Nursing Care and Patient Mobility Benefits
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Questions and Answers

What is the primary concern when managing a patient's pain post-surgery?

  • Taking the patient's vitals frequently
  • Addressing the patient's subjective report of pain (correct)
  • Administering pain medication without further assessment
  • Ensuring they walk as soon as possible

    • Which of the following non-pharmacological techniques can help alleviate a patient's pain?

  • Encourage extensive bed rest regardless of comfort
  • Suggest the patient watches stressful movies
  • Instruct the patient to practice deep breathing only
  • Provide a comfortable environment with distractions (correct)

    • What is the purpose of using proper body mechanics during patient mobility?

  • To eliminate the need for assistive devices
  • To prevent injury to both the patient and the caregiver (correct)
  • To increase the nurse's speed while moving patients
  • To reduce the likelihood of making the patient uncomfortable

    • Which of the following factors increases a patient's fall risk?

    <p>Poor balance and history of previous falls</p> Signup and view all the answers

    What is a critical nursing priority for a patient post-surgery regarding mobility?

    <p>Monitoring for the risk of deep vein thrombosis (DVT)</p> Signup and view all the answers

    How can a nurse effectively minimize friction and shearing during patient transfers?

    <p>Using the Hoyer lift and draw sheets</p> Signup and view all the answers

    What is a purpose of assessing a patient's fall risk?

    <p>To implement preventive measures and ensure patient safety</p> Signup and view all the answers

    Which of the following aspects is NOT an effect of prolonged immobility?

    <p>Decreased risk of pressure ulcers</p> Signup and view all the answers

    Which of the following is a potential benefit of ambulation for patients on bedrest?

    <p>Strengthens lower extremity muscles</p> Signup and view all the answers

    What is a common effect of immobility on the respiratory system?

    <p>Decrease in tidal volume</p> Signup and view all the answers

    What are the potential risks associated with immobility in the musculoskeletal system?

    <p>Atrophy and osteoporosis</p> Signup and view all the answers

    Which action can help prevent thrombus formation in patients at risk due to immobility?

    <p>Use of anticoagulants</p> Signup and view all the answers

    Which of the following patients is at the highest risk for falls?

    <p>A 40-year-old recovering from leg surgery on narcotics</p> Signup and view all the answers

    What is an expected change in metabolism due to prolonged immobility?

    <p>Negative nitrogen balance</p> Signup and view all the answers

    When managing a patient post-surgery, which is an important nursing priority?

    <p>Monitor for signs of thrombus formation</p> Signup and view all the answers

    What immediate action should be taken if a patient shows signs of atelectasis?

    <p>Encourage deep breathing exercises</p> Signup and view all the answers

    What should be encouraged to prevent respiratory complications in a postoperative patient on bedrest?

    <p>Using an incentive spirometer every 1-2 hours</p> Signup and view all the answers

    Which action can be taken to promote circulation and reduce the risk of deep vein thrombosis in immobilized patients?

    <p>Request an order for SCDs or TEDs</p> Signup and view all the answers

    What is the primary goal of performing personal hygiene for a patient during full P.M. care?

    <p>To promote comfort and assess skin integrity</p> Signup and view all the answers

    Which of the following statements correctly reflects best practice for assessing pain in a postoperative patient?

    <p>Ask the patient if they have experienced any pain since their surgery</p> Signup and view all the answers

    What is a potential negative effect of prolonged immobility in patients?

    <p>Increased risk of pressure ulcers</p> Signup and view all the answers

    What is the most appropriate approach to ensure safety for a patient at risk of falls?

    <p>Keeping the bed in a low position and within reach of call light</p> Signup and view all the answers

    Which hygiene practice is vital to prevent oral infections in postoperative patients?

    <p>Cleaning the mouth with a toothette and brushing teeth</p> Signup and view all the answers

    Repeated visits to a postoperative patient for care are primarily aimed at achieving what?

    <p>Establishing rapport and monitoring health status</p> Signup and view all the answers

    Match the symptoms of compartment syndrome with their descriptions:

    <p>Pain = So severe that pain meds don’t work Redness = Visible redness in the affected area Swelling = Feels tight/warm when touching area Decreased Circulation = Toes turn blue, can cause tissue death</p> Signup and view all the answers

    Match the following terms with their definitions:

    <p>Dehiscence = Rupture of surgical wound with edges no longer approximated Evisceration = Internal organs protrude through abdomen Pressure = Relieved by secondary/tertiary intention or will go back to OR Compartment Syndrome = Condition characterized by increased pressure leading to reduced blood circulation</p> Signup and view all the answers

    Match the discharge care instructions with their descriptions:

    <p>Activity level = What are the orders? Weight bearing? Diet Driving restrictions = Limitations on driving after surgery Pain medication = Instructions on use and dosage of prescribed medications Care of drains = Guidelines for managing surgical drains post-discharge</p> Signup and view all the answers

    Match the safety measures with their corresponding actions:

    <p>Side rails = Keep at least two side rails up (top 2) Bed alarm = Use if patient is disoriented Sedation assessment = Assess often for over sedation Patient restraints = Check circulation/distal pulse q 2 h</p> Signup and view all the answers

    Match the possible complications with their characteristics:

    <p>Dehiscence = Sudden increase in abdominal pressure leading to rupture Evisceration = Medical emergency requiring immediate attention Infection signs = Symptoms indicating the presence of an infection post-surgery Abdominal pressure = Can be a risk factor for dehiscence</p> Signup and view all the answers

    In compartment syndrome, pain can be so severe that ______ don’t work.

    <p>pain meds</p> Signup and view all the answers

    Evisceration involves internal organs protruding through the ______.

    <p>abdomen</p> Signup and view all the answers

    Signs of infection to monitor in a discharged patient may include ______ and increased redness.

    <p>swelling</p> Signup and view all the answers

    Patients in wrist restraints should have their circulation and distal pulse checked every ______ hours.

    <p>2</p> Signup and view all the answers

    A sudden increase in abdominal pressure is a risk factor for ______.

    <p>dehiscence</p> Signup and view all the answers

    A complete care patient requires assistance with all of their ______.

    <p>ADLs</p> Signup and view all the answers

    When bathing a patient, proper ______ height is important for safety and comfort.

    <p>bed</p> Signup and view all the answers

    When bathing infants or children, it is crucial to prioritize ______.

    <p>safety</p> Signup and view all the answers

    Using ______ wipes can help prevent healthcare-associated infections in critical care settings.

    <p>CHG</p> Signup and view all the answers

    Patients with a ______ may have increased risk of skin breakdown due to moisture being trapped in skin folds.

    <p>pannus</p> Signup and view all the answers

    To decrease the negative effects that immobility might have on your patient, you should encourage them to use their ______ every 1-2 hours.

    <p>incentive spirometer</p> Signup and view all the answers

    Feet and nails should not be ______ as it can create wounds.

    <p>trimmed</p> Signup and view all the answers

    Washing hair removes dried blood, oils, dirt, and helps get out ______.

    <p>knots</p> Signup and view all the answers

    Offering a ______ can assist patients with toileting needs while on bedrest.

    <p>urinal</p> Signup and view all the answers

    Bathing can help stimulate ______, which is beneficial for overall health.

    <p>circulation</p> Signup and view all the answers

    During a complete bath, the patient does not ______ at all and the care is performed by nursing staff.

    <p>assist</p> Signup and view all the answers

    The primary goal of personal hygiene care during full P.M. care is to promote ______ and comfort.

    <p>well-being</p> Signup and view all the answers

    To promote a positive rapport, nurses should engage in ______ listening with their patients.

    <p>active</p> Signup and view all the answers

    A Stage 1 pressure ulcer is characterized by an area of redness that is ______ to touch.

    <p>unblanchable</p> Signup and view all the answers

    A Stage 2 pressure ulcer involves partial thickness loss of the dermis, resulting in a ______ wound bed.

    <p>red/pink</p> Signup and view all the answers

    In a Stage 3 pressure ulcer, there is full thickness tissue loss and may see ______ fat, but no bone, tendon, or muscle.

    <p>subcutaneous</p> Signup and view all the answers

    Stage 4 pressure ulcers show full thickness loss with exposed ______, tendon, or muscle.

    <p>bone</p> Signup and view all the answers

    Suspected Deep Tissue Injury (DTI) may present as a purple/dark red area of intact tissue, and the skin may still be ______.

    <p>intact</p> Signup and view all the answers

    A(n) ______ wound is characterized by unblanchable redness.

    <p>pressure</p> Signup and view all the answers

    A full thickness tissue loss with exposed muscle and bone is classified as ______.

    <p>stage 4</p> Signup and view all the answers

    The ______ assists the surgeon by holding retractors during surgery.

    <p>scrub nurse</p> Signup and view all the answers

    In the post-operative phase, monitoring vital signs is crucial to prevent ______.

    <p>complications</p> Signup and view all the answers

    During the pre-operative phase, obtaining ______ from the patient is essential.

    <p>consent</p> Signup and view all the answers

    A common effect of surgery on the gastrointestinal system is the development of ______.

    <p>ileus</p> Signup and view all the answers

    Following surgery, ______ can occur as a complication due to decreased mobility.

    <p>deep vein thrombosis</p> Signup and view all the answers

    Monitoring intake and output is vital in assessing a patient's ______ post-surgery.

    <p>urinary function</p> Signup and view all the answers

    Patients should be educated to look for signs of ______ post-surgery, such as fever and drainage.

    <p>infection</p> Signup and view all the answers

    Chlorhexidine or normal saline is used to clean the area around a ______.

    <p>pin</p> Signup and view all the answers

    Post-operative patients should be encouraged to perform ______ and deep breathing exercises.

    <p>coughing</p> Signup and view all the answers

    The circulating nurse in the operating room is responsible for bringing ______ to the sterile field.

    <p>supplies</p> Signup and view all the answers

    Patients are typically kept ______ the night before surgery to prepare for the procedure.

    <p>NPO</p> Signup and view all the answers

    Granulation tissue growth is promoted by the use of a ______ system.

    <p>wound VAC</p> Signup and view all the answers

    Study Notes

    Benefits of Ambulation

    • Strengthens lower extremity muscles and enhances mobility.
    • Decreases calcium loss, reducing the risk of osteoporosis.
    • Maintains normal breathing function and promotes respiratory health.
    • Increases joint flexibility and range of motion.
    • Stimulates circulation, supporting cardiovascular health.
    • Encourages appetite, aiding nutritional intake.
    • Relieves pressure on skin and tissues, preventing ulcer formation.
    • Prevents constipation by promoting gastrointestinal motility.
    • Nurses should assist patients by moving them to their strong side.

    Effects of Immobility on the Respiratory System

    • Immobility leads to decreased activity, lowering basal metabolic rate (BMR) and carbon dioxide (CO2) production.
    • Reduced stimulation to breathe may result in slower, more shallow respirations.
    • Risks associated with immobility include:
      • Atelectasis: Collapse of alveoli causing partial lung collapse.
      • Hypostatic Pneumonia: Lung tissue inflammation due to secretions pooling.

    Effects of Immobility on the Cardiovascular System

    • Orthostatic hypotension can occur; blood pressure should be monitored during movement.
    • Decreased venous return increases the heart's workload.
    • Increased risk for thrombus formation.

    Preventing Thrombus Formation

    • Use anticoagulants like Heparin and Lovenox.
    • Encourage wearing TED stockings.
    • Promote calf pumping exercises.
    • Implement Sequential Compression Devices (SCD) as needed.

    Effects of Immobility on the Musculoskeletal System

    • Increased risk of osteoporosis due to calcium loss from bones.
    • Muscle atrophy occurs due to lack of use.
    • Potential development of contractures and spasticity.
    • Risk of decubitus ulcers increases without regular movement.

    Effects of Immobility on Nutrition and Metabolism

    • Decreased BMR leads to reduced energy utilization.
    • Negative nitrogen balance indicates protein breakdown.
    • Calcium loss from bone contributes to musculoskeletal vulnerabilities.

    Patient Fall Risk Evaluation

    • Increased fall risk in patients:
      • With heart failure who take diuretics.
      • After leg surgery if using narcotics for pain.
    • Healthy individuals and children with mild fever are generally at lower risk.

    Post-Surgery Care to Combat Immobility Effects

    • Encourage incentive spirometer use every 1-2 hours for lung function.
    • Request SCDs or TEDs to prevent thrombus during bedrest.
    • Engage in active patient monitoring rather than leaving them unattended.

    Hygiene and Comfort Basics

    • Feet & Nails: Clean under nails instead of trimming to avoid injuries.
    • Hair Care: Wash to maintain cleanliness, removing blood and dirt.
    • Oral Care: Promote healthy gums; use toothbrushes and toothttes for cleaning.
    • Toileting Assistance: Provide help with urinals and bedpans.
    • Dressing & Grooming: Replace gowns with clean ones for comfort.
    • Active Listening: Make patient interactions engaging and supportive.
    • Building Rapport: Trust is essential; maintain eye contact and touch respectfully.

    Bathing Benefits

    • Removes microorganisms, secretions, and dead skin cells.
    • Stimulates circulation and enhances well-being.
    • Promotes relaxation and manages body odor.
    • Positive patient rapport can be fostered through thorough bathing.

    Levels of Bathing

    • Self: Independent bathing by the patient.
    • Partial: Assistance from a nurse needed.
    • Complete: Care performed entirely by nursing staff.

    Pain Management

    • Pain can elevate vital signs: BP, HR, RR increase in response to discomfort.
    • Subjective pain assessment is essential; prioritize patient-reported pain levels.
    • Non-pharmacological interventions include heat/cold therapy, massage, positioning, and ensuring a comfortable environment.

    Proper Body Mechanics

    • Assess the patient's position and weight before lifting or moving.
    • Resume work with legs instead of the back; use height adjustments to protect posture.
    • Utilize assistive devices for safe patient transfers.

    Fall Risk Assessment

    • Assess balance, previous fall history, and the effect of pain medications on the risk of falling.
    • Utilization of ambulation devices like canes, crutches, walkers, and wheelchairs helps mitigate fall risks.

    Compartment Syndrome

    • Severe pain resistant to pain medications.
    • Redness and swelling; area feels tight and warm upon touch.
    • Pressure may require surgical intervention if not relieved.
    • Decreased circulation leading to blue toes, potential tissue death.

    Possible Complications

    Dehiscence

    • Rupture of surgical wound with edges no longer approximated.
    • Risk factors include age, obesity, and malnutrition.
    • Sudden increases in abdominal pressure heighten risk.

    Evisceration

    • Occurs post-dehiscence where internal organs protrude through the abdomen.
    • Considered a medical emergency and can lead to shock.
    • Cover exposing organs with sterile, saline-moistened towels/gauze.

    Discharge Care

    • Monitor signs and symptoms of infection.
    • Adhere to activity and weight-bearing orders.
    • Manage pain medication and lifting limitations, particularly post-abdominal surgery.
    • Ensure care for drains and schedule follow-up appointments.

    Safety Measures

    • Maintain at least two upper side rails on the patient's bed.
    • Use bed alarms for disoriented patients and assess for over-sedation.
    • Regularly check circulation and distal pulses in patients with wrist restraints.

    Benefits of Ambulation

    • Strengthens lower extremity muscles and decreases calcium loss.
    • Maintains normal respiratory function and flexibility in joints.
    • Stimulates circulation and appetite, prevents constipation.
    • RN role includes assisting movement towards the strong side.

    Effects of Immobility on Body Systems

    Respiratory System

    • Decreased activity and basal metabolic rate (BMR) lead to shallow breathing.
    • Risks include atelectasis (collapsed alveoli) and hypostatic pneumonia (lung inflammation).

    Cardiovascular System

    • Orthostatic hypotension can occur; check BP upon mobilization.
    • Increased heart workload due to decreased venous return presents a thrombus risk.

    Musculoskeletal System

    • Consequences include osteoporosis, atrophy, contractures, spasticity, and pressure ulcers.

    Nutrition and Metabolism

    • Immobility leads to decreased BMR and negative nitrogen balance, hastening protein breakdown.

    Risk of Falls Assessment

    • Higher risk in elderly patients, those with heart failure taking diuretics, and post-surgical patients on narcotics.
    • Healthy individuals and those with mild fever have lower risk.

    Bathing Considerations

    Elderly Patients

    • Be cautious with dry, fragile skin to avoid tearing.
    • Apply lotion while the skin is damp, and monitor water temperature sensitivity.

    Unconscious Patients

    • Remain cautious of biting reflex when cleaning oral cavity.
    • Place emesis basin nearby to prevent aspiration and ensure safe positioning.

    Bed Positions

    • Familiarize with various positions: flat, Low Fowler’s, Semi Fowler’s, High Fowler’s, Trendelenburg, and Reverse Trendelenburg for patient comfort and safety.

    Changing an Occupied Bed

    • Engage in proper identification and safety measures while changing linens.
    • Follow a step-by-step procedure, ensuring that proper safety equipment is used.

    Comfort Techniques

    • Employ distraction and environmental control to alleviate pain and anxiety.
    • Interventions may include guided imagery, music, and touch to promote relaxation and pain relief.

    Special Considerations for Diabetic Patients

    • Educate on foot care, emphasizing daily inspections and proper hygiene without skin irritation.

    Delegation Principles

    • Follow the "Five Rights" for delegation, confirming that team members can perform tasks correctly while maintaining safety standards.

    Basic Asepsis/Sterility

    • Understand practices around maintaining a sterile field and avoiding contamination.

    Factors Affecting Wound Healing

    • Emphasize the importance of nutrition, circulation, immune status, age, obesity, smoking, medications, and stress in promoting wound recovery.

    Wound Assessment and Staging

    • Identify wound types: primary intention (closed, minimal scarring) vs. secondary intention (open, greater scarring).
    • Document conditions, including redness, drainage type, and stage of pressure ulcers based on observations.

    Suspected Deep Tissue Injury (DTI)

    • Recognize purple/dark red intact tissue as a sign of DTI, indicating potential underlying injury.

    Practice Question Scenarios

    • Review scenarios regarding patient conditions and wound documentation for preparedness in clinical settings.

    Compartment Syndrome

    • Severe pain that is unresponsive to pain medication
    • Redness and swelling of the affected area
    • Tight or warm feeling upon palpation
    • Pressure may need to be relieved through secondary/tertiary intention or surgical intervention
    • Decreased circulation can lead to blue toes and potential tissue death

    Complications: Dehiscence & Evisceration

    • Dehiscence: Surgical wound rupture with edges no longer approximated
      • Risk factors include age, obesity, and malnutrition
      • Sudden abdominal pressure increase can lead to this condition
    • Evisceration: Protrusion of internal organs through the abdominal wall
      • Considered a medical emergency
      • May indicate impending shock; cover with sterile towel or gauze moistened with saline

    Discharge Patient Care

    • Reinforce signs and symptoms of infection
    • Provide activity level orders, including weight-bearing and dietary considerations
    • Discuss pain management and use of braces
    • Set lifting limitations after abdominal surgeries
    • Outline restrictions on driving and care for drains
    • Schedule follow-up physician appointments

    Patient Safety Protocols

    • Keep at least two side rails up for patient safety
    • Utilize bed alarms if patient exhibits disorientation
    • Frequent assessments for over-sedation
    • Proper patient positioning is essential
    • For patients in wrist restraints, check circulation and distal pulses every two hours

    Exam Preparation Logistics

    • Exam consists of 50 questions, duration of 60 minutes
    • Includes "Select All That Apply" (SATA) questions with multiple response options available
    • Questions drawn from lectures, textbooks, and lab manuals

    Normal Vital Signs

    • Temperature: 36.5°-37.5°C (97.6°-99.6°F)
    • Pulse: Adults: 60-100 bpm; Newborns: 130-160 bpm
    • Respirations: Adults: 12-20 breaths/min; Newborns: 40-60 breaths/min
    • Blood Pressure: Adults: SBP <10 mmHg upon standing could indicate dehydration or blood loss
    • O2 Saturation: Norms not specified

    Practice Questions

    • Prioritize nursing actions for patients post-surgery experiencing dizziness upon ambulation

    Infection Control Guidelines

    • Central Line-Associated Bloodstream Infections (CLABSI): Issues often due to broken sterile technique
    • Catheter-Associated Urinary Tract Infection (CAUTI): Related to catheter usage
    • Surgical Site Infection (SSI) & Ventilator-Associated Pneumonia (VAP)
    • Superbugs: Examples include VRE, MRSA, C-Diff, and Norovirus, requiring specific hygiene measures for prevention

    Handwashing and Waste Disposal

    • Hand hygiene is crucial before and after patient care, especially with glove use
    • Proper disposal methods:
      • Red bags for biohazard waste
      • Soiled dressings treated with caution against contamination
      • Normal trash for minimal drainage dressings
      • Do not recap used needles, except in medication preparation zones

    Isolation Precautions

    • Contact Precautions: Required for infections spread by touch (e.g., C. diff, MRSA)
    • Droplet Precautions: Implemented for large droplets (e.g., influenza); includes gown and mask
    • Airborne Precautions: Needed for diseases such as TB; requires N-95 respirators and negative pressure rooms

    Aseptic Technique Basics

    • Maintaining sterility by avoiding non-sterile contact with sterile surfaces
    • No contact with the one-inch border around sterile fields; arms must stay above the waist
    • Proper fluid flow management to maintain sterility

    Factors Affecting Wound Healing

    • Nutrition, circulation/oxygenation, immune status, age, obesity, smoking, medications (e.g., steroids), and stress influence healing rates

    Wound Assessment

    • Assess size (width, length, depth) and drainage type for effective documentation
    • Types of drainage:
      • Serous: Clear or pink
      • Sanguineous: Bloody
      • Serosanguinous: Clear/pink
      • Purulent: Pus with potential infection

    Pressure Injury Staging

    • Understanding depth and characteristics for accurate documentation:
      • Stage 1: Unblanchable redness
      • Stage 2: Partial thickness loss; red/pink wound bed
      • Stage 3: Full thickness tissue loss without bone exposure
      • Stage 4: Full thickness loss with exposed bone/tissue
      • Unstageable: Presence of slough/eschar preventing visual assessment

    Suspected Deep Tissue Injury (DTI)

    • Presents as purple/dark red intact tissue, firm or boggy with underlying injury

    Documentation Practice Questions

    • Emphasize clarity in describing stage and characteristics of wounds for accurate medical records

    Wound Staging

    • Unblanchable redness indicates Stage 1 pressure ulcer; may be painful.
    • Stage 2 involves partial thickness loss of dermis with a red/pink wound bed and broken skin.
    • Stage 3 shows full thickness tissue loss with subcutaneous fat visible, but no exposure of bone, tendon, or muscle.
    • Stage 4 demonstrates full thickness loss with exposed bone, tendon, or muscle, possibly with slough or eschar present.
    • Unstageable wounds contain significant slough or eschar, obscuring tissue depth.
    • Suspected Deep Tissue Injury presents as a purple/dark red area of intact skin that is painful and may indicate underlying injury.
    • Mucosal membrane wounds are non-stageable, often resulting from oral injuries.
    • Medical device wounds occur due to external medical apparatus, such as sores from a nasal cannula.

    Pin Care

    • External fixators immobilize limbs to assist in bone healing; care helps prevent infection.
    • Look for infection signs: redness, discharge, or pus.
    • Clean pin sites with pressure to prevent skin adherence.
    • Essential supplies: Chlorhexidine/normal saline, long Q-tips, chuck pads, and sterile/clean gloves.

    Wound VAC (Vacuum-Assisted Closure)

    • Suitable for extensive or irregularly shaped wounds with significant drainage.
    • Benefits include reduced edema, enhanced blood flow, promotion of granulation tissue, expedited healing, and reduced hospital stay duration.
    • Contraindications: presence of eschar/slough, untreated osteomyelitis, active cancer at the wound site, fistulas, active bleeding, anticoagulation therapy, or necrotic tissue.

    Surgical Nursing

    • Types of surgeries include inpatient (hospital admission prior to surgery) and outpatient (same-day discharge).

    Pre-Operative Nursing

    • Patient consent is critical, requiring adequate disclosure and understanding, especially in emergencies.
    • Pre-op instructions include NPO status, assessment of allergies, medication review, and confirming surgical site.
    • Maintain open communication to build rapport with patients.

    Intra-Operative Nursing

    • Involves care from patient entry into the OR until transfer to PACU.
    • OR team includes anesthesiologist/CRNA (in charge during anesthesia), surgeon, scrub nurse, and circulating nurse.
    • Strict sterile technique is vital; avoid touching non-sterile areas and maintain hands above waist level.

    Post-Operative Nursing

    • Involves monitoring in PACU and restoring functionality while preventing complications.
    • Priority interventions focus on airway management, monitoring vital signs, and assessing for cardiovascular complications.

    Effects of Surgery on Systems

    • GU System: Urine output may decline due to surgical stress. Monitor intake, output, and consider catheterization if voiding is an issue.
    • GI System: Ileus may occur; monitor bowel sounds and provide fluids and stool softeners.
    • Respiratory System: Risk for pulmonary embolism and atelectasis; encourage deep breathing and cough exercises.
    • Neurological System: Assess level of consciousness post-anesthesia; perform neuro checks routinely.
    • Cardiovascular System: Monitor for shock and hemorrhage; intervene appropriately to maintain circulatory stability.

    Pain Management

    • Address pain as it can impede recovery and increase anxiety.
    • Interventions include administering medications, using comfort measures, and facilitating early ambulation.

    Possible Complications

    • Infection may manifest as fever or drainage; treat with antibiotics as required.
    • Hemorrhage requires prompt attention, including potential transfusions.
    • Compartment syndrome presents with severe pain, swelling, and decreased circulation; may necessitate surgical intervention.
    • Dehiscence involves surgical wound rupture; evisceration is a medical emergency requiring immediate care.

    Discharge Care

    • Educate on signs of infection, activity restrictions, and medication guidelines.
    • Provide clear instructions on follow-up appointments and care for drains.

    Hygiene and Comfort

    • Ensure thorough denture and oral care, assist with toileting, grooming, and bath.
    • Benefits of bathing include hygiene, circulation stimulation, and patient comfort.

    Bathing Practices

    • Focus on safety for patients of all ages and ensure proper temperature control when bathing children or infants.
    • Special considerations for obese patients include skin fold care to prevent breakdown.

    Documentation of Wounds

    • Document accurately according to observed characteristics, including staging when applicable.

    Safety Measures

    • Maintain patient safety with adequate support, monitor for over-sedation, and regularly assess the patient's condition, particularly those in restraints.

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    Description

    This quiz covers the essential aspects of nursing care related to patient ambulation and the benefits it provides. It discusses effects of immobility, including respiratory challenges, and emphasizes the role of nurses in supporting mobility. Test your knowledge on how proper movement can enhance patient health and well-being.

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