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_____ is freedom and independence in purposeful movement and refers to adapting to and having self-awareness of the environment.

answer

Mobility

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_____ is the inability to move freely and independently at will.

answer

Immobility

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_____ _____ are designed to maintain mobility and prevent or minimize complications of immobility.

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Nursing interventions

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Cutaneous stimulation in the form of ______ and ______ applications helps relieve pain and promote healing.

answer

cold / heat

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Promoting _____ _____ is another key component of reducing the complications of immobility.

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venous return

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Immobility time frames/examples

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Temporary - knee arthroplasty Permanent - paraplegia Sudden onset - fractured arm Slow onset - multiple sclerosis

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The principles of body mechanics are based on:

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alignment balance gravity friction

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Movement depends on:

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Intact skeletal system Skeletal muscles Nervous system

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Assessment of the client focuses on:

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mobility range of motion (ROM) gait exercise status activity tolerance body alignment

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Factors affecting mobility include:

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Alterations in muscles Injury to the musculoskeletal system Abnormal posture Impaired central nervous system Health status and age

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Body systems that can be affected by immobility: See ATI Fundamentals pp400-401 for examples

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Integumentary Respiratory Cardiovascular Metabolic Elimination Musculoskeletal Neurological/Psychosocial Developmental

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Nursing Interventions Integumentary

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Maintain intact skin

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Nursing Interventions Respiratory

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Maintain airway patency, achieve optimal lung expansion and gas exchange, and mobilize airway secretions.

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Nursing Interventions Cardiovascular

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Maintain cardiovascular function, increase activity tolerance, and prevent thrombus formation.

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Nursing Interventions Metabolic

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Reduce skin injury and maintain metabolism.

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Nursing Interventions Elimination

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Maintain or achieve normal urinary and bowel elimination patterns.

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Nursing Interventions Musculoskeletal

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Maintain or regain body alignment and stability, decrease skin and musculoskeletal system changes, achieve full or optimal ROM, and prevent contractures.

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Nursing Interventions Psychosocial

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Maintain an acceptable sleep/wake pattern, achieve socialization, and complete self-care independently.

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Nursing Interventions Developmental

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Continue expected development and achieve physical and mental stimulation.

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Therapeutic effects of heat:

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Increases blood flow Increases tissue metabolism Relaxes muscles Eases joint stiffness and pain

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Therapeutic effects of cold:

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Decreases inflammation Prevents swelling Reduces bleeding Reduces fever Diminishes muscle spasms Decreases pain by decreasing the velocity of nerve conduction

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Clients at risk for injury from heat/cold applications:

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Very young, fair-skinned, and older clients have fragile skin. Immobile clients cannot move away from uncomfortable treatments. Clients with impaired sensory perception may not feel pain/burning. Do not over use treatments or response might be opposite.

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Heat treatment contraindications:

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Bony prominences are more sensitive to heat. Avoid heat applications over metal devices (ex. pacemakers). Do not apply to abdomen of pregnant women. Do not use under an immobile client due to burn risk.

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Cold applications are inappropriate for clients with:

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cold intolerance vascular insufficiency cold aggravated conditions like Reynaud's

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Make sure heat and cold application orders include:

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Location Duration and frequency Specific type (moist or dry) Temperature

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Types of MOIST HEAT applications:

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Hot compresses Hot soaks Sitz baths

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Types of DRY HEAT applications:

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Hot pack Warming blanket

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Types of MOIST COLD applications:

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Large basin of ice Cold water Cold pack to be used in place of ice

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Types of DRY COLD applications:

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Ice bag, Ice collar, ice glove, or a cold pack Cooling blanket

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Assess heat and cold treatment sites every _____ to _____ minutes

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5 to 10

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Symptoms to check for with heat or cold treatments:

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Redness or pallor Pain or burning Numbness Shivering (with cold application) Blisters Decreased sensation Cyanosis (with cold application)

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Most heat or cold applications are used from _____ to _____ minutes.

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15 to 20

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Documentation Heat & Cold Application

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Location, type, length of application Condition of skin before and after Client's ability to tolerate treatment

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TED

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thromboembolic device

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Elastic stockings, or TED's, help maintain external pressure on the _____ of the lower extremities and promote blood return to the heart.

answer

muscles

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SCD

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Sequential compression devices

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IPC

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Intermittent pneumatic compression

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TED's, SCD and IPC help promote _____ _____.

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venous return They require a provider's order.

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ROM exercises promote blood return and can include:

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ankle pumps foot circles knee flexion

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Immobile clients should perform leg exercises, increase their ______ ______, and change positions frequently.

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fluid intake These can all be implemented without a provider's order.

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True or False? When poor venous return or possible thrombus is suspected, the provider must be notified and no pressure applied to a thrombus to avoid dislodging it.

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True

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Remove compression stockings and reapply them at least _____ a day.

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twice

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To reduce compression of leg veins, teach clients to avoid:

answer

crossing the legs sitting for long periods of time wearing restrictive clothing on lower extremities putting pillows behind the knees massaging the legs

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When promoting venous return, ROM exercises are performed _____ while the client is awake.

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hourly

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Thrombophlebitis/deep vein thrombosis is an inflammation of a vein (usually in a lower extremity) that results in _____ formation.

answer

clot

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DVT

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deep vein thrombosis

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Clinical manifestations are:

answer

pain edema warmth erythema

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Nursing actions: DVT's

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Notify provider immediately Position client in bed with leg elevated Avoid pressure at site of inflammation Anticipate giving anticoagulants as prescribed

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A _____ _____ is the occlusion of blood flow to one or more of the pulmonary arteries by a clot.

answer

pulmonary embolism can be life threatening often originates in venous system of lower extremities

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Clinical manifestations of pulmonary embolisms:

answer

shortness of breath chest pain hematemesis decreased blood pressure rapid pulse

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Nursing actions: Pulmonary Embolisms

answer

Prepare to give thrombolytics or anticoagulants as prescribed.

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To help maintain a patent airway in a client on bed rest, you should teach the client to use an _____ _____ while awake.

answer

incentive spirometer

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To reduce the risk of thrombus development:

answer

apply elastic stockings assist the client to change position often

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The proper order to apply elastic stockings:

answer

Perform hand hygiene Assess condition of skin and circulation of legs Measure to select correct stocking size Turn stockings inside to the heal Put stocking on client's foot Pull stocking over heel and on up leg Smooth any creases or wrinkles

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Valsalva maneuver

answer

A maneuver in which a person tries to exhale forcibly with a closed glottis (windpipe) so that no air exits through the mouth or nose as, for example in lifting a heavy weight; The Valsalva maneuver impedes the return of venous blood to the heart

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contracture

answer

A shortening of muscles due to lack of use. Fibrosis of connective tissue that prevents normal movement of a muscle or joint.

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Raynaud's phenomenon

answer

Periodic ischemic attacks affecting the extremities of the body, especially the fingers, toes, ears, and nose. The affected extremities become cyanotic and very painful. These attacks are brought on by arterial constriction due to extreme cold or emotional stress. -> Do not use cold application Also increase workload to heart

ATI Chap. 40 Mobility and Immobility – Flashcards

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