Lesson 8 - Understanding Mobility and Immobility Flashcards
Potential Causes of Immobility
-direct injury (ie. sprain)
-CNS damage (ie. stroke)
-illness (ie. cancer)
-surgery complications
-advanced age
What is a developmental consideration for immobile school age children?
-delay in gross motor skills, intellectual or musculoskeletal development
What is a developmental consideration for immobile adolescents?
-growth patterns
-ability to gain independence
-social isolation
What is a developmental consideration for immobile adults?
-risk for physiological systems
-change in family and social structure
Which group is at the most risk of immobility?
older persons
What is a developmental consideration for immobile older adults?
-loss of bone mass and muscle strength
-increased dependence of other
-loss of capacity for self-care
How can you make older persons feel more independent and decrease immobility risk?
encouraging them to do as much self-care as possible
How do nurses contribute to loss of self-care?
by doing too much for patients
What are some of the “benefits” of bed rest?
-reduced activity and oxygen needs
-reduces pain
-promotes safety
-allows rest
Bed rest is a ______-_______ immobility.
medically-imposed
Deconditioning
when you have not used something in a while, your body forgets how to use it
What is deconditioning a result of?
prolonged bed rest
Etiology (reasons behind) deconditioning
-sleep
-pain
-depression
-immobility
-medical and surgical conditions
-inflammation
-nutrition
Atelectasis
-collapse of alveoli
-can lead to lung collapse
-impaired gas exchange
Hypostatic Pneumonia
-inflammation of the lung from pooling of secretions
-good medium for bacterial growth
Dyspnea
-difficulty breathing
Orthostatic Hypotension
-blood pressure drops when the patient changes from lying to standing
Why does orthostatic hypotension happen from bed rest?
-diminished cardiac output
-heart can’t keep up with changing vertical position
Why is orthostatic hypotension dangerous?
-dizziness may lead to falls
Thrombus
-blood clot that forms in a vessel as a result of vessel injury, slow blood flow, increase in viscosity
What is the most common type of thrombus?
DVT - Deep Vein Thrombosis
Embolus
-dislodged venous thrombus
-can travel and cause an eschemic event (ie. stroke)
Constipation
-may result from decreased GI mobility
Pseudodiarrhea
-may result from a fecal impaction
-liquid stool passes around the impaction
-may lead to mechanical bowel obstruction
Fecal Impaction
accumulation of hardened feces
Urinary Stasis
urine stoppage due to no help from gravity
What are the risks of urinary stasis?
-UTI
-kidney stones
Residual Urine
-urine left in the bladder may increase infection risk
Muscular Atrophy
-decrease in size of muscle tissue
-muscle strength drops 3%/day
Bone Loss
-increased with osteoporosis
-risk for fractures
Disuse Osteoporosis
-less dense bones
-increased fracture risk
Joint Contracture
-abnormal and possibly permanent condition characterized by joint fixation
Foot Drop
-damage to peroneal nerve
-consistent flexion as a result of poor support
Pressure Injury
-bed sores
-caused by pressure and a lack of sensation
How does friction lead to pressure injury?
-weak skin deteriorates
-due to linens
-may be during transfers
How does shear lead to pressure injury?
-sliding down in bed
-creases in clothes, socks, linens
How does hygiene contribute to pressure injury?
-skin breakdown from not clean and moist
What can delay wound healing?
-malnutrition
-bed rest
Psychosocial Effects of Immobility
-social isolation
-sensory deprivation
-changes in coping
-depression
Depression
affective disorder characterized by sadness, melancholy, worthlessness, emptiness
The nurse is caring for a patient with the nursing diagnosis of impaired physical mobility. The nurse needs to be alert for which of the following complications? SATA
a. pulmonary emboli
b. pneumonia
c. impaired skin integrity
d. fatigue
e. increased socialization
a, b, c, d
A patient has been on prolonged bed rest, the nurse is observing for signs associated with immobility. While assessing the patient the nurse is alert to which of the following signs?
a. increased bp
b. decreased hr
c. increased urinary output
d. decreased peristalsis
d
Immobility is a major risk factor for pressure ulcers. In caring for an immobile patient, the nurse needs to be aware of which of the following?
a. breaks in the skin integrity are easy to heal
b. preventing a pressure ulcer is less expensive than treating one
c. a 30 degree lateral position is recommended for patient positioning
d. pressure ulcers are caused by a sudden influx of oxygen to the tissue
c
The nurse is caring for a patient who has suffered a stroke and is partially immobile. As part of ongoing care, what should the nurse do?
a. encourage the patient to perform as many self-care activities as possible
b. provide a complete bed bath to promote patient comfort
c. place the patient on bed rest to prevent fatigue
d. understanding that the patient will not eat because energy needs are decreased
a
Subjective Mobility Assessment
-degree of mobility
-how long has disability been present?
-is the patient fearful
-use of assistive device?
-pain assessment
-effect on lifestyle
-coping
Objective Mobility Assessment
-ROM
-gait
-exercise
-body alignment
-physical deformities
-AOx4
-mood
Active ROM
-on own
Passive ROM
-with help
Mobility Expectations Assessment
-address unrealistic expectations
-do they understand own limitations?
What is important when planning for immobility?
interdisciplinary team collaboration
Nursing Interventions: Respiratory
-deep breathing exercises
-semi/high fowlers position
-couching exercises
-supplementary oxygen
Nursing Interventions: Cardiovascular
-slow position changes
-frequent position changes
-anti-clotting medications
-exercise
-fluids
-TED stockings
-positioning
What do TED stockings do?
increase venous return to the heart
Nursing Interventions: GI System
-nutritional intake
-small meals more frequently
-ambulation to aid in peristalsis
Nursing Interventions: Urinary System
-hydration/fluid intake
-upright elimination position
-increased sitting upright in general
Nursing Interventions: Musculoskeletal
-pillows for positioning
-handrolls
-splints for foot drop
-ROM exercises
-TED stockings
-sequential compression device
-use of mobility aids
Nursing Interventions: Integumentary
-skin integrity assessment
-braden scale assessment
-reposition every 1-2 hours
-hygiene care
Nursing Interventions: Psychosocial
-socialization
-maximize patient participation in care
-activities
-teaching
-self-care
Hemiplegia
muscle paralysis
Hemiparesis
muscle weakness
Muscle Atrophy
loss of muscle tone and joint stiffness
Disease Atrophy
tendency of cells and tissue to reduce in size and function in response to prolonged inactivity
Negative Nitrogen Balance
when an immobile patient’s body excretes more nitrogen than it ingests in proteins
