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N353: Practice of Nursing II > Module 8: MedSurg Impaired Mobility > Flashcards

Module 8: MedSurg Impaired Mobility Flashcards

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1
Q

What is “Alteration of Mobility”?

A

A nursing diagnosis

Defined as a state in which an individual has a limitation (of) independent, purposeful movement of the body or of one or more extremities

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2
Q

Top 3 Causative Factor Types for Altered Mobility

A
  1. Congenital
  2. Internal Factors
  3. Acquired
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3
Q

What does Congenital cause of Altered Mobility mean?

A

Mobility alteration present from birth, may be a muscular, structural, or Neuro issue

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4
Q

What does Internal factors for altered mobility mean?

A

May be mobility impairments from psych concerns - MOBILITY IS NOT JUST PHYSICAL

ex: Pain, fear, anxiety, depression

ex: Do not wanna move when hurt, so fear keeps you from moving

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5
Q

What does Acquired cause of altered mobility mean?

A

Stiffness/Physical Maladies and Disease

ex: Accidents, Aging, Altered Systems (Pathologies), Ailments and Afflictions

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6
Q

Types of Altered Mobility

A
  1. New and Short Term/Limited
  2. New and Long Term/Continuing/Worsening
  3. Life Long (Congenital)
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7
Q

New and Short Term/Limited Altered Mobility

A

Things that temporarily will alter mobility

ex: Bone fracture, surgical pain, flu, joint sprain, high risk pregnancy

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8
Q

New and Long Term/Continuing/Worsening

A

Things that will chronically cause altered mobility

ex: Mult Sclerosis, dementia, Parkinsons, Paralysis from CVA, MVA, Amputations, Arthritis, Polio

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9
Q

Life Long Altered Mobility

A

Altered mobility that is permanent and usually since birth

ex: Cerebral Palsy and Muscular Dystrophy

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10
Q

Benefits of Mobility

A

Psychological well being

Cardiac efficiency

Pulmonary function

Muscle tone

Renal/GI functions

Decrease bone/mineral loss

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11
Q

Benefits for Immobility

A

Relieves pain

Promotes healing

Reduces re-injury of use

Reduces oxygen needs

Reduces threat of miscarriage in some high-risk pregnancies

Sometimes some immobility is a good thing for rest

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12
Q

Consequences of Immobility

A
  1. Generalized deconditioning (can come on fast)
  2. Secondary Disabilities may occur (like contractures)
  3. Severity and Duration can depend on things such as Age, general health and comorbidities, degree of immobility, length of immobility, and rehabilitation strategies
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13
Q

How to minimize the consequences of immobility

A

Early mobilization

Frequent position changes

Good skin care

Maintain all limbs/joints in functional alignment

Active/passive ROM

Maintain clear respiratory system

Maintain nutrition and hydration

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14
Q

What is Nursing Care?

A

The diagnosis and treatment of HUMAN RESPONSES (NOT DIAGNOSES) to actual or potential health problems

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15
Q

Examples of Activity and Exercise Nursing Diagnoses

A

Activity intolerance

Risk for activity intolerance

Impaired physical mobility

Sedentary Lifestyle

Risk for disuse syndrome

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16
Q

Examples of Mobility Decline Nursing Diagnoses

A

risk for falls

fear of falling

ineffective coping

low self esteem

powerlessness

self care deficit

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17
Q

Examples of Prolonged Immobility Nursing Diagnoses

A

ineffective airway clearance

risk for infection

risk for injury

risk for disturbed sleep pattern

risk for situational low self esteem

potential for impaired peripheral circulation

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18
Q

What are the general nursing goals for Impaired/Altered Mobility when caring for a patient?

A
  1. Increased tolerance for physical activity
  2. Restored/improved capability (ambulation, ADLs, etc)
  3. Absence of injury (falling, improper use of body mechanics, etc)
  4. Enhance physical fitness
  5. Absence of complications associated with immobility
  6. Improved social, emotional, intellectual well being

INCREASE FUNCTION, IMPROVE ABILITY, AND AID PSYCHE

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19
Q

Cardiovascular System Responses to Impaired Mobility

A

Decreased HGB

Increased Cardiac Workload (because venous return is less effective)

Increased Resting Heart Rate

Decreased Organ Perfusion

Increased thrombosis formation (could become a pulmonary embolism)

Orthostatic Hypotension

Edema (Swelling) in the legs, hands, or overall venous stasis

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20
Q

Assessments for the Cardiovascular System when the Patient has Impaired Mobility

A
  1. Labs: Hgb&Hct
  2. BP: Lying, Sitting, Standing
  3. Pulse: Apical, Peripheral
  4. O2 Sat
  5. Edema of Extremities Check
  6. Temperature of Extremities Check
  7. Check skin for signs of reduced perfusion
  8. Signs of DVT: Swelling, Redness, Homans Sign, Pain in the Calves
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21
Q

Interventions for the Cardiovascular System when the Patient has Impaired Mobility

A

OOB ASAP w/ ORDER!!!!

ROM Exercises

Change position gradually

Avoid Valsalva maneuver

Encourage fluids

TEDs/SCDs

Do not gatch foot of bed (locks bed angle and can cause blood pooling)

Low does anti coagulation therapy (prevent bleed + clots)

Education

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22
Q

What medicines are used in low dose anticoagulation therapy?

A

Heparin

Coumadin

Lovenox (enoxaparin sodium)

Xarelto (rivaroxaban tablets)

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23
Q

Heparin (Admin, Antidote, Lab Test)

A

Admin - SubQ

Antidote - Protamine Sulfate

Lab Test - PTT

Given as a preventative measure

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24
Q

Coumadin (Admin, Antidote, Lab Test)

A

Admin - PO

Antidote - Vit K

Lab Test - PT/INR

“Warfarin”

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25
Q

Lovenox (Enoxaparin Sodium) (Admin, Antidote, Lab Test)

A

Admin - Subcutaneous

Antidote - Protamine Sulfate

Lab - None

Often given to go home with

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26
Q

Xarelto (rivaroxaban tablets) (Admin, Antidote, Lab Test)

A

Admin - PO

Antidote - Andexanet alfa

Lab - None

newer and more expensive but you do not need to worry about what you eat or having blood work done when taking it

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27
Q

What patient education should be done regarding low dose anti coagulation therapy?

A

Inform other PCPs (physicians and professionals)

Dietary considerations (like when taking Coumadin)

Interactions with other medications (OTC or prescription or herbal preparations)

Importance of lab tests if necessary

Monitor for S/S of bleeding

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28
Q

What are some S/S of bleeding in anti coagulation therapy?

A

ecchymosis

occult blood (hidden blood in stool to test for)

sudden numbness or weakness

HA (brain maybe)

confusion (could be bleeding in brain)

problems with vision, speech, or balance (brain maybe)

N/V

Joint Swelling

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29
Q

Respiratory System responses to Impaired Mobility

A

Decreased HGB

Decreased Lung Expansion

Increased Secretions

Increased risk of Atelectasis

Increased Risk of pneumonia

Stasis of secretions

Impaired gas exchange

Anxiety

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30
Q

Assessments for the Respiratory System when the patient has impaired mobility

A

Labs (H&H)

Vital signs (including pulse ox)

Lung sounds

chest movements

resp. difficulties

s/s of Pulmonary embolism

mentation

blood gases

pulmonary secretions

sputum

31
Q

Interventions for the Respiratory System when the patient has impaired mobility

A

OOB ASAP w/ ORDER!!!!

Encourage C-DB and/or incentive spirometer q2h

Reposition q2h

Raise HOB

ROM (active and passive)

Supplemental O2

Encourage fluids

Specialty beds

Education!

32
Q

Skin response to Impaired Mobility

A

Increased risk of skin breakdown and ulcer formation (protein buildup or infection signs too)

33
Q

Response by the Skin to impaired mobility is compounded by what factors?

A

Impaired body metabolism

Pressure

Shearing force

Friction

Decreased hydration and/or nutrition

34
Q

Assessments for the Skin when the patient has impaired mobility

A

Signs of compromise: Redness, blanching, temp, sponginess, loss of sensation

Labs: H&H, protein, albumin, WBCs

35
Q

Interventions for the Skin when the patient has impaired mobility

A

OOB ASAP w/ ORDER!!!

ROM (active/passive)

ID patients at risk for breakdown (Braden Scale Risk)

Daily skin inspection (do not rub everything, stimulate circulation with bathing, washcloths, ankle rotation, etc)

Keep skin clean and moisturized

Protect pressure points

Stimulate circulation

Adequate

Adequate hydration/nutrition

turn/resposition q2h

Specialty beds

Education

36
Q

Risk Areas for Pressure ulcer

A

Anywhere you lean or has a bony prominence

  1. Back of Head
  2. Shoulder Blade
  3. Elbows
  4. Spine
  5. Hip Bones or (Iliac Crest)
  6. Medial knee (Between the Knee; may need a towel)
  7. Anywhere the leg touches the but, but especially THE HEELS (float the heels!)
37
Q

When measuring a pressure ulcer, what 4 things need to be documented?

A
  1. Size (LxWxD)
  2. Depth
  3. Staging
  4. Presence of undermining, tunneling, or sinus tract

*to measure depth, size, and presence use a sterile, saline damp swab, but never use force

38
Q

What are the 4 Staging levels of Pressure Wounds

A
  1. Redness
  2. Partial thickness
  3. Full thickness
  4. Full thickness past fascia
39
Q

Gastrointestinal responses to impaired mobility in a patient

A

Decreased Appetite

Decreased BMR (Basal metabolic rate)

Decreased gastric motility

Decreased muscle tone

Increased risk of constipation

40
Q

What things are altered in the GI tract if the patient cannot move?

A

Digestion

Utilization of nutrients

Proteins

Metabolism

41
Q

Assessments for the GI system in a patient with impaired mobility

A

Labs: Albumin, Protein levels

Anxiety and/or embarrassment (maybe inability to get to bathroom)

Bowel sounds

Defecation pattern

Abdominal distention

Appetite

Nutrition

Nausea

42
Q

Interventions for the GI system in a patient with impaired mobility

A

OOB ADAP w/ ORDER!!!

Ambulate to BR (do not use a bed pan if possible, they should be upright to go - its torturous)

Record and note bowel elimination pattern

Promote regular bowel elimination

Record dietary and fluid intake

Raise HOB during meals

Encourage fluids/fiber/nutrition

43
Q

Genitourinary System responses in a patient with impaired mobility

A

Decreased Bladder tone

Decreased Urine Output

Increased urine Stasis

Increased risk of UTI

Increased risk of renal calculi

44
Q

Assessments for the GU system in a patient with impaired mobility

A

Anxiety and/or embarrassment barriers

Bladder distention (becomes floppy. and doesn’t fill right)

Vital signs (especially temperature)

Labs: BUN, CR (these two may reflect kidney damage)

Output q shift: Color, odor, clarity, amount

Urine pooling and having urine stasis - increased risk for renal stones and UTI

45
Q

Interventions for the GU system in a patient with impaired mobility

A

OOB ASAP w/ ORDER!!!

Encourage bathroom (v bedpan) use

Encourage fluids

Discourage “holding” urine

Measure and record I&O if ordered

Avoid catheterization

46
Q

The most common type of healthcare associated infection is?

A

Urinary Tract Infection

Accounts for more than 30% of infections

47
Q

Virtually all healthcare associated UTIs are caused by …

A

instrumentation of the urinary tract

48
Q

UTIs are associated with increased what?

A
  1. Morbidity (illness)
  2. Mortality (death)
  3. Hospital cost
  4. Length of stay
49
Q

What are some appropriate uses for Indwelling Urethral Catheter?

A

Acute urinary retention or bladder obstruction

Accurate measurements of output

Peri operative use for selected surgery procedures

Anticipated prolonged duration of surgery

Need for intraoperative monitoring of urinary output

To assist in healing of open sacral or perineal wounds in incontinent patients

Prolonged immobilization

To improve comfort for end of life care if needed

50
Q

What are some inappropriate uses for Indwelling Urethral catheter?

A

Substitute for nursing care of the pt/residence w/ incontinence

As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void

For prolonged postoperative duration without appropriate indications (ex: structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc) = Never want no particular reason

51
Q

Musculoskeletal System responses for patients with impaired mobility

A

Loss of Endurance

Decreased stability, muscle mass, skeletal mass, balance w/ posture changes

Increased muscle atrophy and contractures

Disuse osteoporosis

52
Q

Assessments for the Musculoskeletal system in patients with impaired mobility

A

Muscle strength and weakness

Muscle mass

Muscle tone (hyper/hypo tonic)

Contractures

ROM

Gait/stability w/ ambulation

53
Q

Interventions for the Musculoskeletal system in patients with impaired mobility

A

OOOB ASAP w/ PCP ORDER!!!!

ROM (active and passive)

Assist with activity as needed

PT/OT consults

Protective positioning

54
Q

Types of Range of Motion

A

Resistive

Active

Active Assist

Passive

55
Q

Resistive ROM

A

patient movement using pulling/pushing forces

they move but you give resistance against them

56
Q

Active ROM

A

patient can move joints independently

57
Q

Active Assist ROM

A

patient moves joints with some assistance; encourages normal muscle function without stress to distal joint

Move independently but need some assistance to prevent stress

58
Q

Passive ROM

A

Nurse/Caregiver moves joints for the patient - Individual does not do the movement, someone else does

59
Q

Tips for the Nurse doing PROM

A

Start gradually and work slowly

Move joints to points of resistance BUT NOT PAIN

Avoid neck hyperextension, especially with the elderly as you can cause spinal cord/nerve issues

60
Q

What is the path from Decondition to Dependence like?

A

They take a stepwise pattern down toward dependence for mobility and it is steep and rapid and much quicker than one may think

61
Q

What is the pathway from decondition to dependence?

A
  1. weak wobbly legs
  2. more muscle weakness
  3. less ability to perform
  4. more muscle weakness
  5. less ability top perform
  6. disuse atrophy (muscle shrinkage)
  7. NO ability to perform –> Dependence
62
Q

What is the path upward to mobility independence like?

A

It is a progressive mobilization that is less steep and a little slower than deconditioning to dependence

63
Q

What is the pathway upward to independence?

A
  1. Bed Activities
  2. Sitting
  3. transferring
  4. Standing
  5. Walking
  6. Climbing
  7. Stair (this is commonly point of discharge)
64
Q

What is the Psychosocial response like for patients with impaired mobility

A

Increased sense of powerlessness

Increased risk of depression

Altered sleep wake pattern

Decreased self concept

Decreased social interaction

Decreased Sensory stimulation

65
Q

Psychosocial Assessments/What to assess for the patients with impaired mobility

A

Mood swings

Social interactions

Mentation and Outlook

Ability for abstract thinking

Ability to follow commands

Ability to assimilate new information

Anxiety, Insomnia, Lethargy

66
Q

Psychosocial interventions for patients with impaired mobility

A

Do these when possible as they may not be there long

OOB ASAP w/ ORDER!!!

Note, record, and report changes in any and all patient thought processes, emotional behavior, increased anxiety, insomnia, and lethargy

Establish workable routine for care, rest, and visitors - encourage self care and what they can do on their own (do not take function away from them)

Encourage self care

Positive feedback for “wellness behaviors”

67
Q

Musculoskeletal Responses to Immobility

A

Loss of endurance

Decreased stability, muscle mass, skeletal mass, balance with posture changes

Increased muscle atrophy, contractures

Disuse osteoporosis

68
Q

Respiratory Responses to Immobility

A

Decreased Hgb, lung expansion

Impaired gas exchange

Increased secretions, risk of atelectasis, risk of pneumonia

Stasis of secretions

69
Q

Cardiovascular responses to Immobility

A

Decreased Hgb, organ perfusion

Increased cardiac workload, resting heart rate, venous stasis (leading to thrombosis formation)

Edema of the legs, hands, or overall

Orthostatic hypotension

70
Q

GU responses to immobility

A

Decreased bladder tone, urinary output

Increased urine stasis, risk for UTI, risk for renal calculi

71
Q

Skin responses to immobility

A

Increased risk of skin breakdown, and ulcer formation

72
Q

GI responses to immobility

A

Decreased appetite, BMR, gastric motility, muscle tone

Increased risk of constipation

Altered digestion, utilization of nutrients, protein, metabolism

73
Q

The most important intervention for impaired mobility, regardless of system, is?

A

GETTING THEM OUT OF BED AS SOON AS POSSIBLE (WITH ORDER)

N353: Practice of Nursing II (14 decks)

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