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132 Cards in this Set
- Front
- Back
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Describe the functions of the musculoskeletal (skeleton, skeletal muscles) and nervous systems in the regulation of movement. |
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Discuss physiological and pathological influences on body alignment and joint mobility. |
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Identify changes in physiological and psychosocial function associated with mobility and immobility. |
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Assess for correct and impaired body alignment and mobility. |
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Formulate appropriate nursing diagnoses for impaired body alignment and mobility. |
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Develop individualized nursing care plans for patients with impaired body alignment and mobility. |
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Discuss the importance of no-lift policies for the patient and health care provider. |
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Describe equipment needed for safe patient handling and movement. |
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Discuss the impact of national patient safety resources, initiatives, and regulations in relation to patient handling and movement. |
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Compare and contrast active and passive range-of-motion exercises. |
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Evaluate the nursing plan for maintaining body alignment and mobility. |
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What is needed for mobility: pg. 1127 |
1. Intact musculoskeletal and nervous systems are necessary. |
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Movement is a complex process that requires: pg. 1127 |
coordination between the musculoskeletal and nervous systems. |
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Body mechanics: pg. 1127 define how it caused problems for nurses |
1. The coordinated efforts of the musculoskeletal and nervous systems. It caused problemos for nurses because of lifting stuff yadadadadada. |
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What knowledge do we use instead of body mechanics for nursing interventions now? Pg. 1127-1128 Examples? |
1. Body alignment, balance, gravity, and friction when implementing nursing interventions. Examples: 1. Positioning patients 2. Determining the risk of patient falls 3. Safest way to move or transfer patients |
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Body alignment refers to: pg. 1128 define it as well |
1. the positioning of the joints, tendons, ligaments and muscles while sitting/standing. 2. Defined: means that the individual's center of gravity is stable. |
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What does correct body alignment help with? pg. 1128 |
1. Correct body alignment reduces strain on musculoskeletal structures, aids muscle tone, promotes comfort, and contributes to balance/energy. |
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Gravity and Friction pg. 1128 1. Weight: 2. Where is the center of gravity for most people? 3. Friction: 4. Shear 5. body sling |
1. Force exerted on body via gravity. 2. At 55-57% of their midline! 3. Force that occurs in a direction to oppose movement. 4. When bony structure of body moves while skin remains stationery: example: lying in bed that is elevated. 5. An ergonomic tool to reduce ulcers. |
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Physiology and Regulation of Movement Pg. 1128 Skeletal System 1. The skeleton provides: |
1. Physical attachment for muscles and ligaments and leverage necessary for movement. It is the supporting framework of the body |
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Skeletal system: pg. 1128 Four types of bones: name and describe |
1. Long: contribute to height (femur, fibula, tibia) and length (phalanges of fingers/toes 2. Short: Carpal bones in the foot and patella in the knee. Occur in clusters. When combined w/ ligaments and cartilage, permit movement of extremities. 3. Flat: in skull and ribs. Provide structural contour. 4. Irregular bones: vertebral column, mandible of the skull. |
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Bones are characterized by these qualities: pg. 1128 |
1. Firmness: from salts like calcium and phosphate in bone matrix. 2. Rigidity: necessary to keep long bones straight and to withstand weight bearing. 3. Elasticity: changes with age. Example: newborn to adulthood. |
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Skeletal system has several functions: pg. 1128 1. Pathological factors |
Protects organs and regulates calcium via storage. Also produces red blood cells, long bones contain bone marrow |
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1. What happens when calcium levels are low? Pg. 1128 |
1. Raises risk for osteoporosis and pathological fractures (fractures caused by weakened bone tissue). |
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Patients with altered blood marrow or RBC production: pg. 1128 |
fatigue faster because of reduced hemoglobin and oxygen-carrying ability. Reduces mobility, increases fall potential. |
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Joints Pg. 1128 Define |
Are the connection between bones
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Four classifications of joints: pg. 1128 |
1. synostotic 2. cartilaginous 3. fibrous 4. synovial |
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Describe the 4 types of joints pg. 1128 |
1. Synostotic: refers to bones jointed by bones. No movement: ex: skull 2. Cartilaginous: also called synchrondosis: cartilage unites bony components. Allows for growth over time. Ex: sternocostal. 3. fibrous: syndesmosis: ligament or membrane stretch and unite two bony surfaces. tibia/fibula 4. synovial: true joint. a movable joint where two bones covered with cartilage and lined with synovial membrane. ball-and-socket, pivotal, between fingers. |
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Ligaments: pg. 1128-1129 |
white, flexible bands of tissue binding joints together and connecting bones and cartilage. Note* May have protective function: in vertebrae |
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Tendons: pg. 1129 |
Connect muscle to bone, made of tissue, also white, fibrous. Strong, inelastic, yet flexible. Achilles tendon = strongest |
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Cartilage: pg. 1129 what is unossified? |
1. Nonvascular(w/o blood vessels) supporting connective tissue located chiefly in joints. 2. never hardens, unless in old age or osteoarthritis. |
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1. Skeletal muscles are the working elements of: pg. 1129 end
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movement due to their ability to contract and relax. Attaching to skeletal muscles improves their ability for movement. |
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What are muscles made of? pg. 1129-1130
What stimulates them? Describe what happens in the neuromuscular junction. |
Made of fibers that contract when stimulated by electrochemical impulses that travel from nurse to muscle across the neuromuscular junction. This impulse causes filaments (protein molecules myosin/actin) to slide past one another, causing contraction. |
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3 Muscle contraction categorizations: pg. 1130 |
moving resisting stabilizing parts |
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Concentric tension: pg. 1130 eccentric tension: Their link to isotonic contraction |
1. increased muscle contraction = muscle shortening example: pulling oneself up 2. helps control the speed and direction of movement example: lowering yourself slowly 3. Both are necessary for active movement and referred to as dynamic. |
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isometric contraction (static contraction): pg. 1130
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1. Causes an increase in muscle tension, but no shortening or movement. Ex: tightening and relaxing a muscle w/o movement. |
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Isometric/isotonic linkage? pg. 1130 |
Both needed for voluntary movement. |
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Muscles that attach to bone provide: pg 1130 |
necessary strength to move an object. |
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Leverage: pg. 1130 |
1. an inducing force. Example: humerus and radius/ulna and the elbow joint. Force is applied to one end of the bone to lift the other side as it rotates another bone in the opposite direction. |
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Posture pg. 1130
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the position of the body in regulation to the surrounding space. |
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posture and movement: pg. 1130 |
depend on the skeleton and the shape/development of skeletal muscles. Can reflect mood/personality: Mad: more movement tired: slouch |
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Muscle tone: pg. 1130 |
the normal state of balanced tension |
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The nervous system regulates: pg. 1130 |
movement and posture |
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Precental gyrus: pg. 1130 |
Called the motor strip. Major area in the cerebral cortex for voluntary movement. Motor fibers cross at medulla, thus right side controls left/right. |
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Movement is impaired via the nervous system when: pg. 1130
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1. neurotransmitter production is altered. |
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Four pathological conditions that affect mobility: pg 1130 |
1. Postural abnormalities: can limit ROM. May need a PT 2. Muscle abnormalities: muscular dystrophies 3. Damage to the CNS: Ex: damage to right side of motor strip results in left hemiplegia. 4. Direct trauma to the Musculoskeletal system: trauma, fractures, etc. |
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What is a fracture? pg. 1130 |
A disruption of bone tissue continuity; blunt trauma or deformity of bone/osteogenesis. |
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10 Postural Abnormalities Pg. 1131: table 47-1 |
1. Torticollis: Inclining of head to side: sternocleidomastoid muscle is contracted. Congenital or acquired. 2. Lordosis: exaggeration of curve, lumbar spine. pregnancy/congenital 3. kyphosis: increased convexity in thoracic spine. 4. Pigeon toes: 5. footdrop 6. clubfoot 7. bowlegs 8. knock-knee 9. scoliosis 10. congenital hip dysplasia: hip instability with limited abduction of hips MORE, PG. 1131 |
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Nursing Knowledge Base: Pg. 1131
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1. |
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To determine how to move patients safely, Immobility (Potter, 2013, p. 1132)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
assess their ability to move. 2. inability to do so. |
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Bed Rest: pg. 1132 |
1. an intervention that restricts patients to beds for therapeutic reasons. Lose 3% of muscle strength a day on bedrest. |
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Systemic Effects: pg. 1132 1. Changes in mobility alter: |
1. ndocrine metabolism, calcium resorption, and functioning of the gastrointestinal system. (Potter, 2013, p. 1132)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
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The endocrine system has 5 functions: |
The endocrine system, made up of hormone-secreting glands, maintains and regulates vital functions such as (1) response to stress and injury; ( 2) growth and development; (3) reproduction; (4) maintenance of the internal environment; (5) energy production, use, and storage. (Potter, 2013, p. 1132)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
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Homeostasis is controlled by: pg. 1132 |
the endocrine system |
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Immobility and how it affects the body: pg 1132 |
disputes normal metabolic functioning, or increasing BMR due to fever/wound healing.
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Negative nitrogen balance: pg 1132:
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Usually occurs when immobile as protein produces too much nitrogen, an end product of amino acid breakdown due to lack of use of protein. |
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Calcium resportion due to immobility |
Another metabolic change associated with immobility is calcium resorption (loss) from bones. Immobility causes the release of calcium into the circulation. Normally the kidneys excrete the excess calcium. However, if the kidneys are unable to respond appropriately, hypercalcemia results. Pathological fractures occur if calcium resorption continues as the patient remains on bed rest or continues to be immobile (Huether and McCance, 2008). (Potter, 2013, p. 1132)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
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Two most common respiratory problems Atelactasis: pg. 1133 hypostatic pneumonia |
1. collapse of alveoli. Secretions block bronchiole, alveoli collapse as air absorbed, producing hypoventilation. 2. inflammation of lung from secretion pooling |
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CARDIOVASCULAR CHANGES: pg. 1133
3 changes due to immobilization to cardiovascular system: |
1. orthostatic hypotension 2. increased cardiac workload 3. thrombus formation |
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Orthostatic hypotension: |
is an increase in heart rate of more than 15% and a drop of 15 mm Hg or more in systolic blood pressure or a drop of 10 mm Hg or more in diastolic blood pressure when the patient changes from the supine to standing position (Huether and McCance, 2008). In the immobilized patient decreased circulating fluid volume, pooling of blood in the lower extremities, and decreased autonomic response occur. These are especially evident in the older adult. (Potter, 2013, p. 1133)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
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Thrombus formation: basics and extra 3 factors to venous thrombus formation |
1. an accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel Three factors contribute to venous thrombus formation: (1) damage to the vessel wall (e.g., injury during surgical procedures), (2) alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity). (Potter, 2013, pp. 1133-1134)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 (Potter, 2013, p. 1133)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
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How do nurses help with ROM? RM Q's |
Nurses intervene to maintain maximum ROM in unaffected joints and then design interventions to strengthen affected muscles and joints, improve the patient's posture, and adequately use affected and unaffected muscle groups. Referral to and/or collaboration with a physical therapist enhances the nurse's interventions for a patient with a postural abnormality. Never push a joint where it hurts. Repeat 5 times daily. (Potter, 2013, p. 1130)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
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hazards of immobility: pg. 1132
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The effects of muscular deconditioning associated with lack of physical activity are often apparent in a matter of days. This cluster of symptoms is often referred to as the “hazards of immobility.” (Potter, 2013, p. 1132)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
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Immobility and bed rest for extended periods of time cost: RM |
Periods of immobility or prolonged bed rest cause major physiological, psychological, and social effects. These effects are gradual or immediate and vary from patient to patient. The greater the extent and the longer the duration of immobility, the more pronounced the consequences. The patient with complete mobility restrictions is continually at risk for the hazards of immobility. Can lead to withdrawal as patient is in bed more often and thinks about their condition worsening. (Potter, 2013, p. 1132)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
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Immobility and its Muscle effects: pg. 1134 |
Protein breakdown = loses body mass. Can lead to disuse atrophy. |
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Skeletal Effects: two changes w/ immobilization: pg. 1134 |
Impaired calcium metabolism and joint abnormalities. |
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Osteoporosis Disuse osteoporosis |
1. 80% of osteoporosis female Disuse osteoporosis: immobilization results in reduction of skeletal mass. Goal of those w/ osteoporosis is to maintain ADLs. |
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Joint contracture cause Footdrop: caused by CVAs/brain attacks |
Abnormal/possibly permanent. Fixation of the joint Caused by: disuse, atrophy, and shortening of muscle fibers. Can't achieve full ROM. Cannot dorsiflex |
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Urinary Elimination changes: pg. 1134 |
Immobility alters urinary elimination. Upright/w/ gravity, urine to renal pelvis to ureters and bladder. When flat/immobile, peristaltic contractions not enough, so urine enters ureters: Urinary stasis: increases risk of UTI and renal calculi. Renal calculi are calcium stones that lodge in renal pelvis or pass via ureters. |
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2 other causes of UTI: PG. 1134 |
Wrong perineal care for women, building up e.coli, and catheters |
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Integumentary change: pg. 1135 describe Pressure ulcers as well |
The changes in metabolism that accompany immobility add to the harmful effect of pressure on the skin in the immobilized patient. This makes immobility a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative (WOCN, 2009). A pressure ulcer is an impairment of the skin as a result of prolonged ischemia (decreased blood supply) in tissues (see Chapter 48) Usually on bone/prominence/inflammation (Potter, 2013, p. 1135)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
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Factors influencing mobility-immobility: pg. 1132: |
1. Systemic changes
2. Cardiovascular changes 3. respiratory changes 4. Musculoskeletal changes 5. Integumentary changes 6. Psychosocial effects. |
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Immobilization and its Psychosocial effects: pg. 1135 Link to depression and withdrawal |
1 Every patient responds to immobility diff. 2. Depression due to lack of regular routine: person thinks more about it while bedridden (more time) 3. Causes withdrawal: doesn't participate in anything. |
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Developmental changes occur most often in what age? pg. 1135
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In the very young/older adult stages.
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Developmental changes in Infants, Toddlers, and Preschoolers: pg. 1135 |
1. Posture awkward due to body weight distribution being uneven. Most often immobilization due to trauma from falls: less int./musculosk. development. |
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BOX 47-1 FOCUS ON OLDER ADULTS PG 1135. Nutr. prob. related to immobile older adults in hospitals`' 4 key points |
1. Even after admitted, older adults exp. decline in function (age linked to less muscle/aerobic capacity). 2. Nutritional assessment needed in care plan 3. Insuff. eating/assistance leads to immobility 4. Direct relationship b/w nutrition and adult rehab. |
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Immobilization/developmental changes in Adolescents pg. 1135 |
Growth is very uneven. Immobilization causes social isolation/lack of independence. |
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Immobilization/developmental changes in Adults Pg. 1135 |
immobilization affects all physiological systems. |
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Immobilization/developmental changes in Older Adults: pg. 1135 3 Key points Why immobility occurs/ |
1. Less activity, bone resorption, and hormonal changes = weaker bones
2. Prescribed meds affect balance/increase injuries/falls. 3. Encourage autonomy: don't contribute to immobility. |
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Professional standards developed by these two for immobility management: pg. 1136
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Agency for Healthcare Research and Quality (AHRQ)
Wound, Ostomy and Continence Nurse Society (WOCN) |
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GOOD critical thinking combines these 4: pg. 1136 |
Knowledge, experience, attitude and standards. Ex: immobility Knowledge: of mobility and immobility Experience: with past patients of both types Standards: know how to assess/guidelines Attitude: responsibility and creativity |
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Assessment process for mobility/immobility: pg. 1136-1137 Ask questions about: |
Mobility/immobility |
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Assessment on mobility focuses on: pg. 1136 IMPORTANT |
ROM, gait, exercise and activity tolerance/body alignment. Starts at most supportive pos.: lying down to sitting, transfer chairs, walking. |
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Range of motion (ROM) for Mobility: pg. 1136-1137 IMPORTANT 1. What is range of motion 2. the 3 planes 3. ROM assessment important as a: 4. 2 types of ROM 5. Contractures develop |
1. Maximum amount of movement available at a joint in one of the 3 planes 2. The 3 planes are: 1.Frontal 2. sagittal: lateral/medial 3. transverse: superior/inferior 3. ROM = baseline 4. Active and Passive 5. in joints not moved through their full ROM. |
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Questions to ask about ROM: PG. 1137 |
1. Ask about stiffness, swelling and pain, limited movement/unequal movement. |
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PG. 1139 Explains the neck, shoulder, elbow, forearm, wrist, fingers and thumb, hip, knee, ankle and foot. |
Not highlighted via R.M. |
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Gait: pg. 1139 What is it? Describe the "gait cycle" What can you assess from someone's gait? |
1. manner/style of walking 2. Begins with heel strike and continues to other heel strike 3. Posture, balance, ability to walk w/o assistance. |
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Exercise and Activity Tolerance: Pg. 1139 Exercise Activity tolerance |
1. Exercise is physical activity that conditions the body, improves health. Therapy 2. Imp. in assessment of: ADLs, walking, ROM. The amount of exercise a person can do. Monitor for dyspnea, shortness of breath, chest pain, etc. Less recovery time = better act. tol. Watch for depressed patients. |
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As a person grows older, how does activity tolerance change? pg. 1139 |
1. Muscle, bone mass reduced. Less active, less we're able to do. |
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Body alignment: pg. 1140: IMPORTANT Assessment and its objectives |
Assessment done standing, sitting, or lying down. Objectives: 1. Determine physio. changes in alignment. 2. Deviations due to incorrect posture. 3. Let patient observe posture 4. Learning needs 5. How other things factor in |
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Body alignment for standing: 8 things pg. 1140
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1. Head erect and midline 2. Shoulder/hips straight 3. Vertebral column straight 4. Good S pattern 5. Knees/ankles slightly flexed 6. Arms hang comfortably 7. Toes forward, feet apart 8. midline gravity |
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Body alignment sitting: pg. 1140 |
1. Head erect, neck/vertebrae in alignment 2. body weight evenly distr. in butt/thigh 3. Thighs parallel 4. Both feet on floor 5. small gap between popliteal artery/nerve 6. Forearms supported |
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Orthopnea: pg. 1140 |
1. leaning on the table due to resp. illness |
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Body alignment while lying down. pg. 1140-1141 Patients with these illnesses are more susceptible to getting hurt |
Assess in lateral position with pillow on head. 2. Impaired mobility, decreased sensation, impaired circulation (diabetes), and lack of voluntary control (spinal cord injury) |
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Immobility: how to assess pg 1141 |
Check doing head-to-toe phys. assessment.
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Metabolic system: pg. 1141 How to assess metabolic function. What to look for: IMPRTNT. |
Anthropometric measurements: (height, weight, skin fold thickness) to check for muscle atrophy. 1. Dehydration/edema: can cause SKIN BREAKDOWN 2. intake/output 3. wound healing This helps determine gastrointestinal/metabolic problems and if nutrients reaching wounded tissue. |
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Resp. system: pg. 1141 assessment for resp. system done how often? How to check for atelectasis Where to focus auscultation? IMP. |
1. Every 2 hours. Auscultate 2. Asymmetry in chest movement 3. Dependent(lowest) lung field: pulmonary secretions collect here |
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Cardiovascular system: pg. 1141 1. Longer immobility results in what? 2. 3rd heart sound at apex is sign of? 3. Edema develops why? 4. How to assess edema 5. Assessing for DVT |
1. hypotension when standing 2. Congestive heart failure 3. Due to heart unable to handle increased workload in bed rest. 4. Hands, feet, nose/earlobes cold. 5. Remove stockings every 8 hours for 30 and observe for redness. |
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DVT assessment in detail: pg. 1142 |
Measure bilateral calf circumference and record it daily as an alternative assessment for DVT. To do this, mark a point on each calf 10 cm (3.9 inches) down from the midpatella. Measure the circumference each day using the mark for placement of the tape measure. Unilateral increases in calf circumference are an early indication of thrombosis. ( Potter, 2013, p. 1142)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
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embolus? pg. 1142 |
1. Dislodged venous thrombus: goes to circ. system/lungs and results in tachycardia/short breath. |
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Where do pulmonary emboli usually form? pg. 1142 |
90% in lower extremities |
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Musculoskeletal system: pg. 1142 ROM: |
ROM is a baseline for later joint mobility measured via a goniometer. |
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Integumentary system: pg. 1142 Assessment for immobility: |
1. Look for breakdown/redness. 2. Every 2 hours 3. Use Braden scale. 4. Early indication allows for early intervention. 5. Check when turning, elimination needs, hygiene needs, etc. |
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Elimination system: pg. 1142
Check how often? IMPORTANT Q What does it increase risk of if not adequate fluids? |
1. Intake/output every 24 hours. 2. Renal system/kidney failure and dehydration. |
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Psychosocial assessment: pg. 1142 1. For older adults, what is confusion an indicator of? 2. Abrupt changes in personality usually due to: |
1. UTI/fever
2. meds, surgery, infection, pulm. emb. |
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Developmental Assessment: pg. 1142 Assessment of kids for immobility |
Check if they are meeting developmental tasks and progressing normally. Immobility can affect this.
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Two nursing diagnoses most directly related to mobility: pg. 1143
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1. Impaired phys. mobility 2. risk for disuse syndrome |
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Assessment review: pg. 1143 |
Assessment reveals clusters of data that indicate whether a patient is at risk or if an actual problem exists. The clusters of data include defining characteristics that support the diagnostic label and probable cause of the diagnosis. Locating the probable cause of the diagnosis (based on assessment data) is important to planning patient-centered goals and subsequent nursing interventions that will best help the patient. (Potter, 2013, p. 1144)Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
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What would someone who feels socially isolated do for attention? pg 1143 |
Nurse's call bell |
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Name a few complications due to immobility: pg. 1143 |
1. Renal calculi
2. DVT 3. Pulmonary emboli 4. pneumonia |
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PLANNING: How critical thinking is used along with standards Pg. 1143 |
Critical thinking ensures that the patient's plan of care integrates all that you know about the individual and key critical thinking elements. Professional standards are especially important to consider when you develop a plan of care. These standards often establish scientifically proven guidelines for selecting effective nursing interventions. Finally, as stated earlier, the patient is a full partner in designing the plan of care, and this input must be reflected when establishing the goals and outcomes. (Potter, 2013, p. 1144) Potter, P., Perry, A., Stockert, P., Hall, A. (2013). Fundamentals of Nursing, 8th Edition [VitalSource Bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-0-323-07933-4 |
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Goals and outcomes/planning pg. 1143 What would 2 goals and outcomes of someone with left-sided paralysis be? |
develop to achieve highest level of mobility 1. Goals: 1. patient uses walker to ambulate safely in home 2. Patients skin remains intact (immobility risk) to help with 2nd goal: change position every 2 hours check to see color every 20 mi |
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pg. 1144: an example of a nursing care plan. Name some things that would be on there. |
1. Assessment a. activities b. findings/defining characteristics 2. Diagnosis: a. label b. defining characteristic/related 3. Planning a. Goals b. Outcomes 4. Implement a. interventions b. rationale behind it (cite) 5. Evaluation Nursing actions Patient response/finding Achievement of outcome |
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Priorities: How to set them review. pg. 1145
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Remember to plan therapies according to severity and risk. Prevention is key. Use a CONCEPT MAP, pg. 1146. |
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Prevention of Work-Related Musculoskeletal Injuries pg 1145-1147 1. Most common injury for nurses 2. Happens when: |
1. lumbar back. Good ergonomics prevents this.
2. lifting, transferring, or positioning immobilized patients. |
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4 steps to prevent injury to nurses: pg. 1146
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1. Keep weight as close to you as possible 2. bend at knees 3. tighten abdominal muscles 4. maintain trunk, bend knees |
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How does culture influence mobility? 1147, box 47-5 |
It affects mobility due to cultural activities: koreans like to dance, bangladesh meditate, etc. |
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What are two things important for those with osteoporosis? pg. 1147 |
calcium and vitamin D. |
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Acute care pg. 1147 end -1148 1. Patients in acute care settings suffer from these 3 things due to immobilization usually: |
1. Respiratory illness 2. orthostatic hypotension 3. impaired skin integrity |
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Teaching patients with osteoporosis: pg. 1148 |
Objective is to change lifestyle 1. Foods rich in vitamin D and calcium 2. Risk factors 3. Modify lifestyle 4. Promote positive self-image |
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Metabolic system: pg. 1148 protein vitamin b vitamin c parenteral nutrition |
1. Needed to help rebuild/repair tissue 2. for energy/metabolism processes 3. skin integrity/wound healing 4. delivery of food/nutrition via intravenous catheter: central or peripheral. |
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Respiratory System: pg. 1148 What indicates pneumonia? 2. To help with it? |
1. greenish-yellow sputum, coughing, wheezing, shortness of breath, crackling, dyspnea 2. Every one-two hours cough, incentive spirometer. Deep breathe and yawn |
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Chest physiotherapy? |
CPT. Percussion and positioning. drains secretions from bronchi/lungs into trachea to cough out. |
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How many mL do we need? pg 1148 |
1100-1400 mL at least. |
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Cardiovascular system pg. 1148 3 risks involved with the cardio system. |
1. orthostatic hypotension 2. increased cardiac workload 3. thrombus |
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Reducing orthostatic hypotension pg. 1148 1. What are some symptoms of this? How to alleviate |
1. Increased pulse rate 2. Decreased pulse pressure 3. BP drop To alleviate, mobilize patient a.s.a.p. |
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Reducing Cardiac Workload: pg. 1149 Valsalva maneuver |
Not recommended, can cause death when defecating/moving side to side or up in bed. |
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Preventing Thrombus Formation: pg. 1149 prophylaxis (prevention of disease) 1. herapin 2. SCD/IPC (Intermittent pneumatic compression 3. Positoning 4. ROM |
1. An anticoagulant; suppresses clot formation. Bleeding is side-effect 2. inflates/deflates stocking around leg 3. No pressure around leg veins/knees, massaging legs. 4. reduces contractures/thrombi. do calf pumps. |
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Musculoskeletal system pg. 1149 What does exercising prevent/ CPM |
Muscle atrophy and contractures. For paralyzed patients, use the continuous passive motion (CPM) |
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integumentary system: pg. 1149 Ulcers |
Pressure ulcers are always a concern. Work at prevention by constantly turning/positioning, skin care, and use of therapeutic devices. |
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Elimination system: pg 1151 1. Possible complications with immobility 2. Amt. of fluids 3. Diet? 4. alternatives to diet |
1. Renal calculi and UTI 2. 1100-1400 3. fluids, fruit, vegetables, fiber to facilitate peristalsis 4. stool softeners, enemas, cathartics |
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trochanter roll trapeze bar supported fowler's position |
1. prevents external rotation of hips 2. allows patient to pull up 3. bed elevated 45-60 degrees: |
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Instrumental Activities of daily living pg. 1157 |
instrumental in living: banking, preparing meals, shopping, etc. |
