Immobility - Ch 28 Study Guide PDF

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A summary of chapter 28 (immobility) with screenshots and additional notes to include definitions of conditions mentioned in the chapter....

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Immobility – Chapter 28 Definitions – Nature of Movement 1. 2. 3. 4. 5. 6.

Movement – Coordination b/w the musculoskeletal and nervous system Mobility – Used to show self-defense, perform ADLs, and do recreational activities Body Mechanics – Describes the coordinated efforts of the musculoskeletal and skeletal system Body alignment – The individual’s center of gravity is stable Balance – Required to maintain a static position Friction – Force the occurs in a direction to oppose movement

Terms – Physiology and regulation of movement 321; 226 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

Long bones – Contribute to length and height Short bones – Occur in clusters (carpal bones of the foot) Flat bones – Provide structural contour (skull) Irregular bones – Make up the vertebral column and some bones of the skull Pathological fractures – Caused by weakened bone tissue Joint – Connection between bones Synostotic joint – Bones jointed by bones with no movement Cartilaginous joint – Unites bony components, allowing bone growth and stability Fibrous joint – Joint in which a ligament unites two bony surfaces (paired bones of the the lower leg) Synovial joint – Freely moveable joint, ball and socket joints Ligaments – Fibrous tissue that connect bones and cartilage Tendons – white, glistening, fibrous bands of tissue that connect muscle to bone and are strong, flexible, and inelastic. Cartilage – Nonvascular (without blood vessels) supporting connective tissue located chiefly in the joints and thorax, trachea, larynx, nose, and ear Concentric tension – Increased muscle contraction causes muscle shortening resulting in movement Eccentric tension – Helps control the speed and direction of movement Isotonic contraction – Active movement between concentric and eccentric muscle actions Isometric contraction – Causes an increase in muscle tension or muscle work but no shortening or active movement Leverage – Inducing or compelling force Posture – Position of the body in relation to the surrounding space Muscle tone – Normal state of balance muscle tension

27. Pathological abnormalities that influence mobility

a) Torticollis – Inclining of head to affected side; sternocleidomastoid muscle is contracted

b) Lordosis – exaggeration of anterior convex curve of lumbar spine

c) Kyphosis – increased convexity in curvature of thoracic spine

d) Scoliosis – lateral “S” or “I” shaped spinal column with vertebral rotation

e) Congenital hip dysplasia – hip instability with limited abduction of hips

f) g) h) i) j)

Knock knee – legs curved inward so the knees come together as the person walks Bowlegs – one or both legs bent outward at the knee; which is normal until 2 or 3 years old Clubfoot – 95% medial deviation and plantar flexion of foot Footdrop – inability to dorsiflex and invert foot because of peroneal nerve damage Pigeon toes – internal rotation of forefoot or entire foot; common in infants

28. Damage to a component of the CNS that regulates voluntary movement results in: Impaired body alignment, balance, and mobility 29. Direct trauma to the musculoskeletal system results in: Bruises, contusions, sprains, fractures a. A contusion happens when an injured capillary or blood vessel leaks blood into the surrounding area. Contusions are a type of hematoma, which refers to any collection of blood outside of a blood vessel. While the term contusion might sound serious, it’s just a medical term for the common bruise. Nursing Knowledge Database 30. Mobility – The ability to move about freely 31. Immobility – The inability to move freely 32. Complications of immobility in relation to metabolic functioning of the body a. Decreases the metabolic rate and alters endocrine metabolism (The endocrine system, composed of hormone-secreting glands, maintains and regulates vital functions such as (1) response to stress and injury; (2) growth and development; (3) reproduction; (4) maintenance of the internal environment; and (5) energy production, use, and storage. b. Alters the metabolism of CHO (carbohydrates), fats, and proteins c. Causes fluid, electrolyte, and calcium imbalances i. Edema - Swelling due to fluid buildup in the tissues d. Causes GI disturbances (slow down) 33. Respiratory changes that occur with immobility a. Atelectasis – Collapse of alveoli; producing hypoventilation b. Hydrostatic pneumonia – Inflammation of the lung from stasis or pooling of secretions. i. Mm Hg = millimeters of mercury, used to measure pressure 34. Cardiovascular changes that occur with immobility

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a. Orthostatic hypotension – It’s a drop of blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure and symptoms of dizziness, light-headedness, nausea, tachycardia (abnormally fast heart rate over 100 bpm; typically increase in heart rate of at least 15%), pallor (paleness), or fainting when the patient changes from the supine (lying flat) to standing position. b. Thrombus – Accumulation of platelets, fibrin, clotting factors (Big Ole Clot) Complications of immobility in relation to the musculoskeletal system: a. Loss of endurance, strength, and muscle mass (atrophies) and decreased stability and balance b. Impaired calcium metabolism c. Impaired joint mobility d. Osteoporosis – decrease in bone density which increases risks of bone break e. Joint contractures – Contracture is the shortening of the connective tissue and is an abnormal and possibly permanent condition characterized by decreased range of joint motion and/or fixation of the joint. f. Footdrop Complications of immobility in relation to the urinary system: a. Urinary stasis (renal pelvis fills before urine enters the ureters; aka urinary retention) b. Renal calculi (calcium stones that lodge in the renal pelvis; aka kidney stones) Complication of immobility in relation to the integumentary system: Pressure ulcers Psychosocial effects that occur with immobilization: a. Emotional and behavioral isolation b. Sensory alterations c. Changes in coping

Nursing Process 39. Four (4) major areas of assessment a. Range of motion – The maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, transverse b. If appropriate, assess patient’s ROM as active (unassisted movement of all joints), passive (assisted) or somewhere in between

c. Gait – Particular manner or style of walking d. Exercise and activity tolerance – Physical activity or conditioning i. When a patient begins to walk, monitor for signs of dyspnea (sensation of difficult or uncomfortable breathing), fatigue, or chest pain e. Body alignment - Identifies deviations, learning needs, trauma, risk factors

Orthopnea – sensation of shortness of breath when lying down relieved by sitting up or leaning forward (subjective)

Nursing Diagnosis 40. Potential nursing diagnoses related to an immobilized or partially immobilized patient a. Impaired physical mobility (some limitation but not completely immobile) b. Risk for Disuse syndrome (completely immobile and at risk of multisymptomatic problems because of lack of activity) c. Ineffective airway clearance d. Ineffective coping e. Risk for injury f. Impaired skin integrity g. Insomnia h. Social isolation Planning 41. Expected outcomes for the goal “patient skin remains intact” a. Skin color and temp. return to normal baseline within 20 minutes of position change Implementation 42. Identify examples of health promotion activities that address mobility and immobility: a. Prevention of work-related injury b. Fall prevention measures c. Exercise d. Early detection of scoliosis 43. Nursing interventions that will reduce the impact of immobility on the following body systems a. Metabolic system i. A high protein high calorie diet (tissue repair) ii. Vitamin B and C supplements (assists in energy metabolism and skin integrity/wound healing, respectively)

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iii. Assessment: Monitor labs (electrolytes, serum protein (albumin and total protein), and blood urea nitrogen (BUN)). Respiratory system i. Deep breath and cough every 1 to 2 hours ii. Incentive spirometer 1. Conduct respiratory assessment on patient at least every 2 hours 2. Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes. Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions. iii. CPT (Chest Physiotherapy) – preventing pneumonia; helps the patient drain secretions from specific segments of the bronchi and lungs into the trachea so he or she can cough and expel them. iv. Ensure intake of 1100-1400 mL/day of fluid; helps keep mucociliary clearance normal Cardiovascular system i. Reduce orthostatic hypotension through early mobilization ii. Reduce cardiac workload; avoid Valsalva movements 1. Valsalva movement - a patient holds his or her breath and strains, which increases intrathoracic pressure and in turn decreases venous return and cardiac output. When the strain is released, venous return and cardiac output immediately increase, and systolic blood pressure and pulse pressure rise. These pressure changes produce a reflex bradycardia and possible decrease in blood pressure that can result in sudden cardiac death in patients with heart disease. Teach patients to breathe out while defecating, lifting, or moving side-to-side or up in bed and to not hold their breath and strain. iii. Prevent thrombus formation through prophylaxis (heparin, SCDs, and TEDs) 1. Remove SCDs every 8 hours (or in accordance with agency policy) to assess for DVT. A typical cycle is inflation for 10 to 15 seconds and deflation for 45 to 60 seconds. Inflation pressures average 40 mm Hg. Use of SCD on the legs decreases venous stasis by increasing venous return through the deep veins of the legs. 2. A dislodged thrombus (embolus) can travel through the circulatory system to the lungs (can be life threatening). Musculoskeletal system i. Perform active and passive ROM exercises 1. Head to toe sequence; cupped hand to support movement; repeat 5x ii. CPM (continuous passive motion) machines – moves an extremity to a prescribed angle for a prescribed period. Integumentary system i. Positioning and skin care to prevent pressure ulcers (skin assessment can occur every hour) ii. Use of therapeutic devices to relieve pressure Elimination system

i. Keeping well hydrated ii. Prevent urinary stasis and calculi and infections iii. Monitoring food intake and elimination patterns and assessing wound healing help to determine altered gastrointestinal functioning and potential metabolic problems g. Psychosocial system i. Anticipate change in the patient’s status and provide routine and informal socialization

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44. Explain the use for:

1 Third heart sound at apex is indicative of early congestive heart failure.

a. Trochanter roll – Prevents external rotation of the hips when in the supine position

b. Hand rolls – Maintain the thumb in slight adduction and in opposition to the fingers c. Trapeze bar – Allows the patient to pull with the upper extremities to raise the trunk off the bed, assist in transfer, or to perform exercises 45. Describe the following positions: a. Fowler – HOB (head of bed) elevated 45 to 60 degrees and the knees are slightly elevated b. Supine – Lying on the back c. Prone – Lies face or chest down d. Side-lying – The patient rests on the side with body weight on the dependent hip or shoulder; 30 degree lateral incline recommended for those at risk for pressure ulcers e. Sims – Patient places the weight on the anterior ileum humerus and clavicle

46. Instrumental activities of daily living (IADL) are: Activities beyond ADLs that are necessary to be independent in society 47. How would you assist patients with hemiplegia (right or left side side paralysis) or hemiparesis (right or left side weakness)? a. Always stand on the patient’s affected side and support the patient using a gait belt i. If the patient faints or begins to fall, assume a wide base of support with one foot in front of the other, thus supporting the body weight. Then gently lower the patient to the floor, protecting the head. See page 430-439 for diagrams...