Mobility/Immobility Flashcards
Mobility def
person’s ability to move about freely
Mobility examples
nonverbal gestures
self-defense
ADLs
recreational
satisfaction of basic needs
expression of emotion
Factors affecting Mobility and Activity
developmental
nutrition
lifestyle
stress
environment
diseases and abnormalities
Diseases and Abnormalities associated with Mobility
bones, muscles, and nervous system
pain
trauma
respiratory system
circulatory
psychological/social
Immobility
person’s inability to move about freely
- may involve a specific part of the body due to injury
Paraplegia
may involve lower part of body
Hemiplegia
paralysis on one side of the body
- common in strokes-
Tetraplegia/Quadriplegia
paralysis involving the entire body from the neck down
Bedrest
restricts pts to bed for therapeutic reasons
Bedrest reasons
sometimes prescribed for selected pts
reduces physical activity and O2 demand of the body
reduces pain
allow ill or debilitated pts to rest
allows exhausted pts to rest
duration depends on illness or injury and the prior state of health
Physical causes of immobility
bone fx
surgical procedure
major sprain or strain
illness/disease
cancer
aging process
Psychosocial causes on immobility
stress/depression
decreased motivation
hospitalization
long term care facility residents
voluntary sedentary lifestyles
Prolonged Immobility in order
-Reduced functional capacity
-Altered metabolism (slows down)
-Numerous physiological changes
Effects of Immobility in what systems?
musculoskeletal
lungs
heart and vessels
metabolism
integument
GI
GU
psychological
Immobility - Common effects on body systems
Musculoskeletal
brittle bones
contractures
muscle weakness and atrophy
foot drop
Immobility - Common effects on body systems
Nervous System
lack of stimulation
feelings of anxiety and isolation
confusion
depression
Immobility - Common effects on body systems
Digestive System
decreased appetite and low fluid intake
constipation and/or bowel obstruction
Incontinence
Electrolyte imbalances
Immobility - Common effects on body systems
Integumentary
decreased blood flow
pressure ulcer
infections
skin breakdown and pressure ulcers
Immobility - Common effects on body systems
Cardiovascular
blood clots
reduced blood flow
Immobility - Common effects on body systems
Respiratory
pneumonia
decreased respiratory effort
decreased O2 of blood
Immobility - Common effects on body systems
Urinary
reduced kidney function
incontinence
UTI
Urinary retention
Musculoskeletal Assessments
-activity intolerance (prolonged bedrest)
-anthropometric measurements (weak bones, muscle loss, stiffness)
-nutrition (need high proteins)
For every week on bed rest, the person loses ___% of their muscle mass
10
Bone Reabsorption: Osteoclasts
dissolve bone and pass all Ca into the blood stream
Bone Reabsorption: Osteoblasts
grow bone and deposit Ca back into the bone
Osteoporosis risk factors
Which gender? Especially after?
sex (females are more affected especially after menopause)
insufficient exercise or too much exercise
poor diet ( low in Ca and protein)
smoking
pt on bedrest
Osteoporosis def
porous bone with dead space and easily broken
How to prevent osteoporosis?
Calcium and Vitamin D (sunlight, dairy, green leafy veggies, eggs, and fish
Protein diet
ROM and exercise
Bone density is strongly related to
estrogen
ROM def
maximum amount of movement available at a joint
-exercise improves joint mobility
-easiest intervention to maintain or improve joint mobility
coordinated with other activities
- no moving is at risk for contractures (can be formed within 8 hours
Active ROM
Done by pt completely and instructed by the nurse
Active assist ROM
Done by pt but with help by nurse
Passive ROM
done by nurse
continuous passive motion
If a patient reports pain or muscle spasms during ROM, _____________ exercises immediately to prevent injury
discontinue
ROM essentials and criticals to remember
3 times daily (after bath, midday, bedtime)
support extremity
start gradually and move slowly using smooth motions
stretch the muscle only to the point of resistance/pain
encourage active ROM if possible
Contractures
joints flex into an angle and stay there
- shortening of the muscles (hands, arms, and foot drop
What is the natural angle for hands to be?
fingers angled and prone
Respiratory Assessment
lung sounds
O2 Sats
Respiratory rate
Activity tolerance (SOB)
CXR (black is good, white clouds bad)
ABG
When should you do respiratory assessments of immobile pts?
At risk of developing fluid in lungs
general every 8 hours
critical care every 4 hours
Cardiac Assessment
B/P
Pulse rate
Heart sounds
Activity tolerance (BP, HR, chest pain)
Calf pain
When the patient is laying down and has calf pain, the person is at risk of
DVT
DVT is caused by
decreased muscle activity
pooling of blood
clot formation
DVTs
How do prevent DVTs?
ambulation
TED Hose
SCDs
TED Hose
Thrombo-embolic deterrent hose
-post surgical
-nonwalking patients
SCDs
Sequential Compression Devices
- sleeves around the legs
-alternatively, inflate and deflate
post-surgical/circulatory disorders
Metabolism Assessment
Decreased appetite
Weight loss
Muscle loss
Weakness
Labs
GI slows down: constipation, bowel obstruction, or perfusion
Integument Assessment
Skin assessment
-color changes
-integrity
Nutrition
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
inflammation
forms over bony prominences
longer pressure applied the greater risk of injury
GI Assessment
Bowel sounds
Abdominal palpation
Bowel habits (last bowel movement?)
I & O
GU Assessment
I & O
Palpate abdomen
Incontinence
Urine (color, smell, clarity?)
Kidney stones are formed by
Calcium
Urinary Stasis
when the renal pelvis fills before urine enters the ureters because peristaltic contractions of the ureters are insufficient to overcome gravity
Development of kidney stones and UTIs
When a person is lying, urine can settle in the renal pelvis and bladder, urine is concentrated and thick with calcium
Urinary Elimination Changes
immobility (decreased activity)
decreased fluid intake
dehydration
concentrated urine
increased risk for UTI and kidney stones
Psychological Assessment
Mood
Orientation
Speech
Affect
Sleep
Psychosocial Effects
social isolation
loneliness
decreased coping
depression
anxiety
withdrawal
delerium
Benefits of Mobility
strengthen muscles (abdomen and legs)
joint flexibility (hips, knees and ankles)
stimulates circulation (helps prevent phlebitis and clot development)
prevents constipation (stimulates intestinal tract)
prevents osteoporosis (mineral loss and when they do not bear weight)
stimulates appetite
prevents urinary incontinence and infection
relieves pressure (prevent pressure injuries)
improves self-esteem
decreases anxiety and depression (induced by hospitalization)
Best intervention to prevent immobility complications
ambulation
Mobility Levels
1-dependent
2-moderate assistance
3-minimum assistance
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 are used when the patient
Actions impede medical care
Lack of awareness of potential harm to self and others
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 orders required every calendar day
When discontinuing, the date & time must be documented.
Covenant’s Restraint Policies
Prior to restraining, alternatives must be attempted:
Reorientation
Limit setting
Use of sitter
Increased observation and monitoring
Change the patient’s physical environment
Review and modification of medication regimens
Alternative Measures - Nurses
Orient family and patient to the environment
Offer diversionary activities
Use calm simple statements
Promote relaxation techniques
Attend to needs (bathroom)
Use of glasses/hearing aids
Alternative Measures by modifying measures
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 alarms)
Alternative Measures - Nursing Interventions
Camouflage lines and tubes
encourage family to stay with pt and bring familiar objects from home
orient pt to person, place and time
involve pt in conversation
give pt something to do
Restraint Guidelines
Practioner must order prior to applying.
In emergencies – may apply but practioner 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 min or every 2-3 hours)
Assessment includes vital signs, hydration and circulation, skin integrity and patient’s level of distress)
Risks of Using Restraints
Increase in injury or death
Loss of self-esteem
Humiliation
Fear
Anger
Increased confusion and agitation
Make sure all other measures have been taken to avoid restraints
Complications of Restraints
Impaired skin integrity
Lower extremity edema
Altered nutrition
Physical exhaustion
Social isolation
Immobility complications
Death
Intervention application
Restrict movement as little as is necessary
Make sure restraint fits properly
Always tie (slip knot or bow tie) to bed frame/mattress springs
Always explain the need for restraint
Never leave patient unattended without the restraint
Pad bony prominences
DOCUMENT, DOCUMENT, DOCUMENT
Documentation
any medical evaulation for restraint
Description of the patient’s behavior and the intervention used
Any alternatives or other less restrictive interventions attempted.
Patient’s condition or symptom that warranted the use of restraints
Patient’s response to the intervention used and rationale for continued use of the intervention.
individual pt assessments and reassessments
intervals for monitoring
revisions to the plan of care
orders, consultations, teaching, reponse
easiest intervention to maintain or improve joint mobility
ROM
Requires every ___ hours monitoring and documentation
New orders required every ________
2 hours;
Calendar day
