immobility, transfers, and excerises Flashcards
mobility
adapting to and having self- awareness of the environment
- functional musculoskeletal and nervous systems are essential for mobility
immobility
the inability to move freely and independly ay will
the risk of complications increases with…
degree of immobility and the length of time of immobilization
- period of immobility or prolonged bed rest can cause major physiological and psychosocial effects
cutaneous stimulation
form of cold and heat applications helps relieve paining promotes healing
what does promoting venous return do
reduce the complications of immobility
types of immobility
- temporary ( following knee arthroplasty)
- permanet (paraplegia)
- sudden onset (fractured arm and leg following motor vehicle crash)
- slow onset (multiple sclerosis)
body mechanics involves
coordination between musculoskeletal and nervous systems, and the use of alignment, balance, gravity, and friction
- movement depends on an intact skeletal system, skeletal muscles, and nervous system
assessment focuses on
mobility range of motion gait exercise status activity tolerance body alignment while standing, sitting, and lying
factors affecting mobility
alterations in muscles injury to the musculoskeletal system poor posture impaired central NERVOUS SYSTEM health status and age
systemic effects of immobility
skin and respiratory
- increased pressure on skin
- decreased circulation to tissue causing ischemia, can lead to pressure injury
- decreased respiratory movement resulting in decreased oxygenation and carbon dioxide exchange
- stasis of secretions and decreased and weakened respiratory muscles, resulting in atectasis and hypostatic pneumonia
- decreased cough response
- contractors of muscles/ extremities
systemic effects of immobility (cardiovascular)
- orothstatic hypotension
- less fluid volume in the circulatory system
- status of blood in legs
- decreased cardiac output, leading to poor cardiac effectiveness, results in increased cardiac workload
- increased risk of thrombus development
- decreased urinary elimination of calcium
systemic effects of immobility (urinary system)
urinary stasis
- changed in calcium metabolism with hypercalcemia resulting in renal calculi
- decreased fluid intake and increased use of indwelling urinary catheters, resulting in urinary tract infections
- decreased peristaliss
- decreased fluid intake
- constipation, increasing the risk for fecal impaction
nursing actions for immobility
- increase activity- dangling feet on side of bed or transferring to a chair
- change position
- moe client gradually during position chnages
- instruct clients to avoid valsalva maneuver
- give stool softener to prevent straining
- teach range of motion
- anti embolic exercises (ankle pumps, foot circles, knee flexion)
- use elastic stocking
- use sequential compression devices (SCD) or intermittent pneumatic compression (IPC)
- increase fluid intake if no restrictions
- administer low- dose heparin or enoxaparin subcutaneously prophylactically
nursing actions (urinary, gastro, skin)
- assess i&O
- assess food intake
- review urinary and bowel elimination status
- assess wound healing
- ausuclate bowel sounds
- check skin turgor
- review lab values for electrolytes, blood total protein
- assess bladder for distention
nursing actions for urnairy
- observe urine for color, amount, clarity and frequency
- auscultate bowel sounds
- observe feces for color, amount, frequency
- maintain hydration (at least 2,00 ml/day)
- give stool softener, laxative, or enema
- provide perineal care
- teach bladder and bowel training
- insert a straight or indwelling catheter to relieve or manage bladder distention
- promote urinartion by pouring warm water over perineal area
transferring pt.
- maintain or regain body alignment and stability
- achieve full or optimal ROM, and prevent
- assess ROM capability
- assess muscle tone and mass
- observe for contractures
transferring pt. pt. 2
monitor gait
- motor nutritional intake of calcium
- monitor use of assistive devices to assist with
- change pt every 2 hours and perform weight shifts in wheelchair every 15 min
- provide rom 2 or 3 times a day
- cluster care to promote a proper sleep wake cycle
- request physical therapy
trasferire pt assistive devices
- gait belts
- foot board
- walkers
- canes
- crutches
- wheel chairs
wheelchair
- observe for skin breakdown, warmth, and change in color
- observe boney prominces
- use pressure injury risk scale
- turn every 1 to 2 hours, use devices for support
- move independently move every 15 mins
- limit sitting to every 1 hour
- therapeutic bed
- skin and perineal care
cane
- maintain 2 points of support
- keep cane on the stronger side
- support body weight on both legs
- move cane fowl first
- move weaker leg forward towards cane
- advance stronger leg past cane
crutches
- hand grip with elbows 20-30 degress
- hold crutches in one hand and grasp the arm of char with other hand for balance while sitting and rising from a chair
- tripod position
- place crutches 15cm in front of and 12 cm on the side of each foot to provide a wide base of support
- client alternates weight from one leg to the other as well on the crutches
- cellist should stand with a straight back, hips, and neck and should not place any weight not he axillae
types of gait on crutches
- 4 point gait requires client to bear weight on both legs
- client alternates each leg with opposite crutch so 3 points of support are on the floor at all times
- 3 point gait requires client to bear all weight on one foot while using both crutches
- affected leg should never bear weight or touch ground
- 2 point gait requires client to have partial weigh bearing on both feet
- client moves crutch while moving the opposite leg at the same time
heat
- increase blood flow
- increase tissue metabolism
- relaxes muscles
- eases joint stiffness and pain
cold
decreases inflammation
- prevents swelling
- reduces bleeding
- reduces fever
- diminishes muscle spasm
- decrease pain by decreasing velocity of nerve conduction
deep vein thrombosis (Blood clots)
thrombophlebitis and deep vein thromisosi are inflammation of vein (usually in lower extremity) that result in clot formation
deep vein thrombosis (Blood clots) manifestations
pain, edema, warmth, and erythema at the site
deep vein thrombosis (Blood clots) assessment
another assessment method for clients prone to thrombosis is to measure bilateral calf and thigh circumference daily
elastic (anti embolic stockings)
- assess skin, circulation and presence of edema in legs
- measure calf and or thigh circumference and length of the leg to up the popliteal artery for the calf stockings
- tun the stockings inside to the hell
- smooth any creases or wrinkles
- remove the stockings every 8 hr to assess for redness, warmth or tenderness
- make sure the stockings are not too tight over the toes
- keep stockings clean and dry
- document the application and removal of the stockings
deep vein thrombosis (Blood clots) nursing’s actions
- notify provider immediately
- position the client in bed with the leg elevated
- avoid any pressure at the site of imflammation
- anticipate giving anticoagulants
