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U of R SCHOOL OF NURSING - 372 > NUR 372 CLASS 3 MOBILITY > Flashcards

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
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2
Q

PURPOSE OF HOYER LIFT

A
  • transfer immobile patients from bed to chair or bathtub

- patient poses safety risk to themselves or nurse

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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
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4
Q

PURPOSE OF SLIDE BOARD

A
  • transfer of patients from one bed to another
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5
Q

PURPOSE OF HOVERMATT

A
  • used for boosting patients and decreasing skin breakdown
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6
Q

PURPOSE OF HOVERJACK

A
  • used to put person back on bed after falling onto the floor
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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
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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
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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
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10
Q

OBJECTIVE ASSESSMENT FOR CARDIOVASCULAR SYSTEM

A
  • BP
  • HR
  • pulses
  • edema
  • temp changes
  • Homan’s sign
  • orthostatic BP
  • calf measurements
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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
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12
Q

OBJECTIVE ASSESSMENT FOR RESPIRATORY SYSTEM

A
  • RR
  • cap refill
  • breath sounds
  • cough (color, amount, consistency)
  • airway
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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
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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
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15
Q

OBJECTIVE ASSESSMENT FOR MUSCULOSKELETAL SYSTEM

A
  • muscle tone
  • strength
  • ROM
  • contractures
  • calcium levels
  • use of assistive devices
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16
Q

NURSING INTERVENTIONS FOR MUSCULOSKELETAL SYSTEM

A
  • ROM and strength exercises (ADLs)
  • turning and positioning
  • ambulation
  • ROM with ADLs
  • promote optimal nutritional intake
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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
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18
Q

OBJECTIVE ASSESSMENT FOR INTEGUMENTARY SYSTEM

A
  • skin breakdown
  • sensation
  • anemia
  • protein/albumin levels
  • Braden scale
  • skin color
  • warmth
  • bony prominences
  • turgor
  • incontinence
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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
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20
Q

IMMOBILITY EFFECTS ON URINARY SYSTEM

A
  • urinary stasis
  • renal calculi
  • increased calcium levels
  • decreased fluid intake
  • decreased urine output
  • decreased bladder tone
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21
Q

OBJECTIVE ASSESSMENT FOR URINARY SYSTEM

A
  • I and O
  • VS
  • WB
  • urine color, odor, clarity and amount
  • bladder distention
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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
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23
Q

IMMOBILITY EFFECTS ON GI SYSTEM

A
  • appetite changes
  • altered protein metabolism
  • decreased peristalsis
  • altered digestion and utilization of nutrients
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24
Q

OBJECTIVE ASSESSMENT FOR GI SYSTEM

A
  • bowel sounds
  • bowel movement frequency
  • I and O
  • % meals eaten
  • appetite
  • protein and albumin levels
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25
Q

NURSING INTERVENTIONS FOR GI SYSTEM

A
  • 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
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26
Q

IMMOBILITY EFFECTS ON METABOLIC SYSTEM

A
  • 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
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27
Q

IMMOBILITY EFFECTS ON NEUROLOGICAL/PSYCHOSOCIAL SYSTEM

A
  • sense of powerlessness
  • sensory deprivation or overload
  • pain
  • roles and relationships
  • sexuality
  • altered sleep – wake cycle
  • social
    isolation and depression
28
Q

OBJECTIVE ASSESSMENT FOR NEUROLOGICAL/PSYCHOSOCIAL SYSTEM

A
  • assess emotional state and observe for behavioral change
  • mental status
  • decision making
  • sleep alterations
  • coping skills, ADLs
  • family support
  • social activities.
29
Q

NURSING INTERVENTIONS FOR GI SYSTEM

A
  • coping skills
  • maintain orientation
  • develop schedule of therapies
  • involve client in daily care
  • provide stimuli
30
Q

FALL PRECAUTION ELEMENTS

A
  • used on all patients
  • room free of clutter
  • nightlight
  • call bell instruction
  • non-skid footwear
  • frequent monitoring/toileting
  • bed chair/alarm
31
Q

CRUTCHES

A
  • short or long term assistance with ambulation
32
Q

AXILLARY CRUTCHES

A
  • bar that fits beneath the axilla

- used for temporary ambulatory assistance

33
Q

FOREARM CRUTCHES

A
  • 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
Q

PLATFORM CRUTCHES

A
  • 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
Q

MEASURING FOR AXILLARY CRUTCHES

A
  • 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
Q

MEASURING FOR FOREARM CRUTCHES

A
  • 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
Q

TRIPOD POSITION OF CRUTCH WALKING

A
  • all forms begin in tripod

- crutches placed 6” in front of patient and 6” laterally from foot

38
Q

TWO-POINT GAIT CRUTCH INDICATIONS

A
  • bilateral weakness or disability such as cerebral palsy or arthritis
  • patients with strength, coordination and balance
  • partial weight bearing
39
Q

TWO-POINT GAIT INSTRUCTIONS

A
  • stand with both feet together, move right crutch and left foot, then move left foot and right crutch
40
Q

THREE-POINT GAIT PARTIAL WEIGHT BEARING INDICATIONS

A
  • amputee learning to use prosthesis
  • minor injury to one leg
  • healing injury
  • partial weight bearing status
  • post hip arthroplasty
41
Q

THREE-POINT GAIT PARTIAL WEIGHT BEARING INSTRUCTIONS

A
  • stand with both feet together, advance both crutches and affected leg, advance unaffected leg
42
Q

THREE-POINT GAIT NON-WEIGHT BEARING INDICATIONS

A
  • one amputated, disabled or injured leg
43
Q

THREE-POINT GAIT NON-WEIGHT BEARING INSTRUCTIONS

A
  • 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
Q

FOUR-POINT GAIT INDICATIONS

A
  • bilateral weakness or disability such as cerebral palsy or arthritis but limited weight bearing or weakness
45
Q

FOUR-POINT GAIT INSTRUCTIONS

A
  • stand with both feet together, advance right crutch, advance left foot, advance left crutch, advance right foot
46
Q

CRUTCH WALKING SWING TO INDICATIONS

A
  • patient with weakness of both lower extremities – good upper extremity strength
47
Q

CRUTCH WALKING SWING TO INSTRUCTIONS

A
  • 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
Q

CRUTCH WALKING SWING THROUGH INDICATIONS

A
  • injury or disability to both legs such as a paralyzed person with leg braces or an amputee before fitting for a prosthesis
49
Q

CRUTCH WALKING SWING THROUGH INSTRUCTIONS

A
  • stand with both feet together, advance both crutches, advance both legs by swinging them forward beyond the crutches
50
Q

UPSTAIRS CLIMBING WITH CRUTCHES INSTRUCTIONS

A
  • 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
Q

DOWNSTAIRS CLIMBING WITH CRUTCHES INSTRUCTIONS

A
  • place crutches and bad leg on the stairs
  • bring the stronger leg down on the stairs
  • bad – go to hell!
52
Q

GENERAL CRUTCH TEACHING POINTS

A
  • 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
Q

CANES

A
  • 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
Q

TYPES OF CANES

A
  • 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
Q

MEASURING FOR CANES

A
  • measure from wrist crease to the floor

- handle of cane should be parallel to greater trochanter (hip)

56
Q

AMBULATING WITH CANES

A
  • 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
Q

GOING UP STAIRS WITH A CANE

A
  • step up with strong leg

- move cane and weak leg upon step

58
Q

GOING DOWN STAIRS WITH A CANE

A
  • step down with affected leg and cane

- lower strong leg to the same step

59
Q

WALKER

A
  • require considerable support and assistance with ambulation
  • provide enhanced stability with poor balance
60
Q

STATIONARY WALKER

A
  • four legs with rubber tips and may be used for 2, 3, 4 point or swing through gaits
61
Q

GLIDING WALKER

A
  • me basic design as stationary but has metal plates on the tips instead of rubber and may be pushed or slid
62
Q

WHEELED/ROLLING WALKER

A
  • has wheels on front legs or on all four legs

- also may have fold down seat

63
Q

MEASURING FOR A WALKER

A
  • 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
Q

AMBULATING WITH A STATIONARY WALKER

A
  • 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
Q

AMBULTING WITH A STATIONARY WALKER (PARTIAL WEIGHT BEARING)

A
  • 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

U of R SCHOOL OF NURSING - 372 (12 decks)

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