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56 terms

1255 Immobility

What is immobility? (2)
1. Immobile: prevent or lack movement
2. Regular movement supports the healthy functioning of every body system therefore immobility adversely effects every system.
Ex. pressure ulcers, digestion, circulation, respiratory
What are the 6 P's?
Personal Needs
Pulmonary Hygiene
What are three CARDIOVASCULAR effects of immobility?
- ↑ cardiac workload
- ↑ risk for venous thrombosis
- ↑ orthostatic hypotension (give fluid & then reassess)
- shut down of neuromuscular system
What are three RESPIRATORY effects of immobility?
- ↓ depth & rate (reduced need for O2 by body cells)
- ↑ atelectasis
- ↑ risk of pneumonia
What are four MUSCULOSKELETAL effects of immobility?
- ↓ muscle size (atrophy****), tone & strength
- ↓ joint mobility & flexibility →contractures*** get stiff
- ↑ bone demineralization → osteoporosis
- ↓ endurance & stability
What are four METABOLIC & GASTROINTESTINAL effects of immobility?
- ↑ or ↓ metabolic rate
- fluid & electrolyte imbalances → confusion, look at Na, K, CO2.
- constipation
- alter/poor food utilization
What are three URINARY & INTEGUMENT effects of immobility?
- ↑ risk of UTI's = dehydration, not enough fluid
- ↑ risk of calculi (kidney stones)
- skin breakdown = incontinent
What are the psychosocial effects of immobility?
- ↓ self esteem
- ↑ risk of depression
What are three psychological benefits of regular exercise?
1. Improved self-concept
2. Improved sleep
3. Improved energy
What is the patient's history in regards to mobility? (6)
1. Daily activity level = what do you do?
2. Endurance = how have you been doing?
3. Fitness goals = what are your goals?
4. Mobility problems = arthritis, fx
5. Physical or mental health alterations
a. Chronic diseases = COPD, diabetes
b. Neuromuscular problems = parkinsons
c. Pain - get under control
6. External factors = Environment (churches) & financial
What to assess in physical exam for mobility? (5)
1. Gait
2. Walk = shuffling
3. Speed
4. Stance & swing
5. Assistive devices = cane, walker
What are three consideration of Alignment (3)
1. Ear, shoulder & hip in a straight line
2. Base of support on soles & heels of feet
3. Erect posture
What 3 things do you look for in the appearance of a joint?
1. Size
2. Shape
3. Color = variation in color
moving extremity away from body
moving extremity towards body
pull toes toward body
point toes
consolidation and immobilization of a joint
bone demineralization
muscle atrophy
muscle MASS that is decreased through disuse or neurologic impairment
- wasting
increased muscle MASS resulting from exersize or training
no muscle TONE
- increased TONE that interferes with movement
- spasms
What are three nursing diagnoses?
1. Impaired Physical Mobility
2. Activity Intolerance
3. Risk for Injury
What is the equipment used to maintain body alignment (impaired physical mobility?
- pillows, wedges
- splints
- c-collers
- braces
- side rails
- trapeze bar
- foot board, mediboot (prevent foot drop)
What are two advantages of Fowlers position
↑ ease of breathing
↓ risk of aspiration
What is a disadvantages of Fowlers position
↑ risk of pressure ulcers
What are two advantages of Supine position
easy to move patient
decrease pressure points
What are three disadvantages of Supine position
- aspiration
- foot drop
- breathing problems
What are two advantages of the lateral position?
1. ↓ ulcer (if turning)
2. Comfort
- float heels and watch elbows
What are two disadvantages of the lateral position?
1. spinal misalignment
2. pressure ulcer (ilium)
What is the Sims position?
patient is lying on left side with the right knee and thigh drawn up
- sometimes used for enemas
What is an advantages of Sim's position
Redistributes pressure points
What are three disadvantages of Sim's position?
- New pressure points (humerus, clavicle and ilium)
- foot drop
- internal rotation & adduction (shoulder & hip)
Ex. right ilium ulcer, don't put into right Sims position
Advantages of prone position
- Good alignment and prevents hip and knee problems
- some believe good for respiratory problems
Disadvantages of prone position
Inhibits adequate respirations and ↑ foot drop
What position is used for patients on ventilators?
prone position
minimum frequency for ROM exercises
2-3 times a day
what is active exercise?
patient independantly moves joints
what is active assist exercise?
nurse provides some support
what is passive exercise?
- nurse moves each joint through ROM
- 2 times per day, 2-5 times each exercise
What are eight ROM exercise guidelines?
- should not cause pain or fatigue
- older adults should not hyperextend neck
- all movement should be smouth and rhythmic
- stop when resistance is met without pain
- support distal joint
- perform each movement 2-5 times
- avoid friction/injury to skin
- return joint to normal position when done
This type of ROM improves muscle tone strength and mass
How often should you turn a patient
every 2 hours
How does turning prevent immobility complications? (3)
1. Pressure ulcers
2. Atelectasis & pneumonia?
3. Urinary stasis and infection?
If BMI is greater than ____ use bariatric equipment
What are ten general guidelines for moving patients?
1. Use appropriate assistive devices
2. Encourage patient to help as much as possible
3. Ensure enough help is available
4. Remove obstacles
5. Plan and communicate plan to patient & your help
6. Position and lock bed, w/c, stretcher, etc.
7. Use good body mechanics
8. Patient pain should be controlled
9. Avoid injury/friction to skin
10. If BMI >50% then use bariatric equipment
What are the Immobility Quality Measurements for ECF?
Must show evidence that mobility was maintained or improved
What are the Immobility Quality Measurements for a Hospital?
Integrated into specific best practice guidelines

Ex: hip & knee surgery: post-op physical therapy
Heart Attack: cardiac rehab
COPD: pulmonary rehab
What approach should the nurse take when handling a patient with dementia?
Incorporate established behavior patterns
what does foot drop look like?
plantar flexion
What are two examples of endurance?
1. ability to perform ADLs
2. ability to tolerate increased activity
What are eight variables leading to injury
1. Uncoordinated lifts
2. size, height differences among lifters
3. Moving patients without assistance
4. Lifting when fatigued
5. Lifting after a recent recovery
6. Repetitive movement & repositioning
7. Moving uncooperative or confused patients
8. Standing for long periods
What are six activity intolerance interventions?
1. Monitor response
a. Baseline VS with pulse ox
b. Slow down if
c. Stop if
2. Increase gradually
3. Plan a purpose
4. Provide physical support
5. Provide emotional support
6. Rest periods
What are four additional strategies for the older adult?
1. Avoid sudden position changes
2. Avoid extreme temperatures during exercise
3. Stop if chest pain occurs
4. Use proper footwear
if the patient has respiratory issues when performing ADLS, what is the diagnosis?
Activity intolerance