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Immobility
Ch. 35
| Question | Answer |
|---|---|
| Factors that contribute to immobility | length/severity of illness, presence of pain, cognitive/emotional status (i.e. depression) |
| Respiratory changes due to immobility | decr lung expansion, stasis of secretions, lead to atelectasis (collapse of alveoli), hypostatic pneumonia |
| Metabolic changes b/c of immobility | BMR decr, decr ability to produce insulin or metabolize glucose, negative nitrogen balance (breakdown of protein) |
| Fluid/electrolyte changes | Diuresis(incr. urine excretion), affects CA levels leads to hypercalcemia(release of CA in circulation) |
| Gastro changes | risk for constipation |
| Cardio changes | Orthostatic hypotension, incr workload, need O2, incr resting HR 4-15 bpm, risk for DVT, peripheral edema |
| What is a thrombus? | accumulation of platelets, fibrin, to int. wall of vein/artery |
| What is Virchow's triad | loss of integrity of vessel wall(injury), slow blood flow from bedrest, change in clotting factors |
| Musculoskelatal changes | loss of strength and endurance, decr muscle mass, decr balance/stability, joint contractures(footdrop), disuse osteoporosis(bone reabsorption) |
| Integument Changes | risk for pressure ulcers, ischemia (decr. blood flow) |
| Urinary elimination changes | urinary stasis incr UTI's, renal calculi(CA stones) |
| Psychosocial Changes | depression, sleep wake disturbances, impaired coping |
| Two most common nursing diagnoses related to immobility | impaired physical mobility and risk for disuse syndrome (multisystem complications) |
| Nursing interventions for musculoskeletal immobility | managed excercise progs, ROJM exercises, pedal pulse, walking |
| Respiratory interventions | position changes q2h for lung expansion, fluid intake of 2000mL/day, coughing/deep breaths |
| Metabolic interventions | dietary plan (carbs,proteins, fats), |
| skin interventions | position changes q2h, dry/clean, balance nutrition, pressure relief devices |
| elimination interventions | good hydration, timely toileting, monitor I/O, stool softeners |
| Psychosocial interventions | socialization, keep pxt involved in care, stimuli for orientation |
| cardio interventions | sequential suppresion devices, isometric excercises (tighten, heparin therapy (anticoagulant) |
| What is the Valsalva maneuver? | pxt in defecation, holds breath, strains, incr intrathoracic pressure, decr venous return and CO, lead to death Pxt must breathe out in moving |
| Goals of restorative and continuing care for immobilized pxts | maximize independence, incr endurance and prevent injury |
| IADL's | instrumental activities of daily living: shopping, preparing meals, banking, taking meds |
Created by:
palmerag
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