Complications of Immobility
Musculoskeletal System
Body Mechanics
Assistive Devices
Pressure Ulcers & DVT's
Terminology
100
Patients that are immobile are at an increased risk of this- their muscle fibers becoming smaller and weaker.
Atrophy
100
What are 3 functions of the skeletal muscle?
1. Movement
2. Posture
3. Generate body heat
100
Center of gravity for the human body
Umbilicus/Waist
100
When assisting a client with walker use, the nurse knows that this is the proper height for the walker
at the wrists
100
Which pressure ulcer stage involves full thickness skin loss, where the muscles, tendons, ligaments, and bones are visible to the outside.
Stage 4
100
The act of having a client sit on the edge of the bed before moving to a standing position.
Dangling
200
Name 3 nursing interventions to prevent atelectasis
1. Incentive Spirometer
2. Cough & Deep Breathing exercises
3. Elevate HOB 30-45 degrees
4. Turn & reposition the patient
5. Monitor Pox and administer O2 PRN
200
Nonflexible fibrous connective tissue that attaches muscle to bone.
Tendons
200
Having your feet shoulder width apart widens this
Base of Support
200
During the ___ point gait, the patient has the inability to bear weight on one leg. They advance the non-weight bearing foot and crutches together, then bring the other foot to the position of the crutch.
3- point gait
200
Clients who are immobile are at a greater risk for developing a ___ due to their increased blood viscosity and the atrophy of muscles that normally assist the body in pumping the blood. These factors diminish the body’s ability to effectively circulate blood, leading to venous stasis.
DVT (Deep Vein Thrombosis)
200
A decrease in blood pressure that occurs upon standing, especially from a lying or sitting position. A significant drop in the blood pressure caused by a change in position.
Orthostatic Hypotension
300
How do nurses assess for constipation?
1. auscultate bowel sounds to assess for peristalsis
2. palpate the abdomen for pain and discomfort
3. assess for nausea, vomiting, abd pain, passing of flatus
300
Muscle fibers shorten during this, causing the movement of bones
Contraction
300
- Stand or move as close to the object as possible.
- Keep the abdominal muscles contracted and the lower back in its normal position.
- Maintain the head upright with shoulders raised up.
- Bow the hips slightly and squat.
- Do not twist the torso. Always pivot or side-step.
- Push up from the knees and use that momentum to lift the object.
Proper Body Mechanics
300
When assisting a client with quad cane use, the nurse places the cane of the client's ______ side.
strong/unaffected
300
Name 5 bony prominences that are at an increased risk for pressure ulcers
1. back of head
2. shoulders
3. elbows
4. sacrum/coccyx
5. knees
6. ankles
7. heels
300
Excessive outward curvature of the upper area of the spine.
Kyphosis
400
What are 3 nursing interventions to prevent urinary tract infections?
1. increase fluid intake
2. Initiate a toileting schedule and encourage frequent voiding
3. Maintain perineal cleanliness
400
Name this patient position
Prone
400
the study of body mechanics in relation to the demand and design of the work environment, along with the equipment used. It focuses on designing, adjusting, and arranging items so that people can work safely and efficiently.
ergonomics
400
When using a gait belt, have the patient ____ to help them stand.
Rock
400
These are 2 nursing interventions that nurses can take in regards to their lower extremities to reduce the patient's risk of DVT
1. SCD's (sequential compression devices)
2. TED hose (anti-embolism hose)
400
Stones that develop in the kidney and usually related to dehydration or an increase of stone-forming substances.
Renal Calculi (Kidney Stones)
500
____ occurs when bones have become thinner and weaker as a result of prolonged bed rest. This demineralization results in fragile bones, which are prone to breaking even under minor stress. The resulting injuries are termed fragility fractures.
Disuse osteoporosis
500
Flexible connective tissue that coats bony areas, allowing them to glide over each other and absorbs shock.
Cartilage
500
Name 4 things nurses do to have improper body mechanics when lifting/moving patients?
1. turn at the torso to pivot patients
2. Bend at the waist and use back muscles
3. Position objects 12 inches away that need to be moved.
4. Look down when walking
500
When the client is gripping the cane, the elbow should be bent at approximately a ____ angle
15º to 30º
500
Name 4 nursing interventions for pressure injury prevention
1. Ensure the client is repositioned at least every 2 hours to promote adequate blood flow to bony prominences.
2. Use pillows and cushions to support the client in different positions.
3. Use assistive devices and proper technique when repositioning to minimize additional skin trauma.
4. Use pressure redistribution devices on mattresses and chairs to decrease prolonged pressure on areas susceptible to breakdown.
5. Moisturize dry skin to decrease the risk of skin breakdown.
6. Ensure intake of adequate calories, protein, and micronutrients to promote healing of damaged areas.
7. Keep skin free from moisture due to incontinence, wound drainage, or perspiration, all of which increase the risk of skin breakdown.
500
Collapse of airways and small sections of the lung as a result of shallow breathing. The collapsing of the lung during expansion.
Atelectasis