Lec 2: Immobility

Respiratory System: Nursing Care

-Exercise and activity (increased activity = increased lung expansion) -Turn and reposition every 2 hrs -Deep breathe and cough every 2 hrs (incentive spirometer) -Encourage fluids (thinner sputum= more likely to cough it out) -Careful use of narcotics and sedatives (respiratory depression) -Respiratory assessment to note changes early (O2 status, hyper or hypo ventilating?) -Use of oxygen and mechanical ventilation as needed

Crutch walking: Proper fit -adjust for pt's height, adjust hand grips, there should be _-_ fingers width (_-__ inches) between rest pad and armpit -hand grips should be even with top of ___ line (elbows flexed __ degrees)

2-3; 1-1.5; hip; 30

Restraints: -all restraints are required to be represcribed every __ hours -cannot be ___ -restraints should be removed and activity and skin care provided -tied only to the bed frame (not rail) -assessment? -pulse near the restrained area -temp of restrained area -skin integrity surrounding restraint -behavior leading to the need for restraint

24; PRN assessment: -pulse near the restrained area -temp of restrained area -skin integrity surrounding restraint -behavior leading to the need for restraint *BiPAP- not allowed to put restraint, need a sitter

Orthostatic Hypotension Values:

A decrease in systolic pressure of 20 A decrease in diastolic pressure of 10

Which statement by the pt indicates the development of a DVT? A. "My legs itch" B. "My left leg is swollen compared to my right" C. "The skin on my legs is dry and scaly" D. "My left leg feels cool when I touch it"

B. "My left leg is swollen compared to my right"

A nurse is assessing the extremities of a client who has wrist restraints applied 2 hrs ago. Which assessment finding, if present, is of greatest concern? A. The client is able to wiggle the fingers B. The restraint is secured to the bed's frame C. The skin of the hand feels cool to the touch and is pale D. The nurse is able to insert two fingers under the restraints

C. The skin of the hand feels cool to the touch and is pale

Patient Position: lies on abdomen, head turned to side; body is straight; helps prevent flexion contractures of hips and knees; contraindicated in people with spinal problems

Prone position

Patient Position: pt lie on their left side; left hip and lower extremity straight, and right hip and knee bent

Sims position *enema

permanent fixation of joint and muscles as a result of disuse

contracture

how to take an orthostatic vital?

take BP when: -lying down -sitting up -standing

Urinary Elimination from Immobility: -_____ _____= urine formed by the kidneys must enter the bladder against gravity due to the shifting of anatomy when recumbent -UTI: use of catheters, change in voiding -Predisposition to renal calculi, what is this?

urinary stasis stone- caused from hypercalcemia bc of bone breakdown

Airborne precautions: pts who have infections that spread through the ___ such as __, _______ (chicken pox) and ______ (measles); these pts get private _______ pressure rooms, anyone entering the room must use a ______

air; TB; varicella; rubeola; negative; respirator

muscles decrease in size when not used- leading to a loss of both strength and muscle mass

atrophy

Cardiovascular: Thrombus (DVT) Formation- Virchow's Triad -changes or injury to ______ ____ -hypercoagulability of the blood (changes in clotting factors) -venous stasis or slowing of blood (external pressure of the bad against the legs, lack of motion of the legs, hypovolemia and increased hematocrit)

vessel wall traid: vessel wall injury, venostasis, hypercoagulability= thrombosis

Cardiovascular: Cardiac Workload -prolonged bed rest increases the _____ ____ 4-15 BPM (increases more with activity) -heart works harder and less efficiently

heart rate

Joint Contractures: *prevent it before it happens

-Contractures occur in the skin, the tissues underneath, and the muscles, tendons, ligaments, and joint area -they affect ROM and function in a certain body part -flexion or extension and FIXATION OF A JOINT -caused by disuse, atrophy, and shortening of muscle fibers

Assessment for Immobility:

-Detect risk of complications of immobility -Determine amount of assistance the person will need

Cardiovascular: Nursing Care Interventions

-Exercise (ambulate ASAP, active and/or passive ROM) -turn and reposition every 2 hrs -change to a rising position slowly and monitor BP -defecation (proper positioning, prevent constipation, avoid Valsalva maneuver)

Aseptic Technique: -includes all activities to prevent or break the chain of infection 2 categories?

-Medical asepsis: clean technique -Surgical asepsis: sterile technique

Muscle and Bone: Nursing Diagnoses

-Activity intolerance -Impaired physical activity

Patient Position: semi-sitting position; head of the bed is elected to 45 to 60 degrees- promotes cardiac and respiratory functioning, providing the max space in the thoracic cavity; there are variations within the fowler's position (High fowlers- HOB is 90 degrees, semi fowlers- HOB is 30 degrees

Fowler's position

Risk for Disuse Syndrome:

Affected by: -Level of inactivity -Duration on inactivity -Age -Body weight -Chronic illnesses -Discomfort -Environment -Psychosocial/culture

Seizure Precautions: after

After: -assess neuro, physical injury -follow protocol -document: time, duration, symptoms

The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is incorrect to teach? A. To prevent a confused client from pulling out an IV line B. To prevent an adult client from getting up at night when there is insufficient staffing on the unit C. To prevent ventilated pt from dislodging the ventilator D. To keep an older adult client from falling out of bed after a surgical procedure

B. To prevent an adult client from getting up at night when there is insufficient staffing on the unit

Seizure Precautions: before

Before: -O2 and suction -bed at lowest point -loosened clothing (clothes can restrict movement) -side rails up and padded -low stimulation (AURA= pt senses they're abt to have a seizure)

Patient Position: side lying position

Lateral recumbent position

Cardiovascular: Nursing Care (Legs)

Leg assessment: -DVT symptoms= red, swollen, pain -Never massage the legs if you know it's a blood clot bc you don't want it to dislodge -TED (Thrombo-Embolic Deterrent) -get pt up and moving -compression stockings -Sequential compression device (SCD)- moves blood so no pooling -Assess for thrombophlebitis -know high risk groups for DVT

Metabolic Issues with Immobility

Nutrition: -disturbance in appetite -decreased/increased intake of food -poor digestion and utilization of food -weight loss or gain, depending on situation -SCI: decreased skeletal muscle, increased adipose tissue, insulin resistance and hyperinsulinemia, dyslipidemia, HTN

used in the care of all hospitalized pts regardless of their diagnosis or possible infection status applies to? new additions?

Standard Precautions -apply to blood, all bodily fluids, secretions, and excretions except sweat, nonintact skin, and mucous membranes -new additions are respiratory hygiene/cough etiquette, safe injection practices, and directions to use a mask when performing high-risk prolonged procedures involving spinal canal punctures

Urinary Elimination: Nursing Care

-Adequate fluids -Use of retention catheters for shortest time period (intermittent catherization) -potential use of incontinence care strategies -monitor for infection

Respiratory System: Nursing Diagnoses

-Alteration in respiratory function -Ineffective airway clearance -Impaired gas exchange -High risk for altered body temperature -High risk for infection

Urinary Elimination: Nursing Diagnoses

-Alteration in urinary elimination -High risk for altered body temperature -High risk for infection

Droplet precautions: for pts w an infection that is spread by large particle droplets such as ______, _____, ________; these pts get ______ rooms; ___ upon entering the room

rubella, mump, influenza; private; PPE

Contact precautions: in direct contact with the _____ ex?

surface C. diff

Crutch walking: Gates?

*before pt ambulates w crutches, use gait belt and tripod position (crutches abt 6 inches out diagonally from feet) 2-point= move R crutch and L foot together + vice versa 3- point= move both crutches and injured leg together then move non-injured leg 4-point= more R crutch then L foot + vice versa Swing-to-gait= both crutches forward then both feet forward IN LINE w crutches Swing-through-gait= both crutches forward then both feet forward PAST crutches

4 Categories Responsible for Majority of Hospital-Acquired Infections (HAIs)

-Catheter-associated UTI (CAUTI) -surgical site infection (SSI) -Central-line associated bloodstream infection (CLABSI) -ventilator-associated pneumonia (VAP) *need good oral hygiene

Use of Surgical Asepsis:

-OR, L&D areas -certain diagnostic testing areas -pt bedside (for procedures that involve insertion of urinary catheter, sterile dressing changes, or preparing and injecting medicine)

The order in which PPE is put on and removed:

-Putting on= gown, mask, goggles, gloves -taking off= if gown ties in front, untie string first then remove glove taking care not to touch the outer surface, remove goggles/face shields then gown

Concerns of Immobilized Person:

-Survival (hygiene) -Interaction in the environment (trash in home? bad living conditions?) -Spatial relationships (wheelchair, can you access stove?) -Sensory deprivation/overload (always talked down to if in wheelchair) -Productivity and development -Economics -Life style -Emotional factors (had mobility, then lost it)

Muscle and Bone: Nursing Care

-Weight bearing activity and exercises as able -ROM of all joints -Proper body alignment while sitting and lying (hand splints) ^use of pillows and wedges, feet: space/moon boots; vascular boots; PRAFOs, reposition every 2 hrs

Prevent C. diff infection:

-avoiding the use of electronic equipment that is difficult to clean (electronic thermometers) -disinfecting dedicated pt care items and equipment (stethoscopes) between pts -using full-barrier contact precautions (gown and gloves) -placing pts in private rooms; cohort pts with the same strain of CDI -performing meticulous hand hygiene -performing environmental contamination of rooms -educating health care providers (and pt/family) on clinical presentation, transmission, and epidemiology of CDI -using antimicrobials as an appropriate dose and only when indicated

How does immobility affect GI?

-constipation (decreased muscle tone, decreased peristaltic movement, embarrassment, ignore the defecation reflex) -neurogenic bowel after spinal cord injury

Muscle Changes from Immobility

-reduced muscle endurance for activity -muscle atrophy -decreased stability (increased risk for falls)

Psychosocial Consideration from Immobility

-support systems -mental stats (body image, self-concept, self esteem, self worth) -sexual assessment and counseling (may not be sexually active anymore) -discharge planning and home care needs (wheelchair)

Cardiovascular: Anticoagulation medication

-teach abt the med -teach self-injection -med and insurance coverage -follow up re-coagulation clinic/primary provider -encourage fluids -ambulation

The nurse performs ROM exercises on an immobile client to avoid which complication associated with immobility?

-urinary stasis -constipation -contractures

Evaluating Pt Goals:

-use technique of medical asepsis -identify health habits and lifestyle patterns promoting health -state signs and symptoms of an infection -identify unsafe situations in the home environment

Which intervention should a nurse plan to incorporate in the care of a surgical client to decrease the risk of DVT and PE? A. use of intermittent compression devices on the lower extremities B. administration of heparin intravenously C. coughing and deep breathing exercises D. turn pt every 2 hrs

A. use of intermittent compression devices on the lower extremities (moving pooled blood around)

Metabolic: Nursing Diagnoses and Care

Alteration in nutrition: Less/Greater than body requirements -Nutrition assessment (food preferences, calorie counts_ -Nutrition teaching -Monitoring lipid and glucose levels (risk diabetes)

Cardiovascular: Nursing Diagnosis

Alteration in tissue perfusion Etiology: -orthostatic hypotension -blood dyscrasia: thrombus

A primary health care provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior; which action would the nurse take? A. Ask the health care provider to specify the type of restraint in the prescription B. Notify the provider that PRN prescriptions for restraints are unacceptable C. Implement the restraint prescription when the client begins to act out D. Ensure that the entire staff is aware of the prescription for the restraints

B. Notify the provider that PRN prescriptions for restraints are unacceptable

Bone Changes from Immobility:

Bone resorption (breakdown): -hypercalcemia -bone less dense -osteoporosis (risk of pathologic fractures)

GI: Nursing Intervention

Constipation: -privacy and positioning -dietary fiber -adequate fluids -pharmacologic agents: stool softeners, bulk formers, laxatives (can use for short period of time) -bowel training program (pt encouraged to go to bathroom at certain times)

Which point requires correction regarding the use of restraints? A. Less restrictive interventions must have been unsuccessful before applying restraints B. All other alternatives must have been tried and exhausted before applying restraints C. Restraints may be applied to ensure the physical safety of the resident or other residents D. A written order for restraints is not required

D. A written order for restraints is not required

Fire safety: -4 steps to take if you discover a fire -how to operate a fire extinguisher

Discover a fire: RACE R- rescue anyone in immediate danger of the fire A- alarm; activate the nearest fire alarm and call your fire response telephone number C- contain fire by closing all doors in the fire area E- extinguish small fires; if fire cannot be extinguished, leave area and close door Fire Extinguisher: PASS P- pull the pin, release a lock latch or press a puncture lever A- aim the extinguisher at the base of the fire S- squeeze the handle of the fire extinguisher S- sweep from side-to-side at the base of the flame

Seizure Precautions: during

During: -call for assistance (rapid response team) *first thing to do -protect airway -prevent injury -protect head (remove items on floor) -side lying position -provide O2 as necessary -don't insert anything in mouth (pt having seizure bites teeth) -don't restraint pt -stay w pt

The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important?

If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia

Rendering of a part incapable of being moved; may range from a minor decrease in range of motion to complete loss of motion

Immobility

for pts with known or suspected infection or colonization with infectious agents which require additional control measures to effectively prevent transmission; the precaution matches the method of transmission of the infectious agent. precautions include?

Transmission-Based Precautions -contact precautions -droplet precautions (influenza) -airborne precautions (COVID, TB ...all around env)

Patient Position: the body is laid supine, of flat on the back on a 15-30 degree incline with the feet elevated above the head

Trendelenburg position *if pt experiencing hypotension

Respiration protection currently requires the use of a _____ with ___ or higher filtration to prevent inhalation of infectious particles

respirator; N95

any physical or chemical means or device that restricts client's freedom to an ability to move about and cannot be easily removed or eliminated by the client

restraint -assess appropriateness of the type of restraint -follow policy (least restrictive restraints, timed client monitoring) -monitor/evaluate client response to restraints

Respiratory System Changes: -decreased _____ and _____ of respirations (decreased lung expansion) -generalized ______ weakness (pressure of bed and chair, poor expansion) -stasis and retention of _______ (decreased cough, decreased effectiveness of cilia, medium for bacterial growth- pneumonia) *can lead to infection; secretions sit unless lung expands -a lot of secretions sitting in lungs and can lead to pneumonia is called?

depth; rate; muscle; secretions; atelectasis

what is a sequential compression device?

device that attaches to the legs; moves blood so no pooling -minimize adverse effects to skin -pt comfort -able to assess skin

Crutch walking: stairs

down w the devil= crutches 1dt, then bad leg, then good leg up w the angel= good leg 1st, then crutches and bad leg

drop in systolic BP of 20mmhg or more when going from a sitting to a standing position

orthostatic hypotension

Cardiovascular: decreased ability to equalize blood supply (low BP) when moving from a lying to a standing position (can lead to falls) causes?

orthostatic hypotension causes: -decreased circulating fluid volume -pooling of blood in the lower extremities -decreased autonomic response results: -decreased venous return -decreased cardiac output -decreased BP

An immobile postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition?

pneumonia

The most serious complication of deep vein thrombosis is:

pulmonary embolism (PE) -DVT/PE is a "never event"