Flashcards in Immobility 2 Deck (41):
Effects on Gl System ?
Constipation: (decreased peristalsis,
inadequate hydration, diet)
Increased use of Valsalva Manoeuvre:
(a forced expiratory effort against a
closed glottis that increases intra-thoracic pressure, hampering venous return to the heart)
Assessments/Interventions: GI System?
Monitor food intake and elimination patterns
Assess bowel sounds, abdominal assessment (Health assessment)
Diet HIGH in fiber, fruits and vegetables
Avoid narcotics (increase constipation)
Types of laxatives?
What is the reason for laxatives?
Increase stool volume
Increase speed of movement of chyme (semi-fluid mass of partly digested food expelled by the stomach into the duodenum) through the intestine
Facilitate the evacuation of stool from the rectum
Bulk Forming Laxatives?
Action: Absorbs water , thereby softening and enlarging the fecal mass; fecal swelling promotes peristalsis. Works in the small &large intestine, produces a soft stool in 1-3 days
Candy has had surgery for Crohn’s disease, and is aware of the signs of intestinal obstruction. She feels bloated, is constipated and is passing a small amount of gas. She is experiencing abdominal discomfort.
Should she take Metamucil to relieve the constipation ? Her friend, who has irritable bowel says it works for her .
no. contraindication of bowel obstruction. pt must pass gas and have bowel sounds to take a laxative
Surfactant Laxatives/ stool softners?
Docusate sodium (Colace)
Surfactant action softens the stool by facilitating penetration of water; also causes secretion of water and electrolytes into the intestine. Works in the small & large intestine; produces soft stool in 1-3 days.
lubricates bowel by adding water
Mr Kay is in the Coronary care unit. He was admitted for a Myocardial Infarction. He had been prescribed Colace 100 mg po, bid. He stated at home he was using Metamucil. Should he change the laxative to Colace and why?
yes, due to heart attack, pt should avoid straining. stool will pass with ease
(used less; causes liquid stool, more electrolytes are lost)
Stimulates peristalsis and softens feces by increasing secretion of water & electrolytes into the colon, and decreasing water and electrolyte absorption. Produces semifluid stool in 6-12 hrs.
Dr. Dee has the suspicion that Angela is abusing stimulant laxatives as a measure to keep her weight in check. What assessments would you perform as a nurse ?
- hydration of skin for s+s of dehydration, MM
- verify weight and log it
- verify BP + orthostatic hypotension
- PO intake + elimination
- question and attempt to build relationship with pt, build up their self-esteem
- note clothes (will usually wear big clothes to hide wt loss)
- colonoscopy will rule out laxative abuse
- blood test to check electrolyte levels
(high risk; renal function is mandatory)
Magnesium hydroxide (MOM)
Consists of a solution of poorly absorbed salts whose osmotic action draws water into the intestinal lumen & thereby softens the stool ; fecal swelling promotes peristalsis. Works on small & large intestine; produces semifluid stool in 6-12 hrs.
Coady has a mental health problem, and his treatment involves regular use of an antipsychotic medication that has the side effect of constipation. What must be assessed before Coady can take MOM?
kidney function (Mg can only be excreted by kidneys)
(strong laxative, used when other's don't work)
Lactulose ( cephula)
Actions: Prevents absorption of ammonia in the colon by acidifying the stool; increases water, softens stool. Produces a soft stool in 1-3 days.
used mostly for sclerosis pt's
Mary is constipated, she should be experiencing her menstrual period tomorrow , and is complaining of abdominal cramps. She requests a laxative for her constipation. Would you suggest lactulose ?`
no, causes severe cramping.
What are enemas?
Invasive method to evacuate feces
Usually administered after nutritional and/or laxative therapy failed
Commercially prepared low volume hypertonic solutions (fleet enema)
Cleansing enemas (prepared on the unit, up to 1000ml liquid, causes distension and stimulates defecation)
Position for enemas?
left-lateral and knee-chest
Where does this fit in orem?
Examples of Nursing Directives for USCR Elimination GI System (TNP)?
Asses for bowel movements every day
Provide diet high on fiber and fluids
Walk every day length of hallway twice
Administer laxative as per order.
Give enema if no bowel movement for 3 days/ or follow the protocol of the hospital
Effects on the Metabolic System?
Decreased BMR (slows down peristalsis, difference in food metabolism)(Biology, Nutrition)
Negative nitrogen balance (increased catabolism) -> malnutrition (Biology, Nutrition) loss of muscle mass
Anorexia (decreased BMR)
Negative calcium balance (greater calcium is extracted from bones than can be replaced) (Fiona osteporosis, Biology)
Delayed wound healing (protein intake is reduced)
Assessments/Interventions: Metabolic System?
Check height, weight and skinfold thickness (evaluate muscle atrophy)
Provide HIGH protein, HIGH calorie diet, fluids (ensure)
Monitor Lab values (serum protein, albumin and BUN)
Where does it fit in Orem?
disturbance in appetite
altered protein metabolism
altered digestion and utilization of nutrients
↑ risk of electrolyte imbalance
Examples of Nursing Directives for USCR Nutrition and Fluids (TNP)?
Ensure adequate calorie intake, do a calorie count
Weigh patient every Monday and
Thursday before breakfast
Check lab values every Tuesday, if
Albumin < xyz advise MD
Effects on the Integumentary System?
Reduced skin turgor (atrophy of skin)
Skin breakdown , leading to pressure ulcers
Risk factors for pressure ulcers?
Intrinsic contributing factors include ( BCF) :
Nutritional deficiencies, anemia
Immobility , contractures
Elevated body temperature
Prolonged use of steroids
Low diastolic BP ( < 60 mmHg)
External contributing factors include:
Initially, STAGE 1 ulcer?
eddened area on the skin that, when pressed, does not turn white.
Progression: Stage 2 ulcer?
skin blisters or forms an open sore. top layer of skin is removed
Progression, Stage 3 ulcer?
open, sunken hole called a crater. There is damage to the tissue below the skin
Progression, Stage 4 ulcer?
damage to the muscle and bone, and sometimes to tendons and joints
Unstageable , deeper than Stage 4, but how deep ?
The base of the ulcer is covered by slough( yellow, tan, grey, green, brown) or eschar ( tan, brown or black) OR BOTH in the wound bed.
Requires debridement to determine it’s depth.
Treatment of Pressure Ulcers?
Occulsive dressing does not allow oxygen to diffuse from the atmosphere to the wound bed.
Occlusion does not interfer with wound healing and supports debridement. Used for wounds with slight drainage.
provision of a barrier to micro-organisms
helping with pain management.
Assessments/Interventions: Integumentary System?
Assess for skin breakdown
Turn & Position Q 2 hours
Evaluate risk of breakdown using (Braden Scale)
Skin Care Q shift
Assess the risk of developing a pressure ulcers (decubitus ulcers or bedsores)
In acute care , reassess the patient every 24 hours
In LTC, reassess a resident weekly for the first 4 weeks , then monthly.
In home care , reassess the patient at each nurse visit
↑ risk of skin breakdown and formation of pressure sores
Examples of Nursing Directives for USCR Safety (TNP) ?
Turn & Position Q2hours
Skin care every shift and PRN
Inspect skin every shift
Braden scale Q Monday
Treat coccyx ulcer as per wound care #xyz
Ensure high protein diet
Prevent shear when moving patient
Increase fluid intake to 2 liter a day
Impaired skin integrity related to pressure and inadequate circulation as evidenced by pressure ulcer.
Nursing interventions and rationales:
Use Braden scale to assist in the formation of a care plan to reduce factors that can contribute to the development or progression of pressure ulcer.
Document wound stage and characteristics on a regular basis to provide baseline and ongoing data for monitoring pressure ulcer.
Effects on the Psycho-neurological System ?
Decreased endorphins (lack of exercise)
Decreased self esteem (increased dependence on others)
Assessments/Interventions: Psychoneurological System?
Evaluate for confusion, feelings of boredom and isolation, depression
Maintain sleep cycle
Prevent social isolation
Encourage client to perform ADLs
Reorient patient prn
↑ sense of powerlessness
USCR SOLITUDE & SOCIAL INTERACTION?
↓ social interaction
↓ sensory stimulation
↑ risk of depression
Examples of Nursing Directives for USCR’s Normalcy, Solitude & Social Interaction (TNP)?
Asses for confusion every shift
Encourage family visits
Accompany patient every Monday, Wednesday & Thursday to exercise group
To wash face and upper body every morning
To eat in dinning room with other patients