Immobility Nurs 204 PDF

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Lecture notes for immobility chapter 39....

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Immobility Nurs 204 Lecture Notes Scientific Knowledge Base ● Body mechanics ● Implications of impaired mobility ● Balance and alignment ● Gravity and friction The effects of immobility ● Mobility ○ A person’s ability to move about freely ● Immobility ○ Inability to move about freely ● Bed rest ○ Muscles will weaken ○ Disuse atrophy ■ Tendencies of cells and tissues to reduce in size and function ○ Physiological ■ Cardiovascular issues ■ Muscular skeletal issues ○ Psychological ■ Hostility ■ Giddiness ■ Fear ■ Anxiety ■ Altered sleep patterns ■ Coping ● Depression ● Sadness ● Dejection ○ Social ■ Isolation ● Systemic effects ○ Metabolic ■ Metabolism slows down ■ GI function ■ Calcium absorption ○ Respiratory ■ Atelectasis ● Collapse of alveoli ■ Hypostatic pneumonia ● Inflammation of the lungs due to pooling of secretions in the lung

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Cardiovascular ■ Thrombus formation Muscle effects ■ Loss of muscle mass ■ Muscle atrophy Urinary elimination ■ Urinary stasis ■ Renal calculi

Quick Quiz ● You notice a respiratory change in your immobilized postoperative patient. The nurse recognizes which of the following is most likely the result of a respiratory change? ○ Atelectasis Developmental Changes Related to Immobility ● Infants/toddlers/preschoolers ○ Skeletal abnormality ○ Trauma ● Adolescents ○ Related to ■ trauma ■ Illness ■ Surgery ○ Causes social isolation ● Adults ○ All physical systems are put at risk ○ Job loss ○ Can affects self concept ● Older adults ○ Progressive loss of total bone mass ■ Weaker bones ○ Walk slowly ○ Take smaller steps ○ Prescribed medications ■ Balance issues ■ Affect BP ● Sudden position changes ○ Increased risk for falls ad injuries Nursing Process Assessment ● Immobility ● Metabolic system ● Respiratory system ○ Hypostatic pneumonia

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Check lung sounds ● Crackles ● Wheezing ■ Check respirations at least every 2 hours Cardiovascular system ○ Blood pressure ■ At increased risk for orthostatic hypotension ○ Heart rate ○ Cardiac workload ○ A 3rd heart sound at the apex of the heart is a early sign of heart failure Musculoskeletal system ○ Range of motion ■ Maximum amount of movement available at a joint in one of the 3 planes of the body ● 3 planes ○ Sagitt ○ Transverse ■ Horizontal line that divides the body into upper and lower portions ○ Frontal ■ Passes through the body from side to side ■ Divides a body into front and back ● Types of motion ○ Abduction ○ Adduction ○ Rotation ○ Flexion ○ Extension Integumentary system ○ Skin ○ Pressure ulcers ■ Turning patients to remove pressure ■ Braden scale Elimination system ○ Measure intake and output ■ Ensures proper hydration ■ Ensures proper urination ○ Ask about frequency and consistency of bowel movements Psychosocial assessment ○ Depression ○ Anxiety ○ Fear ○ Social isolation ○ Anger

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Developmental assessment ○ Levels of health ■ Independence ■ Functional state of health...