Transcript NUR 130 Fundamentals of Nursing

Immobility & Body Mechanics
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Refers to the ability to engage in activity and
free movement, which includes walking,
running, sitting, standing, lifting, pushing,
pulling and performing ADLs (Activities of
Daily Living)
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Is a therapeutic intervention that achieves:
◦ Rest for client’s who are exhausted
◦ Decreases body’s O2 consumption
◦ Reduces pain and discomfort
◦ To reverse effects of gravity-abdominal hernia
After 48 hr of bed rest-structural changes in joints
and shorten muscles occur
7 days are needed to restore function lost after 1
day of bed rest (Eliopoulos, 1999)
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Metabolic: decrease in BMR r/t decreased
energy requirements, which is directly r/t
cellular 02 demands
Results in > % body fat & loss of lean body
mass
Altered carbohydrates ,proteins, fats
metabolism
Fluid and electrolyte imbalances
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Orthostatic hypotension due to prolonged bed rest.
Drop of 15 mm Hg or more in systolic BP with
position change
Decrease circulating volume, pooling of blood in
lower extremities(edema), decreased autonomic
response results in decrease in venous return,
central venous pressure, stroke volume, increase in
HR=>>>cardiac workload,02 demand
Due to stasis >>> risk thrombus formation
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Increase activity slowly but progressively
Avoid crossing legs, pressure behind knee
Encourage antiembolic leg exercises q 2
hours, other isometric exercises
Ant embolic hose
Gradually raise client noting BP, HR, assess
dizziness/lightheadedness
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Decrease in lung expansion, generalized
respiratory muscle weakness, and stasis of
secretions
Decreased hemoglobin levels
Atelectasis --collapse of alveoli resulting in
decrease of 02 / C02 exchange
Hypostatic pneumonia– inflammation of the
lung from stasis or pooling of secretions
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Change of position q 1 – 2 hr which
allows elastic recoil property of lungs
and clears dependent lung secretions
Cough and deep breath q 2 hr, incentive
spirometry, chest physiotherapy
Fluids to 3000 ml / 24 h to thin
secretions
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Decrease in appetite, peristalsis, constipation
NI: high fiber foods, fluids to 3000 ml/24hr
Small frequent foods of choice
Monitor bowel sounds q shift
Monitor bowel patterns 24 hours
Stool softeners daily as ordered
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Muscle atrophy
Loss of strength and decreased endurance
Joint contractures
Decreased stability or balance
Disuse osteoporosis, a disorder characterized
by bone reabsorption-results from impaired
calcium metabolism
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Frequent ROM: active, passive, active assist q
4 hours
Develop an individualized progressive
exercise program
Isometric and isotonic exercises q 4 hours
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Urine formed by the kidney must enter the
bladder against gravity due to recumbent
position
Ureters insufficient to overcome gravity, renal
pelvis may fill with urine-urinary stasis which
increases risk for UTI & renal calculi
Renal calculi-calcium stones lodged in in
renal pelvis and pass through ureters
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Position change q 1-2 hours
Position 30 degrees of higher to enhance
gravitational forces required for normal urine
flow through kidney, ureters, bladder
I & O q 8 hours
Fluids to 3000 ml 24 hours
RD for diet plan r/t calcium intake
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Increase isolation, passive behavior, changes
in sleep/wake cycles, stressors, sensory
deprivation/overload
Decrease in self-identity, self-esteem, coping
strategies
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Anticipate changes-provide routine and
informal socialization—interact with staff q
1-2 hours
Place in room with others
Encourage family and friends to visit-space
Activity and recreational consult
Schedule nursing cares from 10pm-7am to
minimize interruptions
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Increase in dependence
Regression in development
NI: care should stimulate client mentally,
focus on activities that promote cognitive
awareness, allow client to make care
decisions, allow to be as independent as
condition permits
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Previously called: a decubitus ulcer
A pressure sore
A pressure ulcer
A bedsore
is a wound caused by unrelieved pressure
that damages underlying tissue
◦ Jury still out: caused by external pressure
transmitted inward or from the bone and proceeds
outward
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Pressure ulcers is a wound caused by unrelieved
pressure that damages underlying tissue.
The pressure interferes with the tissue blood
supply, leading to vascular compromise, tissue
anoxia, and cell death
Tend to be located over bony prominences:
*elbows, posterior calf, *sacrum/coccyx ischial
tuberosities, trochanter, lateral malleous, *heel,
lateral edge of foot also: ears, occiput, great toe
region
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AHCPR: Agency for Health Care Policy and
Research establish guidelines to identify atrisk individuals needing prevention and the
specific factors placing them at risk
Risk assessment tool: Braden Scale or Norton
Scale are most commonly used.
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Assesses sensory perception: ability to
respond meaningfully to pressure-related
discomfort
Moisture: degree to which skin is exposed to
moisture
Activity: degree of physical activity
Mobility: ability to change and control body
position
Nutrition: usual intake pattern
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Friction and Shear:
Each category measured from 1-4 with low
score having most limitation
Overall score: Maximum of 23, little or no risk
A score of 16 or < indicates ‘at risk”
A score of 9 or < indicates ‘high risk”
Implement preventive measures for ‘at risk’
and ‘high risk’ clients
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Tissue ischemia is localized absence of blood
or major reduction of resulting in mechanical
obstruction. The reduction of blood floe
caused blanching (to become pale-blotchy)
When obstruction of blood flow is removed
normally there will be reactive hyperemia, the
blood vessels dilate and skin is red
Will last for less than 1 hr and is effective
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only if there is no necrosis of tissue
Abnormal reactive hyperemia is an excessive
vasodilatation and induration in response to
pressure.
Skin appears bright pink and there is
localized edema under the skin—may last up
to 2 weeks after pressure is removed
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Shearing force: sliding down in bed
Friction: linens on the bed
Moisture: diaphoresis urine, wounds, feces
Poor nutrition: neg nitrogen balance
Anemia: < 02 carrying capacity
Obesity: poor vascular supply, weight
Age: epidermis thins with age, < blood flow
LOC: drowsy, sedated, comatose=1position
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Non blanchable erythema of intact skin.
Does not resolve in 30 minutes but remains
for longer than 2 hours after pressure is
relieved
This occurs as an acute inflammatory
response involving the epidermis
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There is partial thickness loss
Pressure area appears as an abrasion, blister,
or shallow crater surrounded by erythema
and induration
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Ulcer involves full-thickness tissue
destruction involving subcutaneous tissue, as
well as epidermis and dermis
The muscle layer is in tact
Requires Wound Nurse consult, may require
surgical intervention
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Includes all of above changes, plus, extensive
damage involving muscle, bone, or
supporting structures such as tendons or
joint capsule
Requires Wound Nurse consult and surgical
intervention
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Emphasis is on prevention !!!
Autolysis: uses body’s own enzymes and
moisture to re-hydrate, soften and liquefy
necrotic tissue
Use occlusive or semi-occlusive dressings:
hydrocolloids, hydrogels, transparent films
Used with wounds with little drainage and
uninfected
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Very selective, with no damage to
surrounding skin
Safe, using the body’s own defense
mechanisms to clean the wound of necrotic
tissue
Effective, versatile and easy to perform
Little or no pain for the client
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Not as rapid as surgical debridement
Wound must be monitored closely for signs
of infection
May promote anaerobic growth if an occlusive
hydrocolloidal is used
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Chemical enzymes are fast acting products
that produce slough of necrotic tissue. Some
enzymatic debriders are selective, while some
are not.
Best uses: on any wound with a large amount
of necrotic tissue
Escar formation
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Fast acting
Minimal or no damage to healthy tissue with
proper application
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Expensive
Requires a prescription
Application must be performed carefully only
to necrotic tissue
May require secondary dressing
Inflammation or discomfort may occur
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Uses force to remove necrotic tissue, for
example wet-to-dry, whirlpool treatment, or
wound irrigation devices
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Cost of the actual material is low
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May traumatize healthy or healing tissue
Time consuming
Can be painful
Hydrotherapy can cause tissue maceration
and water borne pathogens may cause
contamination or infection
Disinfecting additives may harm health
tissues
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Cutting dead tissue away from the wound
Considered the fastest and most effective
type of debridement
Can be done at bedside, surgical suite, or in
an outpatient setting
Should be considered when infection such as
cellulitis or sepsis suspected
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Wounds with a large amount of necrotic
tissue
Used in conjunction with infected tissue
Fast and selective
Cant be extremely effective
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Painful
Costly, esp if operating room is required
Requires transport of client to OR
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Maggot larvae placed in wound and ingests
the microorganisms
Used extensively in Europe and is gaining
popularity in the US
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Develop and post a turning schedule
Use a pressure-reducing devices
Assess pressure points daily
After urinating or stooling cleanse, rinse, dry
Establish a bowel/bladder program
barrier
Monitor intake and output q 8 hr
Use trapeze and foot boards
Protect friction-prone areas
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Proper diet: good protein intake, Vitamin C,
supplements between meals if necessary
Use lift sheets, hoyer lift, smooth roller
Personal hygiene measures—keep clean dry and
linens wrinkle free.
Avoid use of alkaline and deodorant soaps due to
dryness. Use emollients to preserve natural state
of skin moisture
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Coordinated effort
of the
musculoskeletal
system to maintain
posture, balance,
and body alignment
during lifting,
bending, etc.
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Refers to the relationship of
body parts to one another.
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Reduces muscle strain
Maintains muscle tone
Contributes to balance
Contributes to “system”
functioning
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Directly related to alignment
and achieved when:
COG is low
Stable (wide) base of support
Vertical line from COG thru
base of support
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Imaginary vertical line which goes thru center
of body
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Point at which all of
the mass of an
object is centered;
in the adult, who is
in a standing
position it is in the
pelvis;
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Foundation of an object
To stabilize: lower your
center of gravity and
broaden your base of
support
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Force exerted by gravity on the
body.
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Force that occurs in a direction to oppose
movement.
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Reduce surface area
Passive object
produces more
friction
Lift rather than pull
object
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Use wide base of support
Keep COG low
Keep line of gravity passing through base of
support
Face direction of movement when possible
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Roll, pull, push objects rather than
lift
Use largest & strongest muscles
Keep object close to COG
Reduce area of contact
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Move object on flat level, smooth
surface
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Bed: Deep breath, neck rolls, knees to chest, pelvic
tilts, head raising, leg lifts, foot dorsi and planter
flex, ankle rotations, rolling, arms over head, side
to side, palms up and rotate
Chair: deep breathing, head rolls, knee to chest,
head to knees, shoulder rolls, hands on head, leg
lifts, ankle rotation, push down of legs, lean
forward, lift up.
Use Thera bands
handball
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Refers to the presence of a blood clot in one
of the veins
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Risks: prescribed bedrest
General anesthesia for client’s > 40 years of age
Leg trauma resulting in immobilization
Previous venous insufficiency
Obesity
Oral contraceptives
Malignancy
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Anti embolic hose: TED are effective in
providing support to vasculature while client
is in bed
Compression Hose: JOBST are effective in
providing support to vasculature while client
is ambulatory—ALWAYS apply BEFORE client
gets out of bed in the AM. Often removed at
HS.`