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Chapter 34 Potter
Immobility
| Question | Answer |
|---|---|
| inability to move around freely | immobility |
| Factors that contribute to the extent of a patient's immobility include: | length & severity of illness, emotional status, & physical condition |
| ________________ is used therapeutically to limit movement as in the application of a cast. | immobilization |
| ________________ occurs when a patient is unable to move independently or is restricted for therapeutic reasons. | immobility |
| ________________ results from pain, cognitive, or neurological changes and also form emotional changes such as depression. | immobility |
| No ________________ is immune to the hazardous effects of immobility. | body system |
| Despite a patient's age, impairment as a result of ________________ affects the respiratory system, metabolism, fluid and electrolyte balance, gastrointestinal tract, cardiovascular system, musculoskeletal system, integument, and urinary elimination. | immobility |
| Decreased lung expansion, generalized respiratory muscle weakness, and stasis of secretions often contribute to the ________________ and hypostatic pneumonia. | atelectasis |
| collapse of alveoli | atelectasis |
| inflammation of the lung from stasis or pooling of secretions | hypostatic pneumonia |
| Decreased lung expansion, generalized respiratory muscle weakness, and stasis of secretions often contribute to the atelectasis and ________________. | hypostatic pneumonia |
| With decreased lung expansion and weakened respiratory muscles, ________________ in the dependent lung regions. | secretions stagnate or pool |
| In ________________, secretions block a bronchiole or a bronchus and the distal lung tissue (alveoli) collapses. | atelectasis |
| ________________ reduce the patient's ability to cough due to generalized muscle weakness. | respiratory changes |
| With respiratory changes, ________________, particularly when the patient lies supine (flat position), providing ans excellent medium for bacterial growth. | mucus accumulates |
| A patient's ________________ decreases in response to reduced cellular energy and oxygen demands. | basal metabolic rate (BMR) |
| In the presence of an infection, immobilized patients have ________________ as a result of fever or wound healing. | an increased |
| Fever and wound repair ________________ cellular oxygen requirements. | increase |
| Prolonged bed rest ________________ the body's ability to produce insulin and metabolize glucose. | decrease |
| When the body is unable to metabolized glucose, it begins to break down ________________ for energy. | protein stores |
| ________________ is the end product of protein metabolism. | nitrogen |
| ________________ provides a reliable indicator of protein use by the body. | nitrogen balance |
| A ________________ exists when the excretion of nitrogen from the breakdown of protein exceeds intake. | negative nitrogen balance |
| A ________________ predisposes your patient to problems with wound healing and normal tissue growth. | negative nitrogen balance |
| ________________ causes a loss of lean body mass and an increased percentage of body fat. | immobility |
| increased urine excretion | diuresis |
| ________________ occurs as a result of increased blood flow ti the kidneys and expanded circulating blood volume. | diuresis |
| Diuresis causes the body to lose ________________ such as potassium and sodium. | electrolytes |
| ________________ affects serum calcium levels. | diuresis |
| Immobility ________________ calcium resorption (loss) from bones, causing a release of excess calcium into circulation. | increases |
| excess calcium | hypercalcemia |
| The immobile patient is at risk for ________________ from lack of activity and from hypercalcemia, which depresses peristalsis. | constipation |
| ________________ occurs in patients on bed rest and after prolonged sitting. | orthostatic hypotension |
| ________________ is a drop of 20 mm Hg or more in systolic blood pressure or a decrease in diastolic blood pressure of more than 10 mm Hg when the patient rises from a lying or sitting position to a standing position. | orthostatic hypotension |
| In the ________________ decreased circulating fluid volume, pooling of blood in the lower extremities, and decreased autonomic response occur. | immobilized patient |
| Decreased circulating fluid volume, pooling of blood in the lower extremities, & decreased autonomic response result in decreased venous return, decreased central venous pressure & stroke volume, & a drop in systolic blood pressure when ________________. | patient stands |
| Prolonged bed rest increases the ________________, producing a need for more oxygen. | heart's workload |
| ________________ increases the resting heart rate 4 to 15 beats per minute. | bed rest |
| ________________ are at risk of r deep venous thrombosis (DVT). | immobile patients |
| A ________________ is an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall or a vein or artery, sometimes occluding the lumen of the vessel. | thrombus |
| Three factors contribute to venous thrombus formation: (1) loss of integrity of the vessel wall, (2) abnormalities of blood flow, & (3) alterations in blood constituents. | Virchow's triad |
| 2 additional problems predispose immobile patient to ________________: (1) wt. of legs on bed compresses blood vessels of calves, causing stasis & injury to vessel linings. | DVTs |
| 2 additional problems predispose immobile patient to ________________: (2) skeletal muscles in legs lose pumping action, leading to stasis & less blood returning to heart. | DVTs |
| DVT = | ineffective tissue perfusion |
| Assessment of the patient's ________________ focuses on range of motion, muscle strength, activity tolerance, gait, and posture. | mobility |
| Perform a ________________ at least every 2 hours for acutely ill patients with restricted activity. | respiratory assessment |
| If a patient has ________________ area, breath sounds will be asymmetrical. | an atelectatic |
| When assessing the patient's metabolic functioning, us ________________ (body measures of height, weight, and skinfolds) to evaluate muscle atrophy. | anthropometric measurements |
| ________________ of the immobilized patient includes monitoring blood pressure, apical and peripheral pulses, and observing the venous system. | cardiovascular assessment |
| ________________ increases the cardiac workload and results in an increased pulse rate. | recumbency |
| ________________ indicates the heart's inability to handle the increased workload. | edema |
| Because fluid moves to dependent body regions, assessment of the ________________ includes the sacrum, legs, feet, and hips. | immobilized patient |
| If the heart is unable to tolerate the ________________, the peripheral body regions such as the hands, feet, nose, an earlobes will be colder than the central body regions. | increased cardiac workload |
| Assess the ________________ for DVT. | venous system |
| To assess for ________________, remove the patient's antiembolic stockings or sequential compression stockings once every 8 hours and observe the calves and thighs for unilateral leg swelling, redness, warmth, and tenderness. | DVT |
| Use of the ________________ assesses a patient's risk for pressure ulcer formation. | Braden Scale |
| Assess the patient's ________________ on each shift, and asses the total intake and output every 24 hours. | elimination status |
| Changes in psychosocial status usually occur ________________. | slowly |
| Psychosocial condition: Observe for changes in ________________ (e.g., depression) and ________________ (e.g., cooperative patients who become argumentative or modest patients who begin to expose themselves repeatedly). | emotional status; behavioral changes |
| Continual ________________ with family members is vital because they will identify an report changes in personality that you may not recognize. | communication |
| You need to identify and correct any changes in the patient's ________________, such as difficulty falling asleep or frequent awakenings. | sleep-wake cycle |
| Decreasing ________________ causes the patient to become disoriented, confuse, or depressed. | coping ability |
| Developmental ________________ of older adults enables you to determine the patient's ability to meet needs independently. | assessment |
| A ________________ who does too much or too little in an attempt to help the patient will seriously impede the patient's progress. | family |
| You will contribute to promoting health for many types of patients by encouraging or starting ________________. | managed exercise programs |
| Encourage ________________ to do stretching, ROJM, and light walking, depending on their physical capabilities. | hospitalized patients |
| Measure ________________ walked in feet and yards instead of "walked to the nurse's station and back to room." | distances |
| Make sure the immobile patient has a fluid intake of at least ________________ per day, if not contraindicated, to help keep mucociliary clearance intact. | 2000 mL |
| ________________ are necessary to meet energy requirements. | carbohydrates |
| ________________ are necessary for tissue repair. | proteins |
| ________________ prevent further breakdown of nutritional stores. | fats |
| Perform a gradual, extended ________________ (e.g., 15 minutes) to maximize flexibility and decrease muscle injury. | exercise warm-up |
| Perform ________________ until heart rate returns to resting level to decrease postural hypotension and cardiac dysrhythmias. | cool-down |
| Monitor ________________ before, during, and after exercise when assisting patients. | vital signs |
| ________________, those activities that involve muscle tension w/o muscle shortening, do not have any beneficial effect on preventing orthostatic hypotension but improve activity tolerance. | isometric exercises |
| Necessary steps in transferring a patient from supine position to sitting position: (1) First obtain a ________________ and pulse with the patient in the supine position. | baseline blood pressure |
| Necessary steps in transferring a patient from supine position to sitting position: (2) Raise the patient to a high ________________, and measure blood pressure and pulse again to detect decreases in blood pressure or elevations in pulse. | high-Fowler's position |
| Necessary steps in transferring a patient from supine position to sitting position: (3) Leave the patient in high-Fowler's position for ________________ to allow the body to adapt. | 2 minutes |
| Preventing thrombus formation: Teach ________________ to avoid crossing the legs, sitting for prolonged periods of time, wearing tight clothing that constricts the legs or waist, putting pillows under the knees, and massaging the legs. | patients |
| The immobilized patient needs to ________________ to prevent excessive muscle atrophy, decreased endurance, and joint contractures. | exercise |
| The amount of activity required to prevent physical disuse syndromes is only about ________________ in a 24-hour period, and you schedule this regularly throughout the day based on individual patient needs. | 2 hours |
| The best method to prevent complications from impaired mobility is to ________________. | encourage ambulation |
| Although turning every ________________ is recommended for preventing ulcers, it is sometimes necessary to use devices for relieving pressure. | 1 to 2 hours |
| Teach patients who are able to move to shift their weight every ________________. | 15 minutes |
| Encourage ________________ to wear their glasses or dentures and to shave or apply makeup. | patients |
| Make sure ________________ are within easy reach so the patient can attend to personal needs. | hygiene and grooming articles |
| Encourage the patient to cough and deep breathe every ________________ while awake. | 1 to 2 hours |
| Postoperative patients who have undergone ________________ need to cough and deep breathe to prevent atelectasis and stasis of secretions. | anesthesia |
| Encouraging early ________________ helps prevent multiple pulmonary complications. | ambulation |
| Direct ________________ at reducing cardiac workload. | nursing interventions |
| Make sure to apply elastic stockings properly and remove and reapply them at least every ________________. | 8 hours |
| Always observe the status of ________________ to the extremities and check to be sure stockings are properly fitted. | circulation |
| Immobilized patients are frequently on prophylactic (preventative) low-dose heparin therapy to minimize the risk of ________________. | venous thromboembolism |
| Newer ________________ heparins such as ardeparin and enoxaparin are being prescribed in place of older forms of unfractionated heparin. | low-molecular-weight (LMW) |
| When you suspect ________________, do not massage the area. | DVT |
| When you suspect DVT, report your assessment findings to the ________________ immediately. | physician or health care provider |
| If a patient complains of shortness of breath or severe chest pain, suspect a ________________. | pulmonary embolus |
| Coordinate your nursing care to prevent as many ________________ as possible. | interruptions |
| The goal of ________________ for immobilized patient is to maximize independence, increase endurance, and prevent injury. | restorative and continuing care |
| ________________ focus on instrumental activities of daily living (IADLs) such a s shopping, preparing meals, banking, and taking medications, in addition to ADLs. | restorative interventions |
Created by:
chaptravelman
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