Immobility

Question 1

Causes of immobility

Answer 1

• Bedrest
• Physical restriction/ limitation of movement—casts, traction
• Damage to the CNS
• Direct trauma to the MS system

Question 2

Hazards of immobility

Answer 2

• Psychological: Can make you sad not moving
• Nutrition/metabolic: not digest food as well
• Respiratory: lungs can’t expand as well
• Cardiovascular: heart is working overtime to get blood to body
• Musculoskeletal: lose endurance
• Urinary tract: sits still, can lead to bladder/kidney infxns
• Skin: pressure injuries

Question 3

Assessment: physical exam neuro

Answer 3

• Orientation
  • Person, time, place, situation (why are they here)
• month, year, what season we’re in
• Level of Consciousness (LOC)
  • Alert: awake but can still be confused
  • Lethargic (Somnolent): extreme drowsiness
  • Stupor (Semicomatose): responds unpurposefully to painful stimuli
  • Coma: unresponsive

Question 4

Glasgow coma scale

Answer 4

• Normal 15
• Patient in coma scores 7 or less
• Eye opening: spontaneously (4), to speech (3), to pain (2), none (1)
• verbal response: oriented (5), confused (4), inappropriate (3), incomprehensible (2), none (1)
• motor response: obeys commands (6), localizes to pain (5), withdraws from pain (4), flexion to pain (3), extension to pain (2), none(1)

Question 5

Pressure injuries: stages of injuries

Answer 5

• Stage 1: Reddening of skin which does not disappear when pressure relieved
• Stage 2: Superficial circulatory & tissue damage. May appear as blister.
• Stage 3: Destruction of subcutaneous layers
• Stage 4: Destruction of subcutaneous capillaries, muscle mass & possibly bone —> poor blood flow. Can show muscles, tendons, sometimes bone

Question 6

What does the Braden Scale evaluate?

Answer 6

A. Skin integrity at bony prominences, including any wounds
B. Risk factors that place the patient at risk for skin breakdown (18 or below) (CORRECT)
C. The amount of repositioning that the patient can tolerate
D. The factors that place the patient at risk for poor healing

Question 7

The effects of immobility on the cardiac system include which of the following? (Select all that apply.)

Answer 7

A. Thrombus formation: heart isn’t able to adequately pump the blood thru. Blood may slow down. Form a clot in the leg (CORRECT)
B. Increased cardiac workload (CORRECT)
C. Increased apical pulse (CORRECT) (heart is working harder)
D. Increased capillary refill
E. Orthostatic hypotension (CORRECT)

Question 8

The nurse is performing an assessment of an immobilized client. Which of the following causes them to take action?

Answer 8

A. Heart rate 88
B. Reddened area on sacrum (CORRECT)
C. Nonproductive cough
D. Voiding clear yellow urine

Question 9

Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?

Answer 9

A. Isometric exercises
B. Administration of low-dose heparin
C. Suctioning every 4 hours (excessive)
D. Use of incentive spirometer every 1-2 hours while awake (CORRECT)

Question 10

ASSESSMENT: PHYSICAL EXAM CARDIOVASCULAR & RESPIRATORY

Answer 10

• Heart & Lung Sounds: is heart beating? Do lungs sound clear to auscultation?
• Activity Tolerance
• Orthostatic Hypotension (BP DROPS)
• Signs of Thrombophlebitis (clotting of vein/inflammation of vein)
  • Redness, Tenderness, Swelling
• result of immobility

Question 11

ASSESSMENT: PHYSICAL EXAM GI/GU SYSTEMS

Answer 11

• Abdominal distention/ bowel sounds
• Urinary output
• Bowel movement regularity
• Bowel and bladder continence
• can make you constipated if u aren’t moving

Question 12

ASSESSMENT: PHYSICAL EXAM SKIN INTEGRITY

Answer 12

• Bruises, cuts, scratches, scars —> could be from bones being in one place for so long
• Condition of skin
  
  • Risk factors—sensory/perception, moisture, activity, mobility, nutrition, friction/shear

Question 13

sites for pressure ulcer development

Answer 13

• pts need to be up and moving
• if they can’t move, we need to be turning these pts every 2 hours, putting pillows under them, putting protective pads @ areas that are at risk

Question 14

braden scale

Answer 14

• score 18 or below = risk for skin breakdown
• Sensory Perception: Completely limited(1), Very limited(2), Slightly limited(3), No impairment(4)
• Moisture: Constantly moist (1), Very moist (2), Occasionally moist (3), Rarely moist (4)
• Activity: Bedfast (1), Chairfast (2), Walks occasionally (3), Walks frequently (4)
• Mobility: Completely immobile (1), Very limited (2)
  Slightly limited (3), No limitations (4)
• Nutrition: Very poor (1), Probably inadequate (2),
  Adequate (3), Excellent (4)
• Friction & sheer: Problem (1), Potential problem (2), No apparent problem (3)

Question 15

ASSESSMENT: PHYSICAL EXAM MOBILITY

Answer 15

• ROM, Muscle Strength –> see if they can move their arms and legs around
• Coordination
• Ability to Perform ADL –> can they use a wash cloth, can they wash their face, can they put their clothes on, etc
• Assistive Devices Needed –> do they need a walker, a cane
• Get Up & Go Test –> how long does it take them to complete it (7-10 sec)

Question 16

timed get up and go test

Answer 16

• begin timing
• rise from standard arm chair
• walk to line on floor (approximately 10 ft away from chair)
• turn and return to chair
• sit in chair again
• end timing

Question 17

impaired mobility

Answer 17

• Difficulty or inability to facilitate movement

Question 18

• Risk for impaired skin integrity

Answer 18

• Increased chance of injury of damage to the skin
• if you have the risk, we’re going to put in place interventions to help prevent the skin damage from happening

Question 19

impaired tissue integrity

Answer 19

• Damage to mucous membranes, corneal integumentary or subcutaneous tissues
• there is skin breakdown

Question 20

nursing intervention categories

Answer 20

• Pressure management
• Wound care

Question 21

maintain existing fxn (musculoskeletal)

Answer 21

• Provide sufficient stimuli –> get them up and move them around
• Ensure use of assistive devices
• Maximize residual function

Question 22

maintain limb mobility and prevent contractures

Answer 22

• Work with OT/PT
• ROM
• Proper alignment
• Exercises
  
  • Gluteal setting
  • Quadriceps setting

Question 23

Promote Optimal Respiratory Functioning (Respiratory)

Answer 23

• TCDB q 2 hours –> turn, cough, deep breaths, helps get secretions moving around
• Incentive spirometer q 1-2 hours –> inhale and this helps open the lungs
• Force fluids (2000ml-3000ml) –> helps thin out any secretions
• Chest PT/ suctioning PRN –> only do when it is necessary

Question 24

Improve Venous Blood Flow (Cardiovascular)

Answer 24

• Leg exercises, ROM exercises
• Change position q 2h
• NEVER massage legs –> if someone has a clot, you could dislodge it and it could move around the body
• Sequential compression stockings
• Anti-emboli ted hose
• Administer anticoagulants when ordered
  
  • Lovenox

Question 25

antiemboli stockings

Answer 25

- help push that blood up from the legs and help keep their blood from pooling in the lower extremities

Question 26

foot drop contracture

Answer 26

- complication of immobility

Question 27

prevent urinary stasis (GU)

Answer 27

* 2000-3000 ml/ day * Monitor I&O

Question 28

prevent constipation (GI)

Answer 28

* 2000-3000 ml/ day * Dietary fiber

Question 29

Reduce monotony/ Provide opportunities for control

Answer 29

- asking what types of fluids they want to drink, what foods they want to eat

Question 30

maintain skin integrity

Answer 30

* Any sustained pressure >32 mm Hg can lead to skin breakdown * Assess skin at least 2x/day * Reduce shearing/friction * Keep skin clean & dry * NEVER massage reddened areas * Keep heels off of bed * Maintain/ improve nutritional status * Maintain proper positioning/ alignment

Question 31

elevate heel

Answer 31

- relieve pressure off the heels

Question 32

30 ° LATERAL POSITION

Answer 32

- prevents skin breakdown - look at pic on slide -- pg 28 immobility preclass

Question 33

maintain skin integrity (cont)

Answer 33

* Use specialized beds PRN * Gel pads for those confined to wheelchairs * Post stroke * Spinal Cord Injured * NEVER use donut shaped pads

Question 34

what cushions should you never use?

Answer 34

DONUT SHAPED

Question 35

evaluation

Answer 35

- ensure the pt has good functioning of all body parts - respiratory

Question 36

low airloss bed

Answer 36

- lets air out - helps prevent pressure ulcers