Nursing Intro Ch47 - Mobility and Immobility

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Potter & Perry Fundamentals of Nursing Study Guide 7th Edition Chapter 47 - Mobility and Immobility

Movement

Visible aspect and contributes to self-worth and well-being

Mobility

Used to show self-defense, perform activities of daily living (ADLs) and recreational activities

Body mechanics

Coordinated efforts of the musculoskeletal and nervous system

Body alignment

Reduces strain, maintains muscle tone, comfort, conserves energy

Balance

Required to maintain a static position

Friction

Force that occurs in a direction to oppose movement

Long bones

Contribute to height

Short bones

Occur in clusters (carpal bones in the foot)

Flat bones

Provide structural contour (skull)

Irregular bones

Make up the vertebral column and some bones of the skull

Pathological fractures

Caused by weakened bone tissue

Synostosis joint

Bones jointed by bones with no movement

Cartilaginous joint

Unites bony components

Fibrous joint

joint in which a ligament unites two bony surfaces (paired bones of the lower leg)

Synovial joint

Ball and Socket Joint (hip)

Ligaments

Fibrous tissue that connect ones an cartilages

Tendons

Connect muscle to bone

Cartilage

Nonvascular, supporting tissue (joints and thorax)

concentric tension

Increased muscle contraction causes muscle shortening resulting in movement

Eccentric tension

Helps control the speed and direction of movement

Isotonic contraction

Active movement between concentric and eccentric muscle actions

Isometric contraction

Causes an increase in muscle tension or muscle work but no shortening or active movement

Leverage

Inducing or compelling force

Posture

Position of the body in relation to the surrounding space

Muscle tone

Normal state of balanced muscle tension

Torticollis

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

Lordosis

Exaggeration of anterior convex curve of lumbar spine

Kyphosis

Increased convexity in curvature of thoracic spine

Scoliosis

Lateral S- or C-shaped spinal column with vertebral rotation, unequal heights of hips and shoulders

Congential 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)

knock-knee

Legs curved inward so that knees come together as person walks

Bowlegs

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

Inability to dorsiflex and invert foot because of peroneal nerve damage

Pigeon Toes

Internal rotation of forefoot or entire foot; common in infants

Damage to component of the central nervous system that regulates voluntary movement results in

impaired body alignment, balance, and mobility

Direct trauma to the musculoskeletal system results in

bruises, contusions, sprains, and fractures

Mobility

person's ability to move about freely

Immobility

inability to move freely

Identify the obJectives of bed rest.

a. Reducing physical activity and the oxygen needs of the body
b. Reducing pain, including postoperative pain or after acute injury, to the lower back
c. Allowing ill or debilitated clients to rest
d. Allowing exhausted clients the opportunity for uninterrupted rest

Identify the complications of immobility in relation to the metabolic functioning of the body

decreases the metabolic rate; alters the metabolism of CHO, fats, and proteins; causes fluid and electrolyte and calcium imbalances; and causes GI disturbances

Atelectasis

collapse of alveoli

Hydrostatic pneumonia

inflammation of the lung from stasis or pooling of secretions

Orthostatic hypotension

increase in heart rate of more than 15% and a drop of 15 mm Hg or more in SBP

Thrombus

accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery that occludes the lumen of the vessel

Identify the complications of immobility in , relation to the musculoskeletal system

a. loss of endurance, strength, and muscle mass and decreased stability and balance
b. impaired calcium metabolism
c. impaired joint mobility
d. osteoporosis
e. joint contractures
f. footdrop

Identify the complications of immobility in relation to the urinary system.

a. urinary stasis (renal pelvis fills before urine enters the ureters)
b. renal calculi (calcium stones that lodge in the renal pelvis)

Identify the psychosocial effects that occur with immobilization

a. emotional and behavioral responses
b. sensory alterations
c. changes in coping

Range of Motion (ROM)

39. is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, or transverse

Gait

particular manner or style of walking

Exercise and activity tolerance

physical activity for conditioning the body, improving health, and maintaining fitness

Body alignment

identifies deviations, learning needs, identifies trauma, risk factors

Ust the actual or potential nursing diagnoses related to an immobilized or partially immobilized client.

1. ineffective airway clearance
2. ineffective individual coping
3. risk for injury
4. impaired skin integrity
5. disturbed sleep pattern
6. social isolation
7. impaired urinary elimination

List the expected outcomes for the goal "client skin remains intact"

a. skin color and temperature return to normal baseline within 20 minutes of position change
b. changes position at least every 2 hours

Identify some examples of health promotion activities that address mobility and immobility

a. prevention of work-related injury
b. fall prevention measures
c. exercise
d. early detection of scoliosis

Identify the nursing interventions that will reduce the impact of immobility on Metabolic Systems

a. a high caloric diet
b. vitamin B and C supplements

Identify the nursing interventions that will reduce the impact of immobility on Respiratory system

a. deep breathe and cough every 1-2 hours
b. CPT c. ensure intake of 2000 mL of fluid per day

Identify the nursing interventions that will reduce the impact of immobility on Cardiovascular system

a. deep breathe and cough every 1-2 hours
b. CPT
c. ensure intake of 2000 mL of fluid per day

Identify the nursing interventions that will reduce the impact of immobility on Musculoskeletal system

a. perform active and passive ROM exercises
b. CPM machines

Identify the nursing interventions that will reduce the impact of immobility on Integumentary system

a. positioning and skin care
b. use of therapeutic devices to relieve pressure

Identify the nursing interventions that will reduce the impact of immobility on Elimination system

a. well-hydrated
b. prevent urinary stasis and calculi and infections

Identify the nursing interventions that will reduce the impact of immobility on Psychosocial

a. anticipate change in the client's status and provide routine and informal socialization
b. stimuli to maintain client's orientation

Trochanter roll

prevents external rotation of the hips when the client is in supine position

Hand rolls

maintain the thumb in slight adduction and in opposition to the fingers

Trapeze bar

allows the client to pull with the upper extremities to raise the trunk off the bed, assist in transfer, or to perform exercises

Fowlers

HOB elevated 45-60 degrees and the knees are slightly elevated

Supine

rest on their backs; all the body parts are in relation to each other

Prone

lies face or chest down

Side-lying

the client rests on the side with body weight on the dependent hip and shoulder

Sims

client places the weight on the anterior ileum humerus and clavicle

Instrumental activities of daily living (IADLs)

Are activities beyond ADLs that are necessary to be independent in society

Describe how you would assist clients with hemiplegia or hemiparesis

Always stand on the client's affected side and support the client by using a gait belt.

Identify the evaluative measures in mobility

the client's ability to maintain or improve body alignment, improve mobility; protect the client from the hazards of immobility

What is a potential hazard that you should assess when the client is in a prone position

footdrop

joint contracture

Abnormal and usually permanent condition of a joint, characterized by flexion and fixation and caused by disuse, atrophy, and shortening of muscle fibers.

anthropometric measurements

Measures of height, weight, and skinfold thickness to evaluate muscle atrophy.

disuse osteoporosis

A decline is bone density that is associated with impaired mobility or immobilization of an extremity because of fracture, paralysis, or bone or joint inflammation.

embolus

A foreign object, a quantity of air or gas, a bit of tissue or tumor, or a piece of thrombus that circulates in the bloodstream until it becomes lodged in a vessel.

gait belt

Leather belt that encircles the waist and has handles attached for the nurse to hold.

muscle atrophy

Loss of muscle tissue.

negative nitrogen balance

Condition occurring when the body excretes more nitrogen than it takes in.

unossified

Not hardened, soft.

chest physiotherapy (CPT)

Group of therapies used to mobilize pulmonary secretions.

hemiplegia

Paralysis of one side of the body.

hemiparesis

Muscular weakness of one half of the body.

Body mechanics are the coordinated efforts of the

musculoskeletal and nervous systems as the person moves, lifts, bends, stands, sits, lies down, and completes daily activities

Findings from evidence-based nursing research about safe client handling prevents

injuries to nurses and clients when moving and transferring clients

The skeletal system provides bony support structure for

movement, attachment of ligaments and muscles, protection of vital organs, some of the regulation of calcium, and production of red blood cells.

The nervous system provides

initiation and voluntary control of movement

Coordination and regulation of muscle groups depend on

muscle tone; activity of antagonistic, synergistic, and antigravity muscles; and neural input to muscles

Body alignment is the condition of

joints, tendons, ligaments, and muscles in various body positions.

Balance occurs when there is a wide base of

support, the center of gravity falls within the base of support, and a vertical line falls from the center of gravity through the base of support.

Developmental stages influence

body alignment and mobility; the greatest impact of physiological changes on the musculoskeletal system is observed in children and older adults.

The risk of disabilities related to immobilization depends on

on the extent and duration of immobilization and the client's overall level of health.

Immobility sometimes results from

illness or trauma or is prescribed for therapeutic reasons.

Immobility presents hazards in

the physiological, psychological, and developmental dimensions.

The nursing process and critical thinking assist in providing

care for clients who are experiencing or are at risk for the adverse effects of impaired body alignment and immobility.

Clients with impaired body alignment require nursing interventions to

maintain them in the supported Fowler's, supine, prone, side-lying, and Sims' positions.

Client movement algorithms serve as

assessment tools and guide safe client handling and movement.

Appropriate friction-reducing assistive devices and mechanical lifts need to be used for

client transfers when applicable.

No-lift policies benefit

all members of the health care system: clients, nurses, and administration.

Range-of-motion exercises include

one or all of the body joints

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