Foundational Concepts of Nursing Practice: Mobility Flashcards
What purpose does the musculoskeletal and nervous system serve?
Work together to coordinate movement, positioning, and balance.
What is the proper body mechanic to reduce risk of injury secondary to physical strain?
Stable center of gravity
Wide base
Proper alignment of spine and shoulders
What is the purpose of the field of ergonomics?
Design items so they are safe, easy to use, and efficient.
What is the importance of planning assessments for immobile patients?
Minimize any complications that could occur due to their altered immobility.
What should be performed before getting a patient up to ambulate or transfer?
A mobility assessment.
How often should a patient who is unable to independently change positions be repositioned?
Every two hours.
What is the importance of ROM exercises?
Preserving joint flexibility and preventing contractures from forming.
Musculoskeletal effects of decreased mobility include these major groups…
- Bones
- Muscles
- Joints
Detrimental effect on bones from decreased mobility?
- Disuse osteoporosis, which can result in fragility fractures from bone thinning.
Detrimental effects of decreased mobility on muscles?
- Atrophy
- Sarcopenia
Atrophy vs Sarcopenia
Atrophy: Muscle deterioration from disuse.
Sarcopenia: Specifically refers deterioration of lean muscle mass, fast twitch muscle fibers.
Detrimental effects of decreased mobility on joints?
- Joint contractures
- Foot drop
What muscle group does the contracture orients towards?
Flexor muscles, this is because they are typically stronger than extensor muscles.
How does muscle atrophy lead to foot drop?
Muscle atrophy leads to nerve changes; nerve entrapment and shortening of the calf muscle and Achilles tendon in the lower leg.
T/F Muscle atrophy is the only thing that leads to foot drop.
False, nerve injuries can result in foot drop as well.
This lowered demand results in atrophy of the heart muscle.
Cardiac deconditioning.
Detrimental cardiovascular effects of immobility?
- 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
Detrimental respiratory system effects of immobility?
- Atelectasis
- Pneumonia
Atelectasis vs Pneumonia
Atelectasis: partial or complete collapse of the lung, airway, or small section of lung tissue.
Pneumonia: lung infection
Detrimental effects of immobility on the GI system?
- Constipation
- Gastroesophageal reflux
Detrimental effects of immobility on the GU (Genitourinary) system?
- Urinary retention
- Renal calculi formation
Detrimental effects of immobility on the integumentary system?
Skin breakdown/pressure injury
What areas are most susceptible to skin breakdown?
- Back of the head
- Shoulder blades
- Elbows
- Sacrum
- Ischium
- Heels
How deep do each of the four stages of skin breakdown go?
Four stages of skin breakdown:
- No skin breakdown
- Breakdown that tunnels into epidermal layers or blister formation
- Breakdown that tunnels to muscle
- Breakdown that tunnels to bone
In regards to disuse osteoporosis what should you notify to the provider?
If you suspect a fragility fracture
How often should you round on patients with disuse osteoporosis?
Hourly
What should you monitor in a patient with disuse osteoporosis?
Pain with ambulation
What should you do to protect the patient from falls and injuries with disuse osteoporosis and sarcopenia?
(Not side rail question)
Assist in patient ambulation
How should you proceed with activities in a patient with sarcopenia?
What do they include?
Gradually increase them.
- They include:
- Dangling
- Sitting
- Standing to build strength
How often should joints be moves to promote joint mobility?
Every 8 hours. They should be repositioned every 2 hours to prevent skin breakdown.
What intervention is ordered by the provider to support and stretch the limb of a patient with foot drop?
A splint.
What intervention should be performed in all patients with decreased mobility to reduce cardiovascular complications?
Antiembolism stockings or sequential decompression devices
This intervention helps promote blood flow to the lower extremities an immobile patient.
Elevating HOB.
The use of this device helps prevent respiratory complications from immobility.
Incentive spirometer
How high should the HOB be elevated to encourage deep breathing?
30-45 degrees
This position is used to promote drainage secretions in patients who cannot tolerate elevating the HOB.
Prone positioning
How often should a patient be turned and repositioned to promote lung expansion?
Every two hours
These interventions decrease risk of constipation?
- Fluids
- High fiber foods
- Increased mobility to promote peristalsis
This intervention is important after eating to promote collection of gastric secretions in the lower stomach.
Elevating the HOB.
This position promotes adequate bladder emptying.
Upright position.
Psychological complications from immobility?
- Depression
- Social isolation
What problem can arise from using an antiembolic stocking of the wrong size?
Can create a reverse pressure gradient, increasing risk of DVT development.
What is the importance of providing patient education?
Reduces patient anxiety and promotes nurse-patient relationship.
Why should you fold up the antiembolic stocking until it is rolled up?
Decreases amount of fabric needing to be pulled up over the extremity.
Once the stocking has been pulled up to the heel, what should you do before pulling it the rest of the way up? Why?
Ensure patient can move their toes.
If they cannot, then the stocking may be the wrong size.
When should you assess patient circulation and comfort after antiembolic stocking application?
Approximately 30 min after application
How often should sequential compression devices be removed?
Typically every 8 hours, but check with hospital policy.
Where should you station yourself with a patient who is ambulating with a cane?
On the affected side, slightly behind the patient.
When a patient is ambulating with a cane, how should the ambulate?
- Cane on strong side
- Move cane 6-12 in. forward
- Advance weaker leg forward followed by stronger leg.
Which leg should a patient step with first after advancing their walker 6-8 in. in front of them?
Weaker leg first
These two crutch gaits require weight bearing on both legs?
Four and two point gaits
How does the four point crutch gait vary from the two point crutch gait?
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.
(T/F) When performing passive ROM exercises the nurse should always move the joint to the point of considerable resistance.
False. To the point of slight resistance.
When doing passive ROM exercises do you focus on the larger or smaller joints first?
Larger.
Approximately how many times should you move each joint when doing passive ROM exercises?
3-5 times.
How often should passive ROM exercises be performed during the day?
3-4 times.
How often should you instruct a patient, who is on bed rest, to cough and deep breath?
Every hour.
(T/F) It is okay for a patient, who is completely with it, to request to leave all of their side rails down.
True. A patient who is completely alert and oriented may request to keep all four side rails down. Be sure to document this.
What macro and micronutrients should a patient increase in their diet to promote bone formation?
Calcium, vitamin D, magnesium, Vitamin K, and protein.
