Chapter 47 mobility and immobility Flashcards
Visible aspect and contributes to self-worth and well-being
Movement
Used to show self-defense, perform activities of daily living (ADLs) and recreational activities
Mobility
Coordinated efforts of the musculoskeletal and nervous system
Body mechanics
Reduces strain, maintains muscle tone, comfort, conserves energy
Body alignment
Required to maintain a static position
Balance
Force that occurs in a direction to oppose movement
Friction
Contribute to height
Long bones
Occur in clusters (carpal bones in the foot)
Short bones
Provide structural contour (skull)
Flat bones
Make up the vertebral column and some bones of the skull
Irregular bones
Caused by weakened bone tissue
Pathological fractures
Bones jointed by bones with no movement
Synostosis joint
Unites bony components
Cartilaginous joint
joint in which a ligament unites two bony surfaces (paired bones of the lower leg)
Fibrous joint
Ball and Socket Joint (hip)
Synovial joint
Fibrous tissue that connect ones an cartilages
Ligaments
Connect muscle to bone
Tendons
Nonvascular, supporting tissue (joints and thorax)
Cartilage
Increased muscle contraction causes muscle shortening resulting in movement
concentric tension
Helps control the speed and direction of movement
Eccentric tension
Active movement between concentric and eccentric muscle actions
Isotonic contraction
Causes an increase in muscle tension or muscle work but no shortening or active movement
Isometric contraction
Inducing or compelling force
Leverage
Position of the body in relation to the surrounding space
Posture
Normal state of balanced muscle tension
Muscle tone
Inclining of head to affected side, in which sternocleidomastoid muscle is contracted
Torticollis
Exaggeration of anterior convex curve of lumbar spine
Lordosis
Increased convexity in curvature of thoracic spine
Kyphosis
Lateral S- or C-shaped spinal column with vertebral rotation, unequal heights of hips and shoulders
scoliosis
Hip instability with limited abduction of hips and, occasionally, adduction contractures (head of femur does not articulate with acetabulum because of abnormal shallowness of acetabulum)
Congential hip dysplasia
Legs curved inward so that knees come together as person walks
knock-knee
One or both legs bent outward at knee, which is normal until 2 to 3 years of age
Bowlegs
95%: medial deviation and plantar flexion of foot (equinovarus) 5%: lateral deviation and dorsiflexion (calcaneovalgus)
Clubfoot
Inability to dorsiflex and invert foot because of peroneal nerve damage
Footdrop
Internal rotation of forefoot or entire foot; common in infants
Pigeon Toes
Damage to component of the central nervous system that regulates voluntary movement results in
impaired body alignment, balance, and mobility
Direct trauma to the musculoskeletal system results in
bruises, contusions, sprains, and fractures
inability to move freely
Immobility
Identify the objectives of bed rest.
a. Reducing physical activity and the oxygen needs of the body
b. Reducing pain, including postoperative pain or after acute injury, to the lower back
c. Allowing ill or debilitated clients to rest
d. Allowing exhausted clients the opportunity for uninterrupted rest
Identify the complications of immobility in relation to the metabolic functioning of the body
decreases the metabolic rate; alters the metabolism of CHO, fats, and proteins; causes fluid and electrolyte and calcium imbalances; and causes GI disturbances
collapse of alveoli
Atelectasis
inflammation of the lung from stasis or pooling of secretions
Hydrostatic pneumonia
increase in heart rate of more than 15% and a drop of 15 mm Hg or more in SBP
Orthostatic hypotension
accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery that occludes the lumen of the vessel
Thrombus
Identify the complications of immobility in , relation to the musculoskeletal system
a. loss of endurance, strength, and muscle mass and decreased stability and balance
b. impaired calcium metabolism
c. impaired joint mobility
d. osteoporosis
e. joint contractures
f. footdrop
Identify the complications of immobility in relation to the urinary system.
a. urinary stasis (renal pelvis fills before urine enters the ureters)
b. renal calculi (calcium stones that lodge in the renal pelvis)
Identify the psychosocial effects that occur with immobilization
a. emotional and behavioral responses
b. sensory alterations
c. changes in coping
- is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, or transverse
Range of Motion (ROM)
particular manner or style of walking
Gait
physical activity for conditioning the body, improving health, and maintaining fitness
Exercise and activity tolerance
identifies deviations, learning needs, identifies trauma, risk factors
Body alignment
Which nursing diagnoses is related to an immobilized or partially immobilized client.
1 ineffective airway clearance
- ineffective individual coping
- risk for injury
- impaired skin integrity
- disturbed sleep pattern
- social isolation
- impaired urinary elimination
List the expected outcomes for the goal “client skin remains intact”
a. skin color and temperature return to normal baseline within 20 minutes of position change
b. changes position at least every 2 hours
Identify some examples of health promotion activities that address mobility and immobility
a. prevention of work-related injury
b. fall prevention measures
c. exercise
d. early detection of scoliosis
Identify the nursing interventions that will reduce the impact of immobility on Metabolic Systems
a. a high caloric diet
b. vitamin B and C supplements
Identify the nursing interventions that will reduce the impact of immobility on Respiratory system
a. deep breathe and cough every 1-2 hours
b. CPT
c. ensure intake of 2000 mL of fluid per day
Identify the nursing interventions that will reduce the impact of immobility on Cardiovascular system
a. deep breathe and cough every 1-2 hours
b. CPT
c. ensure intake of 2000 mL of fluid per day
Identify the nursing interventions that will reduce the impact of immobility on Musculoskeletal system
a. perform active and passive ROM exercises
b. CPM machines
Identify the nursing interventions that will reduce the impact of immobility on Integumentary system
a. positioning and skin care
b. use of therapeutic devices to relieve pressure
Identify the nursing interventions that will reduce the impact of immobility on Elimination system
a. well-hydrated
b. prevent urinary stasis and calculi and infections
Identify the nursing interventions that will reduce the impact of immobility on Psychosocial
a. anticipate change in the client’s status and provide routine and informal socialization
b. stimuli to maintain client’s orientation
prevents external rotation of the hips when the client is in supine position
Trochanter roll
maintain the thumb in slight adduction and in opposition to the fingers
Hand rolls
allows the client to pull with the upper extremities to raise the trunk off the bed, assist in transfer, or to perform exercises
Trapeze bar
HOB elevated 45-60 degrees and the knees are slightly elevated
Fowlers
rest on their backs; all the body parts are in relation to each other
Supine
lies face or chest down
Prone
the client rests on the side with body weight on the dependent hip and shoulder
Side-lying
client places the weight on the anterior ileum humerus and clavicle
Sims
Are activities beyond ADLs that are necessary to be independent in society
Instrumental activities of daily living (IADLs)
Describe how you would assist clients with hemiplegia or hemiparesis
Always stand on the client’s affected side and support the client by using a gait belt.
Identify the evaluative measures in mobility
the client’s ability to maintain or improve body alignment, improve mobility; protect the client from the hazards of immobility
What is a potential hazard that you should assess when the client is in a prone position
footdrop
Abnormal and usually permanent condition of a joint, characterized by flexion and fixation and caused by disuse, atrophy, and shortening of muscle fibers.
joint contracture
Measures of height, weight, and skinfold thickness to evaluate muscle atrophy.
anthropometric measurements
A decline is bone density that is associated with impaired mobility or immobilization of an extremity because of fracture, paralysis, or bone or joint inflammation.
disuse osteoporosis
A foreign object, a quantity of air or gas, a bit of tissue or tumor, or a piece of thrombus that circulates in the bloodstream until it becomes lodged in a vessel.
embolus
Leather belt that encircles the waist and has handles attached for the nurse to hold.
gait belt
Loss of muscle tissue.
muscle atrophy
Condition occurring when the body excretes more nitrogen than it takes in.
negative nitrogen balance
Not hardened, soft.
unossified
Group of therapies used to mobilize pulmonary secretions.
chest physiotherapy (CPT)
Paralysis of one side of the body.
hemiplegia
Muscular weakness of one half of the body
hemiparesis
the coordinated efforts of the musculoskeletal and nervous systems as the person moves, lifts, bends, stands, sits, lies down, and completes daily activities
body mechanics
safe patient handling prevents
injuries to nurses and clients when moving and transferring clients
The skeletal system provides bony support structure for
movement, attachment of ligaments and muscles, protection of vital organs, some of the regulation of calcium, and production of red blood cells.
initiation and voluntary control of movement
nervous system
Coordination and regulation of muscle groups depend on
muscle tone; activity of antagonistic, synergistic, and antigravity muscles; and neural input to muscles
Body alignment is the condition of
joints, tendons, ligaments, and muscles in various body positions.
Balance occurs when there is a wide base of
support, the center of gravity falls within the base of support, and a vertical line falls from the center of gravity through the base of support.
Developmental stages influence
body alignment and mobility; the greatest impact of physiological changes on the musculoskeletal system is observed in children and older adults.
The risk of disabilities related to immobilization depends on
on the extent and duration of immobilization and the client’s overall level of health.
illness or trauma or is prescribed for therapeutic reasons.
Immobility sometimes results from
Immobility presents hazards in
the physiological, psychological, and developmental dimensions.
The nursing process and critical thinking assist in providing
care for clients who are experiencing or are at risk for the adverse effects of impaired body alignment and immobility.
Clients with impaired body alignment require nursing interventions to
maintain them in the supported Fowler’s, supine, prone, side-lying, and Sims’ positions.
Client movement algorithms serve as
assessment tools and guide safe client handling and movement.
Appropriate friction-reducing assistive devices and mechanical lifts need to be used for
client transfers when applicable.
No-lift policies benefit
all members of the health care system: clients, nurses, and administration.
Intervention that restrict patients to bed for therapeutic reasons.
Bed rest
It is an increase in heart rate or more than 15%, a drop 15mm in systolic Bp, drop 10mm or more in diastolic. when the pt change from supine to standing position
Orthostatic hypotension
factors that contribute to venous thrombus formation
damage on the vessel wall.(injury)
alteration in blood flow
alteration in blood constitute(change in clotting factors)
impairment of the skin as a result of prolonged ischemia (decrease blood supplies in tissues)
Pressure ulcer
head of the bed is elevated 45-60 degrees. Pt knees are slightly elevated without pressure to restrict circulation in the lower legs.
Supported Folwer’s Position
