Nursing 120 - Test 3- Olol -Mobility/immobility

Front 1

What is Mobility?

Back 1

Communicates how body and self is performing at any given time

Front 2

What are two types of Mobility?

Back 2

1. Optimal mobility
2. Functional mobility

Front 3

What are Body mechanics?

Back 3

coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture and body alignment

Front 4

What is alignment?

Back 4

posture, positioning of the joints, tendons, ligaments and muscles while standing, sitting and lying

Front 5

What is Balance?

Back 5

individual's center of gravity is stable and body strain is minimal. no pain should be involved

Front 6

What is Gravity and Friction?

Back 6

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

Front 7

What is a Nursing Hint for Gravity and Friction?

Back 7

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

Front 8

How Movement is Regulated?

Back 8

1. Skeletal system
2. Muscular system
3. Nervous system

Front 9

What are some Internal (Pathologic Influencers on Mobility?)

Back 9

1. Postural Abnormalities
2. Impaired Muscle Development
3. Damage to the CNS
4. Direct Trauma to the Musculoskeletal system

Front 10

Postural Abnormalities will?

Back 10

limit ROM (Range of Motion)

Front 11

What is Immobility?

Back 11

inability to move about freely or anything that restricts movement

Front 12

What is Bedrest?

Back 12

intervention that restricts client to bed for therapeutic reasons.

Front 13

What are Metabolic Changes associated with immobility?

Back 13

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).

Front 14

What are some Respiratory Changes?

Back 14

Atelectasis-collapse of alveoli, decreased oxygenation, decreased respiratory capacity

Front 15

What are some Cardiovascular Changes?

Back 15

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

Front 16

What is Thrombus?

Back 16

Accumulation of platelets, fibrin, clotting factors, to the wall of a vein or artery

Front 17

What are Musculoskeletal Changes associated with immobility?

Back 17

permanent or temporary disability, muscle weakness, osteoporosis which places client at risk for fractures, joint contractures, foot drop

Front 18

What are Urinary Elimination Changes?

Back 18

urinary stasis, renal calculi, kidney stones, decreased urinary output

Front 19

What are Integumentary Changes?

Back 19

pressure ulcers, tissue ischemia, atrophy of muscle

Front 20

What are Psychosocial Effects

Back 20

emotional and behavioral, sensory, changes in coping, sleep-wake alterations

Front 21

Nursing Process: Assessment

Back 21

1. Mobility
2. Body Alignment
3. Physiological Assessment
4. Psychosocial Assessment

Front 22

Assessing Mobility:

Back 22

assess gait, ROM, exercise, activity, strength levels, head to toe

Front 23

Nursing Diagnosis

Back 23

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

Front 24

Planning:

Back 24

Goals should be related to restoring as much mobility as possible and preventing complications of immobility, measurable, realistic

Front 25

Implementation

Back 25

ROM, prevention, exercise, postitioning techniques, use of aid as needed, - think Head to Toe

Front 26

Evaluation

Back 26

of outcomes

Front 27

A physiological risk associated with prolonged immobility is?

Back 27

increased cardiac workload

Front 28

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

Back 28

Orthostatic Hypotension

Front 29

The purpose of elastic stockings after a surgical procedure is?

Back 29

Facilitate the return of venous blood to the heart

Front 30

The most important objective of bed rest for a client with bilateral pneumonia would be to?

Back 30

Reduce the oxygen needs of the body

Front 31

The client at greatest risk for developing adverse effects of immobility is a

Back 31

`78-yr old man in traction for a broken hip

*reason so many elderly die of a broken hip

Front 32

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?

Back 32

Risk for activity intolerance

Front 33

heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of DVT. Common dosage for heparin therapy is

Back 33

5000 U given SC 2 hrs b4 surgery and repeated every 8-12 hrs

Front 34

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

Back 34

Trapeze Bar

Front 35

The client in this position is lying face or chest down?

Back 35

Prone

Front 36

These activities are necessary to be independent in society and include such skills as shopping, preparing meals, banking and taking meds.

Back 36

Instrumental Activites of Daily Living (IADLs)

Front 37

Some effects of bed rest or immobilization on the cardiovascular system include?

Back 37

orthostatic hypotension, increased cardiac workload, and thrombus formation

Front 38

What would the nurse expect to find in a physical assessment of a pt after bed rest?

Back 38

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

Front 39

What are TEDs?

Back 39

Elastic stocking (thromboembolic device hose) they maintain external pressure on the muscles of the lower extremities and thus may promote venouse return

Front 40

What would a nurse expect to find in the presence of an infectious process in a immobilized pt?

Back 40

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.

Front 41

What can have a significant effect on the older adult's levels of health, independence, and functional status?

Back 41

Immobility

Front 42

What are symptoms of activity intolerance?

Back 42

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

Front 43

What are IADLs?

Back 43

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.

Front 44

The 2 diagnoses most directly related to Mobility Problems
(textbook pg. 1443)

Back 44

-Impaired physical mobility

-Risk for disuse syndrome

Front 45

Nursing Diagnosis: Impaired physical mobility

Back 45

Used for the client who has some limitation but is not completely immobile

Front 46

Nursing Diagnosis: Risk for disuse syndrome

Back 46

Should be considered for the client who IS immobile and at risk for multisystem pathophysiology because of inactivity

Front 47

List of potential diagnoses related to immobility problems:

Back 47

-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

Front 48

Range-of-Motion Exercises for specific body parts:
(Textbk -Table 46-2- pp.1435-1439)

Back 48

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

Front 49

Neck, cervical spine

Back 49

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

Front 50

Shoulder

Back 50

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)

Front 51

Elbow

Back 51

Flexion: bend elbow so that lower arm moves toward its shoulder joint and hand is level with shoulder
Extension: straighten elbow by lowering hand

Front 52

Forearm

Back 52

Supination: Turn lower arm and hand so that palm is up
Pronation: Turn lower arm so that palm is down

Front 53

Wrist

Back 53

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

Front 54

Fingers

Back 54

Flexion: Make fist
Extension: straighten fingers
Hyperextension: bend fingers back as far as possible
Abduction: Spread fingers apart
Adduction: Bring fingers together

Front 55

Thumb

Back 55

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

Front 56

Hip

Back 56

Flexion: move leg forward and up
Extension: move back beside other leg
Hyperextension: move leg behind body

Front 57

Knee

Back 57

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

Front 58

Ankle

Back 58

Dorsal flexion: Move foot so that toes are pointed upward
Plantar flexion: Move foot so that toes are pointed downward

Front 59

Foot

Back 59

Inversion: Turn sole of foot medially
Eversion: Turn sole of foot laterally

Front 60

Toes

Back 60

Flexion: curl toes downward
Extension: Straighten toes
Abduction: Spread toes apart
Adduction: Bring toes together

Front 61

What is a common and debilitating contracture?

Back 61

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)

Front 62

Postural Abnormalities
(Text, pg.1426, Table 46-1)

Back 62

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

Front 63

Torticollis

Back 63

Inclining of head to affected side, in which sternocleidomastoid muscle is contracted

Front 64

Lordosis

Back 64

Exaggeration of anterior convex curve of lumbar spine (e.g. pregnancy)

Front 65

Kyphosis

Back 65

Increased convexity in curvature of thoracic spine (e.g. "humpback")

Front 66

Scoliosis

Back 66

Lateral "s" curvature of spine, unequal heights of hips and shoulders

Front 67

Congenital hip dysplasia

Back 67

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.

Front 68

Knock-knee (genu valgum)

Back 68

Legs curved inward so that knees come together as person walks

Front 69

Bowlegs (genu varum)

Back 69

One or both legs bent outward at knee, which is normal until 2 to 3 years of age.

Front 70

Clubfoot

Back 70

95%: medial deviation and plantar flexion of foot (equinovarus)
5%: lateral deviation and dorsiflexion (calcaneovalgus)

Front 71

Footdrop

Back 71

Inabiliity to dorsiflex and invert foot because of peroneal nerve damage

Front 72

Pigeon-toes

Back 72

Internal rotation of forefoot or entire foot, common in infants

Front 73

Implementation-
Textbook, pg.1455 "Developmental Changes" - For an Immobilized child:

Back 73

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.

Front 74

Implementation-
Textbook, pg.1455 "Developmental Changes" - For an immobilized Older Adult:

Back 74

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.

Front 75

Negative Nitrogen Balance

Back 75

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