Immobility Study Guide PDF

**Immobility (Potter chapter 46 + 38)** Explain potential consequences of immobility in relation to different body systems \- Identify interventions to reduce the hazards of immobility \- Recognize risk factors for falls \- Identify interventions to reduce the risk of falls **Atelectasis**; Col...

**Immobility (Potter chapter 46 + 38)** Explain potential consequences of immobility in relation to different body systems \- Identify interventions to reduce the hazards of immobility \- Recognize risk factors for falls \- Identify interventions to reduce the risk of falls **Atelectasis**; Collapse of the alveoli that prevents normal gas exchange between carbon dioxide and oxygen **Contracture**; A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff **Pressure injury**; localized damage to the skin and underlying soft tissue (usually occurring over a bony prominence/related to medical devices) characterized by initially by inflammation *Ischemia* develops when the pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin. Pressure affects cellular metabolism by decreasing or totally eliminatinge tissue circulation. *Bony prominences*; scapulae, elbows, coccyx, heels more at risk to breakdown **Thrombus**; accumulation of platelets, fibrin, clotting factors and the cellular elements of the blood **Mobility**: "Refers to the ability to move easily and independently" **Immobility**: "Inability to move about freely" **Body mechanics**: Coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing ADLs **Immobility, e.g. bed rest** Intervention that restricts patients to bed for therapeutic reasons Individual of average weight and height without a chronic illness on bed rest loses muscle strength at a rate of 3% a day complication and risk if the patient stay a long time in bed. Reasons; - Reduce physical activity and the oxygen needs of the body - To reduce pain, including postoperative pain, and the need for the large doses of analgesics - To promote safety for patients recovering from the effects of anaesthetics or who are sedated - To allow patients who are ill or debilitated to rest - To allow patients who are exhausted the opportunity for uninterrupted rest Disease atrophy = tendency of cells and tissue to reduce in size **What are potential consequences of immobility?** - Loose autonomy (weak muscle) - Loose capacity to walk (decondition) - Cardiovascular (thrombosis) - Pressure injury - Blood coat **Systemic effects of immobility** - **Metabolic changes;** immobility disrupts normal metabolic functioning by decreasing the metabolic rate, calcium loss from bones, decrease of BMR = fluid, electrolyte and calcium imbalanced, decrease appetite, slowing peristalsis - **GI;** decrease in peristalsis, decrease in appetite, constipation, difficulty passing stools, pseudo diarrhea may result from fecal impaction - **Respiratory; [Atelectasis]** (collapse of alveoli), hypostatic **[pneumonia]** (inflammation of the lung from stasis or pooling of secretions) - **Cardiovascular;** Deep vein thrombosis (accumulation of platelets), orthostatic hypotension (drop of blood pressure, increased cardiac workload (the heart works harder and less efficiently during periods of prolonged rest). **[DVT]** (deep vein thrombosis); clot in the vein, Atrophy - **MSK;** loss of endurance, strength, and muscle mass (osteoporosis), decreased stability and balance, impaired calcium metabolism and impaired joint mobility, footdrop (inability to dorsiflex permanently fixed in plantar flexion), joint contracture (fixation of joint), lose of normal ROM - **Urinary Elimination;** Urinary stasis (urine cannot empty from the bladder), not moving =urinary not getting out of the bladder upright position gravitational force facilitates flow of urine out. - **Integumentary;** pressure injury (localized damage skin) - **Psychosocial;** loss of independence, decrease of social interaction, social isolation, sensory deprivation, depression **Advantages of mobilisation** ***↓ hazards of immobility*** +-----------------------------------+-----------------------------------+ | Metabolic system | Often require high-protein, | | | high-calorie diet | +===================================+===================================+ | Respiratory system | -Repositioning | | | | | | -Deep breathing & coughing | | | | | | -Fluid intake | +-----------------------------------+-----------------------------------+ | Cardiovascular system | -Change positions slowly | | | | | | -Leg exercises | | | | | | -Graduated compression stockings | +-----------------------------------+-----------------------------------+ | Musculoskeletal system | -ROM exercises | +-----------------------------------+-----------------------------------+ | Elimination system | Ensure diet is rich in fluids, | | | fruits, vegetables and fibre | +-----------------------------------+-----------------------------------+ | Integumentary | Repositioning | +-----------------------------------+-----------------------------------+ | Psychosocial | Promote patient participation | +-----------------------------------+-----------------------------------+ **Leg exercises** - Dorsiflexion, plantarflexion - Flexion of the knee - Ankle rotation **Elastic stockings** Circulation of the lower extremities **Sequential compression stockings** Circulation of the lower extremities **Falls** "An event which results in a person coming to rest inadvertently on the ground or floor or other lower level" Some statistics Approximately 20-30% of older adults fall each year 95% of hip fractures among older adults are caused by falls **Nurses' role:** - Assessment; Screen risk for falls Instruments e.g. Morse Fall Scale - Identification of risks factors Individual factors + Environmental factors **Vocabulary;** **Friction;** force that occurs in a direction opposing movement (force of two surface that move across one another) **Shear;** force exerted against the skin while the skin remains stationary and the bony structures move. E.g head of a hospital bed is elevated beyond 60 degrees and gravity pulls a patient so that the bony skeleton moves toward the foot of the bed while the skin remains against the sheets. [Blood vessels in underlying tissue = stretched + damaged] (deformation of tissue by two opposite force) **Pressure injures** often develop within the undermined tissues, surface tissue appears less affected **Pressure**: force perpendicular to a surface **Hemiparesis;** weakness of one side of the body (muscle weakness **Hemiplegia**; complete or partial paralysis on one side of the body (muscle paralysis) **Quadriplegia**; four limb paralysis **Paraplegia**; two limb paralysis **Muscle atrophy;** loss of muscle tissue **Pain & Comfort (Potter chapter 32)** \*Review exercices (mise en situation) in the ppt **Pain =** unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" "Whatever the experiencing person says it is (self report), existing whatever it does" **Pain =** fifth vital signs (can influence the other VS) More than a physical sensation includes affective (emotional), cognitive, behavioural, and sensory components that are shaped by past experience, culture and situational factors **Types of pain** (depending on what they are, we treat them differently) +-----------------------------------+-----------------------------------+ | **\*Nociceptive** | **\*Neuropathic** | +===================================+===================================+ | ------------- -------------- | \*Origin of pain, what is causing | | **Somatic** **Visceral** | the pain | | ------------- -------------- | | +-----------------------------------+-----------------------------------+ **Nociceptive** - Caused by tissue injury - Can be classified as somatic or visceral **Somatic**; arises from skin, bones, joints, muscles or connectives tissue (shark, aching quality help you different) WELL LOCALIZED, ACHING, THROBBING **Visceral**; arises from internal **organs** e.g. kidney, stomach, intestine, gallbladder. FAIRLY WELL-LOCALIZED VS POORLY LOCALIZED PAIN. E.g. Tumor: still are in the organ but are more difficulted localized. More general **Neuropathic** - Arises from abnormal or impaired pain nerves. E.g. trauma to the spinal cord, diabetic neuropathy - Described as burning, shooting, electrical shocks, tingling, pins and needles - Lesion = abnormality *quality is different = treatment is different* "Nociceptive pain develops in response to a specific stimulus to the body, but neuropathic pain doesn\'t. Neuropathic pain is pain that comes from damage to the nerves or nervous system. It causes a shooting and burning type of pain or numbness and tingling" **Neuro =** brain **Pathy =** disease **\*\*Vocabulary** **Analgesia;** decreased or absence of pain sensation **Referred pain**; originates in one location but is felt at another site **Radiating**; sensation of pain that extends from the side of injury to another body part **Nerves fiber;** hypothesis? **Types of pain** (duration different) +-----------------------------------+-----------------------------------+ | **Acute** | **Chronic** | +===================================+===================================+ | Short term (less than 3 months) | Persists past the normal time of | | | healing | | Follows a predictable trajectory | | | | Types are malignant | | Dissipates after injury heals | (cancer-related) and nonmalignant | | (surgery heals) | | | | e.g. cancer, fail back syndrome = | | = good; ability to sense, to know | failed surgery = constant pain | | that something is wrong = | | | receptors are protective defense | | +-----------------------------------+-----------------------------------+ **Responses to pain** = intensity of the pain Physiological (body function) responses may include. - Changes in blood pressure and heart rate (could go up or down) - Pallor (pale, blood toward important organs) - Diaphoresis (sweating) Behavioural responses may include. - Facial expression (jaw clenching, frowning, grimacing ) - Vocalizations (e.g. crying, moaning, moaning, gasping) - Body movements (e.g. protecting the painful part, rocking, bent, posture, restlessness) - Social interactions (e.g. withdrawal, avoidance of conversation, reduced attention span) **Factors influencing pain** +-------------+-------------+-------------+-------------+-------------+ | **Physiolog | **Social** | **Spiritual | **Cultural* | **Psycholog | | ical** | | ** | * | ical** | +=============+=============+=============+=============+=============+ | - Age | - Distrac | | | - Anxiety | | | tion | | | | | - Sleep | | | | - Meaning | | | - Previou | | | of pain | | - Heredit | s | | | | | y | experie | | | | | | nce | | | | | - Neurolo | | | | | | gical | - Family | | | | | functio | and | | | | | n | social | | | | | | support | | | | +-------------+-------------+-------------+-------------+-------------+ **Assessment of pain** - Person's self report of pain is the gold standard! ask the patient to tell you - Include PQRSTU, physiological & behavioural indicators, pain history - Establishing a pain goal with you patient will enable you to interpret the information you collected E.g. "what is an acceptable level of pain for you?" - **Different scales exist** **Pain scales** - Numeric rating scale 0-10 - Visual analog scale (when pt's can't describe their pain) - Simple descriptive pain scale - SN4 (neuropathic pain) - Behavioural scales (somatic reactions) **Possible sources of error** 1. Bias; overestimation or underestimation the pt's pain 2. Unclear assessment questions which lead to unreliable assessment data 3. Excluding the pain context and trajectory or change in an individual's expression of pain over time **Nonpharmacological pain-relief interventions** - Relaxation e.g. meditation, guided imagery, deep breathing, lying, siting - Distraction (music, biofeedback, acupuncture, therapeutic touch - Massage - Heat/cold **Controlling stimuli in the patient's environment** - Change wet dressings and linens - Patient positioning - Prevent urinary retention and constipation - Reduce lighting and ambient sound **Pharmacological pain-relief interventions** - Nonopioid analgesics - Opioid analgesics (narcotics) work by changing the brain's perception of pain - Adjuvants/Analgesics drugs with a primary indication other than pain that have analgesic properties in some painful conditions. **Adjuvants (co-analgesics) =** medications that were originally developed to treat conditions other than pain but have been shown to have analgesic properties. E.g. antidepression that can be used for pain relief Placebo: any treatment thought not to have any specific effects **Barriers to effective pain management** - **Patient** (fear of addiction, previous experience with poorly controlled pain, worry about adverse pain) - **Health care provider (**Concern about addiction, fear of giving a dose that will kill the patient, opiophobia, no visible cause of pain exists) - **Health care system** (ability to fill prescription, extensive documentation requirements, poor pain policies and procedures regarding pain meangement) **Evaluation** - Must evaluate the response to a pain-relieving intervention (readjustment if needed) - Evaluating the appropriateness of pain medication will vary according to the onset and peak of the medication - May need to try another pain-relieving intervention **Nutrition (Potter chapter 43)** Identify the different components of a nutritional assessment Accurately obtain and interpret anthropometric measurements Recognize signs of dysphagia Explain risks for aspiration Apply aspiration & dysphagia precautions Accurately measure and analyze intake and output Differentiate different types of diet Identify nursing interventions to promote improved nutrition Identify clinical indicators of poor nutritional status **Malnutrition** "Commonly overlooked in hospitalized patients. As many as 30--50% of patients show risk of malnutrition at admission, and malnutrition is a major contributor to increased morbidity and mortality, decreased quality of life, longer hospitalizations, more frequent readmissions, and increased resource utilization---all leading to higher health care costs (Siegel et al., 2019)." 1. **Nutritional assessment** **Anthropometry** Height, weight, Body Mass Index (BMI), waist circumference **Laboratory and biochemical tests** **Diet history and health history** Food practices, allergies, symptoms, 24-hour recall, chewing & swallowing, hunger, elimination patterns, chemical substances, knowledge **Clinical observation and physical examination** Assess for aspiration risk and dysphagia **Alternative food patterns** - Religion-based dietary restrictions and guidelines - Vegetarian diet - Octo-lacto - Lacto - Pesco-vegetarian - Vegans **Factors affecting nutrition** Age-related GI change Diseases and medication Low income and education Lack of transportation Socialization **Clinical observations and physical examination** Clinical signs of nutritional status potter p. 1117 Assessment for dysphagia difficulty swallowing Assessment for aspiration risk food or liquid goes into your airway instead of your esophagus (we swallow to prevent aspiration) **Signs of dysphagia** Delayed swallowing Coughing during eating Abnormal gag reflexe Change in voice tone or quality after swallowing Abnormal movement of the mouth, tongue or lips Slow, weak imprecise, uncoordinated speech Saliva or food leaking around mouth Incomplete oral clearance or pocketing of food Regurgitation **Risks of aspiration** Risks: Dysphagia ↓ level of alertness ↓ gag or cough reflexes Difficulty managing saliva Wet, gurgling voice Silent aspiration **Aspiration & Dysphagia precautions** - **Before feeding**, assess the patient's risk for aspiration. Patient should sit as upright with head tilted slightly forward and maybe supported by pillows, (if patient is lying back or has the back arched or hyperextended = should not be fed). Glasses, hearing aids and dentures - **During feeding**, patient is kept upright, metal teaspoon best for feeding, nurse assess swallowing during feeding, give patient with dysphagia enough time to chew, allowing at least 5 to 10 seconds for each bit or sip, the pt's Adam's apple should move up and down. Nurse who is helping the patient to eat should sit in the patient's line of vision - **After feeding**, patient should remain upright for 30 minutes after eating. Nurse should check for pocketing of food. Head of the bed can be raised to sitting up level. Food intake should be documented. Nurse should identifyif any particular food was eaten faster or with difficulty + report and document of choking and fatigue **Interventions for promoting nutrition** Eliminate unpleasant odors Oral hygiene Meals in a chair rather than in bed Presence of family members Medications **Types of diet** **Clear liquid:** limited to broth, bouillon, coffee, tea, clear fruit juices, gelatin **Thickened liquid:** all liquids (juice tea, water) must be thickened to the appropriate consistency (nectar, honey, or pudding) when thin fluids cannot be safely swallowed and may be aspired **Full liquid;** smooth-textured dairy products custards, refined cooked cereals, vegetables juice, puréed vegetables, or any fruit juices **Puréed;** scrambled eggs, puréed meats and vegetables, fruits (ripe bananas, mashed cooked fruits without skins) or smashed potatoes and gravy **Mechanical soft;** ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes **Soft or low residue:** low fibre, easily digested foods, such as pastas, casseroles, moist tender meats, canned cooked fruits and vegetables **High fibre:** fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits **Low sodium:** 4g (no added salt), 2g, 1g or 500mg sodium **Low cholesterol:** restricted to \