Mobility And Immobility -exam 7 Flashcards
A persons ability to move about freely
Mobility
Mobility - 6
- nonverbal gestures
- self defense
- ADLs
- recreational
- satisfaction of basic needs
- expression of emotion
Factors affecting mobility and activity - 6
- developmental
- nutrition
- lifestyle
- stress
- environment
- diseases and abnormalities
Diseases and abnormalities -6
- bones, muscles, and nervous system
- pain
- trauma
- respiratory system
- circulatory
- psychological/Social
May involve lower part of body
Paraplegia
A persons inability to move about freely
Immobility
May involve one side of body
Hemiplegia
May involve entire body from the neck down
Quadriplegia
Bedrest
restricts patients to bed for therapeutic reasons
sometimes prescribed for selected patients
Bed rest
reduces pain
Bed rest
Allows exhausted patients to rest
Bed rest
reduces physical activity and O2 demand of the body
bed rest
allow ill or debilitated patients to rest
bedrest
duration depends on illness or injury and prior state of health
bedrest
physical causes of immobility-6
- bone fracture
- surgical procedure
- major sprain or strain
- illness/disease
- cancer
- aging process
psychosocial causes of immobility - 5
- stress/depression
- decreased motivation
- hospitalization
- long term care facility residents
- Voluntary sedentary lifestyle
prolonged immobility
- reduced functional capacity
- alerted metabolism
- numerous physiological changes
effects of immobility
- musculoskeletal
- lungs
- heart and vessels
- metabolism
-integument - GI
-GU - Psychological
immobility common effects - Musculoskeletal system
brittle bones
contractures
muscle weakness and atrophy
footdrop
immobility common effects -Nervous system
- lack of stimulation
- feelings of anxiety
- feelings of isolation
- confusion
- depression
immobility common effects -digestive system
- decreased appetite and low fluid intake
- constipation and or bowel obstruction
- incontinence
- electrolyte imbalances
immobility common effects -integumentary system
- decreased blood flow
- pressure ulcers
- infections
- skin breakdown and pressure ulcers
immobility common effects -Cardiovascular System
- blood clots
- reduced blood flow
immobility common effects -respiratory system
- pneumonia
- decreased respiratory effort
- decreased oxygenation of blood
immobility common effects -urinary system
- reduced kidney function
-incontinence - UTI
- Urinary retention
Musculoskeletal assessment
- activity intolerance
- anthropometric measurements
- nutrition
osteoclasts
- move along surface of bone
- dissolved material, including calcium, is passed through osteoclasts and into blood stream for recuse by the body
osteoblasts
- occurs when bone is injured, added bone strength is required
- deposits calcium into the bone
bone resorption - 2 ways
- osteoclasts
- osteoblasts
osteoporosis
- females are more affected than males
- insufficient exercise or too much exercise
- poor diet
- smoking
ROM
maximum amount of movement available at a joint
joints not moved are at risk for
contractures
ROM exercises improves
joint mobility
ROM exercise is the easiest intervention to maintain or
improve joint mobility
ROM exercises can be
coordinated with other activities
What are 3 ROM exercises?
- active ROM
- active assist ROM
- Passive ROM
Active ROM
done by the patient
Active assist ROM
done by patient but with help
Passive ROM
done by the nurse or caregiver
- continuous passive motion (CPM)
Range Of Motion
- 3 times a day
- support the extremity
- encourage active ROM if possible
- stretch the muscle only to the point of resistance/pain
- start gradually and move slowly using smooth motions
respiratory assessment
- lung sounds
- O2 sats
- respiratory rate
- activity tolerance (SOB)
- chest xray
- arterial blood gas
Cardiac assessment
- BP
- Pulse rate
- Heart sounds
- Activity tolerance (BP, HR, chest pain)
- calf pain ***
Deep vein thrombosis (DVT)
- decreased muscle activity
- pooling of blood
- clot formation
Ways to prevent DVTs
- ambulation
- TED hose
- SCDs
TED Hose
- post surgical
- non walking patients
- no wrinkles
- take off periodically to exam skin
Sequential compression device (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
- nutrition
- incontinence
Pressure injury
- impairment of the skin as a result of prolonged ischemia in tissues
Ischemia
Decreased blood supply
Which Patients are at highest risk for pressure injury?
Immobile patients
GI assessment
- bowel sounds
- abdominal palpation
- bowel habits
- I&O
GU assessment
- I&O
- palpate abdomen
- incontinence
- urine
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 fluid intake
- dehydration
- concentrated urine
- increased risk for UTI and kidney stones
Psychosocial assessment
- mood
- orientation
- speech
- affect
- sleep
Psychosocial effects
- social isolation
- loneliness
- decreased coping
- depression
- anxiety
- withdrawal
- delirium
Benefits of mobility
- strengthen muscles
- joint flexibility
- stimulates circulation
- prevents constipation
- prevents osteoporosis
- stimulates the appetite
- prevents urinary incontinence
- relieves pressure
- improves self esteem
- decreases anxiety and depression
Ambulation is the best intervention to
Prevent immobility complications
Mobility level 1
Dependent
Mobility level 2
Moderate assistance
Mobility level 3
Minimum assistance
Mobility level 4
Modified independent
Non-violent restraints
- unable to follow commands and comply with safety instructions
- attempts to pull out tubes, drains or other lines
- requires every 2 hours monitoring and documentation
- new order required every calendar day
Restraint types
- extremity
- mitten
- posey
- belt
- papoose or mummy restraint
Alternative measures to restraints
- Orient family and patient to environment
- offer diversionary
- use calm simple statements
- promote relaxation techniques
- attend to needs
- use of glasses/ hearing aids
Modify the environment
- increase or decrease the light
- place personal items within reach
- place near nurses station
- reduce environmental noise
- keep call button accessible
- use special furniture accordingly (bed alarms)
Camouflage
-Camouflage IV lines and tubes
Encourage
Encourage family to stay with patient and being familiar objects from home
Orient
Orient patient to person, place, Time
Involve
Involve patient in conversation
Give
Give patient something to do
Restraint guidelines
- doctor must order prior to applying
- new order ~ daily
- must be discontinued at the earliest time
- monitoring varies
- assessment
Risk of using restraints
- increase in injury or death
- loss of self - esteem
- humiliation
- fear
- anger
- increased confusion and agitation
Complications of restraints
- impaired skin integrity
- lower extremity edema
- altered nutrition
- physical exhaustion
- social isolation
- immobility complications
- death
Intervention application of restraints
- restrict movement as little as possible
- make sure restraint fits properly
- always tie (slip knot/bow tie) to bed
- always explain the need for restraint
- never leave patient unattended
- pad bony prominences
Assessment of restraint
- assess the need for restraints
- inspect placement area
- patients behavior
- circulation, motion, sensation
- fits properly
- vital signs
- skin color, edema
- palpate for skin temp
- palpate pulse
- check capillary refill
- mental status
Interventions of restraints
- ROM
- Reposition
- nutrition/ hydration/ toileting
- release at the earliest possible time
