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ImmobilityFundamentals of Nursing

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How is the metabolic system assessed for changes due to immobility?
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Anthropometric measurements, I&O records, labs for electrolytes/serum protein/BUN, assess food intake/elimination
How is the respiratory system assessed for changes due to immobility?
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Inspecting chest wall movement during inspiration/expiration, auscultation for decreased breath sounds/crackles/wheezes
An immobilized client get a respiratory assessment every ____.
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2 hours
How is the cardiovascular system assessed in an immobilized client?
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BP (orthostatic), apical/peripheral pulses, s/symptoms of venous stasis, edema assessment, look for s/symptoms of DVT, take calf and thigh measurements daily
When assessing for edema, what areas should be checked?
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Sacrum, legs, feet
An immobilized client has cold hands, feet, nose, and earlobes but their central body regions are warm. This means?
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The heart is unable to tolerate the increase work load leading to cardiac failure (common in elderly)
You hear a third heart sound in an immobilized elderly woman. You suspect that?
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her heart cannot handle that increased workload and she is going into CHF **heard at apex**
A client should be assessed for DVT every ____ hours.
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8
How should you assess a client for DVT?
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Measure calf circumference 10 cm down from mid patella daily, measure thigh, and check for redness, warmth, and tenderness
Who is most at risk for disuse osteoporosis?
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Clients on bed rest, postmenopausal women, steroids, increased serum and urine calcium
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____ increases the risk for skin breakdown, thrombus, respiratory infections, UTIs, and constipation.
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Dehydration
Grandma is uncharacteristically confused. You suspect?
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UTI
What is the major difference between a diagnosis of impaired physical mobility and risk for disuse syndrome?
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Physical: some limitation, not completely immobile; disuse: immobile and at risk of multisystem problems
What are lifestyle risk factors for osteoporosis?
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Smoking, caffeine, alcohol, menopause
An immobilized, acute care client should be on a ____ diet.
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High calorie, high protein with vitamins B&C
What interventions improve the respiratory status of immobilized patients?
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Cough and deep breathe ever 1-2 hours, use incentive pyrometer every hour, three deep breaths and cough with third exhale, chest physiotherapy (CPT), Ambu and suction is unconscious
An immobile client should consume ____ mL of fluid a day to decreased viscosity of pulmonary secretions.
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2000 mL
Orthostatic hypotension is characterized by ____ (increase or decrease) in pulse rate, ____(increase or decrease) in pulse pressure and ____ (increased or decreased) BP.
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Increased pulse rate, decreased pulse pressure, decreased BP
What is the primary intervention for decreased cardiac workload?
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Discourage Valsalva maneuver (can lead to sudden cardiac death)
What interventions can prevent DVTs?
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Leg/foot/ankle exercises, fluids, position changes, get out of bed ASAP, meds, intermittent pneumatic compression (IPC/SCD), heparin, TED hose
What positions should be avoided for someone at risk for DVTs?
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Crossed legs, prolonged sitting, restrictive clothing around legs or waist, pillows under knees
  
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