What are the body hazards of immobility?
- metabolic changes
- GI changes
- respiratory changes
- cardiovascular changes
- musculoskeletal changes
- integumentary changes
- urinary changes
When there’s metabolic changes because of immobility, what are some effects the patient will experience?
- Decreased basal metabolic rate
- decreased in oxygen demand
- conserve energy
- Anorexia –> decreased protein intake –>negative nitrogen balance-malnutrition
- catabolism of muscle mass (muscle shrinking) - Hypercalcemia (bones release too much calcium & so too much calcium is now in the blood causing bone weakness) –> calcium reabsorption from bone loss
What are the nursing care(interventions) for altered BMR (basal metabolic rate)?
- Check TPR (temp, pulse, respiration) – if they have fever, it will increase oxygen demand
- monitor muscle mass, wound healing
- Anorexia care: small attractive meals, monitor protein intake, high protein diet, consult dietary as indicated
- monitor serum albumin (>3mg) and hemoglobin (>12)
What is the nursing care (interventions) for Hypercalcemia that happens when there’s metabolic changes?
- Monitor serum calcium
- increased fluid intake (flush out the excess calcium)
- Weight bearing & exercises to stimulate bones to retain calcium
If somebody has an infection, LIKE FEVER, their basal metabolic rate is gonna go down or up? Why?
Up! Because the body needs the energy trying to treat the infection!!
It’ll increase their oxygen demand, respiratory rate, pulse rate, etc
What are some effects of GI changes someone undergo when they are immobile for long periods of time?
- Decreased GI motility (peristalsis starts to slow down & so it causes u to have constipation)
- Constipation
- Impaction (so much HARD stool that can’t get out & can end up with an ileus)
- Ileus –> inability of the intestine to push food & waste out of your body. liquid stool that goes around the impaction if there’s little squirt of stool and none of the hard stool
What are the nursing care/interventions for GI changes?
- Abdominal assessment
- Increase fluids, fibers, & fruits
- Administer stool softeners
- get patients UP & MOVING
What Respiratory changes do people who are immobile experience?
- Stasis/inactivity of secretion (means tht they don’t rlly create enough secretion from coughs and stuff), atelectasis (collapse of the lung)
- Decreased cough ability –> hypostatic pneumonia (disease that results from collection of fluid in the lungs)
What are the nursing assessments & care/interventions for Respiratory changes?
- Assessment of lungs (so that if anything bad happens, we can catch it early to prevent it)
- Educate patient on TCB (turn, cough, deep breath)
- Encourage ICS (device that helps see ur lungs expansion) every 10 times every hour
- Increase fluids (helps bc it THINS out the secretion and it’ll be easy to cough up)
- Supplemental 02 if needed
- Elevate head of bed (bc they’ll have better lung expansion & airway duh)
What some issues do someone go thru in cardiovascular changes?
- Orthostatic hypertension (low blood pressure that happens when standing after sitting or lying down) (they might pass out or fall during this change)
- Decreased in systolic blood pressure (SBP) by 20mmHg or more OR Decreased in Diastolic blood pressure (DBP) by 10mmHg
- Cardiac deconditioning (when too much blood is hanging out in the periphery and is getting thicker )
- Thrombus Formation or DVT (deep vein thrombosis)
( basically a blood clot that forms since it hangs out in the periphery bc there’s no movement in the body)
What are some ways to reduce Risks of Orthostatic Hypotension in cardiovascular changes?
- mobilize patient ASAP
- “Dangle” their feet on side of bed (before standing them up)
- AVOID Valsava maneuver (when patient is holding their breath)
What are some ways to prevent risk of Thrombus in cardiovascular change?
- Identify those @ increased risk
- Early ambulation & position changes
- Foot & ankle exercises and ROM/rate of motions
- Use compression stockings (called TED Hose)
- Sequential compression device/SCD (device that inflate & deflate to message ur legs)
- Check peripheral pulses & edema
- Administer anticoagulants if prescribed
What are cardiovascular change assessments and care/interventions for DVT (deep vein thrombosis) and PE (pulmonary embolism)?
- Check for edema, red or warm tender leg veins
- use TED hose, ROM, leg exercises to prevent
- NO STRONG LEG MESSAGE !!!
- S0B (Sit up, 02, Call HCP) when there’s chest pain.
What are some of the musculoskeletal changes somebody experience bc of immobility?
- Decreased muscles mass
- Pathological fractures (like bone weakness)
- Joint confractures (when not moving their joints)
- Flexors are stronger than extensors
- foot drop
What are some nursing interventions for musculoskeletal changes?
- ROM exercises
- Positioning & turning every 2 hr
- Assess muscle strength
- Encourage ADL/activities of daily living participation (like brushing ur teeth, bathing ur self, tying ur shoes, etc)
- Monitor patient’s gait
- Use splints (as prescribed)
What are integumentary changes include?
- Pressure ulcer
- skin breakdown, redness
What are the Nursing assessments & care of integumentary changes?
- Turn at least every 2 hr
- Assess pressure points @ each turning
- Regular skin care (give them lotions, making sure the sheets underneath them r clean, etc)
- Nutrition
- Gentle handling (no vigorous/hard message)
- Educate patients to shift their weight often
What are the high risks for pressure injuries?
heel
sacrum
shoulders
head
ear
elbow
buttocks
hip
What are some urinary changes?
- urinary stasis/inactivity (bc there’s no gravitational flow for the urine since ur just laying down all the time)
- renal calculi (kidney stones tht forms in ur kidney)
What are some nursing interventions to prevent urinary changes?
- enough hydration
- Raise Head of Bed to 30 deg. or more
- Position to void (to pee)
- Monitor I & O (input &output)
- Monitor urine clarity, if it burns when peeing
- Cranberry juice to acidify urine
What are nursing assessments & interventions for ppl with immobility in general ?
- Listen, encourage independence
- Monitor for changes in behavior
- Allow time for interrupted sleep
- Provide meaningful mental stimulation
- consult case manager as necessary
What are the 7 patient’s bed positions?
- High Fowlers
- Head of Bed 60-90 degrees - Fowlers
- Head of Bed 45-60 degrees
- Semi Fowlers
- Head of Bed 15-30 deg
- Supine
- Flat on back
- Prone
- On stomach
- Tredelenburg
- Flat on back w/ FEET raised HIGHER than head
- Reverse Tredelenburg
- Flat on back w/ Head raised HIGHER than feet
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Spiritual Cultural11
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Health & Wellness10
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Infection Control16
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Immobility22
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Management of Patient Care8
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Documentation14
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Hygiene8
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Grief and Lost11
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Ethical & Legal considerations15
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Sleep14
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Pharm57
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Medication Administration28
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Nutrition26
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Drug Classification32
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Skin Integrity20
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Antibacterials13
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Lab Values50
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electrolytes9
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Fluids15
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Surgical Patient39
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Elimination Pt.118
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Urinary Elimination (pt.2)10
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Patient Education5
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Bowel Elimination11
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Acid Base13
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Oxygenation part 19
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End-Of-Life Care4
