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Unit 5 > Foundational Concepts of Nursing Practice: Mobility > Flashcards

Foundational Concepts of Nursing Practice: Mobility Flashcards

1
Q

What purpose does the musculoskeletal and nervous system serve?

A

Work together to coordinate movement, positioning, and balance.

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2
Q

What is the proper body mechanic to reduce risk of injury secondary to physical strain?

A

Stable center of gravity

Wide base

Proper alignment of spine and shoulders

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3
Q

What is the purpose of the field of ergonomics?

A

Design items so they are safe, easy to use, and efficient.

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4
Q

What is the importance of planning assessments for immobile patients?

A

Minimize any complications that could occur due to their altered immobility.

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5
Q

What should be performed before getting a patient up to ambulate or transfer?

A

A mobility assessment.

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6
Q

How often should a patient who is unable to independently change positions be repositioned?

A

Every two hours.

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7
Q

What is the importance of ROM exercises?

A

Preserving joint flexibility and preventing contractures from forming.

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8
Q

Musculoskeletal effects of decreased mobility include these major groups…

A
  • Bones
  • Muscles
  • Joints
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9
Q

Detrimental effect on bones from decreased mobility?

A
  • Disuse osteoporosis, which can result in fragility fractures from bone thinning.
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10
Q

Detrimental effects of decreased mobility on muscles?

A
  • Atrophy
  • Sarcopenia
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11
Q

Atrophy vs Sarcopenia

A

Atrophy: Muscle deterioration from disuse.

Sarcopenia: Specifically refers deterioration of lean muscle mass, fast twitch muscle fibers.

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12
Q

Detrimental effects of decreased mobility on joints?

A
  • Joint contractures
  • Foot drop
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13
Q

What muscle group does the contracture orients towards?

A

Flexor muscles, this is because they are typically stronger than extensor muscles.

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14
Q

How does muscle atrophy lead to foot drop?

A

Muscle atrophy leads to nerve changes; nerve entrapment and shortening of the calf muscle and Achilles tendon in the lower leg.

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15
Q

T/F Muscle atrophy is the only thing that leads to foot drop.

A

False, nerve injuries can result in foot drop as well.

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16
Q

This lowered demand results in atrophy of the heart muscle.

A

Cardiac deconditioning.

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17
Q

Detrimental cardiovascular effects of immobility?

A
  • Orthostatic hypotension
  • DVT
  • PE as a result of DVT breaking off in leg
  • TIA (transient ischemic attack), clot travels to brain
  • Myocardial infarction, clot travels to heart vessel
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18
Q

Detrimental respiratory system effects of immobility?

A
  • Atelectasis
  • Pneumonia
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19
Q

Atelectasis vs Pneumonia

A

Atelectasis: partial or complete collapse of the lung, airway, or small section of lung tissue.

Pneumonia: lung infection

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20
Q

Detrimental effects of immobility on the GI system?

A
  • Constipation
  • Gastroesophageal reflux
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21
Q

Detrimental effects of immobility on the GU (Genitourinary) system?

A
  • Urinary retention
  • Renal calculi formation
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22
Q

Detrimental effects of immobility on the integumentary system?

A

Skin breakdown/pressure injury

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23
Q

What areas are most susceptible to skin breakdown?

A
  • Back of the head
  • Shoulder blades
  • Elbows
  • Sacrum
  • Ischium
  • Heels
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24
Q

How deep do each of the four stages of skin breakdown go?

A

Four stages of skin breakdown:

  1. No skin breakdown
  2. Breakdown that tunnels into epidermal layers or blister formation
  3. Breakdown that tunnels to muscle
  4. Breakdown that tunnels to bone
25
Q

In regards to disuse osteoporosis what should you notify to the provider?

A

If you suspect a fragility fracture

26
Q

How often should you round on patients with disuse osteoporosis?

A

Hourly

27
Q

What should you monitor in a patient with disuse osteoporosis?

A

Pain with ambulation

28
Q

What should you do to protect the patient from falls and injuries with disuse osteoporosis and sarcopenia?

(Not side rail question)

A

Assist in patient ambulation

29
Q

How should you proceed with activities in a patient with sarcopenia?

What do they include?

A

Gradually increase them.

  • They include:
    • Dangling
    • Sitting
    • Standing to build strength
30
Q

How often should joints be moves to promote joint mobility?

A

Every 8 hours. They should be repositioned every 2 hours to prevent skin breakdown.

31
Q

What intervention is ordered by the provider to support and stretch the limb of a patient with foot drop?

A

A splint.

32
Q

What intervention should be performed in all patients with decreased mobility to reduce cardiovascular complications?

A

Antiembolism stockings or sequential decompression devices

33
Q

This intervention helps promote blood flow to the lower extremities an immobile patient.

A

Elevating HOB.

34
Q

The use of this device helps prevent respiratory complications from immobility.

A

Incentive spirometer

35
Q

How high should the HOB be elevated to encourage deep breathing?

A

30-45 degrees

36
Q

This position is used to promote drainage secretions in patients who cannot tolerate elevating the HOB.

A

Prone positioning

37
Q

How often should a patient be turned and repositioned to promote lung expansion?

A

Every two hours

38
Q

These interventions decrease risk of constipation?

A
  • Fluids
  • High fiber foods
  • Increased mobility to promote peristalsis
39
Q

This intervention is important after eating to promote collection of gastric secretions in the lower stomach.

A

Elevating the HOB.

40
Q

This position promotes adequate bladder emptying.

A

Upright position.

41
Q

Psychological complications from immobility?

A
  • Depression
  • Social isolation
42
Q

What problem can arise from using an antiembolic stocking of the wrong size?

A

Can create a reverse pressure gradient, increasing risk of DVT development.

43
Q

What is the importance of providing patient education?

A

Reduces patient anxiety and promotes nurse-patient relationship.

44
Q

Why should you fold up the antiembolic stocking until it is rolled up?

A

Decreases amount of fabric needing to be pulled up over the extremity.

45
Q

Once the stocking has been pulled up to the heel, what should you do before pulling it the rest of the way up? Why?

A

Ensure patient can move their toes.

If they cannot, then the stocking may be the wrong size.

46
Q

When should you assess patient circulation and comfort after antiembolic stocking application?

A

Approximately 30 min after application

47
Q

How often should sequential compression devices be removed?

A

Typically every 8 hours, but check with hospital policy.

48
Q

Where should you station yourself with a patient who is ambulating with a cane?

A

On the affected side, slightly behind the patient.

49
Q

When a patient is ambulating with a cane, how should the ambulate?

A
  1. Cane on strong side
  2. Move cane 6-12 in. forward
  3. Advance weaker leg forward followed by stronger leg.
50
Q

Which leg should a patient step with first after advancing their walker 6-8 in. in front of them?

A

Weaker leg first

51
Q

These two crutch gaits require weight bearing on both legs?

A

Four and two point gaits

52
Q

How does the four point crutch gait vary from the two point crutch gait?

A

Four point: Move crutch first, then opposite side foot. And repeat on the other side.

Two point: Move crutch and opposite foot simultaneously. And repeat on the other side.

53
Q

(T/F) When performing passive ROM exercises the nurse should always move the joint to the point of considerable resistance.

A

False. To the point of slight resistance.

54
Q

When doing passive ROM exercises do you focus on the larger or smaller joints first?

A

Larger.

55
Q

Approximately how many times should you move each joint when doing passive ROM exercises?

A

3-5 times.

56
Q

How often should passive ROM exercises be performed during the day?

A

3-4 times.

57
Q

How often should you instruct a patient, who is on bed rest, to cough and deep breath?

A

Every hour.

58
Q

(T/F) It is okay for a patient, who is completely with it, to request to leave all of their side rails down.

A

True. A patient who is completely alert and oriented may request to keep all four side rails down. Be sure to document this.

59
Q

What macro and micronutrients should a patient increase in their diet to promote bone formation?

A

Calcium, vitamin D, magnesium, Vitamin K, and protein.

Unit 5 (2 decks)

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