Mobility can be defined as
A person's ability to move around free in his or her environment. It serves many purposes. Bed rest is an intervention in which the client is restricted to bed for therapeutic reasons.
Patient mobility care
To reduce the risk of injury to the client or yourself, you must know and practice proper body mechanics.
Body Mechanics
Coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment used during lifting, bending, moving, and performing activities of daily living. Balance is achieved when a relatively low center of gravity is
Principles of Body Mechanics
Equilibrium maintained as long as center of gravity aligns with base of support Facing direction of movement prevents abnormal twisting of the spine Balanced use of arms & legs reduced risk of back injury. Leverage, rolling. Turning & pivoting requires le
Debridement can be defined as
Removal of dead necotic tissue from a wound.
Dehiscence can be defined as
An unintentional opening of a wound.
Evisceration can be defined as
Bursting open of a suture line with protrusion of organs.
Orthostatic intolerance is also known as
Postural hypotension, a drop in blood pressure caused by change in position that may be accompanied by dizziness or vertigo; the client should change positions slowly.
Primary intention is
Healing of a wound without infection or scarring; wound edges are well approximated.
Purulent exudate is
Wound drainage containing pus.
A client uses a cane to assist with ambulation. After teaching the client how to use a cane, the client makes the following statements. Which one indicates to the nurse the need for additional teaching?
I should hold the cane on my weaker side.
A patient with a long history of arthritis complains of sensitivity and warmth in the knees. To determine the degree of limitation, the nurse should assess
Range of joint motion.
You must know and practice proper body mechanics.
By reduce the risk of injury to the client or yourself.
Facing direction of movement prevents
Abnormal twisting of the spine
Using proper body mechanics
Balanced use of arms & legs reduced risk of back injury
Leverage, rolling. Turning & pivoting requires less work than lifting
Less friction = less force needed to move object
Alternating period of rest & activity helps to reduce fatigue and injury.
Individuals who fail to maintain a balance within their center of gravity are.
Unsteady and at risk for injury or falls
When an object is lifted, the lifter must:
Overcome the object's weight and be aware of its center of gravity.
Back injuries, Shearing forces, Rest and activity for you and patient sitting in chair may be exhausting
Bend at knees stay in alignment watch center of gravity to prevent.
The Nervous System
Regulation of movement and posture, Requires neurotransmitter production, transmission of impulses from nerve to muscle and activation of muscle activity.
Pathological Influences on Mobility
Congenital defects, Disorder of bones, joints and muscles, CNS damage, Musculoskeletal trauma.
The effects of immobility
Physiological effects, Respiratory changes, Changes in metabolic rate, Changes in metabolism of carbohydrates, fats, and proteins, Fluid and electrolyte balances, Gastrointestinal changes.
When the patient is immobile
The body often excretes more nitrogen than it ingests protein, which causes a negative nitrogen balance leading to weight loss, decreased muscle mass, and weakness resulting from tissue breakdown (catabolism).
Lack of movement and exercise places patients
At higher risk for respiratory complications, for developing pulmonary complications, like atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions.
Muscle weakness and atrophy are common results of
Prolonged immobilization.
A pressure ulcer is an impairment of the skin that results from
Prolonged ischemia (decreased blood supply) in tissues
The ulcer is characterized initially by inflammation and usually forms
Forms over a bony prominence
The older adult is especially at risk. For example, an older adult who is immobilized on a backboard following a trauma can develop skin breakdown within.
3 hours
Immobilization changes the patient's daily routine
And the patient has more time to worry about disability.
Withdrawn patients often do not
Want to participate in their own care.
Psychosocial Effects
Emotional and behavioral responses (hostility, fear, anxiety) sensory alterations (Altered sleep pattersn) , and changes in coping (Depression, sadness, dejection.
Developmental stages influence body alignment and mobility; the greatest impact of physiological changes on the musculoskeletal system is observed in.
Children and older adults
Why are older adults experience mobility problems?
Because decreased physical activity, hormonal changes, bone reabsorption.
Why are infants & toddlers experience mobility problems?
Prolonged immobility delays gross motor skills, intellectual development, or musculoskeletal development.
Assessment of mobility
Range of joint motion, Gait, activity tolerance, body alignment, pain association with activity.
Nursing interventions for the completely or partially immobilized client focus on
Health promotion and prevention of the hazards of immobility.
Nursing Interventions and Health Promotion focus on
Musculoskeletal system, Skin integrity, Elimination system, Psychosocial problems, Developmental changes.
Health promotion for a person that is immobile and the benefits would be
Structured exercise programs for immobile clients can enhance their feelings of well-being, as well as their endurance, strength, and health.
Nursing Interventions in Acute Care
Respiratory system, Maintaining a patent airway, Cardiovascular system.
Lifting Techniques consist of
Tighten stomach muscles, tuck pelvis
Bend at the knees
Keep weight lifted close to the body
Maintain trunk erect and knees bent
Avoid twisting
Maintain a center of gravity.
Therapeutic Positioning for clients with
Impaired nervous or musculoskeletal system functioning; increased weakness, or restricted to bed rest benefit from therapeutic positioning.
Repositioning Clients should be repositioned as needed and
At least every 2 hours if they are in bed and every 20 to 30 minutes if they are sitting in a chair.
When positioning
Support pressure areas.
Devices Used for Positioning
Foot boots/splints, washcloth rolls, trochanter rolls, trapeze bar.
The easiest intervention to maintain or improve joint mobility for clients is the use of range-of-motion exercises.
Range-of-Motion Exercises
Active range-of-motion exercises are when
The client is able to move his or her joints
Passive range-of-motion exercises are when
The nurse moves the client's joints
When assisting clients with ambulation and the client has hemiplegia/hemiparesis you must use
Gait belts & Support affected side
When assisting with ambulation and the client is feeling dizzy or faint you must
Return to closet bed or chair. Or gently lower client to floor to prevent injury if necessary.
The nurse gathers information regarding the patient's ability to stand, sit, and lie down, as well as degree of mobility, ROM, gait, ability to exercise and activity tolerance.
Assessment
In the nursing process NANDA has approved list regarding mobility so the nurse come up with proper
Nurse Diagnosis
The nurse tailors a plan of care to the patient's specific needs
Planning goals and outcomes
The nurse provides health promotion, restorative/continuing care, or restoration of activity this part of the nursing process is called
Implementation
Health promotion may focus on
Body mechanics, range of joint motion (ROJM), maintenance of the musculoskeletal system, joint mobility, and walking.
Restorative care and continuing care may focus on
the use of assistive devices for walking (canes, crutches)
Restoring of activity and coping with chronic illness may require
That you specifically address issues surrounding activity and coronary heart disease, hypertension, chronic obstructive pulmonary disease, and diabetes mellitus.
You will always evaluate whether the patient has
met goals/outcomes and adjust nursing interventions as necessary.
Mr. Indelicato will attain a tolerable level of pain during ambulation. The outcome will be
Mr. Indelicato's pain will be a 2 to 3 on a scale of 0 to 10 during ambulation
Mr. Indelicato will gain optimal functioning of the right knee with independent, purposeful movement. The outcome will be
Mr. Indelicato will ambulate 50 to 75 feet with the aid of a walker without reports of increasing fatigue.
Mr. Indelicato will gain a minimum of 90-degree flexion in the right knee by the time of discharge.
Mr. Indelicato will demonstrate proper use of a walker while ambulating. The outcome will be
Mr. Indelicato will perform a return demonstration of proper use of a walker.
If a patient begins to faint and fall, follow these steps to ensure that you both have a less traumatic fall:
A, Stand with feet apart to provide a broad base of support.
B, Extend one leg and let patient slide against it to the floor. (Notice the nurse putting one foot back.)
C, Bend knees to lower the body as the patient slides to the floor.
Marilyn wants to help Mr. Indelicato with ambulation and strength training. To implement her plan of care, she:
Encourages Mr. Indelicato to use PCA pump before ambulation
Explains why he should sit in bed and dangle his legs before standing to ambulate
Establishes realistic increments for Mr. Indelicato to increase walking distance during ambulation
Talks with him
Peak actions of analgesic will occur as
The patient begins activity
Allowing the patient to dangle before changing position prevents
orthostatic hypotension, maintains safety, and prevents injury to the patient.
Gradually increasing physical activity and setting realistic goals for ambulation encourages.
Activity in older adults
The presence of symptoms such as breathlessness, rapid pulse, pallor, or light-headedness indicates .
The need for the patient to stop activity.
Principles of transfer and positioning techniques always remember
When moving pt's the knowledge of safety transfer & positioning in crucial. Pathological influences on body alignment & mobility. (Congenital defects, disorders of bones, joints, and muscles, CNS damage & musculoskeletal trauma.
Teaching a patient's family to transfer the patient from bed to chair increased and reinforces
The family's knowledge about proper transfer and position techniques.
Congenital abnormalities affect the efficiency of the musculoskeletal system with regards to three main things:
Alignment, balance and apearance
Osteogenesis imperfecta, Scoliosis are example of
Congenital defects
Osteoporosis is a aging disorder, resulting in reduction of bone density or mass the cause can be from
Uncertainty, but theories vary from hormonal imbalance to insufficient intake of nutrients.
Ostemalacia is a metabolic disease characterized by?
Inadequate and delayed mineralization, resulting in compact and spongy bone.
In elderly their joint mobility may be limited due to
Inflammatory & non-inflammatory joint disease & articular disruption like arthritis (joint degeneration)
As part of the teaching process, Marilyn consults with a physical therapist on proper use of the walker. She and the physical therapist instruct the patient and family caregivers on the proper use of a walker, and Marilyn provides written material that re
Making sure that the patient uses the walker correctly to ensure safe use of the assistive device. & Providing instruction in a quiet environment and giving written instruction in large easy-to-ready print enhances learning for the older adult.
Ensure patient safety is essential as a nurse. To ensure patient safety it is important to
Communicate clearly, mentally review transfer steps, Assess pt's mobility & strength, determine assistance needed. Raise side rail on opposite side of bed, arrange equipment, evaluate body alignment, understand equipment & educate patient.
When a patient is immobile, the focus is not only on ADLs but also on
IADL's instrumental activities of daily living
When a patient is immobile the goal for the patient is to
Maximize functional deficits such as impaired gait & decreased endurance with restorative and continuing care.
Types of assistive devices for walking
Walkers, cane, crutches
Persons cane should be
Length equal to the distance b/w the greater trochanter & floor
Patient should keep the cane on which side
The stronger side
Crutches are needed to increase
Mobility, measuring crutches, crutch gait & sitting in a chair with crutches teaching
A goniometer verifies
The correct degree of elbow flexion for crutch use.
When measuring for crutches should be 15cm distance from
Crutches pads and axilla, a tripod position is a basic crutch stance
Four-point alternating gait the feet
Should be solid and crutch tips show order of foot & crutch tip movement in each of the four phases.
Three-point gait is when
Weight borne on unaffected leg. The solid foot & crutch tip show weight bearing in each phase.
Two-point gait
With weight borne partially on each foot & each crutch advancing with opposing leg. Solid areas indicate leg & crutch tips bearing weight.
Ascending stairs consist of a nurse helping patient to
Walk up & down the stairs using crutches. With weight placed on crutch, then transferred from crutches to unaffected leg on stair, then crutches are aligned with unaffected leg on stairs.
Descending Stairs consists of the nurse helping a patient to
Have body weight on unaffected leg, body weight is transferred to crutches. Unaffected leg is aligned on stairs with crutches.
When sitting in a chair with crutches the nurse teaches the patient
Both crutches are held in one hand. Patient transfers weight to crutches & unaffected leg. Patient grasps arm of chair with free hand & begins to lower themselves into the chair. The patient completely lowers herself into chair.
The nurse evaluates how effective her plan of care has been. She asks the patient to rate the level of pain on a scale fom 0-10, observes his ROM and use of CPM (continuous passive motion ) machine, and observes his ambulation with a walker. The patient r
The patient pain is under control & he is able to ambulate with minimal discomfort. He expresses an understanding for the need for ROM and the continuous passive motion (CPM) machine. He can demonstrate correct use of his walker.
A patient with a long history of arthritis complains of sensitivity and warmth in the knees. To determine the degree of limitation, the nurse should assess.
Range of joint motion
The patient has been in the nurses care for 5 weeks and has been progressing steadily to increase both weight bearing & range of joint motion on the affected knee. Patient still has been from when he was in the hospital, but he never followed up with PT.
After pain control measures were implemented, the patient reports that his pain was almost gone, and that he was working on increasing strength so he could return to sports. He says he will likely give up racquetball & tennis
Manually lifting and transferring patients contributes
To the high incidence of work related musculoskeletal problems & back injuries in nurses and other healthcare staff.
Nurse knowledge base on safe patient handling
Ergonomic assessment protocol, patient assessment criteria, algorithm for pt handling and movement, special equipment, back injury resource nurses, "after-action review", no-lift policy.
Patient movement algorithms serve as
An assessment tools & guide safe patient handling and movement.
Appropriate friction-reducing assistive devices & mechanical liefts need to be used for
Patient transfers when applicable
No-life policies benefit
All members of the healthcare system: patients, nurse and administration.
Using findings from evidence-based nursing research about safe patient handling to
Prevent injuries to nurses and patients when moving and transferring.
Immobility
Inability to move about freely
Bed rest
An intervention that restricts patients for therapeutic reasons.
Systemic effects on metabolically due to immobility
Endocrine, calcium absorption, and GI function.
Systemic effects cardiovascular
Orthostatic hypotension, thrombus
Muscle effect due to immobility
Loss of muscle mass, muscle atrophy
Urinary effects due to immobility
Urinary stasis, renal calculi
Respiratory effects due to immobility
Atelectasis and hypostatic pneumonia.
Musculoskeletal changes due to immobility
Loss of endurance and muscle mass decreased stability and balance.
Skeletal effects due to immobility
Impaired calcium absorption & joint abnormalities
Integumentary effects due to immobility
Pressure ulcers and ischemia.
The longer the patient is immobile
The greater and more pronounced the consequences of immobility will be.
Prolonged bed rest increases
The heart's workload, producing an increase in oxygen demand.
Immobility can lead to
Joint contracture, which is characterized by abnormal fixation of a joint.
Immobility presents hazards in the
Physiological, psychological, and developmental dimensions.
the risk for disabilities related to immobilization depends on the
Extent and duration of immobilization and the patient's overall level of health.
You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with
Atelectasis
SCD's abbreviation for
Sequential compression devices
Sequential compression devices (SCD's) can be delegated to
NAP, but the nurse is responsible for assessing circulation in the extremities. Instruct NAP to notify nurse if pt complains of pain in leg or discoloration.
SCD insufflator with air hoses attachment or Velcro compression stockings/SCD sleeve, hygiene supplies.
Assess patient for the need for sequential compression stocking, perform hand hygiene. Obtain baseline assessment date about status of circulation, pulse, skins integrity of pts lower extremities before initiating sequential compression stockings.
Should identify patient using two identifiers
Name & DOB, or Name & account #, ask patient to state name & DOB
Before apply antiembolitic elastic stockings be sure there is no
Leg pain or swelling or has any skin irritation. elevate legs while sitting and before applying stockings to improve venous returns, not to massage the leg & avoid wrinkles in stockings.
After completing preoperative teaching for a surgical patient, you can evaluate the patient's understanding of the use of elastic stockings when the patient states.
I can remove them for 30min every 8 hrs.
A trochanter roll
Prevents external rotation of the hips when pt is in a supine position
Trapexe bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bed frame. it is used to
It allows the patient to pull with the upper extremities to raise the trunk off the bed, assist in transfer from bed to wheelchair, or perform upper arm exercises.
Transferring patient from bed to stretcher you must.
Determine patient's ability to assist, communicate actions to patient, Use appropriate resources.
Implementation for mobility consist of
Restorative & continuing care, IADL's, ROM exercise, walking.