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Mobility

Terms in this set (27)

musculoskeletal
✯ Normal Mobility
▪︎ Structures of the ____________ system
⇢ Bones
⇢ Muscles
⇢ Ligaments
⇢ Tendons
⇢ Joints
➢➢ Adduction, abduction, rotation, flexion, extension, supination, pronation, inversion, eversion
physiological
✯ Normal Mobility
▪︎ Normal ____________ function
▪︎ Alignment
▪︎ Posture
▪︎ Balance & Gait
▪︎ Coordinated Movement
▪︎ Body Mechanics
▪︎ Full Range of Motion
C
A nurse stretches out a patient's leg and moves it in a circle. This is an example of what type of body movement?
▪︎ A. Abduction
▪︎ B. Flexion
▪︎ C. Circumduction
▪︎ D. Dorsiflexion
Factors
✯ ________ Affecting Mobility
▪︎ Lifestyle & Habits
▪︎ Intactness of Musculoskeletal System
▪︎ Nervous System Control
⇢ Afferent nervous system conveys information to the CNS.
⇢ Neurons conduct impulses from one part of the body to another.
Information is processed by the CNS.
⇢ Efferent system conveys a response from the CNS to skeletal muscles via the somatic nervous system.
▪︎ Spinal cord injury: paralysis below the level of injury
⇢ Paraplegia: decreased motor/sensory function to the legs
⇢ Tetraplegia: paralysis of arms/legs and muscle movement below level of injury (formerly termed quadriplegia)
▪︎ Pain
▪︎ Circulation and Oxygenation
Paraplegia
Spinal Cord Injury: Paralysis below the level of Injury:
✯ Decreased motor/sensory function to the legs
Tetraplegia
Spinal Cord Injury: Paralysis below the level of Injury:
✯ Paralysis of arms/legs and muscle movement below level of injury (formerly termed quadriplegia)
Altered Mobility
✯ ___________ ____________
▪︎ Manifestations of altered mobility
⇢ Decreased muscle strength and tone
⇢ Lack of coordination
⇢ Altered gait
⇢ Falls
⇢ Decreased joint flexibility
⇢ Pain on movement
Cardiovascular System
Impacts of Immobility:
✯ Blood clots can form. When blood pools it tends to clot. When you are immobile the blood is not moving enough to keep it flowing as effectively.
⇢ Thrombus- Blood clot
⇢ Embolism- Moving Blood Clot

✯ When patients are immobile they have an increased HR because of the lack of venous return. The heart has to work harder and faster to pump that fluid around.

✯ Orthostatic Hypotension- Rapid decrease in BP and rapid increase in HR. Blood rushes from head/core.. Body compensates for this with baroreceptors. Lack of use makes the baroreceptors not respond as quickly causing this.
Respiratory System
Impacts of Immobility:
✯ Immobility causes decreased respiratory expansion. Can be further complicated by pain. You can have retained secretions in your lungs if you aren't taking deep breaths. This can lead to pneumonia. The alveoli can collapse when you aren't taking deep breaths.
⇢ Atelectasis- is the collapse of the alveoli. If they collapse there is less surface area for the gas exchange to occur= less gas exchange
⇢ Pulmonary Embolism (PE)- Blood clot travels through veins and lands in a vein in your lungs and impairs circulation to your lung tissue
▪︎ Musculoskeletal System
Impacts of Immobility:
✯ Muscle gets smaller & loses its shape. Contractures can occur (permanent contractions of a joint). If the joint doesn't move then it will get stuck.
⇢ Disuse Osteoporosis- Weakening state of the bone. Without weightbearing activity they break down faster than they can be built.
Integumentary System
Impacts of Immobility:
✯ Immobility makes the patient more prone to skin injuries. Like pressure ulcers or inflammation of the skin.
Neurological System
Impacts of Immobility:
✯ Patient may experience helplessness, body image disturbances, impaired coping, etc..
Urinary
Impacts of Immobility:
✯ Designed to work upright. The fluid becomes stasis (stays where it shouldn't) if the patient is not moving. Patients can experience UTIs, Urinary Retention (bladder holds onto extra fluids), increased kidney stones due to immobility (fluid is sitting and calcium is collecting).
Gastrointestinal/Metabolism
Impacts of Immobility:
✯ Immobility causes decreased appetite and anorexia. Decreased peristalsis of the GI tract. Can lead to nausea and constipation. When patients are immobile due to another illness it causes an increased need for nutrition and protein. Metabolic rate can exceed their intake.
Impacts
✯ _________ of Immobility
▪︎ Sleep & Rest
▪︎ Self-Perception & Self-Concept
▪︎ Roles & Relationships
▪︎ Coping & Stress Tolerance
▪︎ Sexuality
Nursing Process
✯_________ __________: Assessment

▪︎ Subjective
⇢ Normal pattern identification related to activity
⇢ Risk identification
➢➢ Patients on bedrest
➢➢ Risk for falls
⇢ Dysfunction identification
➢➢ Inability to tolerate activities

▪︎ Objective
⇢ General Survey
⇢ Neurological
⇢ Cardiovascular
⇢ Respiratory
⇢ Gastrointestinal
⇢ Urinary
⇢ Musculoskeletal
Diagnoses
✯ Nursing Process: ____________
▪︎ Impaired physical mobility
▪︎ Ineffective tissue perfusion
▪︎ Ineffective breathing pattern
▪︎ Impaired wheelchair mobility
▪︎ Impaired walking
▪︎ Activity intolerance
▪︎ Constipation
▪︎ Risk for injury
▪︎ Impaired transfer ability
▪︎ Impaired bed mobility
▪︎ Imbalanced nutrition: less than body requirements
▪︎ Urinary retention
▪︎ Risk for disuse syndrome
▪︎ Acute pain
▪︎ Risk for impaired skin integrity
Planning
✯ Nursing Process: ___________
▪︎ Establish measurable patient-centered goals and outcomes
⇢ Pt's lungs will be clear to auscultation by discharge
⇢ Patient will tolerate to sitting in a chair for 20 minutes within 2 days
Health Promotion
Nursing Process: Implementation
⇢ Physical fitness
⇢ Injury Prevention
➢ ➢ Osteoporosis prevention
▪︎ Systemic Interventions
Cardiovascular System
Nursing Process: Implementation
⇢ SCDs
⇢ Medication to thin their blood (anticoagulants)
⇢ Early Ambulation (improves blood flow)
⇢ Gradually change patient's position
Respiratory System
Nursing Process: Implementation
⇢ Deep Breathing & Coughing
⇢ Use of a Incentive Spirometer
⇢ Drinking more fluids (If allowed, helps to clear secretions)
⇢ Get them up and moving
Musculoskeletal System
Nursing Process: Implementation
⇢ Range of Motion Activities
⇢ Use of Devices
⇢ Foot Board or High Top Sneakers (prevent plantar flexion/ foot drop)
⇢ Early ambulation
⇢ Be aware of certain musculoskeletal restrictions
Integumentary and Neurological System
Nursing Process: Implementation
⇢ Stays clean and dry but well moisturized
⇢ Prevent wrinkles in the linens or gowns
⇢ Reposition patients
⇢ Let patients have some kind of control
⇢ Respect patient's space
⇢ Provide meaningful stimuli
Gastrointestinal
Nursing Process: Implementation
⇢ Increase fluid intake (decrease constipation)
⇢ Upright for meal
⇢ Get them ambulating/moving
Urinary
Nursing Process: Implementation
⇢ Increase fluids to keep flushing the system
⇢ Often frequent toileting
⇢ Upright position is better during elimination
Progressive Mobility
✯ Implementation: _________ _________
⇢ Progress mobility as the patient can tolerate
⇢ Dangle at the side of the bed
⇢ Must use non-slip socks
⇢ Use transfer belts and ambulation devices
⇢ Isometric exercises to enhance muscle strength
⇢ Obtain proper equipment and assistance
Evaluation
✯ _________
▪︎ Have goals and outcomes been met?
▪︎ Supporting documentation of progress, stagnation, or recession
▪︎ Modify or discontinue the care plan as needed
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