Nursing Interventions for Immobility
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Questions and Answers

What is the primary cause of pressure ulcers?

  • Prolonged pressure (correct)
  • Impaired blood flow
  • Decreased sensation
  • Poor nutrition

    • What should be monitored closely when administering opioid analgesics?

  • Increased heart rate
  • Skin irritation
  • Increased appetite
  • Sedation (correct)

    • What is the maximum daily intake of acetaminophen to avoid liver toxicity?

  • 4000 mg (correct)
  • 3000 mg
  • 5000 mg
  • 2500 mg

    • What is a key consideration when using NSAIDs?

    <p>Monitor for GI bleeds</p> Signup and view all the answers

    What is the purpose of turning a patient every 2 hours?

    <p>To prevent pressure ulcers</p> Signup and view all the answers

    Which of the following is a type of chemical restraint?

    <p>Sedative medication</p> Signup and view all the answers

    What condition may arise due to the application of a physical restraint?

    <p>Pressure ulcers</p> Signup and view all the answers

    When assisting a client with a gait belt, where should you position yourself?

    <p>On the client's weaker side, slightly behind</p> Signup and view all the answers

    What is the proper elbow position when fitting crutches?

    <p>Flexed at about 30 degrees</p> Signup and view all the answers

    What is the correct sequence for going up stairs with crutches?

    <p>Non-injured leg first, then crutches and injured leg</p> Signup and view all the answers

    What is the recommended position of a cane during ambulation?

    <p>4 inches to the side of the foot</p> Signup and view all the answers

    During the two-point gait, which limbs move together?

    <p>The non-injured leg and the injured crutch</p> Signup and view all the answers

    What is not a purpose of using a cane?

    <p>To provide full weight-bearing support</p> Signup and view all the answers

    Which statement about proper gait belt use is incorrect?

    <p>It can be secured tightly around the waist</p> Signup and view all the answers

    What is the primary purpose of compression devices in patient care?

    <p>To promote blood return to the heart</p> Signup and view all the answers

    Which assessment is essential for monitoring respiratory function in immobile patients?

    <p>Auscultating breath sounds</p> Signup and view all the answers

    Which type of diet is most beneficial for metabolic and nutritional needs in immobile patients?

    <p>High-protein and rich in fruits and vegetables</p> Signup and view all the answers

    What is a key sign to monitor for in cardiovascular assessments related to immobility?

    <p>Orthostatic hypotension</p> Signup and view all the answers

    What aspect of the skin should be assessed in immobile patients frequently?

    <p>Color changes and integrity</p> Signup and view all the answers

    Which activity is classified as a Basic Activity of Daily Living (ADL)?

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

    What is an effective nursing intervention for respiratory needs in immobile patients?

    <p>Using an Incentive Spirometer</p> Signup and view all the answers

    Which equipment is commonly used to assist with mobility for immobile patients?

    <p>Compression stockings</p> Signup and view all the answers

    What should be monitored during the elimination system assessment?

    <p>Bowel sounds and habits</p> Signup and view all the answers

    Which type of care intervention is recommended for assisting immobile patients with toileting?

    <p>Assisting with toileting as needed</p> Signup and view all the answers

    What is the primary function of gas exchange in the respiratory system?

    <p>Transfer of oxygen to blood</p> Signup and view all the answers

    What role does the cardiovascular system play in oxygenation?

    <p>It transports oxygen and carbon dioxide</p> Signup and view all the answers

    What occurs during inhalation according to the breathing mechanism described?

    <p>Diaphragm contracts and moves down</p> Signup and view all the answers

    What is ischemia?

    <p>Insufficient flow of oxygenated blood</p> Signup and view all the answers

    Which condition results from a deficiency of oxygen in the blood?

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

    What could potentially result from prolonged hypoxemia?

    <p>Cell injury or death</p> Signup and view all the answers

    How does the body signal the respiratory center to control breathing rates?

    <p>Primarily through carbon dioxide and hydrogen concentrations</p> Signup and view all the answers

    Anoxia refers to what condition?

    <p>Complete lack of oxygen to tissues</p> Signup and view all the answers

    What is the primary benefit of using a spacer with a Metered Dose Inhaler (MDI)?

    <p>It improves drug delivery and makes dosing more predictable.</p> Signup and view all the answers

    Which step is NOT part of the proper administration technique for a Dry Powdered Inhaler (DPI)?

    <p>Block the opening with the tongue if necessary.</p> Signup and view all the answers

    What is a purpose of diaphragmatic breathing?

    <p>To strengthen the diaphragm and maximize inhalation.</p> Signup and view all the answers

    Which technique is NOT included in Chest Physiotherapy for respiratory function improvement?

    <p>Deep Tissue Massage</p> Signup and view all the answers

    What indicates the need for suctioning a patient?

    <p>Inability to expel or cough out secretions.</p> Signup and view all the answers

    How long should a patient hold their breath after using an MDI?

    <p>5-10 seconds.</p> Signup and view all the answers

    Which of the following actions is recommended after using a Metered Dose Inhaler (MDI)?

    <p>Rinse MDI with soap and water after each dose.</p> Signup and view all the answers

    What is the recommended position for an unconscious patient during suctioning?

    <p>Side-lying.</p> Signup and view all the answers

    Study Notes

    Immobility

    • Can lead to a number of issues, including pressure ulcers, respiratory issues, and cardiovascular problems.
    • Key assessments for immobility include:
      • Metabolic Assessment: Monitor anthropometric measurements and intake/output to check for dehydration.
      • Respiratory Assessment: Inspect chest movement and auscultate for breath sounds (decreased, crackles, wheezes).
      • Cardiovascular Assessment: Measure vital signs, peripheral and apical pulses, and assess for orthostatic hypotension, DVT, and edema. Watch for embolus risks impacting circulation and oxygenation (tachycardia, shortness of breath).
      • Musculoskeletal Assessment: Evaluate muscle strength, tone, mass loss, contractures, and range of motion (ROM).
      • Skin Assessment: Check for integrity and early changes in skin condition.
      • Elimination System Assessment: Monitor intake/output, bowel sounds, and bowel/bladder habits.

    Nursing Interventions for Immobility

    • Respiratory Needs:
      • Cough and deep breath every 1 to 2 hours, Incentive Spirometer
      • Sit up ASAP
      • Provide chest physiotherapy
    • Metabolic/Nutritional Needs:
      • Provide high-protein, high-calorie diet with vitamin B and C supplements
      • Assist with toileting
      • Serve a diet rich in fluids, fruits, vegetables, and fiber
    • Cardiovascular Needs:
      • Compression Devices
      • Dangling
      • Progress from bed to chair to ambulation
      • Restraints

    ADLs vs. IADLs

    • Basic Activities of Daily Living (ADLs): Basic self-care tasks usually learned as a young child. Include: bathing, dressing, toileting, grooming, transferring, and feeding.
    • Instrumental Activities of Daily Living (IADLs): More complex activities that require thinking skills, usually learned as a teenager. Include: shopping, cooking, cleaning, banking, using the telephone, and managing medications.

    Compression Devices

    • Purpose: DVT Prevention: Both graduated compression stockings and Sequential Compression Devices (SCDs) exert pressure on lower leg veins, promoting blood return to the heart and reducing the risk of blood clots.
    • Important Considerations:
      • Weight Bearing: Only use with clients who can bear weight; those who cannot require mechanical lifts.
      • Contraindications: Avoid use with clients recovering from abdominal surgery or with severe cardiac or respiratory conditions.

    Gait Belt Application

    • Positioning: Assist the client into a sitting position with legs hanging over the edge of the bed.
    • Belt Placement: Wrap the belt around the waist, ensuring it’s not too tight and allows for finger clearance underneath.
    • Safety Grip: Use an underhand grasp when holding the belt.
    • Supporting the Client: Stand on the client's weaker side, placing both hands on their waist for stability. Maintain an erect posture to prevent leaning to one side. Walk behind and slightly to the side of the client for better control.

    Crutches

    • Proper Fit:
      • Gap: 2-3 finger width (1-1.5 inches) between the axillae and crutch rest pad to prevent resting weight on the pads and avoid nerve damage.
      • Elbow Position: Flexed at about 30 degrees when hands are on hand grips.
    • Types of Gaits:
      • Tripod Position: Start position with crutch tips about 6 inches diagonally (in front and to the side) from feet.
      • Two-Point Gait: Move injured crutch and non-injured leg simultaneously. Then move non-injured crutch and injured leg together.
      • Four-Point Gait: Move each crutch and leg separately: Right crutch → Left leg → Left crutch → Right leg.

    Crutches: Up and Down Stairs

    • Going Up: "Good = UP": Move the non-injured leg first, then crutches and injured leg.
    • Going Down: "Bad = Down": Move crutches down first, then the injured leg, followed by the non-injured leg.

    Canes

    • Purpose: Balance Improvement: Canes widen the base of support, enhance stability during ambulation, and support the patient's weight, but they are not intended for full weight-bearing.
    • Proper Fit:
      • Placement: Position the cane 4 inches to the side of the foot.
      • Elbow Position: Flexed at 30 degrees when holding the cane.
    • Posture: Stand erect and hold the cane in the hand on the strong side.
    • Ambulation Technique:
      1. Advance Cane: Move the cane forward 4-12 inches while supporting weight on the strong leg/hand.
      2. Move Weak Foot: Bring the weak foot forward parallel to the cane.
      3. Weight Shift: Support weight on the weaker leg and cane. Advance the stronger leg ahead of the cane (heel slightly beyond the tip of the cane).
      4. Repeat: The weaker leg is moved forward until even with the stronger leg, then advance the cane again.

    Positioning

    • Turn every 2 hours to prevent pressure ulcers
    • Maintain body in alignment
    • Provide skin care

    Pressure Ulcers

    • Injuries to the skin and underlying tissue caused by prolonged pressure, restricting blood flow.
    • Contributing Factors: Poor nutrition, impaired blood flow, lack of mobility, old age, decreased sensation
    • Stages:
      • Inflammation: The ulcer begins with redness and swelling, particularly over bony prominences.
      • Ischemia: Occurs when external pressure exceeds the pressure within small peripheral blood vessels. This restricts blood flow to the skin and underlying tissues.

    Analgesics: Opioids

    • Examples: Morphine, Meperidine (Demerol), Hydromorphone (Dilaudid), Oxycodone (Percocet), Hydrocodone (Lortab)
    • Side Effects:
      • Slows GI system → Constipation.
      • Slows vital signs → bradycardia, hypotension, bradypnea.
        • Depress respiratory system → watch for respiratory depression.
        • Hypotension: sit or lie down if dizzy; make position changes slowly.
      • Sedation: caution with activities that require alertness; avoid alcohol.

    Analgesics: Non-Opioid

    • Examples: NSAIDs (Ibuprofen, Naproxen, Ketorolac/Toradol), Acetaminophen (Tylenol)
    • Key Considerations:
      • Nephrotoxicity → N in NSAID → Nephrotoxic
      • NSAIDS → watch for GI bleeds. Caution if have gastritis, GI ulcers.
      • Limit acetaminophen intake to 4000 mg per day d/t liver toxicity. Assess if for alcoholism.

    Analgesics: Muscle Relaxants

    • Examples: Gabapentin (Neurontin), Cyclobenzaprine (Flexeril), Carisoprodol (Soma), Baclofen
    • Key Considerations: Watch for respiratory depression, dizziness, and drowsiness. Diaphragm is the muscle that helps support breathing → too relaxed → no breathing!!!!!!!

    Restraints

    • Types:
      • Physical restraining: Restrict client movement through the application of a device.
      • Chemical restraints: Medications given to inhibit a specific behavior or movement.
    • Nursing Assessment: Every 15/30 mins
      1. Assess skin
      2. Assess neurovascular status
      3. Check need to urinate
      4. Check ROM
      5. Offer fluids
    • Key Considerations:
      • LAST RESORT
      • Must have an order specifying or have DR assess within 1 hour of application
      • All patients with restraints= fall risk
      • Do not attach the restraint to a side rail, bed rail, mattress, head/footboard, or anything that does not move with the patient.

    Gas Exchange

    • Process by which oxygen is transferred from the lungs to the bloodstream and carbon dioxide is removed from the bloodstream to the lungs.

    Role of the Respiratory & Cardiovascular Systems in Oxygenation

    • Respiratory System: Brings oxygen into the body and removes carbon dioxide through breathing.
      • Respiratory center in the brain: Medulla.
    • Cardiovascular System: Transports oxygen to tissues and removes carbon dioxide through the bloodstream.

    Breathing Mechanism

    • Inhaling: The diaphragm contracts and moves down, and the muscles between the ribs pull the rib cage up and out → ↑space/ volume in the chest cavity → ↓ pressure in chest cavity → pulls air into nose/mouth.
    • Exhaling: The muscles relax → ↓ space/ volume in the chest cavity → ↑ pressure in chest cavity → air is forced out.

    Ischemia

    • Definition: Insufficient flow of oxygenated blood to tissues.
    • Consequences: Can lead to hypoxemia, resulting in cell injury or death. Note: -EMIA= BLOOD!!!!!!

    Hypoxemia

    • Definition: Deficiency of oxygen in the blood.
    • Impact: Insufficient oxygenation of tissues, leading to potential organ dysfunction. Note: -EMIA= BLOOD!!!!!!

    Hypoxia + Anoxia

    • Hypoxia: Inadequate amount of oxygen available to cells/tissues. Effects: Can impair cellular metabolism and function.
    • Anoxia: Complete lack of oxygen to body tissues.

    Metered Dose Inhaler (MDI)

    • Patient Instructions:
      1. Twist canister > Shake well
      2. Patient exhales
      3. Place the mouthpiece into the mouth
      4. Depress the MDI to dispense medication and immediately inhale slowly and deeply.
      5. Hold breath for 5-10 seconds
      6. Wait 1-5 mins b/w puffs
      7. Repeat
      8. Rinse MDI with soap and water or water after each dose

    Metered Dose Inhaler (MDI) - Use of Spacer

    • Benefits of Spacing:
      • Improve drug delivery
      • Acts as a reservoir > makes it less complicated, dose more predictable > longer time to inhale
      • Remove after each use

    Dry Powdered Inhaler (DPI)

    • Patient Instructions:
      • Breathe out: Exhale slowly and completely without inhaling into the DPI.
      • Positioning: Place teeth over and seal lips around the mouthpiece. Avoid blocking the opening with tongue or teeth.
      • Inhale: Breathe in strongly, steadily, and deeply through the mouth for 2-3 seconds.
      • Breath hold: Remove inhaler from mouth and hold breath for 5-10 seconds, then exhale slowly through pursed lips.
      • Post-administration:
        • Wait: 1-5 minutes as indicated before the next dose.
        • Replace Cap: After all prescribed puffs.
        • Rinse Mouth: Gargle with tap water.

    Diaphragmatic Breathing

    • Purpose: Strengthens the diaphragm, maximizes inhalation, and slows respiratory rate.
    • Technique:
      1. Sit upright or lie down.
      2. Place one hand on the abdomen and one on the chest.
      3. Inhale slowly through the nose, letting the abdomen rise.
      4. Exhale gently, allowing the abdomen to fall.
    • Benefits: Enhances lung capacity, promotes relaxation, improves oxygenation.

    Chest Physiotherapy

    • Purpose: Techniques to eliminate secretions and improve respiratory function.
    • Methods:
      • Cough Assist: Helps patients expel mucus.
      • Postural Drainage: Positions the body to promote mucus clearance.
      • Chest Percussion: Clapping on the chest to loosen secretions.
      • Vibration: Manual shaking to aid in secretion mobilization.
    • Benefits: Loosens and mobilizes secretions. Increases mucus clearance, especially in patients with ineffective cough.

    Suctioning

    • Who Requires Suctioning? Unable to expel or cough out secretions; increased respiratory effort; obvious secretions → moist lung sounds; hypoxia; reduced breath sounds.

    How To Suction

    1. Hyperoxygenate patient with 100% O2
    2. Position:
      • Unconscious: Side-lying
      • Conscious: Sitting, upright

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    NUR 112 Exam 4 Review - Mobility, Oxygenation, Elimination, and Infection Control PDF

    Description

    This quiz covers key nursing assessments and interventions for immobility-related issues. It focuses on metabolic, respiratory, cardiovascular, musculoskeletal, skin, and elimination system assessments. Test your knowledge on the importance of monitoring and interventions aimed at reducing complications from immobility.

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