Increased cardiac workload, increased resting heart rate, risk for orthostatic hypotension, increased risk for venous thrombosis, edema, DVT, pooling [esp. in Legs]
Interventions (Cardiovascular System)
Reposition every 2 hours, compression stockings, SCD, assess pedal pulses, capillary refill (less than 3 seconds)
Benefits of Exercise (Respiratory System)
Improved alveolar ventilation, decreased work of breathing, improved rise and fall
Effects of Immobility (Respiratory System)
Decrease in respiration depth and rate, risk for respiratory secretion pooling and congestion, increased risk for impaired gas exchange [ causes Atelectasis]
Interventions (Respiratory System)
Assess pulse Ox/ breath sounds, fowlers position (or high fowlers if tolerated), deep breathing/ coughing exercises
Benefits of Exercise (Musculoskeletal System)
Increase muscle efficiency and flexibility, increased coordination, reduce bone loss, prevents contractions
Effects of Immobility (Musculoskeletal System)
Decrease muscle size, tone and strength, balance and coordination, decrease in joint mobility and flexibility, bone demineralization, increased risk for contractions, foot drop, atrophy
Interventions (Musculoskeletal System)
Assess muscle tone, gait, [ ROM prevents contraction and atrophy ] , ambulate, [ prevention of foot drop: footboard, hightop sneakers, multipodis boot, dorsiflexion, plantar flexion exercises ]
More Joint Movements
Rotation: turning of movement of part around its axis
Internal Rotation: turning inward, toward center
External Rotation: turning outward, away from center
Supination: on back
Pronation: on tummy
Inversion: movement that turns sole of foot inward
Eversion: movement that turns sole of foot outward
Lordosis
Exaggerated anterior convex curvature of spine
Kyphosis
Increase convexity in curvature of thoracic spine
Scoliosis
Curvature of spine
Benefits of Exercise (Gastrointestinal System)
Increase in appetite, increase in intestinal tone, aides in digestion and elimination
Effects of Immobility (Gastrointestinal System)
Disturbance in appetite, decrease in peristalsis, risk for constipation, risk for weight gain/ acid reflux
Interventions (Gastrointestinal System)
Assess bowel sounds/ last bowel movement, increased fluid, ROM, fowlers to help acid reflux, ambulate out of bed to chair
Benefits of Exercise (Renal/Urinary System)
Increased blood flow to kidneys, aides in fluid and acid bases balance, increase efficiency in excreting body waste
Effects of Immobility (Renal/Urinary System)
Increase urinary stasis- reflux, increased risk for kidney stones, decreased bladder tone which causes incontinence
Interventions (Renal/Urinary System)
Assess intake/ outtake (fluids), kegal exercise = increased bladder tone, ambulate to the bathroom, if not enough fluids, then increase fluids
Benefits of Exercise (Integument System)
Improves circulation, increased tone, color and turgor
Effects of Immobility (Integument System)
Increased risk for skin breakdown and pressure injuries (on bony prominence), poor hygiene, skin rashes/tears
Interventions (Integument System)
Braden scale, turn/position q2h, dietary to increase protein, ROM - to improve circulation, skin barrier cream to help skin breakdown
To prevent venous pooling / venous stasis
Compression stockings: should be put on before patient gets out of bed, should have no wrinkles, opening should be on the top, they should come off every shift, should assess skin
SCD- compression device as well (can use both SCD/ compression stockings together)
Contractures
Shortening of the muscle and tendon that leads to deformity and limits joint mobility
Braden Scale
Pressure injury risk prediction. The HIGHER the score the BETTER (highest score = 23)
Trochanter Rolls
Prevent hip rolling; hip rotation; prevents legs rotating outward. Placement? alongside of the ilium to mid thigh
Activity Orders
BR: bedrest
BRP: bedrest privilege
OOBad lib: out of bed, whenever
OOB to chair: out of bed to chair
NWP- non weight baring
T&P- turn and position
RLE- right lower extremity
LLE- left lower extremity
Pressure Ulcer Stages
Stage 1: skin is intact
Stage 2: tissue damage is superficial, partial thickness loss [abrasion, blister, shallow crater]
Stage3: full thickness skin loss, damage to the subcut tissue may or may not have undermining [deep crater]
Stage 4: eschar is present, full thickness loss, extensive destruction, tissue necrosis, damage to muscle, bone or supporting structures
Undermining
Tissuedestruction underneath intact skin along with wound margins
Orthopenic position
Facilitates breathing
Eschar
Thick, leather-like, necrotic tissue. must be removed surgically or enzymatically in order for wound healing to occur "debridement of wound"