Nursing: Unit 4 EXAM

• Impairment- Dysfunction of a specific organ or body system. Generally able to hold a job, complete tasks of daily living, and live independently.
• Disability- Difficulty in performing certain tasks d/t impairment
• Handicap- A physical or mental defect or characteristic that prevents or restricts a person from participating in a normal life or limits the capacity to work; a handicap is usually related to a disability. 
• Patients who are on bedrest are subject to problems of decreased mobility. To prevent hazards of immobility is to prevent injury/illness in the first place. Risks of immobility include fatigue, joint stiffness, weakness, pain, or (metabolic changes, which can lead to obesity) Immobility also increases the risk of blood clots, which cause blood to pool in the extremities. Immobility may cause pneumonia so encourage the patient to cough and deep breathe. Encourage ambulation and range of motion exercises. 
• If a muscle isn't being used, it decreases in strength which leads to weakness. If joints aren't being moved they can be so stiff that they freeze in place, this can increase the risk of falls and injury since the patient is deconditioned and weak, especially if there is a fracture and the patient is unable to move an extremity, that extremity may become frozen in place.
• Movement helps food and gases move through the digestive tract. So immobility may lead to abdominal distention and constipation since peristalsis is decreased.
• Immobile patients are most likely taking shallow breaths. Without air filling the tiny air sacs (alveoli) at the base of the lungs, they may collapse. This is called Atelectasis. Secretions aren’t moved from the respiratory tract so they stay and collect bacteria which may lead to pneumonia. 
• With an immobile patient, it is important to assess their vital signs and respiratory symptoms, if temperature, respiration rate, and heart rate are increased and the patient is complaining of SOB they may have pneumonia. In this case, assess the lungs for crackles as this indicates fluid in the lungs, encourage coughing, and deep breathing (helps fluid out of the body) and notify the provider so the appropriate anti-infection meds are started.
• Effects vary depending on general health. -Age -Degree of immobility -Length of immobility
• Elderly patients are slower to heal and the more limited a patient's immobility is and the longer they are immobile, the more complications they have to experience
• It is important to access daily, test patients' Homan sign (access blood clot), which is where the patient points their toes to their nose and if they have sharp pain in their calf, that indicates a possible blood clot
• -Access mental status because immobility may lead to depression 
• Providing too much assistance may start a cycle of dependence. The patient may become less able to move on their own. Nurses need to break this cycle. We do this by encouraging patients to do activities as independently as possible. This helps to preserve muscle strength and coordination. Nurses can provide tools to help the patient become more independent. For example, if a patient has difficulty repositioning themselves in bed, we may install a trapeze over their bed so they can grab onto it and reposition themselves independently. 
• Do not assign unlicensed personnel to perform tasks for unstable patients. Such as chest pain, severe airway obstruction, and stroke symptoms (one-sided weakness, facial drooping, slurred speech) 
• Fall causes-

  -Peripheral neuropathy or nerve damage in the feet, the patient is more likely to trip.  

  -Postural hypotension or dizziness caused by medications. Encourage these patients to stand up slowly to prevent dizziness and/or falls. 
• Fall causes-Impaired vision like cataracts alters depth perception

  -Impaired hearing may cause a fall because the patient may not hear warnings or directions 

  -Musculoskeletal disorders that impair normal ambulation or balance
• FALL CAUSES: Extreme weakness

  -Oxygen deficit that may cause dizziness and loss of balance

  -A hx of previous falls 

  -Balance or gait problems resulting from stroke or inner ear problems 
• Nursing interventions to prevent falls:
• Keep pathways to the bathroom and door clear of clutter
• Replace loose rugs with a nonslip pad
• Provide adequate lighting
• Keep wheels on all equipment locked when stationary
• Place call light, water bottle, TV remote, phone, and belongings within easy reach
• Answer the call light as soon as possible
• Bend at the legs rather than at the waist to pick something up off the floor
• Avoid highly patterned or slippery floor coverings
• Provide chairs that are the proper height and depth to prevent “falling” into the chair. Chairs that have sturdy arms are the most effective for preventing falls
• Assist the patient with ambulation if they have weakness or are afraid. Ambulation helps to build strength and stamina and staff present will prevent falls
• Physical therapy referral will help increase strength and reduce the fear of falling
• We never react to a patient's fear of falling by keeping the patient immobile
• Assesing all medications a resident is taking to determine the risk of medication-induced postural hypotension or dizziness. (Diuretics (frequent urination)  anti-hypertensive, opioids, antidepressants, sleeping pills, Benadryl)

  -Medications that cause dizziness are a frequent contributor to falls

  -Over-the-counter medications should be considered along with prescriptions   
• Alternatives could include playing peaceful music, providing warm milk or tea, reducing toys, placing high-risk residents near the nurse's station, using a sitter, implementing safety checks, providing activities to keep them busy, ask family to stay with the patient.
• -Exhaust all possible measures first 

  -Restraints require a doctor's order. Orders are only good for 24-48 hours 
• —Physical restraints 

  -Must be visually checked every 30 minutes 

  -Turn patient every 2 hours, check skin and circulation 

  -Reassess the need for restraint every 4-8 hours 

  -Assess for food, fluid, and toileting needs at least once every 2 hours.
• —Chemical restraints-sedatives 

  -Document all failed attempts 

  -Document and time all assessments 
• -Patient deaths have occurred due to improperly applied restraints. Laws require that they be used only as a last resort for safety after all other measures, such as sitter, family at the bedside, alarms, or distractions, have been attempted and failed.
•  Documentation must be thorough, indicating alternative measures that have been tried and that measures have failed. The time the restraint is applied, the condition of the patient at that time, interim assessments, and the time the restraint is removed and the patient's condition at that time must be documented. 
• • A red area that does not blanch (whiten) with pressure is a stage 1 pressure ulcer
• Preventative measures for skin breakdown:

  • Elevate/float heels
  • Avoid massaging reddened areas or areas over bony prominences
  • Avoid alcohol over areas prone to breakdown because alcohol is drying
  • Reposition bedridden patients at least once every 2 hours
  • Encourage adequate nutrition, as protein helps the body repair tissues
  • Clean incontinent patients quickly
  • Use of an air mattress ensures less pressure on bony prominences while lying down
  • A transparent dressing can help prevent an irritated area from further breaking down (obtain an order afterward)
• Promoting function in LTC 

  -it is important for the patient to set realistic goals 

  -Encourage independence in ADLS

  -Encourage previously enjoyed recreational activities. 

  Assistive adaptive devices- like thicker handles on cutlery help those with arthritis. Consult with diet to promote self-feeding.