Moisturize. Special socks. Check q day. Don't clean with hot H2O.
What is Duoderm? Skin-like bandage. Don't use on deep wounds
What is Alginate? Like gauze. Made from algae. Pack in wound to absorb eschudate in wound
What is Hydrophlerablue? Wet it with sterile water or NS to keep wound moist
What factors can affect the healing process of Pressure Ulcers? Neurostatus. Steroids. Diabetes. Circulatory & Respiratory status. Previous PU in same area.
Created by: mcwilliams05