Mobility Flashcards
regulation of movement
- skeletal system: bones and joints
- muscles
- nervous system
- problem with any of these affects mobility
Factors that affect mobility: age
- Infant
a. Spine flexed, no anteroposterior curve until infant raises head
b. Thoracic spine straightens
c. Lumbar spinal curve appears allows sitting & standing
d. Posture awkward–head & upper trunk carried forward–child off balance,
falls easily - Toddler
a. Posture slightly swayback with protruding abdomen
b. Walk–legs & feet far apart & feet slightly everted - School age
a. By third year taller, slimmer & better balanced
b. Improved posture & muscle strength fine motor coordination - Older adult
a. Bones—osteoporosis risk of fx of wrist, vertebrae & neck.
b. Muscles–Regeneration slowed, atrophied tissue replaced with fiber
c. Joints Breakdown in component of joint capsule–arthritis
d. Posture–Height 1.2 cm/20 yrs, long bones remain same length
Factors that affect mobility: physical health
- Congenital disorders—cerebral palsy, spina bifida
- NS disorders—Parkinson’s disease, Spinal cord injury, stroke
- MS disorders—arthritis, fractures. Amputations
- Inner ear injections–vertigo
Factors that affect mobility: mental health
- Depression –> can affect posture
- Chronic stress –> fatigue, decrease in exercise
Factors that affect mobility: nutrition
- Poor nutrition –> muscle weakness, fatigue
- Vitamin D deficiency –> bone deformity
- Calcium deficiency –> Osteoporosis
- Obesity –> altered posture, balance
Factors that affect mobility: personal values
- Sedentary vs active lifestyle
- Value of personal appearance
Factors that affect mobility: external factors
- Weather
- Availability of recreational facilities
Factors that affect mobility: prescribed limitations
- Casts, braces, splints, traction
- Ordered immobility
nursing history: subjective data
- height/wt (pt report)
- activity & rest patterns
- diet: intake of calcium and vit D –> affects bone health
- meds
- arthritis, CNS depressants, sedatives
- do they use a walker, a cane, do they have difficulty ambulating
nursing history
- Functional status
o Walking, standing, sitting up, getting into/ out of bed or chair, ADLs
o Assistive devices—crutches, walker, braces, feeding or grooming aids
o Activity tolerance - Environmental barriers/ aids
- Past history of falls/ injuries
- Symptoms associated with MS problems
- pain/stiffness with movement
- weakness
- dominant hand
physical assessment: objective data
- Height, weight, stature, posture
- Body alignment
- Movement
- In bed, lying –> sitting –> standing
- Get idea of flexibility, agility,
control - gait – steady?
- get up and go test
times get up and go test
- begin timing
- rise from standard arm chair
- walk to line on floor (approximately 10 ft away from chair)
- turn and return to chair
- sit in chair again
- end timing
- should take 7 to 10 seconds
joints
- Swelling, redness, deformity, contractures (unable to stretch their arm out), crepitation (crackling)
- ROM
- Use of cane, walker, crutches, prosthesis
- evidence of past injuries
- any bruises, scratches, scrapes
functional status
- Dressing, bathing, feeding, toileting
- NOC Scale:
0–completely independent
1—requires use of an assistive device
2—needs minimal help
3—needs assistance or some supervision
4—needs total supervision
5—needs total assistance or unable to assist
diagnostics
- X-rays
- Fracture sites—old or new
- DXA (or DEXA) Scan (bone density scan)
- Dual-emission X-ray absorptiometry
- Bone density
- white = more dense
impaired physical mobility
- difficulty or inability to facilitate movement
- Ex: older adult who has experienced a fracture
- someone who broke their leg in their 20s and isn’t able to move around adequately
self-care deficit syndrome
- the state in which an individual experiences an impaired motor fxn or cognitive fxn causing a decreased ability in performing each of the 5 self-care activities (feeding, bathing, toileting, dressing, instrumental things like cooking)
- ex: someone who had a stroke –> cog motor fxn = altered
sedentary lifestyle
- reports a habit of life that is characterized by a low physical activity level
- couch potato, lots of work from a computer
principles of body mechanics
- use proper body mechanics and equipment to protect pt and self
- maintain a wide stable base with ur feet
- put the bed at the correct height
- waist level when providing care
- hip level when moving a pt
- try to keep the work directly in front of u to avoid rotating the spine
- keep the pt as close to ur body as possible to minimize reaching
lifting risks in nursing
- Awkward postures/reaching
- Heavy loads
- No nurse should lift over 35 pounds
- Excessive pushing/ pulling
- Frequent/ repeated lifting and
moving - Tasks that take a long time
- Lack of help
- Lack of equipment
- pt should be able to assist you or you need some medical equipment
- if you had 2 nurses and pt was 100 lbs
Nursing interventions
- do this after you figure out the cause
- should not be lifting more than 35 lbs
- Use mechanical equipment whenever necessary for moving patients
- Increase limb mobility
• ROM exercise 4x/day
• Support extremity to reduce swelling - Medicate for pain
- Positioning
• Maintain body alignment
Active ROM
- they move around themselves
- best form of ROM
Passive ROM
- we assist them to move around if they are unable to do it themselves
Positioning
• Maintain body alignment
• Use the appropriate position: Fowler’s, Semi-Fowler’s, Dorsal Recumbent, Prone, Lateral, Sim’s
Fowler’s position
- bad for ppl who are immobile bc they are @ an increased risk for getting a pressure ulcer
- sitting @ a 45° angle
Prone position
- laying on belly
- best for assisting with breathing
Sim’s position
- laying on side but also partially prone
- one leg up
- pts are placed in this position for an enema
Dorsal recumbent
- laying flat on back
Right lateral position
- laying on right side
Semi-Fowler
- laying on back at a 15-45° angle
Different types of nursing interventions
- assess casts, traction devices, Ace bandages for proper fit (circulation, sensation, motion)
- if something is on too tight, it causes circulation issues
- can assess by doing capillary refill to finger or toes —> <3 seconds
- sensation: Ask if pt is experiencing any numbness or tingling
- motion: Can they wiggle fingers or toes
Provide for progressive ambulation
• Involve Interprofessional Team—PT, OT
• Non-ambulatory
- ROM exercises at least tid
- Out of bed and into chair tid with appropriate equipment
• Ambulatory
- Ambulate with or without assistance in hallway as tolerated (at least tid)
- Get out of bed and into chair for all meals
Health teaching
• OT/ PT consult for assistive devices
• Reinforce teaching done in therapy
• Safety practices
Nursing interventions classification
• Ambulation
• Joint mobility
• Positioning
Which of the following are physiological effects of exercise on the body systems? Select all that apply.
- Decreased cardiac output
- Increased respiratory rate and depth (Correct)
- Increased muscle tone, size and strength (correct)
- Change in metabolic rate (correct)
While assisting the client with a bath, the nurse encourages full range of motion in all the client’s joints. Which activity would best support range of motion in the hand and arm?
- Give the client a washcloth to wash the face. (little movement)
- Move the wash basin farther toward the foot of the bed so the client must reach. (safety issue)
- Have the client brush hair and teeth. (Correct. Has the most ROM)
- Move each of the client’s hand and arm joints through passive range of motion. (active ROM = better)
The nurse recognizes that the older adult’s progressive loss of total bone mass and tendency to take smaller steps with feet kept closer together will most likely:
A. Increase the patient’s risk for falls and injuries (CORRECT)
B. Result in less stress on the patient’s joints.
C. Decrease the amount of work required for patient movement.
D. Allow for mobility in spite of the aging effects on the patient’s joints.
A nursing assistant asks for help to transfer a patient who is 125 lbs (56.8 kg) from the bed to a wheelchair. The patient is unable to help. What is the nurse’s best response?
A. “As long as we use proper body mechanics, no one will get hurt.”
B. “The patient only weighs 125 lbs. You don’t need my assistance.”
C. “Call the lift team for additional assistance.” (CORRECT)
D. “The two of us can lift the patient easily.”
Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.)
A. Patient’s weight (CORRECT)
B. Patient’s level of cooperation (CORRECT)
C. Patient’s ability to assist (CORRECT)
D. Presence of medical equipment (CORRECT. IV, cast on, etc)
E. Nutritional intake
Which of the following is a principle of proper body mechanics when moving patients or lifting objects? (Select all that apply.)
A. Keep the knees in a locked position.
B. Bend at the waist to maintain a center of gravity.
C. Maintain a wide base of support. (CORRECT)
D. Hold objects away from the body for improved leverage.
E. Encourage patient to help as much as possible. (CORRECT)
