Xavier University - Ateneo de Cagayan

College of Nursing

In Partial Fulfillment of Comprehensive Appraisal 1 (CA1)

A Case Study of Care of client with

Mobility/Immobility problems (LT 2)

Submitted by:

Kaycee Ann Arevalo

CA1 BSN-4 NB

Submitted to:
Mary Grace Paayas, RN, MAN
Leny Baguio, RN, MN
Renzi Pepito, RN, MN
Mildred Pinque, RN, MN
Philip Eli Nalzaro, RN, MN

September 5, 2017
Case Study:

Victor Matthew, a 75-year old male, is admitted from his healthcare providers
office to the hospital for treatment of an infected, painful ulcer on the plantar
surface of his right foot. He tells the nurse that he took a pain pill with codeine
an hour ago.

Reflection:

An ulcer is an open sore on the foot and it is characterized by a shallow to

deep red crater which may involve tendons, bones, and other deep structures
of the foot. Open sore sometimes are surrounded by a thick-border like
callused skin which develops through time. This occurs when the outer layer
of the skin is injured and the deeper tissue is exposed. Open wounds can put
patients at increased risk of developing infection in the skin and the bone. It is
common in people who have conditions such as peripheral neuropathy
(Diabetes Mellitus), circulatory problems, and abnormalities in the bones and
muscles of the feet. For peripheral neuropathy condition, it is usually caused
by the nerve damage in the lower extremities (such as feet and legs). It is
usually manifested by tingling sensations or numbness, which can cause them
to not feel the pain if they stepped on something sharp. While for the
circulatory problems, this causes the decrease of blood flow to the lower
extremities which leads to less oxygenation to the legs and feet.

Although the patient is hospitalized, complications may arise due to the

immobilization of the affected lower extremity. These are the possible
complications that may arise, namely: Fluid and electrolyte imbalance
(Hypercalcemia), nutritional deficit, decrease appetite and peristalsis which
could lead to constipation/diarrhea; Atelectasis, hypostatic pneumonia, and
diminished cough reflex; Urinary stasis and decrease urinary output; Venous
thromboembolism, Deep Vein thrombosis, orthostatic hypotension, Muscle
atrophy, joint abnormalities and contractures, and etc. Given the possible
complications for the patient, as healthcare provider, the primary goal is to
control the progression of the infection especially if the patient is diabetic, and
early preventive measures includes control of hypertension and blood glucose
level. It should be treated urgently. Take for example, diabetic foot infection, it
can rapidly progress to limb or life threatening condition. Nursing
responsibilities we should perform is to provide meticulous skin care and
proper foot care, prevent moisture from accumulating, cut toenails straight
across and smooth nails with an emery board, avoid treating corns, blisters, or
ingrown toenails, instruct the patient to not cross legs or wear tight garments
that may constrict the blood flow, and etc.

According to a study I read, The amputation rate in diabetic populations

with foot infections has been reported to range from 12-92% (Tennvall et al.,
2000). The same study stated that, management of diabetic foot ulcer
infections should focus on four integrated parameters of care: 1) Controlling
bacterial balance; 2) Host response/defence; 3) Complete pressure offloading;
and 4) Local wound care. In addition, local wound care involves wound
cleansing and debridement to remove devitalized tissue and reduce bacteria
on the wound. The prescribed antibiotics should be based in the results of the
culture and sensitivity of the organisms in conjunction with the physicians
clinical judgment.

Reference:
1) Tennvall, G. R., Apelqvist, J., & Eneroth, M. (2000). Costs of deep foot
infections in patients with diabetes mellitus. Pharmacoeconomics, 18(3),
225-238.
Questions:
1) . Which of the following would the nurse expect to assess when a patient
experiences a greater breakdown of protein than that which is manufactured?
a.Fluid volume excess
b. A contracture
c. Osteoporosis
d. Negative nitrogen balance

Answer: d. Negative nitrogen balance results when the body excretes more nitrogen
than it takes in. Contractures

2) When explaining the cause of frequent urinary tract infections related to immobility,
the nurse understands that immobility may result in which of the following?
a. Improved renal blood supply to the kidneys
b. Urinary stasis
c. Decreased urinary calcium
d. Acidic urine formation

Answer: b. In a non-erect patient, the kidneys and ureters are level, and urine
remains in the renal pelvis for a longer period of time before gravity causes it to move
into the ureters and bladder, resulting in urinary stasis. Urinary stasis favors the
growth of bacteria that may cause urinary tract infections. Regular exercise, not
immobility, improves blood ow to the kidneys.

3) The nurse is assisting a patient with conditioning to prepare for ambulation. The
nurse correctly instructs the patient to do what?
a. Do full-body push-ups in bed six to eight times daily
b. Breathe in and out smoothly during quadriceps drills
c. Dangle on the side of the bed for 30 to 60 minutes
d. Allow the nurse to bathe the patient completely to prevent fatigue

Answer: b. Breathing in and out smoothly during quadriceps drills maximizes lung
ination. The patient should never hold his or her breath during exercise drills
because this places a strain on the heart.

4) In many situations, a patient has sufficient strength to walk if he or she can do

which of the following?
a. Lie prone for 1 hour
b. Bathe him- or herself
c. Raise the foot off the bed 1 inch
d. Sit up in bed for 1 hour

Answer: c. Being able to raise the foot 1 inch off the bed frequently indicates sufficient
strength for walking.

5) When working with an older patient to develop an exercise program, the nurse
would recommend which of the following?
a. A frequency of six times a week
b. Exercising to the point of breathlessness when trying to speak
c. Maintaining a target heart rate of 220 plus age
d. Obtaining medical clearance before beginning the program

Answer: d. Patients older than 35 years should always get medical clearance before
initiating an exercise program.