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posture, spinal position

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What is body alignment (page 1122)

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when your body is in alignment

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what is balance?

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Proper alignment Wide base of support Avoid bending and twisting Squat to lift Keep objects close when lifting Raise beds Push vs. lift Get help

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What are principles of body mechanics?

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Lifespan Nutrition Lifestyle Stress Environmental factors Diseases & Abnormalities e

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what factors effect mobility?

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bone

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fracture

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stretch injury of a ligament

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sprain

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injury to muscle caused by excessive stress on the muscle

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strain

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when the joint won't go through full range anymore; limited

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what is a joint contracture?

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Muscles and bones lungs Heart and vessels Metabolism Integumentary system Gastrointestinal system Genitourinary system Psychological

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What are complications of immobility?

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Improve or maintain mobility Prevent complications Goals- measureable, specific, time specific

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Goal or outcome associated with immobility?

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Promote exercise Injury prevention from exercise Positioning Moving patients in bed Transferring patients out of bed ROM exercises Ambulation

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Interventions nurses can take

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Positioning Healthy diet Prevent orthostatic hypotension Turn every 2 hours

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Interventions for patients on bedrest

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Change position every 2 hours Firm mattress Clean, dry bed linens Use proper body mechanics Plan the move Avoid manual lift- use assistive devices

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Things pertaining to positioning

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decreases pressure on diaphragm for proper lung expansion

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fowlers position

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laying on side, recumbant-legs straight, oblique-knees flexed

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lateral position

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stomach

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prone position

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left side(raised arm, right leg up and over) , almost prone good for enemas, exposes buttox area

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sims position

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laying flat on your back

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supine position

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Boards Mechanical lifts Transfer belt

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Things used to transfer patients

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3-5x a session a minimum of twice a day

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how often should you perform ROM?

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The stronger side. Go forward with assistive device and weaker or injured leg or side, strong leg then follows through

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if patient is using a cane, which side should the cain be on?

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wide base of support, one leg out, let them slide down and gently slide down with themyou aren't preventing it or breaking their fall

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How do you assist someone to the floor

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High protein- high calorie diet Vitamin B & C Monitor dietary intake at each meal

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metabolic nursing interventions

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Deep breath and cough q 1-2 h Incentive spirometer Minimal fluid intake 1100-1400 mL/day for adults *if not contraindicated

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respiratory nursing interventions

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Body alignment Balance Coordination Joint Mobility Active range of motion (AROM) Passive range of motion (PROM)

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Body Mechanics

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Activity Intolerance Impaired physical mobility Impaired bed mobility Impaired walking Impaired transfer ability Risk for disuse syndrome Sedentary lifestyle

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NANDA Nursing Diagnosis

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Explain purpose Observe patient Support limb Move joint slow, smooth, rhythmic Never force joint Perform PROM BID (3-5 times each session) Return joint to neutral position Encourage AROM

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ROM Exercises

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Reduce orthostatic hypotension Early movement- dangle at bedside or up to chair Avoid straining with BM or moving up in bed- breath out

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Cardiovascular Interventions

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Identify clients at risk ROM exercises Leg, ankle, foot exercises TED hose SCDs Proper and timely administration of anticoagulant medication (Heparin, Lovenox)

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DVT Protocol Intervention

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ROM- active or passive, 2-3 times daily CPM therapy for orthopedic conditions

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Musculoskeletal Interventions

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Reposition q 1-2 h Teach clients to shift weight q 15 minutes; especially sitting in chair Pressure relieving devices

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Integumentary Interventions

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Hydration- 1100-1400 mL fluid/day Toileting routine Monitor bowel movement- frequency and consistency Diet: fruits, vege, fiber

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Elimination Interventions

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Monitor for depression or mood swings Socialization- visitors Daily newspaper Therapeutic communication throughout shift Involve client in care routine- ADL

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Psychosocial Interventions

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usual activity, fitness goals, mobility concerns, underlying health concerns, lifestyle, and external factors.

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A nursing history focused on activity and exercise assesses:

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vital signs, height, weight, body mass index, body alignment, joint function, gait, and activity tolerance.

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Physical assessment that is focused on activity and exercise examines the musculoskeletal system and activity tolerance. Important data include:

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150 minutes per week of moderate-intensity, or 75 minutes per week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity.

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The U.S. Department of Health and Human Services physical activity recommendations:

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the maximum movement possible at a joint.

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Range of motion (ROM) is:

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the movement of the joint through the entire ROM by the individual.

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Active range of motion is defined as:

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Forms the framework of the body Protects the internal organs Produces red blood cells Serves as a storage site for calcium Works with the muscles to cause movement

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Name three purposes of the skeletal system.

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The three types of muscle are skeletal, smooth, and cardiac.

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Identify three types of muscle.

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is turning downward

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Pronation

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The three components of a well-rounded exercise program are flexibility, resistance training, and aerobic conditioning.

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State the components of an exercise program.

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is turning upward

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Supination

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is turning toward midline

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Internal rotation

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is moving in a circular fashion

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Circumduction

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is straightening, increasing the joint angle

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Extension

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is moving away from midline

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Abduction

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is bending, decreasing the joint angle

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Flexion

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Musculoskeletal system. Inactivity causes significant wasting of the gastrocnemius, soleus, and the leg muscles that control flexion and extension of the hip, knee, and ankle. Confinement to bed leads to a 7% to 10% loss of muscle strength (atrophy) per week. Immobility also causes the joints to become stiff. The strongest muscles, usually the flexors, pull the joints in their direction, leading to contractures or joint ankylosis (fusion of the joints). Immobility affects parathyroid function, calcium metabolism, and bone formation. The result of these changes is osteoporosis, calcium depletion in the joints, and renal calculi (stones) due to increased excretion of calcium. These changes place the patient at risk for pathological fractures with minimal trauma.

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Identify the effects of immobility on the musculoskeletal system.

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Disorders that limit activity or mobility include the following: Congenital abnormalities of the musculoskeletal system Disorders of bone formation, integrity, metabolism, or joint mobility Disorders of the central nervous system or other body systems that produce fatigue, shortness of breath, or impaired circulation

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What types of disorders limit activity or mobility?

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Signs and symptoms of a fracture include the following: Tenderness at the site Loss of function Deformity of the area Swelling of the surrounding tissues Diagnosis is confirmed by x-ray. Treatment of a fracture is stabilization until the body can create enough new bone to support function. The type and severity of fracture determine whether casting or surgical repair is necessary.

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What are the signs and symptoms of a fracture?

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A strain and sprain have the following differences: A sprain is a stretch injury of a ligament that causes the ligament to tear. A strain is an injury to muscle caused by excessive stress on the muscle.

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What is the difference between a strain and a sprain?

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Integumentary system. External pressure from lying in one position compresses capillaries in the skin, obstructing skin circulation. Poor circulation causes tissue ischemia and possible necrosis (tissue death). Nursing interventions include frequent turning and skin care to prevent the formation of wounds, known as pressure ulcers.

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Identify the effects of immobility on the integumentary system.

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is moving toward midline

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Adduction

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Cardiovascular system. Immobility increases the workload of the heart and promotes venous stasis. When you are active, the skeletal muscles of the legs assist with pumping blood back to the heart. Recall that the veins are thin-walled vessels with valves. Muscular activity propels blood toward the right side of the heart, and the valves prevent backflow of blood. Without muscular activity (immobility), blood pools in the periphery. To compensate, heart rate and stroke volume increase to maintain blood pressure. In addition to venous pooling, immobility leads to compression and injury of the small vessels in the legs and decreased clearance of coagulation factors, causing the blood to clot faster. These three changes—stasis, activation of clotting, and vessel injury—make up what is known as Virchow's Triad, a trilogy of symptoms associated with a greater chance of thrombus formation in the affected blood vessels. An immobile person is also more prone to orthostatic hypotension. Bedrest causes inactivation of the baroreceptors involved with constriction and dilation of the vessels. As a result, when a patient who has been immobilized changes position, he is unable to maintain his blood pressure. The patient complains of feeling dizzy and lightheaded and may be unable to support his own weight.

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Identify the effects of immobility on the cardiovascular system.

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Immobility might be referred to as a stressor because it triggers the release of epinephrine and norepinephrine, thyroid hormones, adrenocorticotropic hormone (ACTH) from the pituitary gland, and aldosterone from the kidneys. These changes in hormone levels are the same as the stress response, letting us see that immobility can be a stress in itself.

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Why might immobility be referred to as a stressor?

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Immobility slows peristalsis, which often leads to constipation, gas, and difficulty evacuating stool from the rectum. In extreme circumstances, a paralytic ileus (cessation of peristalsis) may occur. With peristalsis slowed, appetite diminishes and food that is consumed is digested slowly. The net effect is usually decreased caloric intake and inability to meet the protein demands of the body. Body muscle is broken down as a fuel source, and further wasting occurs.

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What are three effects of immobility on the GI system?

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Patients who are in bed (immobile) for long periods of time can suffer depression, anxiety, hostility, sleep disturbances, and changes in their ability to perform self-care activities, as well as disorientation and apathy.

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What changes in mood might be seen with immobility?

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The focused assessment includes gathering a nursing history and performing a physical examination. A nursing history focused on activity and exercise assesses past and current activity, as well as future plans. The history addresses the following topics: Usual activity Fitness goals Mobility concerns Underlying health concerns Lifestyle External factors A physical examination focused on activity and exercise assesses the musculoskeletal system and activity tolerance. Important data include vital signs, pain assessment, height, weight, body mass index, body alignment, joint function, gait, and activity tolerance.

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Describe a focused assessment for a patient experiencing mobility concerns.

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Assessing joint function includes inspection and palpation of the joints and assessment of range of motion. Inspect each joint for swelling, erythema, asymmetry, or obvious deformity. Compare the size of the muscles above and below the joint and on each side of the body. Palpate the joint for temperature and crepitus. Warmth over a joint indicates inflammation or infection. Be sure to compare body temperature over several joints and right to left. As you palpate the joint, move it through its range of motion. Auscultation is part of the physical assessment for mobility and range of motion. Listen for crepitus, which is a grating sensation when the joint is moved. It can often be heard as well as felt.

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Identify the assessment methods (inspection, palpation, percussion, and auscultation) used when performing a physical examination focused on mobility concerns.

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The five crutch gaits are the two-point gait, three-point gait, four-point gait, swing-to gait, and swing-through gait.

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Identify five crutch gaits.

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partial weight bearing.

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Two-point and four-point gaits are used for

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non-weight bearing

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Three-point gait is used for

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weight bearing is permitted.

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Swing-to and swing-through are used when

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The forearm support crutch is more likely to be used by a patient with permanent limitations.

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When are forearm support crutches used?

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Protect the patient as you guide him to a seated or lying position.

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What action should you take if a patient begins to fall when ambulating?

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A transfer belt should be used when helping a weak patient from a bed to a chair.

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Helping a weak patient from bed to chair

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A mechanical lift should be used when assisting an immobile patient to a recliner chair.

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Assisting an immobile patient to a recliner chair

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A transfer board should be used when transferring an obese patient from a bed to a stretcher.

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Identify the most appropriate device for the following activities: Transferring an obese patient from a bed to a stretcher

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Conditioning exercises that promote a patient's readiness for ambulation include the following: Quadriceps and gluteal drills. Arm exercises. The arm muscles are used when getting out of bed and for crutch walking. To prepare the patient for ambulation, install a trapeze bar. The trapeze bar exercises the biceps muscles. To exercise the triceps muscles, ask the patient to lift his upper body off the mattress by firmly pressing down with the palms. Push-ups can also be done from a seated position at the side of the bed or from a stationary chair or wheelchair. Dangling Daily activities

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Describe activities that can promote a patient's readiness for ambulation.

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Answer: D. Performing a skin assessment to dependent areas at least once every shift Rationale: Other responses are incorrect. A diet low in calcium will not prevent kidney stones; kidney stones develop only in susceptible people, regardless of calcium intake. Limiting the fluid intake will place the patient at risk for a urinary tract infection. Keeping extremities still will lead to increased venous pooling and risk for the development of blood clots.

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In addition to proper positioning, which of the following would be an important nursing measure for a patient who is immobile? A. Encouraging a low-calcium diet to prevent kidney stones B. Limiting fluid intake so she does not have to use the bedpan as frequently C. Encouraging the patient to lie still so he does not cause a blood clot to become dislodged D. Performing a skin assessment to dependent areas at least once every shift

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Answer: B. Basketball sneakers Rationale: Basketball sneakers are a type of high-top shoes that help to keep the foot in flexion. The other responses are incorrect. A trapeze would not be used by a comatose patient. A pillow is too soft to maintain proper position of the feet. A trochanter roll prevents external rotation of the hips.

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Mary is working in a small rural hospital and is caring for a comatose patient who is beginning to develop foot drop. If there were no footboard available to use for attaining proper positioning of the feet, Mary could use which of the following? A. Overhead trapeze B. Basketball sneakers C. Pillow D. Trochanter roll

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Answer: C. Activity Intolerance Rationale: There is no data to suggest the patient is not coping or has a knowledge deficit. While she does have impaired mobility, the most accurate diagnosis is Activity Intolerance related to her poor oxygenation status.

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Mrs. Williams has severe chronic obstructive pulmonary disease and becomes very short of breath when completing her ADLs. Which of the following nursing diagnoses would most accurately reflect Mrs. Williams' mobility problem? A. Ineffective Coping B. Impaired Physical Mobility C. Activity Intolerance D. Deficient Knowledge

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Answer: True

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When checking a patient to be sure her body is aligned properly, it is desirable to observe the patient from the front, back, and side views.

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Leaning over a pillow on a table

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Orthopneic position

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Lateral curvature of the spine

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Scoliosis

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Used after spinal surgery

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Logrolling

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Fusing of the joints

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Ankylosis

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Creaking of the joint

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Crepitus

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Answer: 4) an x-ray of the extremity is obtained. Rationale: A venous or arterial Doppler is used to detect blood flow and would not be used to detect a fracture. Although the clinical exam of the arm indicates a fracture, an x-ray of the suspected bone is a cost-effective, reliable test to definitively diagnose fracture. Applying ice would aid in decreasing the swelling at the site. Signs and symptoms associated with a sprain, strain, or fracture are the same. The variation in density evident on an x-ray allows the clinician to visually diagnose a fracture.

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A 10-year-old boy fell playing ice hockey. He comes to the emergency department complaining of pain in his right forearm. The nurse notes that the boy's arm is swelling and tender to touch. There is an area of bruising on the lateral aspect of his arm, which upon palpation is very firm. The nurse suspects a fracture; however, it cannot be confirmed until: 1) a venous and arterial Doppler is obtained. 2) clinical exam of the arm indicates a fracture. 3) the swelling is decreased by applying ice. 4) an x-ray of the extremity is obtained.

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Answer: 4) lead with the left leg when going up steps, and lead with the right leg when going down steps. Rationale: To teach the patient how to go down stairs, instruct him to hold his injured leg in front and hop down each stair on his good leg, one step at a time. When going up stairs with no handrail, he should lead with his good leg by standing close to the first step with weight on the crutches, and lift the uninjured leg, landing it solidly on the step. Then bring the crutches up to that same step, and repeat. If there is a handrail, then patient holds the crutches in one hand and handrail with the other. He then brings the good leg up one step, while the injured leg bears no weight.

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A 50-year-old woman had a surgical repair of a fracture of her right tibia 2 days ago. She has been using crutches for ambulation and must remain non-weight-bearing on her right leg, but must learn to use the steps leading into her house. The nurse should instruct the woman to: 1) set the crutches aside and use the stair rail to bear weight only on the left leg when going up or down stairs. 2) use the crutches, maintaining toe-touch weight-bearing on the right leg when going up or down the stairs. 3) have someone carry her up and down the stairs. 4) lead with the left leg when going up steps, and lead with the right leg when going down steps.

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Answer: 3) "The risk of having a heart attack during strenuous exercise is low, but you still should be checked out first." Rationale: Exercise itself is rarely life threatening, especially when compared with the alternative (not exercising). Before starting an exercise program or significantly increasing the intensity of normal workouts, seasoned athletes as well as rank beginners should be screened for underlying health problems, such as high blood pressure, thickened heart muscle (cardiac hypertrophy), electrical abnormalities, and blood vessel abnormalities. Although showing empathy might help establish rapport and asking questions about family medical history might elicit information, neither does anything to address the patient's concern and encourage him to exercise. He is not a "high-risk" patient according to the data in this scenario and would not have a greater risk of heart attack with strenuous physical activity.

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A middle-aged man has no known medical problems, although he is overweight. He tells the nurse that he is a computer programmer and gets little exercise. The nurse suggests to the patient that a fitness program would be beneficial to control his weight and improve his overall health. The patient states "I would like to exercise but I am afraid I will have a heart attack and die if I strain my heart too much." The nurse's best response would be: 1) "It sounds like you are fearful of having a heart attack and dying. I understand why you might feel this way." 2) "There is a health history of heart attack in your family; tell me more about that." 3) "The risk of having a heart attack during strenuous exercise is low, but you still should be checked out first." 4) "The risk of having a heart attack during strenuous exercise increases in a high-risk patient such as you."

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Answer: 3) Activity Intolerance related to morbid obesity and dyspnea secondary to sedentary lifestyle. Rationale: In this scenario, Impaired Physical Mobility is the etiology of another problem: Activity Intolerance. Activity Intolerance is a state in which a patient has insufficient physical or psychological energy to carry out daily activities. Subjective characteristics include fatigue, weakness, and discomfort on exertion, dyspnea, and verbalization of no interest in activity. Objective characteristics include changes in heart rate, blood pressure disproportionate to activity, dysrhythmias, or evidence of ischemia on electrocardiogram (ECG), and pallor or cyanosis with activity. There is no evidence that this patient has limited range of motion. Disuse syndrome is a more severe complication of immobility, more likely to be seen where there is almost total lack of skeletal muscle activity.

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A patient is obese with complaints of fatigue with activity. She states, "I am so tired, I can't even walk out to my mailbox without resting every 5 minutes." Her vital signs are within normal limits at rest; however, upon minimal exertion she experiences dyspnea, and her pulse rises from 80 to 140 beats/min. She denies chest pain and has full range of motion to all joints. The nurse practitioner explains to the patient that she needs to lose weight and begin a fitness program. The best nursing diagnosis for this patient is: 1) Impaired Physical Mobility related to obesity. 2) Risk for Disuse Syndrome related to musculoskeletal inactivity. 3) Activity Intolerance related to morbid obesity and dyspnea secondary to sedentary lifestyle. 4) Impaired Physical Mobility related to limited range of motion, secondary to obesity.

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Answer: 1) Endurance 2) Activity Tolerance Rationale: Both Endurance and Activity Tolerance, if demonstrated by this patient, would show that her problem (Activity Intolerance) is improving. Active Joint Movement and Mobility Level relate to part of the etiology of her problem, which is lack of activity. Even if she demonstrates joint movement and other mobility, this would not necessarily indicate that she is tolerating the activity well.

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A patient is obese with complaints of fatigue with activity. The nurse is planning goals for this patient. Which of the following NOC outcome(s) relate(s) directly to the above nursing diagnosis; that is, which outcome(s), if achieved, would demonstrate resolution of her problem? Select all that apply. 1) Endurance 2) Activity Tolerance 3) Active Joint Movement 4) Mobility Level

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Answer: 1) consult her primary care provider prior to starting a fitness program. 2) increase her level of activity within her daily routine. 3) refuel with protein and carbohydrate within 45 minutes of her workout. 4) rest as needed when her perceived level of exertion is high. Rationale: This patient can begin to improve her activity tolerance by increasing her level of physical activity with everyday activities, such as taking stairs instead of an elevator, or parking farther rather than the closest spot. A regular exercise program has many benefits, including weight loss and improving overall cardiovascular health. However, to reduce the risk of injury and other health complications, she needs to be seen by her primary care provider for a thorough history and physical assessment. If she has not been exercising regularly, it is best to start out slow and gradually increase the intensity and frequency of her workout, and rest as needed when her perceived level of exertion is high. Using the Talk Test, that would be when she is too tired to talk while exercising. After a moderate or vigorous intensity workout, the body needs to be refueled with protein and carbohydrate, regardless of the person's baseline weight (i.e., whether the person is a normal weight or obese). Good hydration, especially water, not only quenches thirst but also replaces the fluid lost by exertion and perspiration.

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A patient is obese wants to lose weight and start exercising. She complains of fatigue with activity. Which of the following nursing interventions would be appropriate for this patient? Encourage her to (select all that apply): 1) consult her primary care provider prior to starting a fitness program. 2) increase her level of activity within her daily routine. 3) refuel with protein and carbohydrate within 45 minutes of her workout. 4) rest as needed when her perceived level of exertion is high.

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Answer: 4) participates in a fitness program at the community center 3 days a week. Rationale: By participating regularly in an exercise program, the patient has demonstrated an increase in activity tolerance (recall that her goal was Activity Tolerance). This is also an indication that her sedentary lifestyle habits are changing.

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A patient is obese with complaints of fatigue with activity. To evaluate your nursing care plan for this patient, at the end of 12 weeks an indication of its effectiveness would be that she: 1) has lost 15 pounds when measured at the same time as the initial weight. 2) has full range of motion to all joints without experiencing pain. 3) jogs five city blocks twice a week without tiring or stopping. 4) participates in a fitness program at the community center 3 days a week.

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Answer: 2) "Gaining weight and getting out of shape takes time; reversing this also takes time." Rationale: Many patients feel they have tried to exercise but that it did not make a difference, and they give up. Remind them that gaining weight and getting out of shape takes time and that reversing these changes also takes time. Patients may not begin to see the effects of an exercise program for at least 12 weeks. Encourage them to be consistent and not give up.

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To promote exercise for a patient who is obese, the nurse's best statement would be: 1) "I know exercising is hard, but you are going to have to do it to remain healthy." 2) "Gaining weight and getting out of shape takes time; reversing this also takes time." 3) "I know exactly how you feel; I absolutely hate to exercise, too." 4) "The problem was probably the exercise program you participated in."

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Rationale: For prevention of weight gain in most adults, adults are encouraged to engage in physical activity for 150 to 250 minutes per week with an energy equivalent of 1,200 to 2,000 kcal/week. However, when an adult has lost a significant amount of weight, more physical activity is needed to help minimize weight regain. Approximately 250 to 300 minutes of physical activity per week is advised by the American College of Sports Medicine, although "more is better."

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To prevent weight gain in an adult who has lost a significant amount of weight, how much physical activity should the nurse recommend? 1) 60 to 119 minutes/week 2) 120 to 150 minutes/week 3) 151 to 250 minutes/week 4) More than 250 minutes/week Answer: 4) More than 250 minutes/week

BASIC NURSING Chapter 33: Mobility – Flashcards

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