Module 1B Quiz

Cane Instructions

• Always ensure two points of support are touching the ground
• Maintain the cane on the stronger side of the body
• Ensure body weight is distributed evenly on both legs
• Advance the cane 6 to 10 inches (15 – 25 cm) forward
• Move the weaker leg forward towards the cane
• Advance the stronger leg past the cane

Ascending Stairs with a Cane

• Hold the cane in the hand opposite the injured or weaker leg
• Step up with the stronger leg first
• Bring the cane and the weaker leg up to the same step

Descending Stairs with a Cane

• Place the cane on the step below first
• Step down with the weaker leg, followed by the stronger leg

Crutch Instructions

• Do not adjust crutches after fitting
• Use the prescribed crutch gait
• Support body weight on hand grips with elbows flexed at 20 to 30 degrees
• Hold crutches in one hand and grasp the arm of the chair with the other for balance when sitting or rising
• In the tripod position, place the crutches 6 inches (15cm) in front and to the side of each foot
• Maintain a straight back, hips, head, and neck, avoid placing weight on the axillae
• Four-point, three-point, and two-point gaits are for different weight-bearing needs

Walker Instructions

• Ensure the walker height aligns with the inside of the client's wrist while standing straight
• Instruct the client to hold the walker with both hands firmly
• The client's elbows should be flexed 15 to 30 degrees when standing inside the walker
• Ensure to stand behind the client while they are using the walker
• Advance the walker 6-8 inches (15-20 cm) forward, then set the walker down with all four feet
• Support body weight on the walker, advance one foot followed by the other foot, then move the walker and repeat

Complications of Immobility - Integumentary System

• Increased pressure on the skin is aggravated by metabolic changes
• Decreased circulation to tissues can cause ischemia, potentially leading to pressure injuries

Complications of Immobility - Respiratory System

• Stasis of secretions and weakened respiratory muscles can cause atelectasis and hypostatic pneumonia
• Respiratory movement decreases, resulting in reduced oxygen and carbon dioxide exchange
• Decreased cough response

Complications of Immobility - Cardiovascular System

• Orthostatic hypotension and stasis of blood in the legs can occur
• Increased oxygenation requirements
• Risk of thrombus development
• Diminished autonomic response
• Decreased cardiac output leads to poor cardiac effectiveness caused

Complications of Immobility - Metabolic System

• Altered protein, carbohydrate, and fat metabolism
• Altered calcium, fluid, and electrolytes
• Resorption of calcium from bones results in weakened bones
• Decreased basal metabolic rate and negative nitrogen balance
• Protein and weight loss can occur
• Decreased urinary elimination of calcium can lead to hypercalcemia

Complications of Immobility - Elimination

• Urinary stasis and constipation
• Changes in calcium metabolism
• Decreased fluid intake and peristalsis

Complications of Immobility - Musculoskeletal System

• Muscle atrophy, decreased stability, and altered calcium metabolism can occur
• Osteoporosis and pathological fractures
• Impaired balance and joint mobility

Complications of Immobility - Neurological/Psychosocial

• Contractures, foot drop, and altered joint mobility
• Altered sensory perception, depression, anxiety, and withdrawal
• Cognitive function and coping ability deficits

Complications of Immobility - Developmental

• Developmental delays in children
• Overall physical and cognitive development deficits

Anti-Embolic Stockings

• Stockings provide continuous pressure to the lower extremities to prevent blood pooling and clots in deep veins
• Use for pre-op, in-op, and post-op situations
• Can be knee-high, thigh-high, or hip-high
• Accurate measurement of leg circumference is key to ensure correct sizing
• Fold stocking down, insert toes, pull to heel, ensure toe movement, then pull up, smooth, and straighten
• Assess pain, circulation, skin integrity, and history of DVT before and during use

Sequential Compression Devices (SCDs)

• SCDs provide intermittent compression to the lower extremities to promote venous return and prevent DVT
• Contraindicated in clients with severe arterial disease
• Proper fit is crucial for adequate support and circulation
• Two fingers should fit between the stocking and the client's leg
• Should be removed every 8 hours or per policy to assess skin and circulation
• Assess pain, circulation, skin integrity, and history of DVT before and during use
• Ensure tubing is not kinked

Positioning Techniques

• Reposition every two hours to prevent pressure ulcers, contractures, and foot drop
• Use pillows, footboards, trochanter rolls, and hand rolls for support
• Common positions include fowler's, semi-fowler's, supine, lateral, prone, Trendelenburg, and reverse Trendelenburg

Range of Motion (ROM) Exercises

• Movement of a joint in any direction that increases joint function and flexibility, improves posture, reduces stiffness, and lowers injury risk
• Perform once or twice daily as prescribed, independently or with assistance
• Active ROM is performed by the client, supervised by a nurse or PT, to maintain and increase muscle strength
• Passive ROM is performed by a nurse or PT for immobilized clients to retain joint range of motion
• Muscles do not contract during passive ROM, so muscle strength is not maintained or decreased
• Support the joint above and below, move through the full range, and stop at any pain

Thrombophlebitis

• Thrombophlebitis or DVT (vein inflammation) manifestations include pain, edema, warmth, and erythema (redness of skin) at the site
• Assess by measuring bilateral calf and thigh circumference daily, unilateral increases indicate thrombosis
• Immediate actions consist of notifying the provider, elevating the legs, avoiding pressure at the site, and anticipating anticoagulants

Pulmonary Embolism

• Pulmonary embolism is a life-threatening occlusion of blood flow to one or more pulmonary arteries caused by a clot originating in venous system
• Manifestations consist of shortness of breath, chest pain, hemoptysis (coughing up blood), decreased blood pressure, and rapid pulse
• Prepare to give thrombolytics or anticoagulants, position in high-fowler positions, obtain pulse ox, administer oxygen, prepare to obtain blood gas analysis, and monitor vital signs

Heat Application Instructions

• Heat increases blood flow, tissue metabolism, relaxes muscles, and eases joint stiffness and pain
• Use caution in young and old, immobile clients or those with impaired sensation
• Avoid prolonged applications and high temperatures
• To avoid heat: monitor bony prominences, no heat over metal devices, no heat to the pregnant abdomen, no heat to a client who is immobile, do not use for the first 24 hours after a traumatic injury, active bleeding, non-inflammatory edema, or some skin disorders

Cold Application Instructions

• Cold decreases inflammation, prevents swelling, reduces bleeding and fever, diminishes muscle spasms, and decreases pain by reducing nerve conduction velocity
• Use caution in young and old, immobile clients, or those with impaired sensation
• Avoid prolonged use and major temperature changes
• Avoid cold if the individual has cold intolerance, vascular insufficiency, open wounds, or ailments made worse by cold

Heat or Cold Therapy Application

• Ensure the call light within reach, and advise reporting any discomfort
• Assess every 5 to 20 minutes for redness, pallor, pain, burning, numbness, shivering, blisters, decreased sensation, mottling, or cyanosis, discontinue if any of these happens, or after a predetermined time

Foot Drop

• Foot drop is plantar flexion contracture, where someone cannot pull their toes toward head (dorsiflexion)
• Results from nerve entrapment and shortening of lower leg muscles (Achilles tendon)
• The foot is arched, toes pointing down, impairing heel placement and causing toe dragging
• Observe foot position at rest
• Monitor gait for toe dragging
• Apply prescribed splints to stretch the limb
• Assist with ambulation to prevent falls
• Notify the provider if foot drop is present

Fall Risk Factors

• History of falls
• Generalized weakness
• Disorientation or confusion
• Certain medications such as antihypertensives, antidepressants, and opioid meds

Fall Prevention Interventions

• Perform a mobility assessment
• Provide nonskid shoes or socks
• Keep the call light within reach
• Use a bed alarm
• Keep the bed in the lowest position

Nursing Care for Negative Pressure Wound Therapy (NPWT)

• A vacuum is used to remove drainage and infectious organisms, increase circulation, and bring the edges closer
• NPWT requires routine sterile dressing changes
• Administer prophylactic analgesics
• Apply skin protectant to the skin surrounding the wound
• Cut a sterile foam dressing to fit the wound and place directly in the wound bed
• Cover with occlusive film dressing, extending 1 to 2 inches (2.5 to 5 cm) past the perimeter for an air-tight seal
• Reattach and insert vacuum tubing, connecting to the vacuum-assisted closure unit
• Apply prescribed negative pressure and observe for foam dressing compression, indicating no air leaks

Proper Body Mechanics

• Plan the lift, and determine if additional help is needed
• Use a transfer belt for clients with minimal weight-bearing ability
• Transfer clients towards their stronger side
• Raise the bed to the appropriate height and lower the side rail
• Avoid bending at the waist, bend at the legs (knees)
• Use a wide stance, but not too wide
• Avoid twisting movements, keep shoulders over the hips

Positioning when assisting clients in transfer

• Wide base of support
• Bend at the knees
• Keep the client close to you
• Do not twist and get help if needed

Deep Vein Thrombosis (DVT)

• Blood clots in deep veins, frequently in the lower extremities, cause diminished or blocked blood flow, leading to inflammation and edema
• Virchow triad (altered blood flow, endothelial damage, and hypercoagulable states) predisposes for DVTs
• Risk factors include: age 65+, immobility, obesity, oral contraceptives, pregnancy, surgery, fractures, malignancy
• Clinical: unilateral edema, pain, redness, warmth, diagnosed with d-dimer and venous doppler

DVT Prevention

• Change positions frequently and walk, perform leg exercises, do not cross legs in bed
• Use compression devices or anti-embolism stockings, and take anticoagulants as prescribed

DVT Nursing Interventions

• Administer anticoagulants, observe for bleeding (bruising or petechiae), perform neurovascular assessment, monitor for PE signs, ambulate early after anticoagulation, explain long term meds and blood testing, and encourage adequate fluid intake

Prevention of Skin breakdown and pressure injuries

• Bony prominences, immobility, malnutrition, incontinence, decreased sensory perception, pressure, and shearing force are all risk factors
• Document by measuring and photography
• Use the Braden scale for pressure injury risk assessment
• Keep skin clean and dry: use barrier protection and ointment
• Reposition clients every 2 hours
• Minimize shearing force, and pad bony prominences
• Use pressure redistribution support surfaces and heel protectors
• Provide nutritional support: high protein supplements and adequate fluid intake
• Encourage active and passive range of motion exercises
• Purulent exudate indicates bacterial infection
• Necrotic tissue needs debridement (negative pressure wound therapy)