NUR 231 Week 3 Notes
NUR 231 Week 3 Notes NUR 231
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This 30 page Class Notes was uploaded by Issy Notetaker on Friday September 11, 2015. The Class Notes belongs to NUR 231 at Ball State University taught by Marsann Shafer, Jane Edwards, Kathryn Humphrey in Summer 2015. Since its upload, it has received 82 views. For similar materials see Fundamental nursing skills in Nursing and Health Sciences at Ball State University.
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Date Created: 09/11/15
Fundamentals Book Notes Objections Clinical Lecture Chapter 45 Elimination 0 Basic function o If fails all organs are affected 0 Psychological alterations can occur Embarrassment Scienti c Knowledge Base 0 All parts need to be intact and functional Efferent and afferent nerves from spinal cord included Good to know the reasons behind problem 0 Kidneys Remove wastes from blood Retroperitoneal L is higher than R Filter wastes from renal artery o 14 of blood per minute Nephron is functional unit 0 Forms urine Cluster of vessels in glomerulus are 1St site for ltration can39t lter large proteins and blood cells and if urine suggest injury to glomerulus and items are ltered into capsule Filter rate of 125mLminute Only 11 of ltrate is excreted in urine Fluid and electrolyte balance Output 12001500 mLday Produce erythropoietin renin Vasoconstriction complex w angiotensin aldosterone water retention prostaglandin and prostacyclin substance to convert Vit D into active form 0 Ureters Transport form kidneys to bladder Tubes that are usually sterile Peristaltic waves Ends connecting to bladder and compressed during micturition to prevent re ux o Bladder Holds until urge to urinate Hollow Distensible Trigone is triangle of smooth mm and 3 openings ureters and urethra Pressure when full 0 Pregnancy has fetus pushing on bladder making it smaller 6001000 mL capacity o Urethra Exit from body Urethral Meatus Forceful ow clears area of bacteria Lined w mucus membranes Shorter in women 152 inches 0 Increased risk for infection Men 0 Also passage for semen 8inches Sections Prostatic Membranous Penile Voluntary mm contraction o Urination All aspects of system must be working properly Cerebral Cortex Hypothalamus Thalamus and Brainstem Inhibit or allow urge to void Contraction of balder relaxation of urethra 24 hrs 24 months neurological function is developed to potty train V increases initiates stretch re ex send signals to spinal cord respond to or ignore External sphincter is relaxed stimulates detrusor mm to contract elimination Re exinconUnence Damage to spinal cord above sacrum No voluntary urination Urination wout warning Over ow Incontinence Bladder is overly full and this pressure exceeds external sphincter involuntary leakage Caused by head injury spinal injury MS ect Factors In uencing Pathophysiological acute and reversible or chronic and irreversible sociocultural psychological uid balance diagnostic procedures medications Disease affects 0 Renal function V or quality micturition act or both Decreased blood ow to and from kidney prerenal Renal tissue renal Obstruction in lower urinary tract preventing ow from kidneys postrenal Narrowing of urethra altered intervention weaken mm 0 Diabetes and NM disease change nerve functions Loss of bladder tone reduced sensation not able to contract bladder 0 Renal Tissue damage End Stage Renal Disease Uremic syndrome sets in Treatment is renal replacement therapy Dialysis Peritoneal or Hemo and organ transplant are replacements Needed when body can no longer control Sociocultural 0 Privacy varies o Expectations breaks affect times for urination Psychological 0 Anxiety and stress increase frequency and urgency 0 Timing and place Fluid Balance 0 Varies w food intake o 12 as much produced at night than during day Nocturia is sign of renal alteration 0 Input should output Polyuria Increased output Oliguria decreased output Anuria No urine is produced 0 Caffeine and alcohol promote urine formation diuresis o Fever makes highly concentrated low volume urine 0 Surgical Procedures 0 Stress triggers GAS ADH released water reabsorption 0 Pre Op orders affect what is consumed o Meds slow renal process Medications 0 Contribute to dysfunction 0 Cause change in color 0 Diagnostic Exam 0 In uences micturition 0 Limit uids before tests restriction diet 0 Dif culty voiding after test bc structure was affected in test Alterations in Elimination Unable to store empty fully permanent or temporary changes 0 Urinary Retention 0 Bladder is unable to drain properly so urine builds UP Usually obstruction 0 Doesn39t response to micturition signal 0 UTI CO 0000 Pressure tenderness discomfort diaphoresis Over ow develops small V escapes Void small amounts 23 times a day Severe cases bladder holds 20003000 mL If present pt must be catheterized Measure residual urine left in bladder 1015 minutes after void Measure twice Normal void should completely clear bladder Post void residual regular catheter beating down increase uid intake Most common health care infection Mainly from catheter Each day in place increase in risk Persons own ora is most common cause Bacteriuria spreads to bacteremiaurosepis infection in blood Women are more susceptible Travel up mucus lining Retention increases risk Stages Lower UTI is burning when urinating Infection worsens fever chills nausea vomiting Cystitis irritation to bladder causes frequent voiding Cystitis and irritation to mucosa leads to blood n urine hematuria Upper UTI Pyelonephritis ank pain fever Chill 0 Urinary Incontinence O O O O O Involuntary urine leakage Temporary or permanent Continuous or intermittent When relate to urinary causes stress or urge to urinate Urge more in younger bc UTI Stress more in older bc urethra mm become weak HyperOveractive bladder more likely to cause incontinence in older Urge incontinence is created Underreported and undertreated Place pt at risk for impaired kin integrity FuncUonal Factors outside tract are causing 0 Nursing Knowledge Base 0 O O Urge and loss of urine before getting to bathroom Schedule toileting and environment alterations Stress Involuntary leak when abdominal pressure is increased Urge involuntary release right after void Mixed Urge and Stress combined Over ow involuntary loss at intervals 0 Urinary Diversions O O O Bladder cancer radiation to bladder chronic urinary infections may need Drain urine from bladder Reservoir are created One from iliem and colon Cateterized 46 times a day Orthotopic neobladder replace bladder w ileal pouch normal voiding o Urine drains continuously ostomy pouch o Nephrostomy Ostomy directly on kidney Fluid Balance 0 Nocturia peeing in the night 0 Polyuria Increased frequency and dilute o Oliguria Decreased output 400mL or less 0 Anuria No output 0 Infection Control and Hygiene Tract is sterile Medical and surgical asepsis when providing care Invasive procedure gets sterile technique 0 In uencing factors Age environment medication psychological factors mm tone uid balance surgical procedures disease Assess bowel elimination Growth and Development 0 Infants and children light yellowclear urine large amount excreted can39t concentrate go often bc no external control Toddlers control external sphincter nighttime voiding wout control is common 0 Pregnancy increase in frequency UTI risk increases multiple pregnancies can lead to stress or urge incon nence Age afftects micturition often impairing kidney and bladder function increased frequency retains urine after voiding MM Tone Poor controlincontinence causes mm wasting Abdominal and pelvic mm are used 0 Nursing Process 0 Assessment Through Pt eyes 0 Frame of reference of experience Understand status and selfcare ability Cognitive ability to understand 55 What do they expect from the care Personal gender social habits 0 Place in comfort position 0 P vacy Know own attitudes Culturally congruent care is important Identifying Urinary Alterations Assess history physical assessment and tests 0 Be aware of culture and language History 0 Review of elimination patterns and symptoms 0 Pattern 0 normal V and recent changes 0 Frequency note common times ie waking up before bed average 5 times a day 0 Symptoms 0 Conditions or factors that aggravate symptoms 0 Fluid balance vs intake 0 Urgency frequency nocturia Dribbling Retention ect o lndwelling catheter presence Physical Assessment 0 Data for presence and severity of alteration Skin and Mucosal Membranes o Hydration status shows o Is breakdown present 0 Rashes or blisters present Kidneys o Palpation Position shape size 0 Tenderness o Bruit sound Bladder o Distended can be palpated in lower abdomen 0 Percussion is a dull sound Urethral Meatus 0 Discharge in ammation and lesions 0 Normal Pink small slit like opening o If yeast is present check the vagina Assessment of Urine o IntakeOutput Daily average intake Change in output V shows alterations in kidney function Measure output For precise measurements use urimeter Report large increases or decreases 0 Concentration of Urine Color Pale straw amber based on concentration Dark Red Bleeding from kidneys Bright Red Bleeding from bladder Food can change color Dark Amber Liver problems Normal Transparent Standing Cloudy Renal Disease Cloudy Bacteria Thick More concentrated means more odor Stagnant Ammonia Diabetes Fruity or sweet Infection Foul Urine Testing Label w name date time Timely transport CoHchon 0 Random clean voidedmidstream sterile timed o Varies based on developmental level and type Collection in children 0 Often dif cult 0 Offer uid 30 minutes before coHchon Common Test 0 Urinalysis First voided specimen Use special strips 0 Speci c Gravity Weight of concentration compared to V of water 0 Culture Sterile cIean voided sample Diagnostic Examinations Radiographic Techniques 0 Direct Indirect Invasive Noninvasive Obtain specimen Assess history Administer bowel cleaning Give pretest diet 0 Following day Assess I and O observe urine encourage uids 0 Diagnosis Focus on urinary elimination alteration or associated factors 0 Planning Building trust is important Goals and Outcomes Realistic and Individualized Collaborate w pt Setting Priorities 0 Personal and intimate Relationship needs to allow discussion and intervention 0 Give attention to pt perceived needs Reinforce good habits Teamwork and Collaboration 0 Consider home environment Specialists in Continence for pelvic oor mm 0 Physical therapist for overall strength to go to bathroom on own 0 Implementation Health Promotion 0 Understanding and participation in selfcare Pt Education 0 Teach about elimination problems 0 Learn symptoms and meanings Promoting normal 0 Prevents problems 0 Stimulating Micturition Re ex Control of sphincter Uses squatting or sitting position for women and standing for men Run water stroke inner thighs pour warm water over perineum Maintaining habits 0 Try to follow normal routine as much as possible Fluid Intake 0 Maintain optimal intake 22002700mL a day 0 Increasing helps to ush 0 Complete Bladder emptying O O 0 Wait till stop in ow void again if needed Schedule toilet times and care Compress downward on bladder o Preventing Infection 0 000000 Acute Care Perineal hygiene Cleaning meatus after voiding Optimal uid intake Void after intercourse Don39t take excessive bubble baths Cotton underwear Drink high acid ash drinks cranberry juice Maintaining habit O O 0 Give 30 minutes to provide specimen Provide as much privacy as possible Have water running Medications O O 0 Drug therapy or other therapy can help Watch medication side effects constipation diarrhea dry mouth Block muscarinic receptor and suppress contractions VESIcare and Ditropan Cholinergic Drugs increase contraction Bethanechol AlphalAdrenergic blocker for men w prostate enlargement related incontinence Flomax Catheterization 0 Tube up urethra into bladder 0 Continuous ow of urine 0 Types 0 O Intermittent straight single use to drain in 5 10 minutes then remove Used for spinal cord or neurologic disorders 0 Straight or curved tip Men w prostate enlargement lndwelling remains in place until voiding on own is able short or long term 0 Small in atable balloon 23 lumens Insertion Requires order Aseptic technique is important Closed Drainage Minimizes risk of infection after insertion Large bag or leg bag that is held BELOW the bladder O O O Watch for tube kinks and cut offs from positioning Perineal Hygiene 3 times daily Use soap and Water Don39t advance catheter into bladder increase infection risk Extra care reduces discomfort and infection Fluid Intake Should remain the same Avoid citrus juice creates environment for growth Preventing Infection Keep system closed break means infection risk Drainage bag site of insertion spigot tube junction junction of tube and bag are all high risk areas Bacteria grow in pools of urine prevent back ow into the bladder Irrigations and lnstillations O O O Flushing w sterile solution Irrigation can ush pus or blockage back into bladder Best to change tubing Antibiotic or antiseptic irrigations can be used w bladder infections Maintenance of closed system w irrigation is recommended 0 Removal of Indwelling Cath O 0000 Promote normal function prevent trauma Clean disposable towel trash sterile syringe De ate balloon completely Burning sensation is felt when pulling out Assess function by dating measuring and timing the voiding for 24 hours 0 Alternatives to Cath O O Suprapubic Cath Surgical insertion of cath Anchored w sutures or ring seal Maintenance is same as indwelling Remains in all the time I and 0 must be monitored Asses for 55 of infection Condom Cath Incontinent or comatose MEN At night or continuously worn Make sure blood supply to penis isn39t cut off Change daily 0 Others Pads need to be changed frequently Restorative Care 0 Strengthening Pelvic Floor mm o Kegel exercises 0 Continued use to maintain o Noninvasive and low risk Bladder Retaining 0 Reduce frequency Retaining normal bladder function Urological consultation is helpful Never refuse to toilet a pt Suppress voiding for 15 minutes and increase by 15 each week 0 Void every 34 hours Habit Training 0 Improve voluntary control 0 Establish pattern 0 Positive reinforcement promoted voiding Selfcath 0 Teach structure of system aseptic tech adequate uid intake frequency 0 56 times a day 0 Skin Integrity 0 Acid urine irritates skin 0 Wash w soap and warm water 0 Comfort 0 Clean dry clothing 0 Protective pads o Analgesics o Stimulating urination may be the only relief 0000 0 Evaluation Pt Eyes 0 Pt is best source of information 0 Remember not just physiological but also psychological Pt Outcomes Make take weeks Chapter 38 0 Regular exercise enhances all aspects of life 0 Scienti c Knowledge 0 Regular activity and exercise contribute to physical and emotional W3 0 Overview of Exercise and Activity MM and Nervous system maintain balance posture and proper alignment lfl proper reduction in injury risk Body Alignment Relationship of body part to part on a vertical and horizontal plane 0 No excess strain is present Adequate mm tone and balance Balance 0 Low center of gravity Widen base to support CoG Bring CoG closer to base C06 in human is 55 up from standing 0 Unsteady greater risk for falls Coordinated Body movement 0 Weight C06 and balance combined Friction Force in direction of opposition of movement Decrease when moving by place pt arms on chest and having them bend knees Use air assisted devices when you can Exercise and Activity 0 Condition body improve health maintain tness Depends on pt activity tolerance 0 Many factors affect Regular activity increase function of all body systems 0 Combination of o isotonic Mm contraction change in length aerobic and light weights enhance cardiopulmonary increase mm mass tone and strength and bone building 0 isometric tightening and tensing mm increase mm mass tone strength increased circulation and bone building 0 resistive isometric Contract mm while pushing against stationary object push up hip lifting mm strength and bone building 0 Regulation of Movement Skeletal System 0 Support protection movement mineral storage hematopoiesis Framework for shape alignment positioning Lever action Joints 0 Connection bw bones o Fibrous Fixed o Cartilaginous Little movement 0 Synovial Moveable Ligaments Tendons and Cartilage o Lig Flexible bands connecting bones to cartilage o Tendons Connect mm to bone 0 Cartilage Firm exible plastic like material Skeletal MM Contraction allow mm 600 in body Origin stays put insertion moves MM w Movement 0 Near skeletal region 0 Lever system MM w Posture 0 Low level of continuous contraction MM Groups 0 Antagonistic MM Movement ofjoint Active contracts while antagonistic relaxes o Synergistic MM Contract for same movement Two MM doing same action 0 Antigravity MM Stabilize Joints Oppose gravity affects Nervous System Regulates movement and posture Voluntary motor area Cerebral Cortex precentral gyrus Motor strip 0 Fibers cross over Impulses are neurotransmitters Proprioception 0 Awareness of body and parts position 0 Receptors on feet signal for posture and balance changes 0 Balance 0 Needed to do really anything 0 Cerebrum and inner ear are in charge 0 Principle of transfer and Positioning Safe pt transfer and positioning for techniques Decrease effort and strain Pathological In uences Congenital defects Affect ef ciency of muscuoskeeta 0 Balance alignment appearance 0 Scoliosis o Osteogenisisimperfecta Disorder of Bones Joints MM 0 Osteoporosis Decrease in bone density 0 Osteomalacia Delayed mineralization replacing rigid bone w soft bone Nonin ammatory joint disease 0 Articular Disruption tear sprain dislocation O CNS 0 If damage to voluntary movement centerD impaired alignment ad immobility Musculoskeletal trauma 0 Bruises Contusions sprains fractures Nursing Knowledge Base 0 In uencing Factors Developmental Changes 0 Appearance and functioning of body changes throughout life Infant through school age 0 Infant spine is exible and only in C shape 0 Toddler has protruding abdomen walks w feet far apart 0 3 year slimmer taller better balance Ies protrusion narrower base more coordinated this point on mm and bones grow and develop Adolescent 0 Growth spurt uneven o Awkward and uncoordinated 0 Female hips widen more fat deposits 0 Male Lone bone growth increase mm mass Young to Middle Adult 0 Correct alignment and posture selfcon dent coordinate 0 Pregnant Sway back bc of fetus back pain 0 Older Adults 0 Progressive bone mass loss 0 Inactivity changes in hormones increased osteocIastic activity Behavioral Aspects More likely to exercise is support system is in place 0 Assess knowledge barriers and current status 0 Stage of readiness is the stage where person is most likely to engage in an exercise program Environmental Issues 0 Work Site 0 Lack of time 0 Some works offer reminders and incentives to exercise 0 Schools 0 Facilitate exercise an activity 0 Community 0 Providing public bike trails or events Cultural and Ethnic What will motivate people from different backgrounds 0 Know wat diseases affect different ethnic backgrounds more frequently diabetes in African Americans and Native Americans Family and Social Support Motivational tool 0 Critical Thinking 0 Include activities that t the ability of the pt Consider ROM and mobility Nursing Process 0 Assessment Note changes in growth and development deviations from the norm and learning needs First assess alignment Through Pt Eyes 0 Assess expectations 0 Determine perceptions Standing 0 Head Erect midline Symmetrical Straight Spine w normal curves Abdomen tucked Knees straight C06 is midline Sitting Head Erect Neck and column are straight Weight on thighs and butt Thighs parallel Feet on floor and arms on arm rest Proper reduces Mskeletal damage Recumbent Position Vertebra are straight Check extremities 0 Don39t want them to be crossed Mobility Determine coordination and balance ability to perform ADL ROM determines degree of damageinjury 0 Shows stiffness swelling pain 0 Increased mobility might be connective tissue disorder tears or fracture Gait 0 Style of walking Rhythm cadence speed Balance posture and ability to walk Smooth OOO Exercise 0 Conditions improves health maintains tness provides therapy Activity Tolerance Kindamount of exerciseactivity a person can do Provides baseline for future activities 0 Diagnosis Often focuses on ability to move 0 Planning Info from many sources Goals and Outcomes Consider risks injuries and preexisting Improve OR maintain mobility Setting Priorities Prevent complications and injury Teamwork and Collaboration Understand pt needs 0 Implementation Health Promotion Encourage to engage in a regular program Holistic approach should be taken Teach calculation of max HR Discuss recommendations Include warm ups and cool downs O Stretching and exibility are good Integrate in ADLs Body Mechanics O O O O Acute Care Stretching and isometric exercises Active ROM exercises O 0 Back Injury is common Before Iifting assess weight need for assistance and available resources Use Lift teams and safe avaiIabIe equipment Use manual lifting only as last resort When unable maintain joint mobility Medicate before if needed Low intensity walking Musculoskeletal O O O O Stretching and isometric Review chart for contradictions Design for speci c pt Contract and relax repeat w gradual increase in sets and reps joint Mobility O 0 Maintain and improve SystemicaIIy assess each joint mobiIity o If not moved joint can become xed 0 Initiate passive ROM as soon as voluntary control is lost 0 Walking 0 Increases joint mobility 0 Measure in feet and yards 0 Note use of aids 0 Helping pt walk Require prep Assess tolerance strength coordination baselines and balance Sit w feet dangling for 12 minutes Assistance methods Gait belts for CoG Restorative Care 0 Implementing exercise and activity after acute care Aids Walkers O O O Canes O O O 0 Light and movable Waist high metal tubing Requires lifting to move Light weight movable metal or wood Less support than walker and less stable Cane on stronger side of body and moe cane weaker le then stronger leg Quad cane is most support Crutches O O 0 Temporary use Need to be measure for appropriate length and use Teach how to walk ascend and descend stairs and rise from sitting Measuring Aillary is commonly used Ht elbow exion distance bw pad and axilla 34 nger widths from axilla to 15cm to lat heel Handgrips are supporting wt NOT axilla Elbow at 30 degree position hand grips Bear wt on 1 legs and on crutch alternatively Assess physical and functional abilities 3 Point Each crutch is 15 cm from lateral heel Axilla bears NO wt 4 Point Bear wt on both legs each is moved alternatively w opposing crutch 2 Point Partial t bearing on each foot move crutch at same time as opposing foot Swing through Plant and swing 0 Walking on Stairs Modi ed 3 pint Ascending Transfer wt to crutches unaffected leg moves up stair shift wt and move crutches Descending Wt to unaffected leg move crutches down move leg down 0 Sitting Position at center front of chair Crutches in hand opposing affected leg Supports wt on unaffected leg grasp arm of chair and slowly lower in Opposite for standing Restoration and Chronic lllness CHD Exercise and activity are secondary prevention 0 Cardia rehabilitation is important 0 Reduces mortality and morbidity Hypertension Exercise reduces BP 0 Low to moderate intensity are most effective COPD Progressive treatment 0 Diabetes Important component to care 0 lmproves glucose control 0 Lower blood sugar levels 0 Evaluation Pt Eyes 0 Pt knows effectiveness and bene ts Chapter 47 Mobility is used for many purposes Effects physical and emotional WB Not just for tness For expressions defense ADL Physical Therapy helps to maintain strength Scienti c Knowledge 0 Nature of Movement Complex Coordination bw musculoskeletal and Nervous system Body Mechanics Coordinated Efforts Need to mechanics around lifting Know balance alignment gravity and friction Alignment and Balance Position ofjoints tendons ligaments and mm C06 is stable Correct reduces stress aids in mm tone promotes comfort conserves energy Wout balance C06 is off increasing fall risk Balance is increased by keeping CoG low and base wide lmpaired balance is a major risk factor Gravity and Friction Wt exerted on body gravity To lift lft must overcome wt of object and its CoG Using only principles of body mechanics in lifting pt leads to injury Friction greater surface area men greater friction Shear occurs when the head of the bed is lifted causing bones to move down and skin to be pulled up 0 Damages underlying structures 0 Use ergonomic assistive devices 0 Physiology and Regulation Skeletal System Attachments for mm and ligaments Leverage Bones 0 Long Ht and length 0 Flat Contour Short Occur in clusters and permit extremity movement Irregular Vertebra and mandible Firmness inorganic salts Rigidity Keep bones straight and wt bearing Elasticity Bone exibility Changes w age cartilage amount Aids in Ca2 regulation Bone marrow creates blood cells Ligaments Some are protective spinal cord Cartilage lnfants have more 0 Permanent Unossi ed O 0000 Skeletal MM Contract and Relax Working element Functional Purpose 0 Moving o Resisting o Stabilizing Concentric tension increased contract mm shortening movement Isometric increases energy expenditure 0 Increase RR and HR are associated Eccentric Tension controls speed and direction mm lengthen Isotonic Voluntary movement is isometric and isotonic contractions MM Movement and Posture o Leverage is created 0 MM in posture maintenance are short and featherlike MM of lower extremities trunk neck and back 0 Stabilize MM Regulation of Posture and Movement 0 Depend on shape development of skeletal mm 0 MM tone is the state of balance mm tension Nervous System 0 Movement and posture regulation Precentral gyrus and motor strip 0 Pathological In uences on Mobility Postural Abnormalities Congenital or acquired Affect balance posture alignment and ROM Cause pain impair alignmentmobility Maintain max ROM in unaffected joints Strengthen affected MM nd joints improve posture and use all mm groups MM Abnormalities Dystrophies Most prevalent in childhood diseases 0 Progressive and symmetrical weaknesswasting Damage to CNS 0 See Chapter 38 Direct Trauma to Musculoskeletal System Fractures most commonly come from external force 0 Nursing Knowledge Base 0 Safe Pt Handling Manually lifting increases risk for injury EB intervention reduce risk Laws mandate safe handling Eronomics assessment protocol for HC environments pt assessment criteria algorithms for pt handling an movement special equipment action after review and no lift policies 0 Factors in uencing MobilityImmobility Assess ability to move freely Broad spectrum bw mobile and immobile Some move back and forth Bedrest restricts pt to bed for therapeutic reasons 0 Duration is dependent on injuryillness and prior health state Hazards of lmmobility are the cluster of MM deconditioning Systemic Effects mobility and immobility effect entire body 0 All systems work better w movement Metabolic Changes 0 Alter endocrine metabolism Ca2 reabsorption and GI function 0 Endocrine system initiates series of responses aimed at maintaining BP and saving life Homeostasis function Thyroid alters BMR o Immobilized pt w infection have increased BMR o Immobilization results in negative nitrogen balance hypercalcemia occurs constipation pseudodiarrhea Fecal impaction o Endocrine Ca2 and GI Respiratory Changes 0 Aerobic enhances function 0 Lack of movement increases complications Atelectasis alveolar collapse Hypostatic pneumonia in ammation of lung or pooling of secretions Decreased oxygenation and increased stays Mucus accumulates Cardiovascular Changes 0 Orthostatic Hypotension increase in HR 15 decrease in BP 15mmHg S and 10mmHg D when supine to standing Pooling occur in immobile and decrease ANS response 0 Thrombus accumulation of platelets brin clotting and cellular elements Damage to cellular wall alterations in blood ow alterations in blood constitutes Virchow39s Triad of clotting factors 0 Increased Cardia Workload 02 consumption increases heart works harder decreases ef ciency output falls Musculoskeletal Changes 0 Permanent or temporary disability 0 Loss in endurance strength and mm mass 0 o Impaired joint mobility 0 MM Effects Loses lean mm Mass cycle less mobility more loss more fatigued less mobility more loss Mm atrophy decreased strength joint instability o Skeletal Effects Impaired Ca2 metabolism Disuse osteoporosis Risk for pathological fractures Joint abnormalities 0 Joint Contracture is abnormal and can be permanent Fixation ofjoint Early prevention is key Footdrop occurs when foot is permanently in plantar exion Urinary Elimination o Kidney move on level plane instead of w gravity 0 Renal pelvis ll w urine bf entering ureters urinary stasis increasing risk for UTI 0 Renal Calculi are calcium stones bc hypercalcemia o Fluid intake diminishes urine becomes concentrated increasing calculi stone risk lntegumentary 0 Pressure on skinD Pressure Ulcers 0 Break in integrity is dif cult to heal 0 Pressure Ulcer resulted of decreased blood supply In ammation over boney prom Older adult is especially at risk Psychological Effects 0 Altered sleep patterns increased anxiety hostility depression emotional behavioral sensory and coping alterations Changes in ADLs sit and worry withdrawn 0 Developmental Changes Infants Toddlers Preschoolers As babdy grow musculoskeletal development occurs allow wt support Posture is awkward Prolonger immobility delays motor skills intellectual development and musculoskeletal development Adolescents Increase in growth 0 Growth is uneven Adults Older Adults Nursing Process 0 Assessment Assess mobility and immobility Through Pt Eye Assess and ask questions about degree Mobility ROM Max amount of movement a joint can go in sagittal transverse and frontal plane Social isolation occurs when immobile Have necessary development and coordination Progressive bone mass loss occurs Progressive or sudden immobilization can occur Encourage to do as many selfcare activities as possible 0 CPM machines 0 Important baseline assessment 0 Passive or active both assessed 0 Neck Reveals altered alignment changes in vision eld decreased independent function 0 Elbow best at 90 degrees xed extended impairs func on o Forearm xed in supination is a serious impairment 0 Wrist Weakened Grasp o Knee Stability Gait heel strike of one leg and heel strike of anther 0 Shows balance posture safety walking ability 0 Requires coordination of systems Tolerance type and amount of exercise pt is able to perform 0 Needed fr planning of interventions 0 Physiological emotional and developmental domains for assessment 0 Exercise cause physiological changes 0 Monitor for dyspnea fatigue pain vital sign change 0 Worried depressed or anxious have lower tolerance o Tolerance changes w age More in childhood less in adolescent pregnancy can cause lack of motivation Older adult has less activity and less tolerance Alignment o Siting Standing Laying down 0 Determine Normal based on growth and development Deviations and cause Opportunities to observe own posture Note learning needs Identify trauma mm damage nerve dysfunction Obtain concerning information 0 Put pt at ease 0 Turning at least every hours if not every hour 0 Aids Pillows blankets lmmobility Metabolic System 0 Anthropometric Measurements to note mm atrophy 0 Note uid intake and output 0 Assess wound healing 0 Note nutrition intake and screen for malnutrition Respiratory System 0 Once every 2 hours 0 Inspect wall and full inspiratory and expiratory o Auscultate lung sounds Cardiovascular System 0 BP Pulses peripheral and apical signs of venous stasis 0 Monitor for orthostatic hypotension longer immobility greater risk 0 Listen for third heart sound indication of heart failure 0 Edema sometimes develops DVT embolus often in lower extermities MusculoskeletalSystem o Decreases tone and strength loss of mass contractures 0 ROM lntegumentary o CONTINUOUSLY assess for breakdown and color changes 0 Use Braden scale 0 Occurs every 2 hours Elimination 0 Evaluate each shift intake and output every 24 hours 0 Dehydration increases complications 0 Includes dietary choices bowel sounds frequency and consistency of movements PsychosocialAssessment 0 Changes in personality 0 Confusion boredom isolation depression anger o Emotional status change 0 Assess for coping O 0 Identify correct and unexplained changes in sleeping Observe on daily basis DevelopmentalAssessment O O 0 Diagnosis Determine if progressing normally implement interventions to assist normal development Assess family and child coping Determine ability to meet needs Assess home and community for resources and risks Impaired physical mobility Risk for disuse syndrome lmmobility can lead to many addition complications so be alert and try to prevent 0 Planning Communicate w respiratory nurses wound care nurses and others Goals and Outcomes Individualized Assist in achieving highest level of mobility and reduction in immobility hazards Setting Priorities 0 Effect on mental and physical status help the determine 0 Immediate needs are met rst 0 Plan according to severity of risks 0 Don t overlook potential complications Teamwork and Collaboration care 0 Implementation Team approach Encourage NAP to help w exercises Determine mobility needs an abilities Dietitian for nutritional Referrals for discharge Keep in mind home environment when planning home Health Promotion 0 Education Prevention and early detection 0 Prevention of Work Related 0 O 0 Increased injuries in workplace Most occur from overexertion Back injury from lifting and bending Strain in lumbar Pt care is best w health staff NoIift policies are instituted and lift teams must be used Know individual capacity and ability 0 Consider pt ability to assist 0 Keep wt close to body bend at knees Tighten abdominal mm maintain trunk erect and knees bent don39t twist trunk Exercise enhance WB and improve health 0 O O Reduces risks Encourage the beginning of managed exercise programs Culture should be taken into consideration Bone Health in Osteoporosis Pt 0 O 0 Acute Care Hazards of Respiratory status orthostatic hypotension impaired skin integrity Reduce impact of immobility Metabolic System 0 0 Increased risk should be screened diet assessment for adequate Ca2 intake and Vitamin D intake Early evaluate and referral is the best Use aids main goal is to maintain ADLs independence High protein high caloric diet is needed w Vitamin C and B supplements Enteral or Parenteral nutrition might be indicated Respiratory O O Reexpand lungs dislodge and mobilize stagnant secretions clear lungs Assess sputum cough pain wheezing Deep breath every 12 hours 3 deep breaths and cough on last one Chest physiotherapy drain by coughing identi es speci c areas Adequate uid intake is key to keep ciliary clearance Cardiovascular 0 Reducing Orthostatic Hypotension Increase Pulse rate Decreased pulse pressure drop in BP Fainting can occur To prevent Mobilize as soon as possible Dangle feet over bed Isometric exercises improve activity tolerance Assess getting up using safe handling algorithm 0 Reducing Cardiac Workload Discourage from using Valsalva Maneuver Pressure changes decrease produce bradycardia Can result in sudden cardiac death 0 Preventing Thrombus Formation Identi cation of risk Leg foot and Ankle exercises Fluids Position Changes pt teaching Heparin therapy Continually assess for signs of bleeding SCDs and lPC use to decrease venous stasis Elastic stockings also antiembolic and keeps blood moving 0 Assess circulation in toes to make sure not too tight Proper positioning 0 Avoid crossing legs sitting for long periods wearing constricting clothing massaging legs Report suspicion immediately elevate leg but avoid pressure ROM reduces risk of contractures Antiembolic exercises done every hour while awake Musculoskeletal 0 Exercise prevent large atrophy and contractures 0 Active ROM is needed in daily schedules and passive is needed 0 CPM use continuous passive motion lntegumentary 0 Pressure ulcer formation 0 Turn every 12 hours 0 Teach to shift weight every 15 minutes Elimination Keep hydrated Prevent stasis calculi and infections Don39t cause distension Record frequency and consistency Fruits Veges and ber diet Stool softeners toileting aids ad hygiene may need to be provided Psychological Changes 0 Check history to determine at risk 0 Note coping ability 0 Incorporate social workers spiritual workers and others OOOOOO OOOOO Place in room w other person for interaction If private have staff go in and talk to pt regularly Books anf TV should be provide Involve in own care Encourage use of hygiene make up shaving hair do 0 Developmental O O O O 0 Continue w normal Mental and physical stimulation is needed Incorporate pay Maintain calendar and clock in room Encourage to perform own ADL Positioning 0 00000000 Pillows folded sheets blankets towels are great aids Positioning boots to prevent foot drop Trochanter roll prevents hip rotation Trapeze bar allows pt to pullassist in transfer Unsupported jointsimpaired alignment Slightly exed is better Use bed to help as much as possible Low Fowlers 15 degrees SemiFowlers 30 degrees lower than this increases risk for respiratory problems minimum for feeding and if respiratory issues comfortable less pressure less risk for pressure ulcers Fowlers 45 degrees oral care bating more pressure and ucer risk less time is spent here Supported Fowler39s Position 4560 degree elevation Knee sighty elevates Eating if can t be moved to chair increased pressure on coccyx Supine Good alignment Pillows and rolls for arms and hands Prone Face or chest down Head turned to side Pace piows under knees and ankle Bene ts in acute respiratory distress Not common Trendelenburg Head down and feet up for shock faint feeling increases blood flow to head DO NOT use if heart problems or head injury are present Entire bed is tilted and no abdomen bending 0 Reverse Trendelenburg Opposite of normal re ux hernias back surgery and pregnancies Mush check of sli ng o SideLying Position Most weight on hip or shoulder 30 degree lat Position Trunk alignment is same as standing Maintain curves of spine Neck must be supported 0 Sim s Position Weight on anterior ileum humerus clavicle Enema and Suppository Transfer Techniques 0 Assess every situation 0 Use algorithm 0 Use pt strength 0 Moving Pt Safety is rst Various levels of assistance are needed Does the pt know what is expected of them Do they know the procedure What is the comfort level lf pt too heavy or immobile to move alone Non slip shoes aids assistance gait belt Stand on stronger side unless use of aid Remove obsticles o Transferring Bed to Chair Move obstacles Ensure there is help Explain procedure place chair next to bed Can pt bear weight 0 Bed to Stretcher ls pt able to assist gt200 pounds use friction reducing and 3 caregivers Restorative and Continuing Care 0 Max functional mobility and independence 0 Reduce de cits Functional for ADLs and lADLs functional beyond self care 0 ROM 0 Ensure joint mobility 0 Provide passive when needed 0 Should NOT cause pain 0 Walking 0 Asses activity tolerance strength pain balance coordination Explain where to who when and why 0 How much independence can they assume 0 Gait belt provides support at the waste to keep CoG midline o Hemiplegia and hemiparesis Stand on affected side and support w gait belt 0 0 Evaluation Pt Eyes 0 Goals met New ones to be planned Pt Outcomes Evaluate understanding of teacher and proper use of techniques
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