WK 6 musculoskeletal, mobility, and immobility Flashcards
multiple components of a musculoskeletal assessment
gait
alignment
symmetry
muscle mass
muscle tone
range of motion
involuntary movements
inflammatory signs
gross deformities
gait
very interconnected with balance
EF of gait
steady, smooth and coordinated
UEF of gait
shuffled gait, uncoordinated gait, pt reporting slower or difficulty walking
who is at risk for gait abnormalities
pt with history of stroke, spinal issues, neurological conditions, lower extremity issues
why do we care about gait abnormalities?
bc pt that have these have a high risk of falling
range of motion
passive and active
looking for symmetrical ROM
understanding terminology is CRUCIAL for conducting a thorough assessment
flexion
movement decreasing angel between two adjoining bones; bending of limb
elbow, fingers, knee
extension
movement increasing angle between two adjoining bones
elbow, knee, fingers
hyperextension
movement of body part beyond its normal resting extended position
head
pronation
movement of body part so that front of ventral surface faces downward
hand, forearm
supination
movement of body part so that front of ventral surface faces upward
hand, forearm
abduction
movement of extremity away from midline of body
leg, arm, fingers
adduction
movement of extremity toward midline of body
leg, arm, fingers
internal rotation
rotation of joint inward
knee, hip
external rotation
rotation of joint outward
knee, hip
eversion
turning of body part away from midline
foot
inversion
turning of body part toward midline
foot
dorsiflection
flection of toes and foot upward
foot
plantarflexion
bending of toes and foot downward
foot
spinal malformations
kyphosis, lordosis, scoliosis
EF of spine
cervical: concave
thoracic: convex
lumbar: concave
sacral coccygeal: convex
kyphosis
exaggerated curvature of thoracic spine
lordosis
exaggerated curvature of the lumbar spine
scoliosis
exaggerated lateral curvature
muscle strength EF
muscle strength to be equal, symmetric and firm bilaterally
grade 5
atrophy
weak, abnormal findings, not using enough muscle strength
hypertophy
overuse of muscle
grade 5
muscle can move the joint it crosses through a full ROM, against gravity, and against full resistance applied the examiner
grade 4
muscle can move the joint it crosses through a full ROM against moderate resistance
grade 3
muscle can move the joint it crosses through a full ROM against gravity but without any resistance
grade 2
muscle can move the joint it crosses through a ROM only if the part is properly positioned so that the force of gravity is eliminated
grade 1
muscle contraction is seen or identified with palpation, but it is insufficient to produce joint motion even with elimination of gravity
grade 0
no muscle contraction is seen or identified with palpation; paralysis
pt that would not be appropriate fro using heat and cold
very old, very young, frail skin, thin skin, extremely immobile pt (paralyzed or sedated), vascular insufficiency, open wounds
T/F: in most cases need a provider to write for heat or cold therapy
true
T/F: can use moist or dry heat and cold
true
nursing implications using heat and cold
assess site frequently (5-10 min) for signs of irritation
D/C if irritation occurs, can removed and replace if symptoms resolve
document
dry heat
hot packs, warming blankets
moist heat
sitz bath, aqua thermia pad, warm soaks
moist cold
cold compresses, cold soaks
dry cold
ice packs
ergonomics
science that focuses on factors or qualities in ab object’s design/use that contribute to comfort, safety, efficiency, and ease of use
main component of ergonomics
body mechanics
mody mechanics
center of gravity, lifting, pushing or pulling
center of gravity
lower the better
lifting
use assistive devices when appropriate
pushing or pulling
wide base of support
what affects mobility?
obesity
congenital defects
bone, joint, and muscle disorders
inflammatory joint diseases
CNS disorder
musculoskeletal traumas
activity intolerance (deconditioning)
obesity
major risk for mobility issues
higher risk of arthritis, back pain and osteoporosis
congenital defects
abnormalities in musculoskeletal system
osteogenesis imperfecta, scoliosis
bone, joint, and muscle disorders
affects integrity of structure, can cause spinal injuries
inflammatory joint diseases
destruction of synovial membranes around joints cause inflammation
osteoarthritis, rhematoid arthritis
CNS disorder
anything that damages CNS which regulates voluntary movement
causes impaired body alignment (trauma head injuries)
musculoskeletal traumas
breaking a leg
activity intolerances
chronic disease state
pt transfers and mobility orders
multi dimensional
typically determined by PT based on pt condition
mobility orders associated with how much assistance the pt requires
T/F: bed rest can be ordered by an MD, usually procedure related, and usually time sensitive
true
positioning in bed
reverse trendelenburg
fowler’s
lateral
lithotomy
prone
supine
sim’s position
trendelenburg
fowler’s
a bed position where the head and trunk are raised, typically between 40-90 degrees
often used for pt who have cardiac issues, trouble breathing or a nasogastric tube in place
lateral
position involves the pt lying on either her right or left side
right lateral means the pt right side is touching the bed, while left lateral means the pt left side is touching the bed
pillow is often placed in between the legs for pt comfort
lithotomy
position involves the pt lying flat on her back with legs elevated to hip level or above, often supported by stirrups
commonly used for gynecological procedures and childbirth
prone
position where the pt lies on his stomach with his back up
head is typically turned to one side
position allows for drainage of the mouth after oral or neck surgery
allows for full flexion of knee and hip joints
reverse trendelenburg
pt is supine with the head of bed elevated and the foot of the bed down
position may be used in surgery to help promote perfusion in obese pt
can be helpful in treating venous air embolism and preventing pulmonary aspiration
sim’s position
prone/lateral position in which the pt lies on his side with his upper leg flexed and drawn in towards the chest, and the upper arm flexed at the elbow
useful for administering and for comfort in pregnancy
supine
position where the pt is flat on his back
considered the most natural at rest position and is often used in surgery for abdominal, facial, and extremity procedures
trendelenburg
position involves a supine pt and sharply lowering the HOB and raising the FOB, creating an upside down effect
position was frequently used to treat hypotension although this can be ineffective and potentially dangerous
helpful during gynecological and abdominal hernia surgeries an placement of central lines
semi-fowler’s
bed elevated 15-45 degrees
normally 30!
fowler’s
bed elevated 45-60 degrees
high fowler’s
bed elevated 60-90 degrees
trendelenburg
entire bed tilted with HOB lower than the foot
modified trendelenburg
pt remains flat but legs elevated above the heart
reverse trendelenburg
entire bed tilted with FOB low to ground and HOB high
in-bed mobility considerations
log roll
trapeze bar
mechanical lift
speciality beds/tilt table
log roll
for pt in spinal/cervical precautions
trapeze bar
allows pt to pull with the upper extremities to raise trunk off the bed
helpful to aide independence
teach pt about proper usage
speciality beds/tilt table
total lift bed
gait belt
assistive deice which helps nurses mobilize pt
reduce chance pt might fall
helps nurses reduce chance of injuring themselves
early mobility…
is best for our pt
early mobility is nurse driven
TRUE
goal for early mobility
to be up with the first several hours after surgery
early mobility helps with:
respiratory function
cardiac function
muscle tone
metabolism/GI function
every body system is better moving
assistive devices
walkers
crutches
canes
canes
light weight, easily movable
single straight legged
provide support and balance for pt with MILD balance or strength impairements
quad canes
commonly used for pt with unilateral weakness
nursing teach points for canes
cane goes on STRONG SIDE
handle of cane should be close to pt wrist crease
move cane forward first, then weaker side, then stronger leg past the cane
walkers
light, movable, waist high, made of light weight materials
can be 4 legs or have wheels on front, or 4 wheels
goal of walkers
provides wide base of support, provides lots of stability and security when walking
nursing teach points for walkers
do not lean over the walker, stand upright
don’t let walker get too much in front of the pt
do not use on multiple stairs
top of walker in line with pt wrist crease (elbows at 15-30 degrees)
make sure pt stepping inside of walker
cane acronym
COAL
Cane
Opposite
Affected
Leg
walker acronym
Wondering Wilma’s always late
Walker
With
Affected
Leg
crutches
2 types: axillary wooden/metal crutch or double adjusted Lofstrand (forearm crutch)
axillary wooden/metal crutch
used for temporary issues
forearm crutch
can be used for longer periods, typically related to some paralysis
T/F: crutch fit measurement is crucial, could cause problems if not used correctly
true
nursing teach points for crutches
crutch pads should be 2-3 finger lengths from the axilla
weight bearing should be on the hand grips
elbows should be flexed 15-30 degrees
basic crutch position
basic crutch position
tripod position, with crutches 6 inches in front of feet and 6 inches to the side
crutch gait
four point, three point, and two point gait
four point gait
weight bearing on both legs
each leg moves alternately and 3 points of contact at all times
three point gait
ALL weight bearing on one leg
affected leg not on ground
two point gait
partial weight bearing on both feet
move opposite crutch and legs alternately (how arms and legs normally move)
facts about immobility
affects ALL body systems
systemic and localized affects of immobility can be seen in days
can have negative effect on psychosocial functioning
can have long lasting consequences on health
effects on psychosocial functioning
depression, alterations in self concept, increased anxiety, behavioral changes
long lasting consequences on health
learning to walk again
metabolic changes
decreases metabolic rate, creates negative nitrogen balance, weight loss, decreases muscle mass
GI changes
constipation, pseudo-diarrhea, overall depressed intestinal function, fluid/electrolyte imbalances
respiratory changes
atelectasis, increased risk of pneumonia, static secretions, decreased oxygenation
cardiovascular changes
orthostatic hypotension, increased cardiac workload, thrombus formaton
musculoskeletal changes
lose lean muscle mass, disuse atrophy, impaired calcium metabolism, joint abnormalities (disuse osteoporosis), contractures, foot drop
urinary elimination changes
urinary stasis, increased risk of UTI, increased risk of renal calculi (kidney stones), dehydration
integumentary changes
pressure injuries
joint contractures
possible permanent, abnormal fixation of the joint
disuse, atrophy, shortening of muscle fibers
no longer full ROM
early prevention is key
foot drop
type of contracture
foot permanently flexed in plantar flexion
causes extreme difficulty when mobilizing again
unable to lift toes off the ground (FALL RISK)
pt with CVA (stroke), with left or right sided weakness high risk for foot drop
pressure injuries
impairment of skin related to prolonged ischemia
inflammation over bony prominence leads to ischemia of the tissue
oxygen and nutrients cannot get to the skin
longer pressure applied more intense the ischemic areas are
PREVENTION IS KEY
how to prevent pressure injuries
turning pt, encouraging pt to move around, mobilize if possible, use assistive devices, turning with pillow, or z-flow devices
common areas of pressure injuries
coccyx, heels, back of head, elbows
thrombus, VTE, DVT
are all essentially the same thing
venous thromo-embolism
clot which has detached from the wall
deep vein thrombosis
clot within the vein blocking flow
3 contributing factors to thrombus, VTE, and DVT
damage to the vessel wall
alteration in blood flow (immobility, bed rest)
alterations in blood constituents (changes clotting factors, increases platelet activity)
creates a high risk for pulmonary embolism
signs and symptoms of thrombus, VTE, DVT
redness, pain, edema at side, many times there are none
nursing interventions to prevent immobility complications
we can mitigate chances of severe, permanent, debilitating consequences of being immobile
metabolic interventions
high protein, high calorie diet
supplement with vitamins B and C
if pt not in taking oral, make sure we are feeding enterally/parentally
do not delay feeding
respiratory interventions
pulmonary toilet
get up, move to chair, ambulate
incentive spirometer
CPT
adequate hydration
pulmonary toilet
turn, cough, deep breathe, positioning
CPT
postural drainage, vibration, cough assist
adequate hydration
thins secretions
cardiovascular interventions
reduce orthostatic hypotension
mobilize early
avoid valsalva maneuvers
reduce orthostatic hypotension
change positions slowly, adequate hydration
avoid valsalva maneuvers
bearing down, avoid constipation, encourage deep breathing
musculoskeletal interventions
in bed exercises
passive/active ROM
walk the pt
encourage activity in any way possible
integumentary interventions
turning Q 2 hours is essential
encourage pt sitting up in chair to move around, assist with repositioning if weak every hour
adequate hydration and nutrition
special mattresses
special dressings over pressure-prone areas
elimination issues interventions
keep well hydrates (800-2000ml per day of fluid)
encourage voiding
stool softeners/laxatives when needed
high fiber diet, fiber supplementation
psychosocial health interventions
encourage routine when possible (cluster care) - SLEEP CYCLES
provide meaningful stimuli
involve pt in care decisions
hygiene and grooming
preventing DVTs
deadliest complication of immobility
requires aggressive prophylaxis
multi dimensional appraoch
multi dimensional approach to preventing DVTs
early ambulation, leg, foot, and ankle exercises (calf pumps), adequate hydration, frequent position changes, pt teaching, SCDs and anti-embolic stockings (TED hose), anticoagulation therapy
anticoagulation therapy
aspirin, heparin, low molecular weight heparin (lovenox)
caring for pt on antocoagulants
proper meds
puts pt at high risk for bleeding
meds commonly used for treatment of anticoagulants
acute: heparin, lovenox
chronic: coumadin, apixaban
anticoagulants puts pt at high risk for bleeding
GI bleeds, head bleeds
nursing teach for care of pt on anticoagulants
labs
dietary considerations
falling
pre-procedural restriction
teaching about bleeding signs
teaching about bleeding signs
stool, GI discomfort, weak, dizzy
Labs for nursing teaching
coaqs
PT/PTT
INR
Anti-Xa
dietary considerations
vit K and coumadin
SCDs or sequential compression devices
prevent clots in lower extremities
inflate and deflate at cyclical pace
best to use constantly while pt is in the bed
always assess skin integrity under device
anti embolic stockings or elastic stockings
maintain external pressure on muscles of lower extremities
promotes venous return
remove at least once per shift to assess skin integrity
applying appropriately is crucial
this is a team effort!
lots of HCP are involved in keeping pt mobile
nurse role
coordinatoe
UAP
assist pt with walking or help with mobilizing or turning in bed
PT
leader for initial ambulation, often recommends mobility orders, assistive devices necessary, and recommendations for goals of mobility
OT
help with fine motor skills and modifications needed for ADLs
RT- respiratory therapy
may assist with mobilizing if pt have high oxygen requirements, teaching and stressing pulmonary toilet and incentive spirometry
a nurse is assessing the skin of an immobilized. what will the nurse do?
use a standardized tool such as the braden scale
a nurse if preparing a care plan for a pt who is immobile. which psychosocial aspect will the nurse consider?
loss of hope
which of the following are complications of immobility? SATA
atelectasis
pneumonia
pulmonary embolus
pressure ulcer
helplessness and anxiety
a nurse is planning care for a pt who is on bed rest. which of the following interventions should the nurse plan to implement?
encourage pt to perform anti-embolic exercises every 2 hours
