Test 2

• Atelectasis

  Incomplete expansion or collapse of a part of the lungs, happens with immobility
• Foot drop

  Complication of extended plantar flexion, irreversible only with surgery
• Flaccid

  Decrease muscle tone
• Pressure Injury

  Injury in skin, caused by pressure
• Atrophy

  Happens from no muscle use, wasted away
• Venous Thrombus

  Blood clot
• Spastic

  Increased muscle tone, tightness
• Joint Movements

  • Abduction: movement away from midline of body
  • Adduction: movement towards the midline of body
  • Circumduction: turning in circular motion
  • Flexion: state of being bent
  • Extension: straight line
  • Hyperextension: looking toward the ceiling
  • Dorsiflexion: foot toward ceiling
  • Plantar flexion: think pointing down like ballerina
• Range of Motion

  • Active- patient performs by themselves, under supervision of nurse (increases strength/ muscle mass)
  • Passive- performed by the nurse (allows for prevention of contraction)
• Benefits of Exercise (Cardiovascular System)

  • Increased heart efficiency, decreased heart rate/blood pressure, increase blood flow, improved venous return
• Effects of Immobility (Cardiovascular System)

  • 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: foot board, high top 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
  • OOB ad 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

  Tissue destruction 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"