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
