NURS 1003 weeks 7-10

factors influencing immobility

• bed rest

• disease atrophy

metabolic changes of immobility

• decrease metabolic rate

• calcium absorption (hypercalcemia)

• negative nitrogen balance

respiratory changes of immobility

atelectasis --- collapse of alveoli
hyperstasis pneumonia --- inflammation of lung from stasis or pooling of secretions

cardiovascular changes of immobility

orthostatic hypotension - drop of blood pressure
greater risk of thrombus formation - accumulation of platelets, fibrin, clotting factors attached to wall of vein or artery

virchows triad

1. loss of integrity of vessel wall

2. alterations in blood flow

3. alterations in blood constituents

embolus

dislodged venous thrombus

muscle changes from immobility

disuse atrophy --- pathological reduction in the normal size of muscle fibres after prolonged inactivity

skeletal changes from immobility

• impaired calcium metabolism and joint abnormalities

• disuse osteoporosis

Urinary elimination changes from immobility

urinary stasis - peristalsis cannot overcome gravity
renal calculi - calcium stones lodge in the renal pelvis and pass through the ureters
inedequate perineal care - E.coli contamination

integumentary system changes from immobility

pressure injury - develops when pressure on skin and greater than pressure inside the small peripheral blood vessels

psychosocial effects of immobility

- decreased social interaction, isolation, sensory deprivation, loss of independence, depression

flexion

decreasing angle

extension

increasing angle

hyperextension

movement beyond its normal resting extended position

dorsiflexion

flexion of toes and foot upward

plantarflexion

bending of toes and foot downward

abduction

movement of extremity away from midine

adduction

movement of extremity towards the midline

eversion

turning of body away from midline

inversion

turning of body towards midline

pronation

movement so front faces downward

supination

movement so front faces downward

circumduction

circular movement of limb in circular manner

gait

• manner or style of walking

• cycle begins with heel strike of one leg and continues to hee, strike of the other

what should you observe for gait?

speed, stride, balance

activity tolerance

type and amount of exercise or worl that a person is able to perform without undue exertion or possible injury

respiratory interventions

reposition Q2HR

• promote expansion of chest and lungs

• prevent stasis of pulmonary secretion

• encourage deep breathe and cough Q1-2HR

how to prevent thrombus formation

leg exercises, fluid intake, position changes, anticoagulation, elastic stockings

how much fluid should be taken in a day

1100-1400 mL of noncaffeinated fluids per day

wedge pillow

triangular shaped pillow form for legs in abduction after hip replacement

foot boot

prevents foot drop, maintains dorsiflexion

trochanter roll

folding cotton bath blanket lengthwise to a width that extends from greater trochanter of femur to lower border of popliteal space prevents external rotation of his when pt is in supine position

sandbags

sand filled plastic tubes shaped to body contoura

hand rolls

maintain thumb in slight adduction, prevents contractures

hand-wrist splints

individually moulded for patients for thumb and wrist

trapeze bar

triangular device over bed frame allows pt to use upper extremities

hyperemia

redness of skin if pressure os relieved and blood flow returns

blanching

when normal red tones of light-skinned patients are absent

risk factors for pressure injury

• impaired sensory perception

• impaired mobility

• alteration in consciousness

• shear

• friction

• moisture

• nutrition

• tissue perfusion

• infection

• pain

• age

stage 1 pressure injury

intact skin with localized area of nonblanchable erythema, changes in sensation, temperature, firmness

stage 2 pressure injury

partial thickness loss with exposed dermis, would bed viable, adipose not visible

stage 3 pressure injury

full-thickness loss of skin in which adipose is visible, slough, eschar may be visible, undermining and tunnelling may occur

stage 4 pressure injury

full thickness tissue loss with exposure to directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in ulcer

unstageable pressure injury

full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because its obscured by slough or eschar

respiratory assessment

• RR, 02 sat

• assess quality of respirations

• cap refill

cardiac assessment

• radial pulse and bp

• check peripheral pulse

• skin warm and dry

• no swelling

abdominal assessment

• last BM

• changes in appetite

• nausea and vomiting

• listen to bowel movement

integumentary assessment

• warm and dry

• intact

• assess for reddened areas

• check pressure areas : heels, sacrum, hip

signs and symptoms of infection

• burning

• pain

• tenderness

• discharge

• foul odour

• skin irritation

how often should you brush

4 times a day

how often should you perform oral care in an unconscious patient

mouth care Q2HR

dental caries

discolouration of the tooth

gingivitis

inflammation of the gums

periodontitis

receding of gum lines

halitos

bad breath

cheilosis

cracking of lips

stomatitis

inflammation inside mouth

denture care

• remove dentures

• place in k(emesis) basin

• have face cloth in sink

• brush carefully

• soak

• rinse

assessing hair

• condition of hair and scalp

• should be clean and shiny

• scalp free of lesions

• inspect for pediculosis capitis (lice)

complete bed bath

when patient is totally dependent and require total hygiene care

partial bed bath

involves bathing only body parts causing discomfort or odour of not cleansed and not easily reached by the patient

basic eye care

- washing with clean washcloth soaked with water inner to outer using different sections of the washcloth for each eye

ear care

• end of a moistened washcloth rotated gently into ear canal

• excessive or impacted cerumen can only be removed by irrigation

basal metabolic rate

energy needed to maintain life-sustaining activities

resting energy expenditure

measurement that accounts for BMR plus energy to digest meals and perform mild activity, baseline energy requirement

kilocalorie

energy required to raise 1kg of water by 1c

fortified foods

additional vitamins and/or minerals to provude added health benefits or enhanced with bioactive components through plant breeding, genetic modification, processing, special livestock feeding techniques

organic foods

vegetables, fruits, eggs, milk, meat produced without synthetic additives

recommended source of energy

carbohydrates

high glycemic index

release glucose rapidly

low glycemic index

release glucose in small fluctuations

purpose of fats

supplies energy, cushions organs, lubricates body tissue, insulates, cell membrane

how many minutes per week of moderate to vigorous aerobic physical activity

150 min

how many minutes of moderate to vigorous activity per day

60 min

anthropometry

• measurement system of the size and makeup of body

• ideal body weight provides an estimate

measures weight corrected for height and serves as an alternative to traditional height-weight relationships

DIVIDES WEIGHT IN KG BY HEIGHT IN M2

FASTCHECK

Food practices
allergies
symptoms
tracking
chewing and swallowing
hunger
elimination patterns
chemical substances
knowledge

during feeding

keep upright
tilted on stronger side of mouth
5-10 seconds per bite
sit in line of vision

after feeding

remain upright 30 minutes
check for pocketing of food

what is the most accurate means to evaluate fluid balance

daily weight at the same time and same scale after voiding

what eternal tube fitting are nurses allowed to insert

nasogastric or orogastric tubes ONLY

large-bore

decompression and short-term eternal feeding

small-bore

preferred, reduces comfort, used for longer periods

how to listen to bowel sounds

• place stethoscope on right side of abdomen and work clockwise

• should hear 5-30 sounds per minute

• should listen for 5 minutes before determining no bowel sounds

What should you ensure is ready before feeding

suction and oxygen

how to encourage swallowing when pocketing

• placing food in mouth

• using empty spoon

renal diet

fluid restrictions, low potassium, low or no sodium

healthy heart

low salt and cholesterol

diabetic diet

low sugar, healthy heart

when is a clear fluid or full fluid diet used

typically after surgery

when is a minced/pureed diet used

difficulty swallowing

Dysphagia

difficulty in swallowing (typically from neurological diseases)

what can dysphagia lead to

• increased risk in aspiration or choking

• aspiration pneumonia

• impaired gag reflex

GERD

gastroesophageal reflux disease (heartburn)

• should have small requent meals

• sit upright 2 hours after meal

• avoid spicy food

gastronomy tube

inserted surgically through abdominal wall directly into stomach

jejunostomy tube

inserted surgically through abdominal wall directly into jejunom

Nasogastric tube

inserted through patients nose down esophagus to the stomach

nasoenteric tube

inserted through patients nose down esophagus to the small intestine

what do you do if occlusion occurs

- flush tube with warm water and large piston syringe