Module 8: MedSurg Impaired Mobility Flashcards
What is “Alteration of Mobility”?
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
Top 3 Causative Factor Types for Altered Mobility
- Congenital
- Internal Factors
- Acquired
What does Congenital cause of Altered Mobility mean?
Mobility alteration present from birth, may be a muscular, structural, or Neuro issue
What does Internal factors for altered mobility mean?
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
What does Acquired cause of altered mobility mean?
Stiffness/Physical Maladies and Disease
ex: Accidents, Aging, Altered Systems (Pathologies), Ailments and Afflictions
Types of Altered Mobility
- New and Short Term/Limited
- New and Long Term/Continuing/Worsening
- Life Long (Congenital)
New and Short Term/Limited Altered Mobility
Things that temporarily will alter mobility
ex: Bone fracture, surgical pain, flu, joint sprain, high risk pregnancy
New and Long Term/Continuing/Worsening
Things that will chronically cause altered mobility
ex: Mult Sclerosis, dementia, Parkinsons, Paralysis from CVA, MVA, Amputations, Arthritis, Polio
Life Long Altered Mobility
Altered mobility that is permanent and usually since birth
ex: Cerebral Palsy and Muscular Dystrophy
Benefits of Mobility
Psychological well being
Cardiac efficiency
Pulmonary function
Muscle tone
Renal/GI functions
Decrease bone/mineral loss
Benefits for Immobility
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
Consequences of Immobility
- Generalized deconditioning (can come on fast)
- Secondary Disabilities may occur (like contractures)
- Severity and Duration can depend on things such as Age, general health and comorbidities, degree of immobility, length of immobility, and rehabilitation strategies
How to minimize the consequences of immobility
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
What is Nursing Care?
The diagnosis and treatment of HUMAN RESPONSES (NOT DIAGNOSES) to actual or potential health problems
Examples of Activity and Exercise Nursing Diagnoses
Activity intolerance
Risk for activity intolerance
Impaired physical mobility
Sedentary Lifestyle
Risk for disuse syndrome
Examples of Mobility Decline Nursing Diagnoses
risk for falls
fear of falling
ineffective coping
low self esteem
powerlessness
self care deficit
Examples of Prolonged Immobility Nursing Diagnoses
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
What are the general nursing goals for Impaired/Altered Mobility when caring for a patient?
- Increased tolerance for physical activity
- Restored/improved capability (ambulation, ADLs, etc)
- Absence of injury (falling, improper use of body mechanics, etc)
- Enhance physical fitness
- Absence of complications associated with immobility
- Improved social, emotional, intellectual well being
* INCREASE FUNCTION, IMPROVE ABILITY, AND AID PSYCHE*
Cardiovascular System Responses to Impaired Mobility
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
Assessments for the Cardiovascular System when the Patient has Impaired Mobility
- Labs: Hgb&Hct
- BP: Lying, Sitting, Standing
- Pulse: Apical, Peripheral
- O2 Sat
- Edema of Extremities Check
- Temperature of Extremities Check
- Check skin for signs of reduced perfusion
- Signs of DVT: Swelling, Redness, Homans Sign, Pain in the Calves
Interventions for the Cardiovascular System when the Patient has Impaired Mobility
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
What medicines are used in low dose anticoagulation therapy?
Heparin
Coumadin
Lovenox (enoxaparin sodium)
Xarelto (rivaroxaban tablets)
Heparin (Admin, Antidote, Lab Test)
Admin - SubQ
Antidote - Protamine Sulfate
Lab Test - PTT
Given as a preventative measure
Coumadin (Admin, Antidote, Lab Test)
Admin - PO
Antidote - Vit K
Lab Test - PT/INR
“Warfarin”
Lovenox (Enoxaparin Sodium) (Admin, Antidote, Lab Test)
Admin - Subcutaneous
Antidote - Protamine Sulfate
Lab - None
Often given to go home with
Xarelto (rivaroxaban tablets) (Admin, Antidote, Lab Test)
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
What patient education should be done regarding low dose anti coagulation therapy?
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
What are some S/S of bleeding in anti coagulation therapy?
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
Respiratory System responses to Impaired Mobility
Decreased HGB
Decreased Lung Expansion
Increased Secretions
Increased risk of Atelectasis
Increased Risk of pneumonia
Stasis of secretions
Impaired gas exchange
Anxiety
Assessments for the Respiratory System when the patient has impaired mobility
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
Interventions for the Respiratory System when the patient has impaired mobility
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!
Skin response to Impaired Mobility
Increased risk of skin breakdown and ulcer formation (protein buildup or infection signs too)
Response by the Skin to impaired mobility is compounded by what factors?
Impaired body metabolism
Pressure
Shearing force
Friction
Decreased hydration and/or nutrition
Assessments for the Skin when the patient has impaired mobility
Signs of compromise: Redness, blanching, temp, sponginess, loss of sensation
Labs: H&H, protein, albumin, WBCs
Interventions for the Skin when the patient has impaired mobility
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
Risk Areas for Pressure ulcer
Anywhere you lean or has a bony prominence
- Back of Head
- Shoulder Blade
- Elbows
- Spine
- Hip Bones or (Iliac Crest)
- Medial knee (Between the Knee; may need a towel)
- Anywhere the leg touches the but, but especially THE HEELS (float the heels!)
When measuring a pressure ulcer, what 4 things need to be documented?
- Size (LxWxD)
- Depth
- Staging
- Presence of undermining, tunneling, or sinus tract
* to measure depth, size, and presence use a sterile, saline damp swab, but never use force
What are the 4 Staging levels of Pressure Wounds
- Redness
- Partial thickness
- Full thickness
- Full thickness past fascia
Gastrointestinal responses to impaired mobility in a patient
Decreased Appetite
Decreased BMR (Basal metabolic rate)
Decreased gastric motility
Decreased muscle tone
Increased risk of constipation
What things are altered in the GI tract if the patient cannot move?
Digestion
Utilization of nutrients
Proteins
Metabolism
Assessments for the GI system in a patient with impaired mobility
Labs: Albumin, Protein levels
Anxiety and/or embarrassment (maybe inability to get to bathroom)
Bowel sounds
Defecation pattern
Abdominal distention
Appetite
Nutrition
Nausea
Interventions for the GI system in a patient with impaired mobility
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
Genitourinary System responses in a patient with impaired mobility
Decreased Bladder tone
Decreased Urine Output
Increased urine Stasis
Increased risk of UTI
Increased risk of renal calculi
Assessments for the GU system in a patient with impaired mobility
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
Interventions for the GU system in a patient with impaired mobility
OOB ASAP w/ ORDER!!!
Encourage bathroom (v bedpan) use
Encourage fluids
Discourage “holding” urine
Measure and record I&O if ordered
Avoid catheterization
The most common type of healthcare associated infection is?
Urinary Tract Infection
Accounts for more than 30% of infections
Virtually all healthcare associated UTIs are caused by …
instrumentation of the urinary tract
UTIs are associated with increased what?
- Morbidity (illness)
- Mortality (death)
- Hospital cost
- Length of stay
What are some appropriate uses for Indwelling Urethral Catheter?
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
What are some inappropriate uses for Indwelling Urethral catheter?
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
Musculoskeletal System responses for patients with impaired mobility
Loss of Endurance
Decreased stability, muscle mass, skeletal mass, balance w/ posture changes
Increased muscle atrophy and contractures
Disuse osteoporosis
Assessments for the Musculoskeletal system in patients with impaired mobility
Muscle strength and weakness
Muscle mass
Muscle tone (hyper/hypo tonic)
Contractures
ROM
Gait/stability w/ ambulation
Interventions for the Musculoskeletal system in patients with impaired mobility
OOOB ASAP w/ PCP ORDER!!!!
ROM (active and passive)
Assist with activity as needed
PT/OT consults
Protective positioning
Types of Range of Motion
Resistive
Active
Active Assist
Passive
Resistive ROM
patient movement using pulling/pushing forces
they move but you give resistance against them
Active ROM
patient can move joints independently
Active Assist ROM
patient moves joints with some assistance; encourages normal muscle function without stress to distal joint
Move independently but need some assistance to prevent stress
Passive ROM
Nurse/Caregiver moves joints for the patient - Individual does not do the movement, someone else does
Tips for the Nurse doing PROM
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
What is the path from Decondition to Dependence like?
They take a stepwise pattern down toward dependence for mobility and it is steep and rapid and much quicker than one may think
What is the pathway from decondition to dependence?
- weak wobbly legs
- more muscle weakness
- less ability to perform
- more muscle weakness
- less ability top perform
- disuse atrophy (muscle shrinkage)
- NO ability to perform –> Dependence
What is the path upward to mobility independence like?
It is a progressive mobilization that is less steep and a little slower than deconditioning to dependence
What is the pathway upward to independence?
- Bed Activities
- Sitting
- transferring
- Standing
- Walking
- Climbing
- Stair (this is commonly point of discharge)
What is the Psychosocial response like for patients with impaired mobility
Increased sense of powerlessness
Increased risk of depression
Altered sleep wake pattern
Decreased self concept
Decreased social interaction
Decreased Sensory stimulation
Psychosocial Assessments/What to assess for the patients with impaired mobility
Mood swings
Social interactions
Mentation and Outlook
Ability for abstract thinking
Ability to follow commands
Ability to assimilate new information
Anxiety, Insomnia, Lethargy
Psychosocial interventions for patients with impaired mobility
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”
Musculoskeletal Responses to Immobility
Loss of endurance
Decreased stability, muscle mass, skeletal mass, balance with posture changes
Increased muscle atrophy, contractures
Disuse osteoporosis
Respiratory Responses to Immobility
Decreased Hgb, lung expansion
Impaired gas exchange
Increased secretions, risk of atelectasis, risk of pneumonia
Stasis of secretions
Cardiovascular responses to Immobility
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
GU responses to immobility
Decreased bladder tone, urinary output
Increased urine stasis, risk for UTI, risk for renal calculi
Skin responses to immobility
Increased risk of skin breakdown, and ulcer formation
GI responses to immobility
Decreased appetite, BMR, gastric motility, muscle tone
Increased risk of constipation
Altered digestion, utilization of nutrients, protein, metabolism
The most important intervention for impaired mobility, regardless of system, is?
GETTING THEM OUT OF BED AS SOON AS POSSIBLE (WITH ORDER)
