mobility and immobility Flashcards
mobility
a persons ability to move freely
• nonverbal gestures
• self- defense
• ADLs
• recreational
• satisfaction og basic needs
• expression of emotion
factors affecting mobility and activity
• developmental
• nutrition
• lifestyle
• stress
• environment
• diseases and abnormalities
diseases and abnormalities
• bones, muscles and nervous system
• pain
• trauma
• respiratory system
• circulatory
• psychological/social
immobility
a person inability to move about freely
• may invoke a specific part of the body due to injury
•may involve lower part of body( paraplegia)
• may involve one side of body (hemiplegia)
•may involve entire body from the neck down (quadriplegia
bedrest
restricts patients to bed for therapeutic reasons (6)
• sometimes prescribed for selected patients
• reduces physical activity and O2 demand of the body.
• reduces pain
• allow ill or debilitated patients to rest
• allows exhausted patients to rest
• duration depends on illness or injury and prior state of health
physical causes of immobility (6)
• bone fracture
• surgical procedure
• major sprain or strain
• illness/disease
• cancer
• aging process
psychological causes of immobility
• stress/depression
• decreased motivation
• hospitalization
• long term care facility residents
• voluntary sedentary lifestyle
prolonged immobility
• reduced functional capacity
• altered metabolism
• numerous physiological changes
effects of immobility
• musculoskeletal
• lungs
• heart and vessels
• metabolism
• integument
• gastrointestinal
• genitourinary
• psychological
musculoskeletal assessment
•activity intolerance
• anthropometric measurements
• nutrition
bone resorption
osteoclasts- move along surface of bone, dissolving grooves into bone with acid and enzymes. dissolved material, including calcium, is passed through osteoclasts and into bloodstream for reuse by the body
• osteoblasts- occurs when bone is injured, added bone strength is required and calcium is elevated in the bloodstream. deposits calcium into the bone.
osteoporosis
risk factors
• sec (female more affected than males, especially after menopause)
• insufficient exercise or too much exercise
• poor diet (low in Ca and protein)
• smoking
ROM
maximum amount of movement available at a joint
•joints not moved are at risk for contractures (can begin forming within 8 hours)
• range of motion exercises improves joint mobility
• ROM exercises is the easiest intervention to maintain or improve joint mobility
• ROM exercise can be coordinated with other activities
ROM exercise
•active ROM
- done by patient
• active assist ROM
-done by patient but with help
• passive ROM
- done by nurse or other caregiver
-continuous passive motion (CPM)
ROM
• three times a day
-after bath
-mild day
-bedtime
• start gradually and move slowly using smooth motions
•support the extremity
• stretch the muscles only to the point of resistance/ pain
• encourage active ROM if possible
respiratory assessment
• lung sounds
• O2 sats
• respiratory rate
•activity tolerance (SOB)
• chest X-ray
• arterial blood gasses
cardiac assessment
• blood pressure
•pulse rate
• heart sounds
• activity tolerance (BP, HR, chest pain)
• calf pain
deep vein thrombosis
• decreased muscle activity
• pooling of blood
• clot formation
• DVTs
-ambulation
-TED hose
-SCDs
TED hose
• thrombo-embolic deterrent hose
• post surgical
• nun-walking patient
sequential compression devices (SCDs)
• sleeves around the legs
• alternately inflate and deflate
• post surgical/ circulatory disorders
metabolism assessment
• decreased appetite
• weight loss
• muscle loss
• weakness
• labs
integument assessment
• skin assessment
-color changes
-integrity
• nutrients
• incontinence
pressure injury
impairment of the skin as a result of prolonged ischemia ( decreased blood supply) in tissues
•develops when pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin
gastrointestinal assessment
• bowel sounds
• abdominal palpitations
• bowel habits (last bowel movement)
• I & O
genitourinary assessment
• I & O
• palpate abdomen
• incontinence
•urine (color, smell, clarity)
urinary stasis
when the renal pelvis fills before urine enters the ureters because peristaltic contractions of the ureters are insufficient to overcome gravity
urinary elimination changes
• immobility (decreased activity)
• decreased fluid intake
• dehydration
• concentrated urine
• increase risk for UTI and kidney stones
psychological assessment
• mood
• orientation
• speech
• affect
• sleep
psychological effects
• social isolation
• loneliness
• decreased coping
• depression
• anxiety
• withdrawal
• delerium
benefits of mobility
• strengthen muscles
• joint flexibility
• stimulates circulation
• prevents constipation
• prevents osteoporosis
• stimulates the appetite
• prevents urinary inconveniences and infection
• relieves pressure-esteem
• improves self esteem
• decrease anxiety and depression
wheel fail outside of room
• mobility level 1 dependent
• mobility level 2 moderate assistance
• mobility level 3 minimum assistance
• mobility level 4 modified independent
restraints
• any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body, or head freely
non- violent restraints
• actions impede medical care
• lack of awareness of potential harm to self and other
• unable to follow commands and comply with safety instructions
• attempts to pull out tubes, drains or other lines/ devices medically necessary for treatment
• requires every 2 hours monitoring and documentation
• new order required every calendar day
• when discontinuing, date & time must be documented
restraint types
• extremity
• mitten
• posey
• belt
alternative measures
• orient family and patient to environment
• offer diversionary activities
• use calm simple statements
• promote relaxation techniques
• attend to needs
• use of glasses/ hearing aids
alternative measure
examples
• increase or decrease the light
• place personal items within reach
• place near nurse station
• reduce environmental noise
• keep call button accessible
• use special furniture accordingly (bed alarm)
alternative measures con’d
• camouflage
• encourage
• orient
• involve
• give
restraint guidelines
• practitioner must order prior to applying
• in emergencies- may apply but practitioner must be notified immediately
• a new order must be obtained daily
• must be discontinued at the earliest possible time
• monitoring varies depending on patient needs and situational factors (could be continuous, every 15 mins or every 2-3 hours)
• assessment includes vital signs, hydration and circulation, skin integrity and patients level of distress)
risks of using restraints
• increase in injury or death
• loss of self- esteem
• humiliation
• fear
• anger
• increase confusion and agitation
MAKE SURE ALL OTHER MEASURES HAVE BEEN TAKEN TI AVOID RESTRAINTS
complications of restraints
• impaired skin integrity
• lower extremity edema
• altered nutrition
• physical exhaustion
• social isolation
• immobility communication
•death
intervention applications
• restrict movement as little as is necessary
• make sure restraint fits properly
• always tie (slip knot or new tie) to bed frame/ mattress spring
• always explains the need for restraint
• never leave patient unattended without the restraint
• pas bony prominences
• DOCUMENT!
assessment
• regularly assess the need for continued use of restraints
• inspect placement area of restraint
• assess patient behavior
• assess circulation, motion, sensation
• make sure restraint fits properly
• vital signs
DOCUMENT ASSESSMENT
assessment con’d
• inspect skin color and edema
• palpate for skin temp
• palpate pulse
• check capillary refill
• mental status
• if they are able to respond- ask them to move the limb
• if they are able to respond - ask if they have tingling
interventions
• ROM
• reposition
• nutrition/ hydration/ toileting
• release at the earliest possible time
documentation
• any medical evaluation for restraint
•description of the patient behavior and the intervention used
• any alternatives or other less restrictive intervention attempted
• patients condition or symptom that warranted the use of restraints
• patient response to the intervention used and rationale for continued use of the intervention
• individual patient assessment and reassessment
• the intervals for monitoring
• revisions to the plan of care
documentation con’d
• patient behavior and staff concerns regarding safety risk to the patient, staff and others that necessitated the use of restraints
• injuries to the patient
• death associated with the use of restraint
• the identity of the practitioner who ordered the restraint
• orders for restraint
• notification of the use of restraint to the attending physician
• consultation
• patient/ family teaching
• response when restraint removed
