NUR 372 CLASS 3 MOBILITY Flashcards
1
Q
PURPOSE OF GAIT BELT
A
- support during transfers or ambulation, especially for patients who are weak, dizzy, or have poor balance
2
Q
PURPOSE OF HOYER LIFT
A
- transfer immobile patients from bed to chair or bathtub
- patient poses safety risk to themselves or nurse
3
Q
PURPOSE OF READY STAND
A
- helpful in assisting patients who can bear weight to assume a standing position but cannot walk long distances
4
Q
PURPOSE OF SLIDE BOARD
A
- transfer of patients from one bed to another
5
Q
PURPOSE OF HOVERMATT
A
- used for boosting patients and decreasing skin breakdown
6
Q
PURPOSE OF HOVERJACK
A
- used to put person back on bed after falling onto the floor
7
Q
MANIFESTATIONS OF ALTERED MOBILITY
A
- decreased muscle strength and tone
- lack of coordination
- altered gait
- falls
- decreased joint flexibility
- pain on movement
- activity intolerance
8
Q
IMMOBILITY EFFECTS ON CARDIOVASCULAR SYSTEM
A
- increased cardiac workload
- decrease in vessel resistance and distribution in blood
- increase on O2 consumption of heart
- work harder and less efficiently
- orthostatic hypotension
- increased risk for thrombus formation
- decreased circulating blood volume
- increased blood viscosity
- venous stasis
9
Q
NURSING INTERVENTIONS FOR CARDIOVASCULAR SYSTEM
A
- dangle feet
- ROM exercises
- TEDs or SCDs
- heparin
- avoid putting pillows under knees
- avoid crossing legs
- encourage fluids
10
Q
OBJECTIVE ASSESSMENT FOR CARDIOVASCULAR SYSTEM
A
- BP
- HR
- pulses
- edema
- temp changes
- Homan’s sign
- orthostatic BP
- calf measurements
11
Q
IMMOBILITY EFFECTS ON RESPIRATORY SYSTEM
A
- reduced red blood cell mass and hemoglobin levels
- decreased depth and rate of respiration
- reduced oxygen delivery to tissues
- reduced lung expansion
- respiratory muscle weakness (impaired cough)
- secretions stasis
- impaired gas exchange
12
Q
OBJECTIVE ASSESSMENT FOR RESPIRATORY SYSTEM
A
- RR
- cap refill
- breath sounds
- cough (color, amount, consistency)
- airway
13
Q
NURSING INTERVENTIONS FOR RESPIRATORY SYSTEM
A
- change position Q2hr
- out of chair, sitting up, etc.
- encourage DB & C
- incentive spirometer
- encourage fluids 2-3L
- suction if needed
14
Q
IMMOBILITY EFFECTS ON MUSCULOSKELETAL SYSTEM
A
- loss of endurance
- decreased muscle size, tone, and strength
- decreased joint mobility and flexibility
- contractures; foot drop
- disuse osteoporosis
15
Q
OBJECTIVE ASSESSMENT FOR MUSCULOSKELETAL SYSTEM
A
- muscle tone
- strength
- ROM
- contractures
- calcium levels
- use of assistive devices
16
Q
NURSING INTERVENTIONS FOR MUSCULOSKELETAL SYSTEM
A
- ROM and strength exercises (ADLs)
- turning and positioning
- ambulation
- ROM with ADLs
- promote optimal nutritional intake
17
Q
IMMOBILITY EFFECTS ON INTEGUMENTARY SYSTEM
A
- increased risk for skin breakdown
- moist skin
- increased risk of shearing and friction
- altered metabolism and/or impaired nutrition
- increased body temperature
- decreased fluid intake
18
Q
OBJECTIVE ASSESSMENT FOR INTEGUMENTARY SYSTEM
A
- skin breakdown
- sensation
- anemia
- protein/albumin levels
- Braden scale
- skin color
- warmth
- bony prominences
- turgor
- incontinence
19
Q
NURSING INTERVENTIONS FOR INTEGUMENTARY SYSTEM
A
- turn and position
- keep skin clean and dry
- therapeutic mattresses
- teach client to move independently q 15 minutes
- monitor nutritional intake
- provide skin and perineal care
20
Q
IMMOBILITY EFFECTS ON URINARY SYSTEM
A
- urinary stasis
- renal calculi
- increased calcium levels
- decreased fluid intake
- decreased urine output
- decreased bladder tone
21
Q
OBJECTIVE ASSESSMENT FOR URINARY SYSTEM
A
- I and O
- VS
- WB
- urine color, odor, clarity and amount
- bladder distention
22
Q
NURSING INTERVENTIONS FOR URINARY SYSTEM
A
- encourage fluids
- measure and record voiding
- drink acidic fluids (cranberry juice) to make urine acidic
- provide perineal care
- bladder and bowel training
23
Q
IMMOBILITY EFFECTS ON GI SYSTEM
A
- appetite changes
- altered protein metabolism
- decreased peristalsis
- altered digestion and utilization of nutrients
24
Q
OBJECTIVE ASSESSMENT FOR GI SYSTEM
A
- bowel sounds
- bowel movement frequency
- I and O
- % meals eaten
- appetite
- protein and albumin levels
25
NURSING INTERVENTIONS FOR GI SYSTEM
- record % meals eaten
- I and O
- include patient’s likes and dislikes
- observe for diarrhea, hydration
- diet that includes fruits and vegetables, and high in fiber
- stool softener
26
IMMOBILITY EFFECTS ON METABOLIC SYSTEM
- fluid and electrolyte disturbances
- altered carbohydrate, protein, fat metabolism
- pancreatic activity decreases (hormone imbalances)
- increase rate of protein breakdown
- decreased basal metabolic rate
- decrease in resting energy expenditure
- check everything and record everything
27
IMMOBILITY EFFECTS ON NEUROLOGICAL/PSYCHOSOCIAL SYSTEM
- sense of powerlessness
- sensory deprivation or overload
- pain
- roles and relationships
- sexuality
- altered sleep – wake cycle
- social
isolation and depression
28
OBJECTIVE ASSESSMENT FOR NEUROLOGICAL/PSYCHOSOCIAL SYSTEM
- assess emotional state and observe for behavioral change
- mental status
- decision making
- sleep alterations
- coping skills, ADLs
- family support
- social activities.
29
NURSING INTERVENTIONS FOR GI SYSTEM
- coping skills
- maintain orientation
- develop schedule of therapies
- involve client in daily care
- provide stimuli
30
FALL PRECAUTION ELEMENTS
- used on all patients
- room free of clutter
- nightlight
- call bell instruction
- non-skid footwear
- frequent monitoring/toileting
- bed chair/alarm
31
CRUTCHES
- short or long term assistance with ambulation
32
AXILLARY CRUTCHES
- bar that fits beneath the axilla
| - used for temporary ambulatory assistance
33
FOREARM CRUTCHES
- crutches that have an arm cuff, no axillary bar
- individuals who need permanent crutches to assist with ambulation (e.g. individuals with cerebral palsy, congenital hip)
34
PLATFORM CRUTCHES
- contain a forearm cuff and are used by individuals who cannot bear full weight on their hands and wrists
- often used by those with rheumatoid or severe osteoarthritis, spina bifida
35
MEASURING FOR AXILLARY CRUTCHES
- 1.5 - 2" below axillary fold to point on floor 4" in front of the pt and 6" laterally from side foot
- wrist crease should line with handgrip (that will allow elbow to be flexed at 30 dg)
36
MEASURING FOR FOREARM CRUTCHES
- handle height same as axillary
- lower end of the shaft adjusted so arm handle is correct height
- forearm piece 2.54 cm from clenched fist to elbow crease
37
TRIPOD POSITION OF CRUTCH WALKING
- all forms begin in tripod
| - crutches placed 6" in front of patient and 6" laterally from foot
38
TWO-POINT GAIT CRUTCH INDICATIONS
- bilateral weakness or disability such as cerebral palsy or arthritis
- patients with strength, coordination and balance
- partial weight bearing
39
TWO-POINT GAIT INSTRUCTIONS
- stand with both feet together, move right crutch and left foot, then move left foot and right crutch
40
THREE-POINT GAIT PARTIAL WEIGHT BEARING INDICATIONS
- amputee learning to use prosthesis
- minor injury to one leg
- healing injury
- partial weight bearing status
- post hip arthroplasty
41
THREE-POINT GAIT PARTIAL WEIGHT BEARING INSTRUCTIONS
- stand with both feet together, advance both crutches and affected leg, advance unaffected leg
42
THREE-POINT GAIT NON-WEIGHT BEARING INDICATIONS
- one amputated, disabled or injured leg
43
THREE-POINT GAIT NON-WEIGHT BEARING INSTRUCTIONS
- stand in tripod position with affected leg bent up, move both crutches forward then bring unaffected leg up to crutches
- no weight on affected leg which remains bent.
44
FOUR-POINT GAIT INDICATIONS
- bilateral weakness or disability such as cerebral palsy or arthritis but limited weight bearing or weakness
45
FOUR-POINT GAIT INSTRUCTIONS
- stand with both feet together, advance right crutch, advance left foot, advance left crutch, advance right foot
46
CRUTCH WALKING SWING TO INDICATIONS
- patient with weakness of both lower extremities – good upper extremity strength
47
CRUTCH WALKING SWING TO INSTRUCTIONS
- advance both crutches forward then, while bearing all weight down through both crutches, swing both legs forward at the same time to (not past) the crutches
48
CRUTCH WALKING SWING THROUGH INDICATIONS
- injury or disability to both legs such as a paralyzed person with leg braces or an amputee before fitting for a prosthesis
49
CRUTCH WALKING SWING THROUGH INSTRUCTIONS
- stand with both feet together, advance both crutches, advance both legs by swinging them forward beyond the crutches
50
UPSTAIRS CLIMBING WITH CRUTCHES INSTRUCTIONS
- place good leg on the stairs
- place crutches on the stairs
- put weight on the crutches
- bring bad leg up the stairs
- good – go to heaven!
51
DOWNSTAIRS CLIMBING WITH CRUTCHES INSTRUCTIONS
- place crutches and bad leg on the stairs
- bring the stronger leg down on the stairs
- bad – go to hell!
52
GENERAL CRUTCH TEACHING POINTS
- keep crutches close to one's side to stabilize under arms
- keep crutches 2-3" to side when ambulating
- position crutches on unaffected side when sitting/rising from a chair
- check rubber tips for softness and pliant
- don't let axilla crutches press under arms (nerve damage)
53
CANES
- ambulatory devices usually made of wood or aluminum
- provide support, aid in balance, relieve pressure on weight bearing joints, and promote stabilization when there is one extremity weakness
54
TYPES OF CANES
- Standard canes have small base of support and come with a C curve or T top
- T top canes provide better hand support
- quad or tripod canes have a wide base of support
55
MEASURING FOR CANES
- measure from wrist crease to the floor
| - handle of cane should be parallel to greater trochanter (hip)
56
AMBULATING WITH CANES
- place cane on unaffected side of the body
- stand upright with the cane 4-6 inches to the side of the toes
- move the cane forward 6-10 inches at the same time as the affected (weaker) leg
- take the next step with the unaffected (strong) leg
- do not lean on cane when getting out of chair
57
GOING UP STAIRS WITH A CANE
- step up with strong leg
| - move cane and weak leg upon step
58
GOING DOWN STAIRS WITH A CANE
- step down with affected leg and cane
| - lower strong leg to the same step
59
WALKER
- require considerable support and assistance with ambulation
- provide enhanced stability with poor balance
60
STATIONARY WALKER
- four legs with rubber tips and may be used for 2, 3, 4 point or swing through gaits
61
GLIDING WALKER
- me basic design as stationary but has metal plates on the tips instead of rubber and may be pushed or slid
62
WHEELED/ROLLING WALKER
- has wheels on front legs or on all four legs
| - also may have fold down seat
63
MEASURING FOR A WALKER
- have patient stand inside walker with hands at sides
- walker handles should be at wrist level
- elbows should be flexed about 30 degrees when using the walker
- patient will rest hands lightly on sides with flex as above
64
AMBULATING WITH A STATIONARY WALKER
- hold onto the walker at padded handgrips with a light grip
- pick up the walker and advance it about 6 to 8 inches forward
- step forward into the walker but not to the front – may make patient unsteady
65
AMBULTING WITH A STATIONARY WALKER (PARTIAL WEIGHT BEARING)
- hold onto the walker at padded handgrips
- pick up walker and advance it about 6 to 8 inches while advancing affected leg into the walker
- advance unaffected leg into the walker
