mobility/immobillity Flashcards
person’s ability to move about freely
mobility
forms of mobility
nonverbal gestures, self-defense, ADLs, recreational, satisfaction of basic needs, and expression of motion
factors affecting mobility and activity:
developmental, nutrition, lifestyle, stress, environment, and diseases & abnormalities
diseases & abnormalities:
-bones, muscles, and nervous system
-pain
-trauma
-respiratory system
-circulatory
-psychological/social
a person’s inability to move about freely
immobility
immobility may involve:
specific part of body due to injury
paralegia:
may involve lower part of body
hemiplegia:
may involve one side of the body
quadriplegia:
may involve entire body from the neck down
restricts patient to bed for therapeutic reasons:
bedrest
bedrest does what for patient:
reduces pain, reduces physical activity and O2 demand, allows ill/debilitated/exhausted patients to rest, and the duration of bedrest depends
physical causes of immobility:
bone fractures, surgical procedures, major sprain/strain, illness/disease, cancer, and aging process
psychological causes of immobility:
stress/depression, decreased motivation, hospitalization, long-term care facilities residents, voluntary sedentary lifestyle
reduced functional capacity -> altered metabolism -> numerous physiological changes
prolonged immobility
musculoskeletal effects of immobility:
brittle bones, contractures, muscle weakness & atrophy, and footdrop
lung effects of immobility:
pneumonia, decreased respiratory effort, decreased oxygenation of blood
heart & vessel effects of immobility:
blood clots and reduced blood flow
effects of immobility on gastrointestinal:
decreased appetite and low fluid intake, constipation, and/or bowel obstructions, incontinence, electrolyte imbalance
effects of immobility on genitourinary:
reduced kidney function, incontinence, UTI, urinary retention
effects of immobility on integument:
decreased blood flow, pressure ulcers, infections, skin break down
effects of immobility on nervous system:
lack of stimulation, anxiety, isolation, confusion, depression
osteoclasts:
break down bone
osteoblasts:
build up bone, deposits calcium into the bone, vitamin D and calcium = need both, vitamin D absorption in intestines
____ fractures are caused by weakened bone tissue
pathological
risk factors of osteoporois:
females are more affected than males, especially after menopause, insufficient exercise/or too much exercise, poor diet (low in Ca or protein), smoking
osteoporosis:
a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes
fractures may occur easily if ___ ___ drops below _____ ______
bone mass, fracture threshold
range of motion:
maximum amount of movement available at a joint
joints not moved are at risk for _____
contractures (can begin forming within 8 hours)
what is the easiest intervention to maintain or improve joint mobility
ROM exercises
what improves joint mobility
ROM exercises
contractures are:
limitations in the passive ROM of a joint secondary to shortening of the connective tissues and muscles (can be permanent)
active ROM:
done by patient
active assit ROM
done by patient but with help
passive ROM
done by nurse or other caregiver (continuous passive ROM)
when do you do ROM:
3x daily (after bath, midday, bedtime)
how do you perform ROM?
start gradually and move slowly using smooth motions, support the extremity, and stretch the muscle only to the point of resistance/pain
respiratory assessment:
lung sounds, O2 patients, RR, activity tolerance (SOB), chest x-ray, and arterial blood gases
TCDB:
turn, cough, deep breath (hold 3 seconds) and cough 2x. first cough loosens sputum and second moves it out
cardiac asessment:
blood pressure, pulse rate, heart sounds, activity tolerance (BP, HR, chest pain), CALF PAIN
deep vein thrombosis (DVT)
decreased muscle activity - pooling of blood - clot formation - DVT
best prevention of DVT
early ambulation
TED hose:
thrombo-embolic deterrent hose: post-surgical, non-walking patient, ** no wrinkles
sequential compression device (SCD)
sleeves around legs, alternately inflate and deflate, post-surgical/circulatory disorders
if your patient has calf pain, do you rub or not rub their calves and why?
no, it will dislodge and go to the lungs and causes a pulmonary embolism
metabolism assessment:
decreased appetite, weight loss, muscle loss, weakness, and labs
integument assessment:
skin assessment (color changes and integrity), nutrition, and incontinence
pressure injury:
impairment of the skin as a result of prolonged ischemia in tissues
symptoms of DVT
pain, swelling, redness
pressure injury develops when:
pressure on skin is greater than pressure inside small peripheral blood vessels, inflammation forms over bony prominences
gastrointestinal assessment:
bowel sounds, abdominal palpitation, incontinence, and 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, increased risk for UTI and kidney
psychosocial assessment:
mood, orientation, speech, affect, sleep
psychosocial effects:
social isolation, loneliness, decreased coping, depression, anxiety, withdrawal, delirium
benefits of mobility:
strengthens, joint flexibility, stimulates circulation, prevents constipation, prevents osteoporosis, stimulates the appetite, prevents urinary incontinence & infection, relieves pressure, improves self-esteem, decrease anxiety and depression
mobility level 1:
red- dependent- total lift without assistance from patient, up in chair 3x
mobility level 2:
orange- moderate assistance - assist x2 - patient requires caregiver to lift more than 35 lbs, patient may be unable to bear weight and require stand lift assistance. Up in chair 3x daily
mobility level 3:
yellow - minimum assistance - patient requires no more help than standby assist or cueing. Walk 3x daily up in chair and chair 3x daily
mobility level 4:
green- modified independent - patient performs tasks safely without physical assistance from staff. Walk 3x daily and 3x chair daily
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 others, unable to follow commands and comply with safety instructions, attempts to pull out tubes/drains, requires every 2 hours monitoring and documentation, new order required every calendar
restraint types:
extremity, mitten, posey, and belt, papoose or mummy restraint (child)
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 regimen
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 d/c at the earliest possible time, monitoring varies- could continuous 15 minutes or every 2-3 hours), assessment includes vital signs, hydration, and circulation, skin integrity, and patient’s level of distressr
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:
restrict movement as little as is necessary, fits properly, always tie (slip knot or bow tie) to bed frame/mattress springs, never leave patient unattended, pad bony prominences, document
if they can respond, ask them to ____ and if they have _____
move the limb, tingling
