immobility Flashcards
describe adduction
lateral movement of a body part toward the midline of the body
describe abduction
lateral movement of a body part away from the midline of the body
describe rotation
- internal rotation: a body part turning on its axis toward the midline of the body
- external rotation: a body part turning on its axis away from the midline of the body
describe flexion
the state of being bent
describe extension
the state of being in a straight line
describe supination
the assumption of the supine position
describe pronation
the assumption of the prone position
describe inversion
movement of the sole of the foot inward (occurs at the ankle)
describe eversion
movement of the sole of the foot outward (occurs at the ankle)
describe trendelenburg position
requires lowing the torso and raising the feet
describe prone position
person lies on abdomen and turns head to the side, body is straight
describe supine position
person lies flat on back with legs extended and knees slightly flexed
describe dorsal recumbent position
patient lays on back with legs separated, knees flexed, and soles of feet on the bed
describe bone
the hard largely calcareous connective tissue of which the adult skeleton of most vertebrates is chiefly composed
describe muscles
an organ that is essentially a mass of muscle tissue attached at either end to a fixed point and that by contracting moves or checks the movement of a body part
describe ligaments
a tough fibrous band of tissue connecting the articular extremities of bones or supporting an organ in place
describe tendons
a tough cord or band of dense white fibrous connective tissue that unites a muscle with some other part (such as a bone) and transmits the force which the muscle exerts
describe joints
the point of contact between elements of a skeleton with the parts that surround and support it
describe alignment
- in the standing position, a straight line can be drawn from the ear through shoulder and hip; in bed, head, shoulders, and hips are aligned
- correct alignment permits optimal musculoskeletal balance and operation and promotes physiologic functioning
- deviations from body alignment result from chronic poor posture, trauma, muscle damage, or nerve dysfunction. Pain, fatigue, and a persons mental status may also influence alignment
describe posture
- the position or bearing of the body
- head erect, vertebrae straight, knees and feet point forward, arms at side with elbows flexed
describe balance
stability produced by even distribution of weight on each side of the vertical axis
describe gait
- the way a person walks
- arms swinging freely in alternation with legs swings, while one leg is in the stance phase the other is in the swing phase
describe coordination
the harmonious functioning of parts for effective results
describe range of motion (ROM)
the maximum degree of movement of which a joint is normally capable
name some factors that influence mobility
- lifestyle and habits
- musculoskeletal function
- nervous system control
- circulation and oxygenation
how could lifestyle and habits influence mobility?
- are they sedentary or active?
- what is their motivation to move?
- what habits do they have?
- what is their living environment and community like?
describe how musculoskeletal function may influence mobility
need adequate structure and function in order to mobilize properly
describe how nervous system control may influence mobility
- spinal cord injury - paralysis below the level of injury
- afferent and efferent nerves connect to the CNS to the periphery and back again
- pain is managed and mediated by the nervous system, pain can impede mobility (anticipate pain on movement and administer pain meds before movement)
describe efferent nerves
impulses move from CNS back to periphery
describe afferent nerves
nerves that help to move impulses from the periphery to CNS
describe how circulation and oxygenation can influence mobility
- skeletal muscle contraction requires significant energy and oxygenation
- any alteration will limit ability to have purposeful movements
what findings during assessment may indicate limited mobility?
- decreased muscle strength and tone
- lack of coordination
- altered gait
- falls
- decreased joint flexibility
- pain on movement
- impact in every body system
how can immobility impact the cardiovascular system?
- increased cardiac workload = skeletal muscles dont help push the blood back to the heart = makes the heart work harder to pump = faster heart rate
- orthostatic hypotension = baroreceptors in the brain are sluggish to respond to body position changes
- thrombus formation and embolism = venous stasis = increase risk of formation of blood pools (venous stasis) in the extremities
what is the difference between a thrombus and embolism
thrombus is a clot, embolism is a moving clot
what are some abnormal findings r/t immobility in the cardiovascular system
- increased HR
- hypotension, particularly with position changes
- edema of extremities
- assessment findings indicating DVT or clot (unilateral edema, redness, swelling, pain, low grade fever)
what interventions can be used to prevent complications of immobility r/t cardiovascular system
- orthostatic VS
- gradual position changes
- DVT prevention (early ambulation, TED hose, SCD pumps)
what impacts does immobility have on the respiratory system
- decreased lung expansion (partially because of a decreased need for oxygen by the body)
- atelectasis - micro collapse of functional unit of the lung (alveoli) where exchange of O2 and CO2 happens
- retained secretions
- pulmonary embolus (thrombus that has moved to circulatory system surrounding the lungs)
describe abnormal assessment findings r/t the respiratory system with immobility
- diminished lung sounds, especially in the bases of the lungs
- increased need for supplemental oxygen or decreased SPO2
- cough or rhonchi
- SOB
- chest pain and tachycardia along with SOB may cause concern for pulmonary embolus (can be life threatening)
what interventions can be used to prevent complications of immobility r/t respiratory system
- coughing, deep breathing
- incentive spirometry
- increase fluid intake
- positioning
- promote activity
describe the impact immobility has on the musculoskeletal system
- muscle atrophy and weakness, impaired endurance
- contractures and joint pain
- disuse osteoporosis = OP is the weakened state of bone structure. without weight bearing activity, bone breaks down faster than it is repaired
describe some abnormal assessment findings with immobility r/t the musculoskeletal system
- atrophy
- impaired strength
- impaired ROM
- pain on movement
- frequent fractures
describe interventions to prevent complications of immobility r/t musculoskeletal system
- turning schedules and positioning aides
- logrolling
- mobility restrictions on recent orthopedic surgery pts
- change positions gradually
- joint mobility maintenance/ROM exercises (support joint being exercised, use of automatic ROM equipment)
- early and progressive mobilization
- dangling
- protect yourself and the pt (transfer and gait belts)
- pt can perform isometric exercises in bed to maintain or improve muscle tone even if unable to get oob
differentiate between active and passive ROM
active - pt moves extremities on their own
passive - pt is assisted to move
what are some different devices used to assist with musculoskeletal interventions for immobility
- foot board
- high top sneakers/boots to prevent plantar flexion (foot drop)
- hand rolls
- trochanter rolls
- transfer/gait belts
what impact does immobility have on the neurologic system
- sensory deprivation
- altered sleep/wake cycles
what are some abnormal assessment findings with immobility r/t neurologic system
- confusion
- impaired short term memory
- irritability
- insomnia
- excessive drowsiness
what are some interventions used to prevent complications of immobility r/t neurologic system
- meaningful stimuli
- promote natural/normal sleep patterns
- mobilize
describe the impact immobility has on psychological/social functioning
- helplessness
- body image disturbance
- exaggerated emotional responses
describe interventions to prevent complications of immobility r/t psychological/social functioning
- give choices
- encourage even limited self care
- mobilize
describe the impact immobility has on the integumentary system
- impaired peripheral circulation
- can lead to impaired skin integrity
describe some abnormal assessment findings with immobility r/t integumentary system
- reddened areas of skin at pressure points
- pressure injuries
- rashes
what are some interventions to prevent complications of immobility r/t integumentary system
- turn q2 for high risk pts, use natural alignment, pillows for support
- keep dry, wrinkle free linens
- progressive mobility (oob as soon as possible)
describe the impact immobility has on the gastrointestinal/metabolic system
- decreased metabolic rate
- cellular demand for O2 decreased, leading to decreased metabolic rate
- negative nitrogen balance (other factors- fever, trauma, illness - cause increased metabolic rate and tissue breakdown occurs faster than can be replaced)
- constipation due to decreased muscle tone in GI organs (decreased peristalsis)
- anorexia/decreased appetite
describe some abnormal assessment findings with immobility r/t GI/metabolic system
- nausea
- appetite decrease
- weight loss
- evaluation of bowel elimination or constipation
describe some interventions that can be used to prevent complications of immobility r/t GI/metabolic system
- increase fluids
- offer frequent toileting
- oob for meals and elimination
- progressive mobility
describe the impact immobility has on the urinary system
- urinary stasis (pooling)
- UTI
- renal calculi (when bone breaks down faster than it can repair, calcium is released into the bloodstream)
describe some abnormal assessment findings with immobility r/t urinary system
- urinary retention
- frequent urination
- cloudy or amber urine
- back or flank pain
describe some interventions used to prevent complications of immobility r/t urinary system
- oob for elimination
- increase fluids
- progressive mobility
describe some subjective data used when assessing for mobility alterations
- normal pattern identification r/t activity
- risk identification (patients on bedrest or risk for falls)
- dysfunction identification (inability to tolerate activities, what causes the mobility issues?)
describe some objective data used for assessing for mobility alterations
- general survey (posture, alignment, gait)
- neurological
- cardiovascular
- respiratory
- GI
- urinary
- musculoskeletal
what are some nursing diagnoses r/t immobility
- impaired physical mobility
- ineffective tissue perfusion
- ineffective breathing pattern
- impaired wheelchair mobility
- activity intolerance
- constipation
- urinary retention
- risk for disuse syndrome
- acute pain
- risk for impaired skin integrity
- impaired bed mobility
what does SMART stand for
Specific
Measurable
Attainable
Realistic
Time Based
describe planning and implementing with immobility
- establish measurable patient centered goals and outcomes
- health promotion (physical fitness, injury prevention, osteoporosis prevention)
- systemic interventions
describe systemic interventions
- interventions that affect the whole person
- ex. encouraging frequent and early mobilization, increased fluid intake
- affective learning - seeing what pts believe about immobility
describe implementing progressive mobility
- personalize how much activity a pt participates in based on how much they can tolerate
- dangle at side of bed
- must use nonslip socks
- use transfer belts and ambulation devices
- isometric exercises to enhance muscle strength
- obtain proper equipment and assistance
describe evaluation with immobility
- have goals and outcomes been met?
- supporting documentation of progress, stagnation, or recession
- modify or discontinue the care plan as needed
