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46 Cards in this Set
- Front
- Back
what does immobility effect?
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Musculoskeletal system
Cardiovascular system Respiratory (pulmonary) system Metabolic system Urinary system Gastrointestinal system Psychoneurologic system Integumentary system |
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How does it effect the musculoskeletal system?
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1.disuse osteoporosis
2. disuse atrophy 3.Contractures 4. stiffness and pain in joints |
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What is disuse osteoporosis?
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bone demineralization occurs,calcium is lost regardless of diet, bone becomes spongey and fractures easy.
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assessment and intervention for disuse osteoporosis
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early ambulation and weight bearing
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what is disuse atrophy?
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Muscles decrease size, strength and function
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assessment and intervention disuse atrophy
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implement exercise program every 4 hours: active, isotonic and passive exercise.
Encourage selfcare activities, overhead trapeze bar, and teach them exercises they can perform in bed |
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Contractures are
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Permenant shortening of the muscle, stronger muscle dominates the opposite muscle. Joint mobility is limited
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Assessment and intervention for contractures:
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Position patient in good alignment, passive and active exercises to maintain joint mobility, dorsiflex feet to prevent foot drop,hip roll to prevent lateral rotation, physical therapy consult
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stiffness and pain in joints
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ankylosis (stiffness or fixtation of a joint,) connective tissue becomes immobile, and calcium may be deposited in the joints
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assessment and intervention for stiffness and pain in joints
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exercise program, early weight bearing and ambulation, ROM exercises
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Cardiovascular system and disuse syndrom
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diminished cardiac reserve, increased use of valsalva maneuver, orthostatic (postural hypotension), venus vasodialation, stasis and edema.
Thrombus formation |
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disuse syndrome on cardiac reserve
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immobility weakens the heart
increases heart rate increases sympathetic activity |
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assessment and interventions of diminished cardiac reserve
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Monitor vital signs, detect and report any changes
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Increased use of Valsalva Maneuver
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Interferes with bloodflow to heart and coronary arteries, surge of blood flow to heart with exhalation, results in tachycardia and arrythmias
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Assessment and intervention of valsalva maneuver
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instruct the client how and when to use valsalva maneuver and avoid constipation
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Orthostatic Postural Hypotension
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Pooling of blood in legs occur, when moved from reclining to sitting and standing position, Patients feel dizzy, lightheaded and may faint, Increase in heart rate
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Assessment and intervention of orthostatic hypotension
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Move patient slowly, anti-emboli stockings,monitor vital signs and have adequate hydration (increase fluid intake)
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Venus vasodialation, stasis and edema
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skeletal muscles atrophy and lose contraction strength, venus valves can become incompetent which causes venus pooling, increased pressure and edema
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Assessment and intervention of vasodialation, stasis and edema
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anti-embolic stockings, leg exercises, elevate legs 20 minutes, sequential compression pump device
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Thrombus
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Clot formation, thrombophlebitis, virchows triad (impaired venus return to the heart, hypercoagulability of the blood, injury to a vessel wall) Embolus (dislodged clot, serious to fatal problem) Large emboli may infarct area of lung, pulmonary function seriously compromised, can be fatal
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Interventions to prevent cardiovascular complications
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anti-emboli stockings, leg elevations, leg exercises,sequential compression device, ROM (passive and active) early ambulation
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Respiratory system and disuse syndrome complication
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decreased respiratory movement, pooling of respiratory secretions, atelectasis, hypostatic pneumonia,
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Decreased respiratory movement complications
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restricted chest movement, abdominal organs push against diaphram, prolonged immobility can cause intercostal joints to become fixed resulting in decreased vital capacity
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Pooling of respiratory secretions complications
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secretions pool by gravity, decreased ability to cough, dehydration thickens secretion,sedative suppress cough reflex
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Atelectasis complications
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decreased surfactant, mucus blockage of bronchial, can possibly collapse a lobe of a lung,entire lung collapse distal to muscus blockage
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complications of hypostatic pneumonia
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pool secretions, good medium for bacterial growth,infection can severly impair o2 and co2 exchange, pnemonia is a fairly common cause of death
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Interventions of respiratory disuse syndrome
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assess breath sounds at least every 8 hours and prn,o2 saturation monitoring, assess chest expansion, TCDB (teach pts. to take 5 deep breaths and cough every waking hour), Position turn every 2 hours around the clock, early standing,chair, ambulation as tolerated
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Decreased metoblic rate and disuse syndrome
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decreased metobolic rate, anorexia and negative calcium balance
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complications of decreased metobolic rate
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Negative nitrogen balance, catabolism (breaking down of muscle mass) anabolism (protein synthesis)
Depletion of protein stores is a big problem, protein is essential for building muscle and tissue and protein is needed for wound healing |
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complications of anorexia
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decreased appetite with inactivity, occurs as a result of decreased metabolic rate, increase catabolism contributes to loss of appetite and malnutrician
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complications of negative calcium balance
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decreased result of immobility, absence of weight bearing and stress to muscoloskeletal structures, loss of calcium from bone demineralization
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Intervention of disuse syndrome of metabolic system
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Monitor pts. weight atleast weekly and monitor calcium intake,monitor nutritional intake, assess serum protein levels (prealbumin, albumin,) consult dietician (high calorie, high protein diet with calcium rich foods, and once again increase activity/mobility
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disuse syndrome on urinary system
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urinary stasis, renal calculi, urinary retention, urinary infection,urinary reflux
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urinary stasis
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gravity important in emptying kidneys and bladder, emptying not as effective in horizontal position, tone of bladder muscles decrease with immobility
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Renal Calculi
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calcium and phosphate are in excess, calcium is alkaline, calcium salts precipitate to form calculi, can obstruct urinary tract, immobility increases risk for kidney stones
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urinary retention
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accumulation of urine in the bladder,bladder distension, urinary incontinence can be a problem
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Urinary infection
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static urine is an excellent medium for bacteria, bacteria likes alkaline urine better than acidic, normal frequent urination is absent, urinary distention can cause minute tears in bladder mucosa (entry for organisims)
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Urinary reflux
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back up urine into renal pelvis can cause damage, serious problem
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assessment and intervention of urinary disuse syndrome
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Monitor urinary output, color, clarity and calculi, promote adequete hydration, if tolerated get the patient out of bed to urinate, cranberry juice may prevent, urinary tract infections, its important for client to have adquete perineal cleansing.
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Disuse syndrome on gastrointestinal
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constipation
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Constipation effects and disuse on g.i.
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decreased perstalis and colon motility, abdominal and perineal muscle weakness, bedpan not easy to use, and pt.s should avoid excessive use of valslava manuever.
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Assessment and intervention on G.I disuse
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high fiber foods, adequete hydration, stool softeners and laxatives, monitor bowel habits (do not wait until your client is impacted) avoid valsalva maneuver
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psychoneurologic system: dis use syndrome
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decreased selfesteem,exaggerated emotional reactions, time perception deteriorates, loss of control, loss of intellectual stimuli, situational depression, anxiety, apathy, withdrawn and regression
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interventions of psychoneurological effects of disuse syndrome
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talk with your pt.s, reorient as needed, promote selfcare and decision making, pt. may need anti-depressant
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effects on integutementary system
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reduces skin turger, skin atrophy , tears easy, less able to withstand trauma, pressure, friciton and shear.
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nursing implications
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Activity Intolerance
Airway Clearance, Ineffective Anxiety Breathing Pattern, Ineffective Cardiac Output, Decreased Constipation Divers ional Activity Deficit Gas Exchange, Impaired Fluid Volume Imbalance, Risk for Incontinence Infection, Risk for Mobility, Impaired Nutrition, Altered Powerlessness Self Care Deficit Self Esteem: Situational Low Sexuality Patterns, Altered Skin Integrity Sleep Pattern Disturbance Social Isolation Tissue Perfusion, Altered Urinary Retention Walking, Impaired |