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Chapter 47 Mobility and Immobility
Terms in this set (62)
The nurse is caring for a client who is on bed rest for a month. The nurse understands that an immobile client may have poor body alignment, which may lead to complications. How should the nurse assess body alignment in this client? Select all that apply.
Bedridden clients are at risk of damaging the body due to inability to perceived muscle strain and lack of circulation. For assessment of body alignment, the client should be placed in a lateral position with a pillow under the head. The body should be supported with an adequate mattress. In this position, a full view of the back and spine is possible. It also helps to determine if the client can maintain this position without supporting aids. All the supporting aids should be removed before the assessment is done. A sitting position does not give a full view of the spine and back for assessment.
Text Reference - p. 1140
The nurse puts elastic stockings on a client following major abdominal surgery. The nurse teaches the client that the stockings are used after a surgical procedure to:
Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces the risk for deep vein thrombosis (DVT) formation in the lower extremities.
The client with hemiparesis needs passive range of motion (ROM) exercises to promote musculoskeletal health. What precautions should be taken to ensure effective ROM exercises? Select all that apply.
1. carry out movements slowly and smoothly
2. never force a joint beyond its capacity
3. perform exercises in a head-to-toe sequence
Unlike active ROM, which is performed by the client, passive ROM is performed by either the nurse or the physical therapist. The movements should be carried out slowly and smoothly to prevent injury to the soft tissues. Forcing a joint beyond its capacity may injure the bones and other soft tissues of the joint. The exercises should be performed in a head-to-toe sequence to prevent missing any joint. ROM should not cause pain; the joint, if forced beyond its capacity may cause pain. Each movement should be repeated 5 times during a session for optimal effect.
Text Reference - p. 1158
An elderly client has undergone hip replacement surgery. On the second postoperative day, the nurse finds that the pedal pulses are absent and the lower extremities are cold to the touch. What should the nurse interpret from this finding?
Absence of pedal pulses and abnormally cold extremities indicate that the client has developed venous thrombus formation. Venous thrombus formation occurs because of stagnation or alteration in the blood flow as a result of immobility or injury to the vessel wall during surgery. The thrombus may block the blood supply to the extremities. The manifestations in the client are not an age-related effect. Hip joint dislocation may not result in absence of pedal pulses. A cool room temperature may cause the extremities to become cold but may not lead to an absence of pedal pulses.
1. the pt has venous thrombus formation
While assessing a child, the nurse finds that the child's legs are bent outward at the knee. Which instruction to the parents is most beneficial for the child?
1. vitamin d-rich diet
Outward bending of the legs at the knee indicates bowlegs. It is generally associated with rickets, which occurs due to deficiency of vitamin D. Therefore, the child should be provided with foods that are rich in vitamin D. Phosphorus reduces the risk of rickets in children. Therefore, parents should not limit phosphorus in a child's diet. Limiting mobility in a child with rickets can impair mobility permanently. A Denis-Browne splint is used to reduce the risk of clubfoot; however, it is not useful as a treatment for rickets.
Nursing assistive personnel (NAP) are applying antiembolitic elastic stockings to the client. What instructions should the NAP give to the client? Select all that apply.
It is necessary to elevate legs while sitting and before applying stockings to improve venous return. Antiembolitic stockings that are free of wrinkles will fit the legs more properly. Massaging the legs may further deteriorate the condition, so massage should be avoided. Sitting cross-legged and wearing garters promote venous stasis and should be avoided.
A nurse is reading an X-ray report of a client which shows that the client has increased convexity in curvature of the thoracic spine. What instructions should the nurse give to the client? Select all that apply.
An increased convexity in the curvature of the spine is called kyphosis. The client can benefit by sleeping without pillows, practicing spine stretching exercises, and using a bed board. Wearing reversed shoes or applying heat to the spine will not help the client as kyphosis is a congenital condition.
Text Reference - p. 1131
The nurse is preparing a dietary plan for the client who has osteoporosis. Which food choice should be recommended by the nurse to increase calcium level? Select all that apply.
The client with osteoporosis requires a calcium-rich diet to replenish the lost calcium. Yogurt, cheese, and green vegetables are rich in calcium, and should be added to the dietary plan. A diet that contains fruits and legumes are good for health but are not good sources of calcium.
The nurse is caring for a child with clubfoot. Which splint should the nurse advise the caregiver to apply on the child?
-Denis Browne splints are used for children with clubfoot to align the foot in the correct position.
- Knee braces are used for clients with knockknee (genu valgus).
-Abduction splints are used for children with congenital hip dysplasia.
-An ankle-foot orthotic is used to maintain the position of the foot in clients with foot drop.
Immobilized clients are at risk for impaired skin integrity. Which of the following interventions would reduce this risk? Select all that apply.
Clients must be repositioned around the clock, not just when they are awake. An objective assessment scale allows the nurse to assess for pressure ulcer risk over time. Once the risk is identified, the assessment tool guides the nurse in selecting appropriate pressure-relief devices. Showing the client how to reduce his or her risk by shifting pressure is also important. Frequent and meaningful position changes that are in concert with the client's condition and risk factors are necessary to reduce pressure ulcer developments.
An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the client cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? Select all that apply.
a.B/P = 128/84
b.Respiration 26 per minute on room air
d.Crackles heard on auscultation
e.Pain reported as 3 on scale of 0 to 10 after medication
b.Respiration 26 per minute on room air
d.Crackles heard on auscultation
Clients with reduced mobility are at risk for retained pulmonary secretions, and this risk increases in postoperative clients. As a result of retained secretions, the respiratory rate increases. The heart rate also increases because the heart is trying to improve oxygen levels. These symptoms are of concern for older adults because, if left untreated, further complications such as heart failure can occur.
The nurse understands that an immobile client is at high risk of thrombus formation. Which factors may contribute to the risk of thrombus formation? Select all that apply.
Alteration in the body weight
Alteration or slowing of blood flow
Damage to the wall of the blood vessels
Alteration in the client's nutritional status
Alteration of the constituents in the blood
1. alteration or slowing blood flow
2. damage to the wall of the blood vessels
3. alteration of the constituents in the blood
Prolonged immobility increases the risk of thrombus formation. Slow blood flow in the calf veins may lead to formation of thrombus. Damage to the blood vessels caused by any surgical procedure may also cause a blood clot. Alterations in the constituents of blood such as clotting factors and platelets may also contribute to formation of thrombus. Alteration in the body weight and client's nutritional status has no effect on thrombus formation.
ergonomics assessment protocol
The purpose of this protocol is to identify and promote ergonomics in the workplace as a
key component of the NOSM Health and Safety Program.
The intent of ergonomics is to provide workstations, work processes, equipment, and
tools that properly "fit" the employee. NOSM promotes a culture where employees are
encouraged to make or request reasonable improvements at their work stations to reduce
or eliminate ergonomic stressors related to routine office, classroom and laboratory tasks.
Such stressors if not properly addressed may lead to such musculoskeletal injuries as
carpal tunnel syndrome, tendonitis, back injuries, and others. Proper ergonomics
enhances performance and productivity by minimizing fatigue and discomfort and
repetitive strain injuries.
After Action Review (AAR)
It works by bringing together a team to discuss a task, event, activity or project, in an open and honest fashion.
Recognize terminology and abbreviations associated with mobility/immobility.
Complete Bed Rest (CBR)
Bed Rest with Bathroom privileges (BRP)
Bed Rest with Beside Commode (BSC)
Dangle on side of bed
Up to Bedside Chair
OOB ad lib
OOB with assistance
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Unit 15; Patient Safety and Positioning
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