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75 Cards in this Set

  • Front
  • Back
What is Mobility?
Communicates how body and self is performing at any given time
What are two types of Mobility?
1. Optimal mobility
2. Functional mobility
What are Body mechanics?
coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture and body alignment
What is alignment?
posture, positioning of the joints, tendons, ligaments and muscles while standing, sitting and lying
What is Balance?
individual's center of gravity is stable and body strain is minimal. no pain should be involved
What is Gravity and Friction?
Force is exerted on the body by gravity, nurses must overcome gravity when moving pts, pts, must overcome gravity when moving self, then also overcome pain, tubes, dressing etc.
Friction- force that occurs in a direction opposite movement
What is a Nursing Hint for Gravity and Friction?
Always think good side, bad side, let pts be mobile for selves when they can but work with their movements, progressive mobility. lift instead of pushing. use equipment aids when possible. Get help from other staff. Protect pt while protecting SELF
How Movement is Regulated?
1. Skeletal system
2. Muscular system
3. Nervous system
What are some Internal (Pathologic Influencers on Mobility?)
1. Postural Abnormalities
2. Impaired Muscle Development
3. Damage to the CNS
4. Direct Trauma to the Musculoskeletal system
Postural Abnormalities will?
limit ROM (Range of Motion)
What is Immobility?
inability to move about freely or anything that restricts movement
What is Bedrest?
intervention that restricts client to bed for therapeutic reasons.
What are Metabolic Changes associated with immobility?
decreases metabolic rate, alters the metabolism of food which can cause GI problems. and other problems with appetite. Negative nitrogen balance ( condition in which nitrogen output exceeds nitrogen intake, resulting in the body’s need to draw on its own stores of protein for energy).
What are some Respiratory Changes?
Atelectasis-collapse of alveoli, decreased oxygenation, decreased respiratory capacity
What are some Cardiovascular Changes?
orthostatic hypotension, drop of 20 mmHg or more in systolic BP and of 10 mmHg in diastolic BP when the client rises from a lying or sitting position because of workload and oxygen consumption, decrease venous return, leads to decreased BP
What is Thrombus?
Accumulation of platelets, fibrin, clotting factors, to the wall of a vein or artery
What are Musculoskeletal Changes associated with immobility?
permanent or temporary disability, muscle weakness, osteoporosis which places client at risk for fractures, joint contractures, foot drop
What are Urinary Elimination Changes?
urinary stasis, renal calculi, kidney stones, decreased urinary output
What are Integumentary Changes?
pressure ulcers, tissue ischemia, atrophy of muscle
What are Psychosocial Effects
emotional and behavioral, sensory, changes in coping, sleep-wake alterations
Nursing Process: Assessment
1. Mobility
2. Body Alignment
3. Physiological Assessment
4. Psychosocial Assessment
Assessing Mobility:
assess gait, ROM, exercise, activity, strength levels, head to toe
Nursing Diagnosis
Think ABC's
1.Airway, Breathing, Circulation
2.Impaired physical mobility
3. Risk for disuse syndrome
4. Activity intolerance
5. impaired skin integrity
6. disturbed sleep pattern
7. social isolation
Planning:
Goals should be related to restoring as much mobility as possible and preventing complications of immobility, measurable, realistic
Implementation
ROM, prevention, exercise, postitioning techniques, use of aid as needed, - think Head to Toe
Evaluation
of outcomes
A physiological risk associated with prolonged immobility is?
increased cardiac workload
A client has been on bed rest for several days. The client stands and the nurse notes that the client's systolic pressure drops 20 mm HG. This is referred to as
Orthostatic Hypotension
The purpose of elastic stockings after a surgical procedure is?
Facilitate the return of venous blood to the heart
The most important objective of bed rest for a client with bilateral pneumonia would be to?
Reduce the oxygen needs of the body
The client at greatest risk for developing adverse effects of immobility is a
`78-yr old man in traction for a broken hip

*reason so many elderly die of a broken hip
A client has been immobilized for 5 days because of extensive abdominal surgery. When getting this client out of bed for the first time a nursing diagnosis related to the safety of this client would be?
Risk for activity intolerance
heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of DVT. Common dosage for heparin therapy is
5000 U given SC 2 hrs b4 surgery and repeated every 8-12 hrs
This allows the client to pull the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair or to perform upper arm exercises
Trapeze Bar
The client in this position is lying face or chest down?
Prone
These activities are necessary to be independent in society and include such skills as shopping, preparing meals, banking and taking meds.
Instrumental Activites of Daily Living (IADLs)
Some effects of bed rest or immobilization on the cardiovascular system include?
orthostatic hypotension, increased cardiac workload, and thrombus formation
What would the nurse expect to find in a physical assessment of a pt after bed rest?
pts have an increased pulse rate, a decrease in pulse pressure, and an increase in fainting in response to a tilting or an erect posture. Orthostatic hypotension
What are TEDs?
Elastic stocking (thromboembolic device hose) they maintain external pressure on the muscles of the lower extremities and thus may promote venouse return
What would a nurse expect to find in the presence of an infectious process in a immobilized pt?
An increased basal metabolic rate as a result of fever or wound healing. Fever and repair of wounds increase cellular oxygen requirements. Bed rest helps to reduce their need for oxygen.
What can have a significant effect on the older adult's levels of health, independence, and functional status?
Immobility
What are symptoms of activity intolerance?
increased pulse, changes in BP, increased respirations, and decreased level of comfort. Can be caused by increased activity after bed rest. This can jeopardize the pt's safety
What are IADLs?
Instrumental activities of daily living are activities that are necessary to be independent in society beyond eating, grooming, transferring, and toileting, and include such skills as shopping, preparing meals banking and taking meds.
The 2 diagnoses most directly related to Mobility Problems
(textbook pg. 1443)
-Impaired physical mobility

-Risk for disuse syndrome
Nursing Diagnosis: Impaired physical mobility
Used for the client who has some limitation but is not completely immobile
Nursing Diagnosis: Risk for disuse syndrome
Should be considered for the client who IS immobile and at risk for multisystem pathophysiology because of inactivity
List of potential diagnoses related to immobility problems:
-Activity intolerance
-Ineffective airway clearance
-Ineffective breathing pattern
-Ineffective individual coping
-Risk for disuse syndrome
-Risk for deficient fluid volume
-Impaired gas exchange
-Risk for infection
-Risk for injury
-Impaired physical mobility
-Impaired skin integrity
-Impaired risk for skin integrity
-Disturbed sleep pattern
-Social isolation
-Ineffective (peripheral) tissue perfusion
-Impaired urinary elimination
Range-of-Motion Exercises for specific body parts:
(Textbk -Table 46-2- pp.1435-1439)
1- Neck, cervical spine
2- Shoulder
3- Elbow
4- Forearm
5- Wrist
6- Fingers
7- Thumb
8- Hip
9- Knee
10- Ankle
11- Foot
12- Toes
Neck, cervical spine
Flexion: bring chin to rest on chest
Extension: return head to erect position
Hyperextension: bend head back as far as possible
Lateral flexion: tilt head as far as possible toward each shoulder
Rotation: turn head as far as possible in circular movement
Shoulder
Flexion: raise arm from side position forward to position above head
Extension: return arm to position at side of body
Hyperextension: move arm behind body, keeping elbow straight
Abduction: raise arm to side to position above head with palm away from head
Adduction: lower arm sideways and across body as far as possible
Circumduction: move arm in full circle (this is a combination of all movements of ball-and-socket joint)
Elbow
Flexion: bend elbow so that lower arm moves toward its shoulder joint and hand is level with shoulder
Extension: straighten elbow by lowering hand
Forearm
Supination: Turn lower arm and hand so that palm is up
Pronation: Turn lower arm so that palm is down
Wrist
Flexion: move palm toward inner aspect of forearm
Extension: move fingers and hand posterior to midline
Hyperextension: bring dorsal surface of hand back as far as possible
Abduction (=radial deviation): bend wrist laterally toward fifth finger
Adduction (=ulnar deviation): bend wrist medially toward thumb
Fingers
Flexion: Make fist
Extension: straighten fingers
Hyperextension: bend fingers back as far as possible
Abduction: Spread fingers apart
Adduction: Bring fingers together
Thumb
Flexion: move thumb across palmar surface of hand
Extension: move thumb straight away from hand
Abduction: extend thumb laterally
Adduction: move thumb back toward hand
Opposition: Touch thumb to each finger of same hand
Hip
Flexion: move leg forward and up
Extension: move back beside other leg
Hyperextension: move leg behind body
Knee
Abduction: Move leg laterally away from body
Adduction: Move leg back toward medial position and beyond if possible
Internal rotation: turn foot and leg toward other leg
External rotation: Turn foot and leg away from other leg
Circumduction: Move leg in circle
Flexion: Bring heel back toward back of thigh
Extension: Return leg to floor
Ankle
Dorsal flexion: Move foot so that toes are pointed upward
Plantar flexion: Move foot so that toes are pointed downward
Foot
Inversion: Turn sole of foot medially
Eversion: Turn sole of foot laterally
Toes
Flexion: curl toes downward
Extension: Straighten toes
Abduction: Spread toes apart
Adduction: Bring toes together
What is a common and debilitating contracture?
Footdrop = foot is permanently fixed in plantar flexion (Client cannot dorsiflex the foot! Therefore, unable to lift toes off the ground.) Susceptible clients are those who suffered CVAs or brain attacks with resulting left- or right-sided paralysis (hemiplegia)
Postural Abnormalities
(Text, pg.1426, Table 46-1)
1. Torticollis
2. Lordosis
3. Kyphosis
4. Kypholordosis
5. Scoliosis
6. Kyphoscoliosis
7. Congenital hip dysplasia
8. Knock-knee (genu valgum)
9. Bowlegs (genu varum)
10. Clubfoot
11. Footdrop
12. Pigeon-toes
Torticollis
Inclining of head to affected side, in which sternocleidomastoid muscle is contracted
Lordosis
Exaggeration of anterior convex curve of lumbar spine (e.g. pregnancy)
Kyphosis
Increased convexity in curvature of thoracic spine (e.g. "humpback")
Scoliosis
Lateral "s" curvature of spine, unequal heights of hips and shoulders
Congenital hip dysplasia
Hip instability with limited abduction of hips and, occasionally, adduction contractures (head of femur does not articulate with acetabulum because of abnormal shallowness of acetabulum). e.g. on examination of infants, knees are uneven.
Knock-knee (genu valgum)
Legs curved inward so that knees come together as person walks
Bowlegs (genu varum)
One or both legs bent outward at knee, which is normal until 2 to 3 years of age.
Clubfoot
95%: medial deviation and plantar flexion of foot (equinovarus)
5%: lateral deviation and dorsiflexion (calcaneovalgus)
Footdrop
Inabiliity to dorsiflex and invert foot because of peroneal nerve damage
Pigeon-toes
Internal rotation of forefoot or entire foot, common in infants
Implementation-
Textbook, pg.1455 "Developmental Changes" - For an Immobilized child:
Interventions-
Provide mental and physical stimulation (i.e. play activities: completing puzzles and reading); encourage parents to stay with hospitalized child; should place immobilized child with same age children who are not immobilized, unless there is a contagious disease; have child participate in their own dressing changes, cast care, care of traction.
Implementation-
Textbook, pg.1455 "Developmental Changes" - For an immobilized Older Adult:
Interventions-
Maintaining a calendar and clock with a large dial; conversing about current events and family members; encouraging visits from significant others; and spending time in the room talking and listening to client may reduce risk of social isolation.

-Encourage older client to perform as many ADLs (activities of daily living) as independently as possible; clients should continue to perform personal grooming if they did so before mobility became restricted = gives clients dignity and sense of accompishment.
Negative Nitrogen Balance
When more nitrogen (the end product of amino acid breakdown) is excreted than is ingested in proteins, the body is said to have a negative nitrogen balance.
Weight loss, decreased muscle mass, and weakness result from tissue catabolism; body starts attacking itself