Assessment Flashcards
Mobility
When a patient is immobile, assessment focuses on the status of the
musculoskeletal system and includes ROM, muscle strength, activity tolerance,
and posture and alignment. Range of motion (ROM) is the maximum amount
of movement available at a joint in one of the three planes of the body: sagial,
transverse, or frontal (Fig. 39.5). The sagial plane is a line that passes through
the body from front to back, dividing it into a left and right side. The frontal
plane passes through the body from side to side and divides it into front and
back. The transverse plane is a horizontal line that divides the body into upper
and lower portions. Ligaments, muscles, and the nature of the joint limit joint mobility in each of
the planes. However, some joint movements are specific to each plane. In the
sagial plane, movements are flexion and extension (e.g., fingers and elbows),
dorsiflexion and plantar flexion (feet), and extension (e.g., hip). In the frontal
plane, movements are abduction and adduction (e.g., arms and legs) and
eversion and inversion (feet). In the transverse plane, movements are pronation
and supination (hands) and internal and external rotation (hips). Assessment of range of motion (ROM) is an important baseline measurement
that compares and evaluates whether loss in joint mobility is developing or has
occurred. Refer to Table 39.2 for normal joint ROM to compare with findings
when you assess a patient’s ROM. Be sure to assess all joints in the body. Ask
questions about and physically examine a patient for stiffness, swelling, pain,
or limited movement, and compare sides for unequal movement (see Chapter
30). If a patient has restricted ROM, your information will help you collaborate
with physical therapists to select the type of ROM exercise a patient is able to
perform, so you can reduce risk of complications (Table 39.3). There are three types of range-of-motion exercises: active, active assisted,
and passive (see Chapter 38). For example, you might need to provide support
for a weak patient and assist while he or she performs most of the joint
movement. Some patients are able to move some joints actively, whereas you
will passively move others. Ligaments, muscles, and the nature of the joint
limit patients’ mobility, and some joint movements are specific to their location
in the body. Abduction and adduction of the arms and legs are an example of
this specific type of movement. Abduction is the movement of an extremity away from the midline of the body, and adduction is the movement of an
extremity toward the midline of the body. The major musculoskeletal changes expected during assessment of an
immobilized patient include decreased muscle strength, loss of muscle tone
and mass, and contractures. Patients with musculoskeletal injuries or chronic
conditions require careful palpation of joints and extremities to minimize
discomfort. Because immobilized patients are weakened, determine whether
difficulty in moving joints is the result of fatigue or decreased ROM.
Remember that a patient’s total musculoskeletal system must be evaluated
from the head and neck down to the toes. Activity tolerance is the type and amount of exercise or work that a person
is able to perform without undue exertion or injury. Many of the patients who
have become immobilized may be very limited in their ability to walk or
change position in bed. After activity, observe patients for difficulty breathing. Assess heart rate and blood pressure response to activity by comparing with
baseline at rest. Both heart rate and blood pressure should increase. As activity is incorporated into the plan of care, monitor patients’ tolerance,
and assess for dyspnea, shortness of breath, fatigue, chest pain, and/or a
change in heart rate or blood pressure. The weak or acutely ill patient is unable
to sustain even slight changes in activity because of the increased demand for
energy. Seemingly simple tasks such as eating and moving in bed often result
in extreme fatigue. When a patient experiences decreased activity tolerance,
carefully assess how much time he or she needs to recover. Decreasing
recovery time indicates improving activity tolerance.
Gait
Gait is the manner or style of walking, including rhythm, cadence, length of stride, and speed. Assessing gait allows for conclusions about balance, posture,
and the ability to walk without assistance (see Chapter 38). While a patient
walks, look for conformity, a regular, smooth rhythm and symmetry in the
length of leg swing; smooth swaying related to the gait phase; and a smooth,
symmetrical arm swing (Ball et al., 2019). An abnormal gait is a common risk
factor for patient falls.
Exercise Pattern
Assess a patient’s exercise history by asking what exercise he or she
normally engages in and the normal amount of exercise performed daily and
weekly. If a patient does not exercise regularly, you will want to focus on his or
her activity tolerance. Chapter 38 describes the approach for assessment of a
patient’s exercise paerns.
Watch for sitting, standing and lying stance. Patients with impaired mobility (e.g.,
traction or arthritis), decreased sensation (e.g., hemiparesis following a CVA),
impaired circulation (e.g., diabetes), and lack of voluntary muscle control (e.g.,
spinal cord injury) are at risk for damage when lying down.
Metabolic System
When assessing metabolic functioning, measures of height and weight figure
prominently. Also examine the turgor of the skin. Dehydration and edema
increase the rate of skin breakdown in a patient who is immobilized. Review
intake and output records for fluid balance. Monitoring laboratory data such as levels of electrolytes,
serum protein (albumin and total protein), and blood urea nitrogen (BUN)
helps you to determine metabolic functioning.Monitoring food intake and elimination paerns and assessing wound
healing help to determine altered GI functioning and potential metabolic
problems. If the patient has a wound, the rate of healing is affected by
nutritional intake and nutrient absorption. Normal progression of healing
indicates that metabolic needs of injured tissues are being met. Anorexia
commonly occurs in patients who are immobilized. Assess the patient’s food
intake before the meal tray is removed to determine the amount eaten. Assess
his or her dietary paerns and food preferences at the onset of immobilization
to help prevent nutritional imbalances
Respiratory System
Perform a respiratory assessment at least every 2 hours for patients with
restricted activity. Inspect chest wall movements during the full inspiratoryexpiratory
cycle. If a patient has an atelectatic area, chest movement is often
asymmetrical. Auscultate the entire lung region to identify diminished breath
sounds, crackles, or wheezes. Focus auscultation on the dependent lung fields
because pulmonary secretions tend to collect in these lower regions.
Assessment findings that indicate pneumonia include productive cough with
greenish yellow sputum; fever; pain on breathing; and crackles, wheezes, and
dyspnea.
Cardiovascular System
Cardiovascular nursing assessment of a patient who is immobilized includes
monitoring blood pressure and heart rate and assessing the arteriovenous
system. Because of the risk for orthostatic hypotension, measure blood
pressure when a patient moves from lying to a siing or standing position.
Move a patient gradually during position changes, and monitor him or her
closely for dizziness while assessing blood pressure in each position. These
measurements document the patient’s tolerance to postural changes and are
vital to know when positioning or transferring patients from one position or
location to another. The longer the period of immobility, the greater is the risk
of orthostatic hypotension when the patient standsAssess heart rate, including the apical pulse. Lying down increases cardiac
workload and results in an increased pulse rate. In older adults, the heart rate
often does not tolerate the added workload, and a form of cardiac failure may
develop. A third heart sound, heard at the apex of the heart, is an early
indication of congestive heart failure.
Monitoring peripheral pulses (see Chapter 30) allows you to assess the
ability of the heart to pump blood and the condition of the arterial system.
Immediately document and report the absence of a peripheral pulse in the
lower extremities, especially if the pulse was present previously. Check for
capillary refill to determine tissue perfusion. Also note the color of extremities,
as changes in venous and arterial function will alter skin color.
Edema sometimes develops in patients who have had tissue injury or whose
heart is unable to handle the increased workload of bed rest. Because edema
moves to dependent body regions, assessment of the patient experiencing
immobility includes inspection of the sacrum, legs, and feet for edema. If the
heart is unable to tolerate the increased workload, peripheral body regions
such as the hands, feet, nose, and earlobes are colder than central body regions.Venous thromboembolism (VTE) is a blood clot in a vein. It is related to two
life-threatening conditions: deep vein thrombosis (DVT) (a clot in a deep vein,
usually the leg) and pulmonary embolus (a deep vein clot that breaks free.Common risk factors for VTE include conditions that influence the
Virchow’s triad: hypercoagulability (e.g., cloing disorders, fever, dehydration);
venous wall abnormalities (e.g., orthopedic surgery, varicose veins); and blood flow
stasis (e.g., immobility, obesity, pregnancy). To assess the venous system for
presence of a DVT determine whether the patient is experiencing leg pain by
gently palpating under the thighs and along the calves. Note any tenderness or
cramping, and look for redness. Gently palpate for presence of edema.
Carefully compare findings in both legs; unilateral redness, tenderness, and
edema indicate possible DVT. Also consider the patient’s risk factors for a DVT
(Box 39.4). The Wells score is an objective and widely used measure for
determining a patient’s risk for a DVT (Table 39.5) (Wells, 1998; Modi, 2016).
When you identify clinical indicators of a possible DVT, report to a health care
provider immediately, and include the Wells score as appropriate. If a patient
has antiembolic stockings or a sequential or mobile compression device
(SCD/MCD), remove the stockings or device once every 8 hours or according to
agency policy and reassess the calves and thighs. Measure bilateral calf circumference and record it daily as an alternative
assessment for DVT. To do this, mark a point on each calf 10 cm down from the
midpatella. Measure the circumference each day, using this mark for
placement of the tape measure. Unilateral increases in calf circumference are an
early indication of thrombosis
Musculoskeletal System
Major musculoskeletal abnormalities to identify during nursing assessment
include decreased muscle tone and strength, loss of muscle mass, reduced
ROM, and contractures. During assessment of ROM (described earlier) you can
detect muscle tone by asking the patient to relax and then passively moving
each limb at several joints to get a feeling for any resistance or rigidity that may
be present. You assess for muscle strength by having the patient assume a
stable position and then performing maneuvers to demonstrate strength of the
major muscle groups
Integumentary System
Continually assess a patient’s skin for breakdown and color changes such as
pallor or redness. Consistently use a standardized assessment tool such as the
Braden Scale. The screening tool identifies patients with a high risk for
impaired skin integrity or early changes in the condition of patients’ skin. Early
identification allows for early intervention. Observe the skin often during
routine care (e.g., when the patient is turned, during hygiene measures, and
when providing for elimination needs). Frequent skin assessment, which can
be as often as every hour and is based on patients’ mobility, hydration, and
physiological status, is essential to promptly identify changes in their skin and
underlying tissues
Elimination System
To determine the effects of immobility on elimination, assess the patient’s total
intake and output each shift and every 24 hours. Compare the amounts over
time. Determine that the patient is receiving the correct amount and type of
fluids orally or parenterally (see Chapter 42). Inadequate intake and output or
fluid and electrolyte imbalances increase the risk for renal system impairment,
ranging from recurrent infections to kidney failure. Dehydration also increases
the risk for constipation.
Immobility impairs GI peristalsis. Assessment of bowel elimination status
includes the adequacy of a patient’s dietary choices, bowel sounds, passing of
flatus, and the frequency and consistency of bowel movements (see Chapter
47). Accurate assessment enables you to intervene before constipation and fecal
impaction occur.
