Risks for complications from immobility

·      Poorly nourished

·      Have decreased sensitivity to pain, 

·      Temp. or pressure

·      Have existing cardiovascular, pulmonary or neuromuscular problems unconscious

What effects does immobility have on the respiratory system and what are appropriate interventions?

Problems
Decreased respiratory movement
Pooling of secretions
Atelectasis
Hypostatic pneumonia
Interventions
Change position frequently
Teach deep breathing/coughing exercises/IS
Increase fluid intake

Problems:
Diminished cardiac reserve
Increased use of valsalva maneuver

Orthostatic hypotension
Venous dilation and stasis
            Edema
            Thrombus
            Embolus

Interventions
Utilize sitting position

Teach how to avoid valsalva maneuver
Use proper positioning technique
Do range of motion exercises – leg exercises
Provide anti-embolism stockings

Teach gradual and frequent position changes

Problems
        Disuse osteoporosis
        Disuse atrophy
        Contractures
        Stiffness and pain
Interventions
        Do range of motion exercises
        Provide frequent and proper position changes
        Encourage early ambulation and weight-                bearing
        Encourage self-care activities

Problems
Reduced skin turgor
Skin breakdown
Intervention
        Change position frequently
        Decrease shearing force
        Use bridging techniques
        Keep skin clean and dry
        Provide adequate diet – protein,Vitamin C
        Provide adequate hydration
        Use massage – only on intact skin/tissue

Problems
        Decreased metabolic rate
        Negative nitrogen balance
        Negative calcium balance
Intervention
        Provide small, frequent feedings
        Monitor intake and output
        Encourage high protein diet
        Encourage high caloric diet-monitor need
        Assist with alternative feeding methods

Problems
        Constipation!
        Anorexia – loss of appetite
Intervention
Adhere to “usual routines”
        Provide privacy
        Increase fluid intake
        Increase dietary roughage
        provide frequent, appetizing meals

Immobility and elimination problems and interventions

Problems   
Stasis
Renal calculi
Retention
Incontinence
Infection

Interventions
Increase fluid intake

Maintain “usual” voiding patterns

Provide privacy

Change positions

Specific state of consciousness that occurs cyclically, is composed of distinct stages and can be characterized as a relative unresponsiveness to the surrounding environment

Two stages: NREM and REM

NREM further breakdown into 4-6 complete cycles including 4 NREM then 1 REM cycle. See page 1200 Potter for details..

Fatigue
Difficulty in performing routine physical tasks
Overall weakness
Decreased ability to concentrate
Nervousness, confusion, irritability, personality changes
Poor judgment
Worsening of current illness or symptoms

Artieral BP falls

Pulse decreases

Peripheral bld vessels dialte

Cardiac output decreases

Skeletal muscles relax

Basal metabolism rate decreases 10% 50 30%

Growth hormone levels peak

Intracranial pressure decreases

Age considerations and sleep

Newborns

Infants

Toddlers

Preschoolers & School aged

Adolescents & Middle-aged

Elderly

1. Dyssomnias
   • Intrinsic sleep disorders
   • Extrinsic sleep disorders
   • Circadian-rhythm sleep disorders
2. Parasomnias
   • Arousal disorders
   • Sleep–wake transition disorders
   • Parasomnias usually associated with REM sleep
   • Other parasomnias
3. Sleep disorders associated with mental, neurologic, or other medical disorders
   • Associated with mental disorders
   • Associated with neurologic disorders
   • Associated with other medical disorders

Alcohol

Beta-blockers

Anticonvulsants

Caffeine

Narcotics

Hypnotics

Diuretics

Antidepressants and stimulants

Benzodiazapines

What is sleep apnea?

What are the s/s?

What are the three types?

Treatment?

  Sleep apnea is a disorder characterized by the lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep.

S/S - Excessive daytime sleepiness, sleep attacks, fatigue, morning headaches, irritability, depression, difficulty concentrating, and decreased sex drive are common. morning headaches (from hypercapnia or increased blood pressure that causes vasodilation of cerebral blood vessels), personality changes, and irritability.

3 Types - Obstructive OSA, Central CSA and mixed

 Treatment includes therapy for underlying cardiac or respiratory complications and emotional problems that occur as a result of the symptoms of this disorder.

What is Obstructive sleep apnea?

What are the risks?

What are the potential complications?

OSA

Occurs when muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, diminishing nasal airflow (hypopnea) or stopping it (apnea) for as long as 30 seconds

Risk factors

Structural abnormalities such as a deviated septum, nasal polyps, certain jaw configurations, or enlarged tonsils predispose a client to obstructive apnea.

Complications

Cardiac dysrhythmias, right heart failure, pulmonary hypertension, angina attacks, stroke, and hypertension, high blood pressure and increased risk for heart attack and stroke

What is Central sleep apnea?

What are the risks?

What are the potential complications?

CSA

Involves dysfunction in the brain's respiratory control center. The impulse to breathe temporarily fails, and nasal airflow and chest wall movement cease. The oxygen saturation of the blood falls. Less than 10% of SA

Risk factors

Common in clients with brain stem injury, muscular dystrophy, and encephalitis and people who breathe normally during the day

Physiological

Ptosis, blurred vision

Fine motor clumsiness

Decreased reflexes

Slowed response time

Decreased reasoning and judgement

Decreased auditory and visual alertness

Cardiac arrhythmias

Psychological

Confusion and disorientation

Increased sensitivity to pain

Irritable, withdrawn, apathetic

Agitation

Hyperactivity

Decreased motivation

Excessive sleepiness

What are the drugs that affect sleep?

How do they affect sleep?

Hypnotics
Interfere with reaching deeper sleep stages
Provide only temporary (1 week) increase in quantity of sleep
Eventually cause “hangover” during day; excess drowsiness, confusion, decreased energy
Sometimes worsens sleep apnea in older adults

Antidepressants and Stimulants
Suppress REM sleep
Decrease total sleep time

Alcohol
Speeds onset of sleep
Reduces REM sleep
Awakens person during night and causes difficulty returning to sleep

Caffeine
Prevents person from falling asleep
Causes person to awaken during night
Interferes with REM sleep

Diuretics
Nighttime awakenings caused by nocturia

Beta-Adrenergic Blockers
Cause nightmares
Cause insomnia
Cause awakening from sleep

Benzodiazepines
Alter REM sleep
Increase sleep time
Increase daytime sleepiness

Narcotics
Suppress REM sleep
Cause increased daytime drowsiness

Anticonvulsants
Decrease REM sleep time
Causes daytime drowsiness

What causes constipation?

S/S?

How is it treated?

Causes

Improper diet (low fiber.  High in animal fats - meat dairy, eggs)

anxiety, deprssion, cognitive impairment

reduced fluid intake

lenthy bed rest,lack of exercise

medications (laxative misuse)

chronic illness (e.g., Parkinson's disease, multiple sclerosis, rheumatoid arthritis, chronic bowel diseases, depression, diabetic neuropathy, eating disorders)

Age - slowed peristalsis, loss of abd muscle

Neuro conditions that blodk impulses to colon

Hypothyroidism, hypocalcemia, hypokalemia

S/S of constipation usually include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feces

Implementation

Teach

proper diet, adequate fluid intake,

factors that stimulate or slow peristalsis, such as emotional stress.

Importance of establishing regular bowel routines and regular exercise and taking appropriate measures when elimination problems develop.  take time for defecation

Fiber and bulk forming laxative (NO stool softeners)

When possible, replace a medication causing constipation with a substitute.

Encourage elders to increase physical activity when

feasible.

Give attention to the potential risk of fluid overload in older adult clients with congestive heart failure or renal failure.

Encourage fiber intake of 20 g/day of wheat bran to start. Observe for bloating and flatulence in older adults.

Stool softeners are no longer recommended for constipation.

Fiber and bulk-forming laxatives are the first step in treating constipation in older adults.

Osmotic laxatives are effective in the treatment of constipation in older adults because they are well tolerated and have no known interactions with other drugs.

Stimulant laxatives are more effective than placebo, but concern remains regarding their adverse effects on older adults.

Older adults who have mobility problems often need enemas to avoid an impaction. A normal saline enema is the safest for regular use. Glycerol suppositories trigger the defecatory reflex and are sometimes useful in treating older adults

·      Impaired physical mobility

·      High risk for disuse syndrome

·      Activity intolerance (describe AEB i.e. unable to walk to bathroom w/o sitting down)

·      Risk for activity intolerance (i.e. patient who has scheduled surgery)

Define anemia

S/S?

Anemia is a deficiency in the number of erythrocytes (RBC) the quantity of hemoglobin, and/or the volume of packed RBCs (hematocrit). Because RBCs transport oxygen (O₂), erythrocyte disorders can lead to tissue hypoxia. This hypoxia accounts for many of the signs and symptoms of anemia. Anemia is not a specific disease; it is a manifestation of a pathologic process. Hemoglobin (Hb) levels are often used to determine the severity of anemia.

S/S

Integumentary changes include pallor, jaundice, and pruritus.

Cardiopulmonary manifestations of severe anemia result from additional attempts by the heart and lungs to provide adequate amounts of oxygen to the tissues.

Age >50

Alcohol limit 1/day

Cigarette smoking

DM

Elevated serum lipids (chlesterol and triglycerides)

Excess Na

Gender men <55 >55 Women

Family hx

Obesity

Ethnicity 2x higher in African American than whites

Sedentary lifestyle

Socioeconomic status Lower = > risk

The incubation period is the time interval between the entrance of the pathogen and the appearance of the first symptoms.

Prodromal stage is the interval from the onset of nonspecific signs and symptoms to more specific symptoms.

Illness stage in the interval when the client manifests signs and symptoms specific to the type of infection.

What are the types of Health Care Association Infections?

What are the risks?

A hospital-acquired infection occurs when a client develops an infection that was not present at the time of admission.

A community-acquired infection is one that was present on admission to the hospital.

An exogenous infection comes from microorganisms outside of the individual, such as Salmonella, Clostridium tetani, and Aspergillus. These do not exist in the body’s normal flora.

Endogenous infections occur when a part of the body’s normal flora becomes altered or an overgrowth results, such as streptococci, enterococci, or yeast.

The number of health care professionals in direct contact with clients as well as the type and number of invasive procedure, therapy, length of hospitalization pose risks to clients. Major sites for health care facility-acquired infections include surgical or traumatic wounds, urinary or respiratory tract infections, and infections in the blood stream.

Medical and surgical asepsis
Control or elimination of infectious agents
Control or elimination of reservoirs
Control of portals of entry
Control of transmission
Hand hygiene
Isolation and isolation precautions

The number of health care employees having direct contact with a client, the type and number of invasive procedures, the therapy received, and the length of hospitalization influence the risk of infection.

What are the lab test to screen for infection?

What do the results mean?

WBC (5,000-10,000/mm3) - Increased in acute infection, decreased in certain viral or overwhelming infections

Erythrocyte sedimentation rate (Up to 15 mm/hr for men and 20 mm/hr for women) - Elevated in presence of inflammatory process

Iron level (60-90 g/100mL) - Decreased in chronic infection

Cultures of urine and bld - (Normally sterile w/o microorganism growth) - Presence of infectious microorganism growth

Cultures and Gram stain of wound, sputum, and throat - No WBCs on Gram stain, possible normal flora. Presence of infectious microorganism growth and WBCs on Gram stain

Differential

Neutrophils (55-70)- Increased in acute suppurative (pus-forming) infection, decreased in overwhelming bacterial infection (older adult)

Lymphocytes (20-40%) -Increased in chronic bacterial and viral infection, decreased in sepsis

Monocytes (5-10%) - Increased in protozoan, rickettsial, and tuberculosis infections

Eosinophils (1-4%) Increased in parasitic infection

Basophils (0.5-1.5%)Normal during infection/allergic rx high

ECF volume excess is fluid overload or overhydration.
Excess in vascular space known as hypervolemia
In the interstitial spaces called third spacing

Caused by

excess Na

Increased ADH

Increased Aldosterone

Complicated by

Cirrhosis of the liver

Heart failure

Renal disorders

Respiratory and Cardiovascular

Cough, dyspnea, crackles, pallor, etc.

Bounding pulse, elevated BP, increased CVP

Other

Peripheral edema

Weight gain

Confusion, seizure, coma

Osmolarity < 275 mOsm/kg

Hct  < 45%

Specific gravity  < 1.010

BUN  < 8 mg/dl

Na < 135 mEq/L

Restrict Sodium

Restrict Fluids
Promote Urine Output (diuretics)

Assessments
Control underlying problem

• Fluid volume excess related to excessive fluid or sodium intake and /or retention
• Risk for pulmonary edema related to hypervolemia
• Risk for impaired skin integrity  related to edema

May result from loss of sodium-containing fluids, from water excess (dilutional hyponatremia), or a combination of both. Hyponatremia causes hypoosmolality with a shift of water into the cells.

Excessive Na intak

IV fluids; hypertonic NaCl, excessive isotonic NaCl, IV HCO3

Hypertonic feedings w/o water supply

Near-drowning in salt water

S/S

Cold clamy skin, dizzy,nausea, diarrhea

S/S

Thirst

Dry flushed skin

Fever

Agitation

What is ECFVD?

Who is at risk?

Etiology
Decrease in intravascular and interstitial fluids
Lack of fluid intake and excessfluid loss.

Decreased LOC (lost in desert)
Who is at risk?
Elderly!! because of decreased renal concentration altered ADH response (impaired thirst), they have increased body fat.  Increased drug to drug interaction and multiple chronic diseases potentiate fluid imbalances.

What are the S/S of EFVD?

Causes?

Severe vomiting, diarrhea
Fever, diaphoresis, hyperglycemia

Causes
GI suctioning etc..
Burns, Blood loss
Third spacing ie
Abdominal – Ascites
(between cells)

ADH and aldosterone secreted to retain fluids by reducing urine output – ADH targets the kidneys to enhance tubular reabsorption of water.
Thirst mechanism is signaled
Decreased volume is sensed by the baroreceptors to increase vasoconstriction

When extracellular fluids are lost, fluids move in from the interstitial spaces to restore vascular volume and dilute the hypernatremic state  ADH and aldosterone are secreted to retain flluids by decreasing urine output.  Get increased systemic vascular resistance and decreased CO and contractility.
**Additional stimulation – trauma, stress, pain, vasopressin

What are baroreceptors?

What do they do?

Definition: a sensory nerve ending that is stimulated by changes in pressure can be found in the walls of atria, vena cava, aortic arch, and carotid sinus.

Cause vessels to dilate or constrict to decrease or increase pressure

Hypervolemia

INHIBITS ADH, Aldosterone, Thirst

contribute to INCREASE urination (to duilute)

Hypovolemia

STIMULATES ADH, Aldosterone, Thirst

contribute to DECREASED unrination (concentration)

Hyperosmolar Fluid Volume Deficit
Water loss is greater than electrolyte -Dehydration
Iso-Osmolar Fluid Volume Deficit
Water and electrolye losses are equal
Most commonly seen
Hypoosmolar Fluid Volume Deficit
Electrolyte loss is greater than fluid loss (Emesis)- water excess

Mental status changes (confusion irritability, restlessness)
dry mucous membranes

decreased skin turgor (*not as specific in elderly), Changes in Vital Signs:
Postural hypotension (systolic drop of >25mm hg; diastolic drop > 20mm hg)
Decrease in blood pressure, CVP, etc. (esp. in sudden loss, trauma pts.)
Flat neck veins
Delayed or absence of hand vein filling
Increased heart rate(for every liter lost HR goes up eight beats per minute).

Increased temperature

Loss of Body Weight
Early and common result of fluid loss
1Liter =1kg (2.2lbs) 1.4 L of fluid equals a 2% loss  of body wt. In an average person
Changes in Intake and Output
A urine output of <400/500ml per day is oligura (decreased urine out )
Urine is usually concentrated with a specific gravity of 1.030

Lab values in EFVD

Osmolality

Na

BUN

Plasma glucose

Hct

Specific gravity

Indicators of Hemoconcentration:
Osmolality>295 mOsm/L - (275-295 m0sm/L)
Na >145 mEq/L –(135-145)
BUN > 25 mg/dl
Plasma glucose > 120 mg/dl
Hct >55%
Urine specific gravity > 1.030
Normal 1.010-1.030

Fluid Restoration:
Oral- for mild dehydration (pedialyte)
IV rehydration
Isotonic ECFVD is treated with isotonic solutions - 09% NS/LR/D5 in H2O
Hypertonic ECFVD is treated with hypotonic solutions – 0.45% NACL (half NS)                                                               
Hypotonic ECFVD is treated with hypertonic solutions - D5 in LR, 3% NS

(Replace fluids and electrolytes and correct the underlying problem.
Oral – for mild lost, such as pedialyte, avoid caffeine.
IV – for severe or life threatening )