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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

c.HR 114

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

c.HR 114

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.
1
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
Discuss the therapeutic reasons for bed rest.
- decrease o2 consumption
- weakness
- safety
- rest a body part (fracture)
- reduce pain
- Equipment availability
- severity of condition
Describe potential complications associated with bedrest.
- Metabolic: glucose intolerance and negative nitrogen balance

- Cardiovascular: postural hypertension, cardiac muscle atrophy, and deep vein thrombosis

- Urinary elimination: calculi and nephritis

- GI: constipation and fecal impaction

- Respiratory: pneumonia, atelectasis, pulmonary embolism
'
- Musculoskeletal changes: osteoporosis, muscle atrophy, and weakness, contractures

- phsycological: depression and anxiety

-*Integumentary: pressure ulcers
metablic changes with bed rest
- glucose intolerance
- negative nitrogen balance
metabolic nursing interventions
high protein diet
- high calorie diet
- Vitamin C and B supplements
skeletal changes with bed rest
- Impaired calcium absorption
- joint abnormalities
- contractures
- osteoporosis (weak brittle bones)
respiratory changes with bed rest
pulmonary embolism (blood clot in lungs)
- Atelectstasis (aveoli collapse)
- hypostatic pneumonia (lung inflammation from fluid)
respiratory diagnosis (problems)
Ineffective airway clearance
•Ineffective breathing pattern
•Impaired gas exchange
respiratory interventions
- move pt q.2h.
- suction oropharyngeal airway p.r.n.
- deep breathing q. 1-2h
- auscultate lungs
- assess
- cough
- chest physiotherapy (IS- Incentive spriometer)
-Assess for decreased ability to cough, accumulation of secretions, colored sputum, fever, shortness of breath (SOB), changes in skin color, changes in pulse oximetry
steps for spirometer procedure
1. hold it level
2. maintain firm seal with lips around the mouthpeice during inhalation
3.inhale slowly
4. keep visual medicator @ the inspiratory goal for several sec
5. remove mouthpeice and exhale normally
urinary problems wiht bed rest
Urinary stasis (UTI)
- Renal calculi (kidney stones)
- difficult voiding
- stagnant urine
urniary interventions
move the pt
hydrate
assess pt
clean catheter
monitor diet
muscle change with bed rest
-muscle atrophy
- less endurance
- decrease stability and balance
muscle interventions
- Passive (assisted) and active ROM
- CPM (continuous passive motion)
- mobility aids (cane, walker, crutches)
integumentary
pressure ulcers
ischemia: inadequate blood supply
integumentary nursing interventions
- move pt q. 1-2h
- skin care
- cleaning pt after elimination
- hydration
- rich diet in fluids, fruits, veges, and fiber
How to use a cane
- with opposite affected leg
How to use walker


Walking
To start, set your cane about one small stride ahead of you and step off on your injured leg. Finish the step with your good leg.
how to use walker
Positioning
When standing up straight, the top of your walker should reach to the crease in your wrist.
Your elbows should be slightly bent when you hold the handgrips of the walker.
Keep your back straight. Don't hunch over the walker.
Check to be sure the rubber tips on your walker's legs are in good shape. If they become uneven or worn, you can purchase new tips at a drug store or medical supply store.

Walking
First, position your walker about one step ahead of you, making sure that all four legs of the walker are on even ground. With both hands, grip the top of the walker for support and move your injured leg into the middle area of the walker. Do not step all the way to the front. Push straight down on the handgrips of the walker as you bring your good leg up so it is even with your injured leg. Always take small steps when you turn and move slowly.
Sitting

To sit, back up until your legs touch the chair. Use your hands to feel behind you for the seat of the chair. Slowly lower yourself into the chair.

To stand up, push yourself up using the strength of your arms and grasp the walker's handgrips. Do not pull on or tilt the walker to help you stand up.
Stairs

Never climb stairs or use an escalator with your walker.
Gastrointestinal changes with bed rest
-constipation
- fecal impaction/obstruction
- paralytic ileus (intestine unable to contract to remove waste)
GI interventions
pharmacological: laxatives, stool softners

nursing interventions:
hydrate pt
move pt
medication for constipation
assess
how to use crutches
- all weight on your hands
- 2-3 fingers between crutch and arm pit
What prevents contractures?
- Changing bed position
- Passive ROM on joints
- Turning pt in bed
- Draw sheet to move pt in bed
Cardiovascular problems with bed rest
- Orthostatic hypotension (sitting>standing dizziness)
- DVT (clot)
- heart muscle atrophy
- increase cardiac workload
-blood to pool leading to edema
-extra fluid in the tissue makes patient more prone to presure injury
-blood clots faster
orthostatic hypotension
- drop in BP
- rapid position change
- increase heart rate
- Immobilized elderly - blood volume depletion
- dizziness, light headedness, pallor (pale appearance), nausea
DVT signs
-redness
-pain
-swelling
orthostatic hypotension interventions
- compression stockings
- raise and lower HOB several times
- raise HOB to fowlers position, have pt sit for 5mn before getting OOB
- have pt dangle legs over side of bed
- observe symptoms
- assist pt to stand
- bed to chair ambulation
- SCDs (sequential compression device)
thromboembilism
clot or part of a clot that traveled to another body part
Cardiovascular implementation
•Progress from bed to chair to ambulation.
•SCDs, TED hose, and leg exercises
sequential compression device (SCD)
inflates with air to accelerate venous blood return
Urinary elimination problems w/ bed rest
- Urinary stasis (UTI)
- Renal calculi (kidney stones)
- difficult voiding
- stagnant urine
psychosocial effects
- emotional/behavioral
- depression/sadness/rejection/ isolation
- anxiety
- fear
- mood changes
- hostility
- giddiness
- disorientation
- altered sleep patterns
- changes in coping
Describe and apply the plan of care for a client experiencing alterations in mobility.
- Recognize hazards of immobility
- prevent complications
- complete assessment
- utilize nursing interventions
Respiratory changes w/ bed rest
- pulmonary embolism (blood clot in lungs)
- Atelectstasis (aveoli collapse)
- hypostatic pneumonia (lung inflammation from fluid)
nursing diagnosis
impaired physical mobility
risk for disuse syndrome
ineffective airway clearance
ineffective coping
risk for injury
risk for impaired skin integrity
social isolation
insomina
nursing plan
Goals and outcomes •Setting priorities

•Example: respiratory, tissue perfusion, then ROM, positioning, exercises, nutrition
.
•Teamwork and collaboration
•need dietician, physical therapy...
Safety guidelines
• Communicate clearly.
• Mentally review transfer steps.
• Assess patient mobility and strength.
• Determine assistance needed.
• Raise side rail on opposite side of bed.
• Arrange equipment.
• Evaluate body alignment.
• Understand use of equipment.
• Educate patient.
Restorative and continuing care
he GOAL is to maximize functional mobility and independence and reduce residual functional deficits such as impaired gait and decreased endurance.
abduction pillow
hip surgery patients
sandbags
and to help facilitate hemostasis after surgical procedures
supine
provides comfort in general and specifically for patients recovering from some types of surgery. To provide support and maintain body alignment in this position, place a pillow under the patient's head and shoulders and a towel roll or small pillow under the small of the back and under the thighs to keep the patient's knees slightly flexed. You can also elevate the patient's forearms on pillows placed at the patient's sides.
prone position
-In the prone position, the patient lies on the abdomen with the head turned to one side.

-The hips are not flexed. Sometimes, one or both arms are flexed on each side of the patient's head.

-Because this position can cause hyperextension of the lower back, difficulty breathing due to pressure on the chest, and foot drop, it is not a position you'll use often.

If a patient does lie prone, place a pillow under the patient's head and a small pillow or towel roll under the abdomen just below the diaphragm.

Also, place a pillow under the lower legs to keep the toes from touching the bed.
lateral
helps relieve pressue on the sacrum

useful for patients who are on bed rest and spend a lot of time in supine or in fowlers position

To maintain proper body alignment in this position, place a pillow under the patient's head and neck, another under the upper arm (with the lower arm flexed), and another between the legs to keep the hips properly aligned.
sims
In Sims' position, the patient is halfway between the lateral and the prone positions.
The upper arm is flexed at the shoulder and elbow, and the lower arm is positioned behind the patient.

Both legs are in a flexed position in front of the patient, with the upper leg more flexed than the lower one.

This position is most often used when patients are receiving an enema or for an examination of the perineal area.

To keep the body in proper alignment in this position, place a pillow underneath the patient's head and under the upper arm to prevent internal rotation. Place another pillow between the legs.
orthopneic, or tripod
Patients who have breathing problems are often placed in the orthopneic, or tripod, position since it allows maximum expansion of the chest. For this position, the patient sits in bed or on the side of the bed with an overbed table in front to lean on and several pillows on the table to rest on.
Fowlers
Patients are often placed in Fowler's position to increase comfort, to improve ventilation, and to promote relaxation after thoracic surgery or for patients with cardiovascular problems. For this position, the head of the bed is elevated 45 degrees. The patient's hips may or may not be flexed. You'll place pillows behind the patient's head and lower back and underneath the forearms, thighs, and ankles for support. You might also use a footboard to keep the patient's feet in proper alignment and to help prevent footdrop.
semi-Fowlers
For semi-Fowler's position, the head of the bed is elevated 30 degrees. This position is useful for patients who have cardiac, respiratory, or neurological problems and is often optimal for patients who have a nasogastric tube in place.
Trendelenburg's position
Placing a patient in Trendelenburg's position involves lowering the head of the bed and raising the foot of the bed. Patients who have hypotension can benefit from this position because it promotes venous return.
Reverse Trendelenburg's position
This is often a position of comfort for patients with gastrointestinal problems, and it can help prevent or minimize esophageal reflux.
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