PP2 - IMMOBILITY COMPLICATIONS

Question 1

what are 4 URINARY complications with immobility

Answer 1

urinary calculi
urinary retention
urinary incontinence
urinary tract infections

Question 2

what is urinary calculi

Answer 2

kidney stones associated with precipitation of calcium

Question 3

what is urinary retention

Answer 3

inability to empty the bladder effectively leading to reflux back up urinary tract

Question 4

what nursing interventions can be taken to manage URINARY SYSTEM complications (3)

Answer 4

avoid bed rest immobility
promote activity and weight bearing exercise
pushing fluids

Question 5

what are the 2 pathophysiology of the musculoskeletal system

Answer 5

skeleton
muscles

Question 6

what are 5 complications associated with MUSCULOSKELETAL SYSTEM in immobility

Answer 6

joint stiffness and pain
muscle atrophy
unsteadiness, balance problems
foot drop
contractures
osteoporosis

Question 7

what are contractures

Answer 7

permanent contraction of muscle groups caused by shortening and fibrosis of muscle fibres
leading to loss of function

Question 8

what is osteoporosis

Answer 8

loss of bone tissue and density resulting in brittle bones that are likely to fracture

Question 9

what are 4 nursing interventions for immobility and musculoskeletal system

Answer 9

mobilise
splinting
active and passive exercise
Vitamin D and calcium supplements
exposure to sunlight

Question 10

what are some nervous system complications associated with immobility

Answer 10

low endorphin levels
boredom
loss of independence
weakness
depression, anxiety
isolation

Question 11

what are some nursing interventions for the nervous system in immobilisation

Answer 11

person centred care
active listening
family visit

Question 12

what can occur to the gastrointestinal tract with immobilisation

Answer 12

peristalsis impaired
poor digestion
constipation disturbed bowel regimes
faecal impaction

Question 13

define faecal impaction

Answer 13

accumulation of hardened faeces in rectum and sigmoid colon that cannot be expelled

resulting in overflow diarrhoea and faecal incontinence

Question 14

what are some nursing interventions for the gastrointestinal system to aid immobility complications

Answer 14

removal of hard faeces
cleansing enemas
high fibre diet
hydration
exercise
medications for constipation

Question 15

what complications are associated with the integumentary system in immobility

Answer 15

pressure injury
infections
poor perfusion

Question 16

what nursing actions can be administered with aiding the integumentary system in immobility

Answer 16

regular skin assessment
continence care
repositioning
hygiene
education

Question 17

what is STANDARD 2 in nursing practise

Answer 17

partnering with consumers based on therapeutic relationships in person centred care

Question 18

what are the 5 components of patient educations

Answer 18

utilising technology
understanding patient learning style
stimulate patient interest
limitations and strengths of patient
include family members

Question 19

what is VTE

Answer 19

venus thromboembolism

Question 20

what are 2 respiratory system complications associated with immobility

Answer 20

1. Atelectasis (collapsed lung)
2. chest infection/pneumonia

Question 21

what is atelectasis

Answer 21

collapsed lung
collapse of airless alveoli

Question 22

what are some signs associated with atelectasis

Answer 22

dyspnoea, cough, fever, decreased oxygen saturations and tachypnoea

Question 23

what is pneumonia and chest infections

Answer 23

pooled secretions causing inflammation
microorganism growth enhanced

Question 24

what are some nursing actions we can take to aid respiratory complications in patients with immobility

Answer 24

mobility
fowlers position (upright)
repositioning every few hours
mouth care
clearing airways
hydration
movement of secretions through exercises

Question 25

what complications are associated with the cardiovascular system in immobility

Answer 25

falls risk increased workload orthotic hypertension venus stasis DVT PE

Question 26

what is venus stasis

Answer 26

pooling of blood and compression of veins in legs between bone and bed

Question 27

what are some nursing interventions for cardiovascular complications associated with immobility

Answer 27

prophylaxis, administer medications and encourage fluid

Question 28

what is venus thromboembolism

Answer 28

blocking of a blood vessel by a blood clot DVT and EV included

Question 29

what is a thrombus

Answer 29

blood clot

Question 30

what is an embolus

Answer 30

blockage of vascular flow (fat, air)

Question 31

what is a phlebitis

Answer 31

inflammation of vein

Question 32

what is thrombophlebitis

Answer 32

inflammation of vein caused by clot

Question 33

what is deep vein thrombosis

Answer 33

blood clot usually forming within the leg veins which slows the flow of blood through a vessel

Question 34

what is a pulmonary embolism

Answer 34

price of a blood clot is broken off and becomes lodged in the lungs , interrupting blood supply

Question 35

how can we prevent VTE

Answer 35

early mobilisation mechanical intervention exercise medications

Question 36

what is mechanical VT prophylaxis

Answer 36

devices that control and increase the blood flow velocity in leg veins and reduces venous stasis

Question 37

what are some mechanical VT prophylaxis examples

Answer 37

graduated compression stockings intermittent pneumatic compression device (IPC - inflatable calf compression) foot impulse device

Question 38

what daily should you monitor mechanical VT prophylaxis

Answer 38

twice daily

Question 39

what is used in pharmacological prophylaxis

Answer 39

anticoagulants

Question 40

what do anticoagulants do

Answer 40

alter process of blood coagulation to prevent VTE

Question 41

what do we need to be aware of with a patient taking anticoagulants

Answer 41

higher bleeding risk monitor signs of bleeding

Question 42

what are 4 factors impacting needle injections

Answer 42

site depth of subcut tissue medication viscosity age

Question 43

what are the 6 would care elements to promote granulation and epithelialisation

Answer 43

cleaning debris and microbes protection from trauma and infection moist and warm environment debridement of NV tissue managing pain and discomfort managing exudate and odour

Question 45

where are the subcut injection sites

Answer 45

back of arm abdomen (umbilical region) things back folds lower loins

Question 46

what are the 5 stages of pressure injury management

Answer 46

1. risk assesssment 2. prevention plan 3. assess 4. treating injury 5. monitor and document