Nursing Care and Patient Mobility Benefits

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?

Poor balance and history of previous falls Signup and view all the answers

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

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

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

Using the Hoyer lift and draw sheets Signup and view all the answers

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

To implement preventive measures and ensure patient safety Signup and view all the answers

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

Decreased risk of pressure ulcers Signup and view all the answers

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

Strengthens lower extremity muscles Signup and view all the answers

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

Decrease in tidal volume Signup and view all the answers

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

Atrophy and osteoporosis Signup and view all the answers

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

Use of anticoagulants Signup and view all the answers

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

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

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

Negative nitrogen balance Signup and view all the answers

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

Monitor for signs of thrombus formation Signup and view all the answers

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

Encourage deep breathing exercises Signup and view all the answers

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

Using an incentive spirometer every 1-2 hours 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?

Request an order for SCDs or TEDs Signup and view all the answers

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

To promote comfort and assess skin integrity Signup and view all the answers

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

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

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

Increased risk of pressure ulcers Signup and view all the answers

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

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

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

Cleaning the mouth with a toothette and brushing teeth Signup and view all the answers

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

Establishing rapport and monitoring health status Signup and view all the answers

Match the symptoms of compartment syndrome with their descriptions:

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 Signup and view all the answers

Match the following terms with their definitions:

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 Signup and view all the answers

Match the discharge care instructions with their descriptions:

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 Signup and view all the answers

Match the safety measures with their corresponding actions:

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 Signup and view all the answers

Match the possible complications with their characteristics:

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 Signup and view all the answers

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

pain meds Signup and view all the answers

Evisceration involves internal organs protruding through the ______.

abdomen Signup and view all the answers

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

swelling Signup and view all the answers

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

2 Signup and view all the answers

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

dehiscence Signup and view all the answers

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

ADLs Signup and view all the answers

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

bed Signup and view all the answers

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

safety Signup and view all the answers

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

CHG Signup and view all the answers

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

pannus 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.

incentive spirometer Signup and view all the answers

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

trimmed Signup and view all the answers

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

knots Signup and view all the answers

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

urinal Signup and view all the answers

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

circulation Signup and view all the answers

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

assist Signup and view all the answers

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

well-being Signup and view all the answers

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

active Signup and view all the answers

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

unblanchable Signup and view all the answers

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

red/pink 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.

subcutaneous Signup and view all the answers

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

bone 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 ______.

intact Signup and view all the answers

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

pressure Signup and view all the answers

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

stage 4 Signup and view all the answers

The ______ assists the surgeon by holding retractors during surgery.

scrub nurse Signup and view all the answers

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

complications Signup and view all the answers

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

consent Signup and view all the answers

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

ileus Signup and view all the answers

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

deep vein thrombosis Signup and view all the answers

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

urinary function Signup and view all the answers

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

infection Signup and view all the answers

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

pin Signup and view all the answers

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

coughing Signup and view all the answers

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

supplies Signup and view all the answers

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

NPO Signup and view all the answers

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

wound VAC 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.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

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.