Flashcards in Immobility Lecture Quiz Deck (28):
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.
What two Meds are given to break up clots?
What three meds prevent the formation of clots?
Activase or Retivase
Heparin, Lovenox, and Coumadin
What would you assess for a suspected blood clot related to immobility ?
Doppler Studies are used to evaluate __________.
Deep Vein Thrombosis
Immobility leads to swelling in what three common locations?
How long does it take a pressure ulcer to form ______?
What are 4 common locations of pressure ulcers?
Elbows, Buttocks, Heels, and Knees
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.
Clots can cause what 3 localized symptoms?
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.
How would you assess a patient for urinary complications related to immobility?
Intake and Output
Assess frequency of urination
What interventions would you implement to prevent your patient from having urinary complications related to immobility?
Create Toileting Schedule
What are 5 high risk immobility related psychological issues?
High Risk for:
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.
Name 1 intervention and 1 referral you would recommend for a patient with psychological problems related to immobility and why?
Encourage participation in care activities to promote independence.
PT/OT to encourage and promote independence.
What three factors should nurses always consider that can lead to pressure ulcers?
How often should the patient be
repositioned to prevent pressure ulcers?
Wrinkles in Sheets
After surgery patients remain on blood thinners in bed until when?
The blood is fully anti-coagulated.
Name 4 nursing interventions to prevent Deep Vein Thrombosis? Which would you do first?
1. Sequential Compression Devices (usually done immediately following post-op)
3. Passive Range of Motion Exercises
4. Compression Stockings
You put SCDs on before Compression Stockings because they are difficult to remove.
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
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)
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.
What test can tell If your patient is burning muscle protein?
Checks for protein levels in urine which shows you are burning muscle instead of fat.
Immobility can cause skin breakdown.
What are the 2 main related factors of this type of skin breakdown?
Name 6 common locations for skin breakdown?
Back of the Head.
How would you prevent skin breakdown related to immobility?
Turn patient Q2Hours
What are two other factors that contribute to pressure ulcer formation?
Decreased nutrition status
Increased pressure results in ischemia
Patients that are immobile are at a high risk for what urinary complications?
High Risk for UTIs, Kidney Stones and Kidney Failure.
______ can cause Emboli
Emboli go to the lungs causing
Emboli can also cause __________.