Chapter 35

  1. What type of changes are you going to see in an immobile pt?
    • Respiratory changes-decreased lung expansion
    • generalized respiratory muscle weakness
    • stasis of secretions.
    • Often cause atalectasis and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions)
  2. What happens in atelectasis?
    • Secretions block a bronchiole or a bronchus and the distal lung tissure (alveoli) collapses.
    • General muscle weakness reduces the pt's ability to cough.
  3. How can immobility cause chang in metabolism?
    • Alters metabolism of carbs, proteins, and fats
    • Pt's BMR decreases in response to reduced cellular energy and O2 demands.
    • Presense of an infection, fever and wound repair, increases cellular O2 requirments and immobilized pt's have an increased BMR
  4. What happens when a body is unable to metabolize glucose?
    It begins to break down it's protein stores for energy.
  5. What happens when a pt has a negative nitrogen balance?
    Predisposes the pt to problems w/ wound healing and normal tissure growth, resulting in a loss of lean body mass and an increased percent of body fat
  6. Immobility influences fluid and electroyte balances how?
    It can cause diuresis (increased urine excretion) in your pt which can lead to hypercalcemia if the kidneys are unable to respond appropriately and the danger of pathological fractures if the immobility continues.
  7. What type of gastrointestinal changes should you look for in your immobile patient?
    • Pt is at risk for constimpation from lack of activity and from hypercalcemia which depresses peristalsis.
    • Could cause fecal impaction
  8. What type of cardiovascular changes should you look for in your immobile patient?
    • Orthostatic hypotention- a drop of 20 mm Hg or more in systolic blood pressure or a decrease in diastolic blood pressure of more than 10 mmHg when the patient rises from a lying or sitting position to a standing position.
    • Increases the heart's workload producing a need for more oxygen
    • Increases the resting heart rate 4 to 15 beats per minute
    • Risk for deep vein thrombosis (DVT)
    • Two additional problems predispose the immobilized patient of DVT's
    • (1) the weight of the legs on the bed compresses the blood vessels of the calves, causing stasis and injury to vessel linings
    • (2) the skeletal muscles in the legs lose their pumping action, leading to stasis and less blood returning to the heart
    • Threee factors contrinbe to DVT's.. these three factors are referred to as Virchow's triad
    • (1) Loss of integrity of the vessel wall (like injury)
    • (2) Abnormalities of blood flow (like slow blood flow in calf veins associated with bed rest)
    • (3) Alterations in blood constituents (like change in clotting factors or increased platelet activity)
  9. What kind of musculoskeletal changes does immobility cause?
    • leads to loss of strength, and endurance, decreased muscle mass, and decreased balance or stability
    • musclres are not exercised, muscle mass continues to decrease
    • muscle atrophies and ther size decreases
    • affects the leg muscles the most
    • causes two skeletal changes
    • (1) a joint contracture - an abnormal and possibly permanent condition
    • (2) a disuse osteoporosis - characterized by bone reorption - immobility increases the rate of bone resorption - results in reduced bone tissure density
    • Common and debilitating contracture is footdrop - permanently in plantar flexion
    • Increases the patient's risk for pathological fractures
  10. How does immobility affect changes with the skin?
    • risk for developing pressure ulcers
    • weight of the body is on bony prominences due to immobility
    • longer pressure is applied, the longer the period of ischemia (temporary decrease of blood flow to an organ or tissure) and therefore the greater the risk for skin breakdown
  11. What type of urinary changes can you see in immobile patients?
    • risk for urinary tract infection and renal calculi
    • renal calculi are calcium stones that lodge in the renal pelvis and pass through the ureters
  12. What type of psychosocial effects can immobilization cause?
  13. What type of developmental effects can immobilization cause?
    • more commonly affect the very young and older adult
    • delays child's motor skill and intellectual development (make sure as a nurse you try to plan activities that provide physical and psychosocial stimuli when careing for infants, toddlers, or preschoolers)
    • increases older pt's physical dependence on others and accelerates functional losses in physiological systems
  14. How can you try to maintain some type of mobility in your immobile patient?
    • Range of Joint Motion (ROJM)
    • get a baseline to assess pt's overall level of mobility by assessing the pt for stiffness, muscle strenth, pain, and swelling of joints, and unequal or limited movement, then determine the extent of assistance needed to help the client maintain self-care skills
  15. What can you do to keep respiratory problems from occuring in your immobile patient?
    • respiratory assessment every 2 hours
    • monitory pt's respiratory rate and 02 saturation
    • chest wall movements asculate lungs for adventitious lung sounds
    • if pt has atelectatic area, breath sounds will be asymmetrical
  16. What type of things will you assess in the patients while doing metabolic functioning assessment?
    • Intake and output
    • lab data to evaluate fluid and electrolyte status
    • nutritional status
    • anorexia is common in immobility - assess food intake and remove unpleasant odors or noises that interfere with appetite
    • anthropometric measurements - height, weight circumferences
  17. How do you assess the cardiovascular system in your immobilized patient?
    • Monitor blood pressure, apical and peripheral pulses, observing the venous system
    • measure blood pressure when patient moves from lying to a sitting or standing position b/c of the risk of orthostatic hypotention
    • Assess for DVT's... to assess for DVT remove the pt's antiembolic stockings or compression devices once every 8 hours
  18. How do you assess the skin in your IP? (Immobilized Patient)
    • assess for signs of pressure ulcer formation especially over bony prominences
    • blanching is normal ... skin that does not blanch is an early sign of skin injury
    • use the Braden Scale or the Gosnell Scale to assess the pt's risk for pressure ulcer formation
  19. Assessing elimination
    • assess intake and output every 24 hours
    • assess frequency, bowel sounds, consistency, and pt's typical urine and bowel patterns
  20. How can you assess for psychosocial conditions?
    • observe for changes in emotional status like depression and behavioral changes like cooperative pt's who become argumentative or modest pt's who begin to expose themselves repeatedly
    • evaluate pts rediness to improve their level of independence
  21. What is Buck's Traction?
    one of the most common orthopedic mechanisms by which pull is exerted on the lower extremity with a system of ropes, weights, and pulleys. Buck's traction, which may be unilateral or bilateral, is used to immobilize, position, and align the lower extremity in the treatment of contractures and diseases of the hip and knee. The mechanism commonly consists of a metal bar extending from a frame at the foot of the patient's bed, supporting traction weights connected by a rope passing through a pulley to a cast or a splint around the affected body structure
  22. What can you do to prevent respiratory problems in your pt?
    • promote expansion of the chest and lungs
    • reposition pt every 2 hrs or more often
    • fluid intake of at least 2000mL per day
    • method for removing pulmonary secretions is chest physiotherapy (CPT)
    • Combine coughing with deep breathing
  23. What can you do to prevent metabolic problems in your pt?
    dietary plan of carbs, proteins, and fats
  24. What can you do to prevent cardiovascular problems in your pt?
    • proper positioning
    • anticoagulants
    • antiembolic stockings
    • avoid crossing the legs, sitting for prolonged periods of time, wearing tight clothing that constricts the legs or waist, putting pillows under the knees and massaging the legs
    • ROJM prevent thrombi
  25. What can you do to prevent musculoskeletal problems in your pt?
    regular ROJM
  26. What can you do to prevent skin breakdown in your pt?
    • pressure relief devices
    • teach pts who are able to move to shift their weight every 15 to 20 minutes
    • turn pt every 1 to 2 hours
Card Set
Chapter 35