Exam 5 Flashcards
Effects of Immobility on the Cardiovascular System
Orthostatic hypotension
Less fluid volume in the circulatory system
Stasis of blood in the legs
Diminished autonomic response
Decreased cardiac output, leading to poor cardiac effectiveness,
Increased oxygenation requirement
Increased risk of thrombus development
Embolus
(traveling blood clot) blocks blood flow to a portion of a vital organ. Oxygen and nutrients are prevented from reaching the tissue, resulting in the death of the affected cells. ( most preventable cause of death during hospitalization)
Orthostatic Hypotension
decrease in b/p that occurs when a pt changes from reclining/flat position to sitting/standing
How to Prevent Orthostatic Hypotension
Encourage movement/Passive ROM, Flexion of feet
Change pts position frequently, vertical/horizontal.
Remain with pt the first few times they are out of bed.
Nursing Interventions to Prevent Cardiovascular Complications
Encourage movement of extremities, passive ROM
Apply TED stockings or a compression device.
Effects of immobility of the Respiratory System
-Hypostatic pneumonia: lung infection that occurs when a pt. is immobile
-Atelectasis: collapsed lung tissue affecting part or all of a lung caused by inability of lung to fully expand. (can occur when pt doesn’t take full deep breaths to keep the alveoli open)
Decreased respiratory movement resulting in decreased oxygenation and carbon dioxide exchange
Stasis of secretions and decreased and weakened respiratory muscles, resulting in atelectasis and hypostatic pneumonia
Decreased cough response
How to Prevent Respiratory Complications
Turn pts from side to side every 2 hours to help with lung expansion
-Elevate the HOB 45º or more
-Encourage cough & deep breathing exercises every hour(hold for 3 sec and exhale slowly at least 5x.
-Encourage the pt to use an incentive spirometer taking 10 deep breaths every hour
Effect of the GI system
Decreased peristalsis
Decreased fluid intake
Constipation, increasing the risk of fecal impaction
Nursing Complications that Prevent GI complications
-Encourage food and fluid intake
-Muscle contraction & exercise help stimulate peristalsis
-Encourage bedside commode, use of bathroom and normal movements
-Reposition every 2 hours and Passive ROM on all joints every 8 hours
-Place pt in a sitting position to poop
-Help select well-balanced nutritious meals
-Encourage food high in fiber, including fresh fruit and veggies
-Avoid drinking out of straws
-Provide laxative or stool softener as needed
Effects of immobility in the Urinary System
Urinary Stasis
Change in calcium metabolism with hypercalcemia (renal calculi)
Decreased fluid intake & increased use of catheters
Increased risk of UTI
Complicatons of prolonged bedrest
Blood clots, Pneumonia, Bone demineralization, Kidney stones, constipation, pressure injuries, urinary retention, depression, and contractures.
How to manual transfer a patient
uses proper body mechanics, using a wide base of support and standing close to the object being moved, keeping back straight, and avoiding twisting your torso. Use thigh muscles in your back and remember to explain to the pt what you are going to do during the transfer.
How does nutrition effect wound healing?
Lack of calories and adequate protein impairs tissue growth.
Deficiency in intake of vitamin A, C and zinc in diet
Inadequate fluid intake causes the wound to be dry
What is Primary intention healing
the wound is clean with little tissue loss (surgical incisions.)
Edges are approximated/wound is sutured, glued, stapled, or stitched closed. (helps prevent germs and healing process to occur quickly)
What is secondary intention healing?
Greater tissue loss/wound edges are irregular; edges
cannot be brought together. (pressure injury or traumatic wound) Left open to gradually heal with a wide scar. Must be packed with moist gauze to absorb drainage and allow tissue to grow (STERILE TECHNIQUE)
What is tertiary intention healing?
(delayed primary closure healing): wound is left open for a time to allow granulation to occur then its sutured closed. (drainage wound)
What is foot drop
Permanent plantar flexion of the foot (foot pointing downward)
Will prevent the patient from being able to walk normally when they can ambulate
-May be caused by injury, paralysis, and weakness of the muscles and nerves of the foot.
Trochanter Roll
rolled towel/cylindrical device place snugly against the lateral aspect of the pts thigh to prevent the leg from rotating.)
Foot drop boots
a splintlike padded device that supports the foot in the proper plantar flexion and suspends the heel over a small pocket of air
Stage 1 of Pressure Ulcer
Over bony prominences that will not blanch or turn white when gently touched.
Area may feel warm, firm, soft or boggy. Pts may report burning/tingling of site. (can
be prevented)
What is Stage 2 Pressure Ulcer?
Partial thickness loss and exposed dermis. Serum filled blisters, broken blisters that reveal a shallow, pink or red ulceration that is moist. Subcutaneous tissue not visible. (harder to heal/infection possible)
Not a result of adhesive skin injury,incontinence or traumatic wound.
What is Stage 3 Pressure Ulcer
Full thickness loss involves damage to the epidermis, dermis & subcutaneous tissue but doesn’t involve muscle/bone. It may be infected, produce drainage, and take longer to heal than stages 1 & 2. (Rolled wound edges are present at this stage)
What is a Stage 4 Pressure Ulcer
Thickness skin and tissue loss; involves deep tissue, necrosis of muscle, fascia, tendon, joint capsule, and sometimes bone. (An infection can involve deeper
tissues such as bone (osteomyelitis).) It is extremely slow to heal completely & depends on the patient’s health status
What is an Unstageable Ulcer
Full thickness tissue loss/ impossible to accurately stage because of Eschar.
