The nurse planning care for a patient after severe head trauma and long-term unresponsiveness considers which effect of immobility affecting the lungs? Select all that apply
a. Atelectasis
b. Hyperventilation
c. Pooled secretions
d. Reactive airway
e. Hypocarbia
A, C
Immobility decreases the strength of muscles involved in chest wall expansion, which also affects ventilation. The depth of respirations decreases (hypoventilation), and secretions pool in the airways. The ability to effectively cough and expectorate secretions diminishes as muscle tone of the abdomen and chest decrease. As a result, pooled secretions block air passages and alveoli, decrease oxygen and carbon dioxide exchange (hypoxema and hypercarbia), and often lead to atelectasis (collapse of air sacs), or pneumonia. The smooth muscle in the mainstem airway is not reactive as it would be for the patient with asthma, for example.
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