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Nursing Intro Ch47 - Mobility and Immobility

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