Immobility Lecture Quiz Flashcards Preview

Block One Exam 3 Practice Test > Immobility Lecture Quiz > Flashcards

Flashcards in Immobility Lecture Quiz Deck (28):
0

What are some immobility related respiratory complications for patients that are on bed rest?
What can be the result?

Decreased Lung Capacity leads to
Decreased circulation and oxygenation
Results in ischemia to the body tissues.

1

What two Meds are given to break up clots?
What three meds prevent the formation of clots?

Activase or Retivase

Heparin, Lovenox, and Coumadin

2

What would you assess for a suspected blood clot related to immobility ?

Pulses
Pain Level
B/P
Capillary Refill

3

Doppler Studies are used to evaluate __________.

Deep Vein Thrombosis

4

Immobility leads to swelling in what three common locations?


Hands
Feet
Scrotum (Men)

5

How long does it take a pressure ulcer to form ______?
What are 4 common locations of pressure ulcers?


30 Minutes

Elbows, Buttocks, Heels, and Knees

6

What 3 types of patients are at the highest risk for pressure ulcers and why?

If sitting in a chair the patient needs to be moved how often?

Trauma patient with spinal injuries, paraplegic, and quadriplegic is at the high risk for pressure ulcers because they cannot feel the pain or assess their pain level due to lack of sensation.

Every 20 minutes.

7

Clots can cause what 3 localized symptoms?

pain
swelling
redness

8

How does immobility affect the kidneys and urinary tract?

If patient lays flat gravity cannot work on the ureters and pull urine down into the bladder.

9

How would you assess a patient for urinary complications related to immobility?

Intake and Output
Assess frequency of urination

10

What interventions would you implement to prevent your patient from having urinary complications related to immobility?



Adequate Hydration
Create Toileting Schedule

11

What are 5 high risk immobility related psychological issues?


High Risk for:

Depression
Sadness
Dejection
Helplessness
Hopelessness

12

How would you assess a patient for immobility related psychological issues?

Screen for Depression

Observed mood changes or mood swings

Talk with patient and family members about changes noticed.

13

Name 1 intervention and 1 referral you would recommend for a patient with psychological problems related to immobility and why?

Intervention
Encourage participation in care activities to promote independence.

Referral
PT/OT to encourage and promote independence.

14

What three factors should nurses always consider that can lead to pressure ulcers?

How often should the patient be
repositioned to prevent pressure ulcers?

Sweat
Wrinkles in Sheets
Incontinence

Q2hrs

15

After surgery patients remain on blood thinners in bed until when?

The blood is fully anti-coagulated.

16

Name 4 nursing interventions to prevent Deep Vein Thrombosis? Which would you do first?


1. Sequential Compression Devices (usually done immediately following post-op)
2. Positioning
3. Passive Range of Motion Exercises
4. Compression Stockings



You put SCDs on before Compression Stockings because they are difficult to remove.

17

What happens to a patients muscles who is immobile and placed on bed rest ?

List 3 major complications?


Muscles get weak leading to atrophy.

Decreased muscle strength
Decreased muscle endurance
Decreased muscle volume

18

What are the 3 most common skeletal complications of immobility related to best rest?

How would you describe their effects on the patient?



Contracture (bones won't move)

Foot drop (permanent muscle atrophy in the calf)

Osteoporosis (decreased bone density)

19

How do you assess for musculoskeletal changes caused by immobility ?


1. Symmetry (common in patients that wear a cast)
2. Pain Level of swelling, muscle, skin, and nerve endings (bones don't hurt)
(Muscle contraction from atrophy is painful)
3. Monitor muscle to fat ratio.
Look for increase in body fat. Decrease in muscle.

20

What test can tell If your patient is burning muscle protein?


Urine dip.

Checks for protein levels in urine which shows you are burning muscle instead of fat.

21

Immobility can cause skin breakdown.
What are the 2 main related factors of this type of skin breakdown?

Pressure
Friction

22

Name 6 common locations for skin breakdown?

Sacrum,
Coccyx,
Heels,
Elbows,
Shoulder Blades,
Back of the Head.

23

How would you prevent skin breakdown related to immobility?

Turn patient Q2Hours

24

What are two other factors that contribute to pressure ulcer formation?

Decreased nutrition status
Increased pressure results in ischemia

25

Patients that are immobile are at a high risk for what urinary complications?


High Risk for UTIs, Kidney Stones and Kidney Failure.

26

______ can cause Emboli
Emboli go to the lungs causing
_________ _____________.
Emboli can also cause __________.

DVT

Pulmonary Embolism

Stroke

27

During pressure ulcer formation it is important to remember:
If the tissue is _______ it can be saved.
If the tissue is _______ it is dead.

Red

White