Transcript Motor Needs
Nursing Management of Clients with Stressors that Affect Motor Function NUR101 Fall 2008 LECTURE # 4 K. Burger, MSEd, MSN, RN, CNE PPP By: Sharon Niggemeier RN MSN Revised KBurger806 Mobility Related to the fulfillment of other basic needs Requires an intact musculoskeletal and nervous system Body Mechanics = efficient use of body; coordination of muscles/bones/nerves Assessing Motor Functioning Developmental considerations Physical Health Mental Health Lifestyle/ Health habits Nerve impairments Skeletal abnormalities Muscular impairments Fatigue/Stress External factors Gait/Posture Assessment of Impaired Mobility Underlying conditions affecting mobility? ROM; MAE? What is range (degrees)? Gait steady? Standing erect? Immobility effects on body systems? Psychosocial effects? Developmental effects? Client expectations? Nursing Diagnosis ACTUAL Impaired physical mobility RISK Risk for disuse syndrome Risk for: Impaired skin integrity Ineffective airway clearance ETC. ETC. ETC. Planning “Client will walk 100 feet unassisted with steady gait by 9/22/06” “Client will maintain intact skin throughout hospital stay” “Client will increase abduction ROM of R shoulder to 180degrees within 2 months” Effects of Immobility on the Body Cardiovascular Increased workload Increased risk for venous thrombus Increased risk for orthostatic hypotension Nursing Interventions Ambulate ROM (Range of motion) exercises Avoid prolonged knee/hip flexion Never massage calf muscles Apply antiembolitic stockings/ sequential TEDS Sleep with HOB elevated Effects of Immobility on the Body Respiratory Decreased respiration rate and depth Pooling of secretions Impaired gas exchange Nursing Interventions Ambulate T & P q2h (turn and position every 2 hours) Encourage coughing and deep breathing Keep hydrated Effects of Immobility on the Body Gastrointestinal Appetite changes Constipation Altered digestion of nutrients Nursing Interventions Ambulate T&P q2h Increase fluids and fiber ROM exercises Maintain regular exercise Hi protein, Hi Kcal Effects of Immobility on the Body Musculoskeletal Decreased muscle tone & strength Decreased flexibility, joint movement Decreased endurance Increased contracture formation Bone demineralization Nursing Interventions Ambulate ROM Encourage ADLs Apply assistive devices (braces/splints) Encourage participation in physical therapy rx Effects of Immobility on the Body Integumentary (skin) Increased risk for skin breakdown !!!!! Pressure sores/ decubitus ulcers Nursing Interventions Ambulate ROM T&P Skin dry & clean Bed linens wrinkle free Apply assistive devices (heel pads/ specialty mattress) Good nutrition Reduce shearing forces Effects of Immobility on the Body Psychological Well-Being Increased risk for depression Decreased self esteem Decreased socialization Altered sleep pattern Nursing Interventions Ambulate Encourage independence Increase socialization Increase stimuli Effects of Immobility on the Body Urinary Increased urine stasis Risk for renal calculi Decreased bladder muscle tone Increased risk for UTI (urinary tract infection) Nursing Interventions Ambulate Encourage fluids Maintain usual voiding pattern Assist with bedpan/urinal Position for full bladder emptying Effects of Immobility on the Body Metabolic System Increased risk for electrolyte imbalance Altered exchange of nutrients and gases Nursing Interventions Provide appropriate diet- high calorie/high protein Monitor intake and output Monitor weight Monitor lab values Monitor skin turgor Explore alternatives to oral feedings Meeting Motor Needs Nursing Responsibilities Exercise: prevents illness and promotes wellness Isotonic Isometric Isokinetic Range of motion exercises Range Of Motion Goal: to exercise and keep body in best possible physical condition when bedrest is needed or immobility is present PROM- passive ROM – patient is unable to move independently and the nurse moves each joint through full range of motion AROM- active ROM – patient able to perform joint movement through full range of motion ROM Explain what each exercise is and how it is done Move each joint through full range of motion Move to point of resistance not pain Perform each movement 5 times smoothly and evenly several times a day Allow for rest periods prn ROM Return body part to normal anatomical position Avoid friction LIFT body part don’t drag Utilize cupping, cradling and supporting to prevent muscle/joint injury Note drastic change in VS, extreme fatigue. ROM Exercises Adduction Abduction Flexion Lateral Flexion Extension Hyperextension Supination Pronation Rotation Internal Rotation External Rotation Circumduction Opposition Dorsiflexion Plantar flexion Inversion Eversion Transferring Safety is the MAJOR concern Know Dx, ability to bear weight, medications Confirm MD activity order Plan for assistance Position bed to proper height/Lock wheels Skid-free shoes, sensible clothing Clutter free environment Transferring Use proper body mechanics Maintain body alignment Use assistive devices Hoyer Lift Medicate for pain prn Have patient assist as much as possible Explain! Use coordinated count and movement Motor Needs Log rolling Dangling Ambulating Walker/Canes/Crutches Principals of Body Mechanics Efficient way to use your body as a machine while caring and transferring for patients. Also used to maintain personal health and well being. Body Mechanics based on 4 components Balance Posture (body alignment) Coordinated body movement Postural reflexes Principles of Body Mechanics Ask for help !!!!!!!!!!!!!!!! Maintain erect posture ( wide base of support & low center of gravity) Bent at the knees NOT with your back Use strong arm/leg muscles for power Maintain internal girdle to support abdomen Work close to an object Principles of Body Mechanics Better to Push objects then to pull (not patients) Better to slide/push or pull objects than lift. Use body weight as a force for motion Use back supports Meeting Motor Needs Nursing Responsibilities Position pt. correctly to maintain alignment Use devices to aid in positioning Pillows Mattresses Adjustable beds Trapeze Footboard Side rails Hand rolls/splints/braces Trochanter rolls / sandbags / wedge pillows Siderails Meeting Motor Needs Nursing Responsibilities Protective positioning Fowlers Supine Dorsal Lateral Sim’s Prone recumbent Summary: Promoting Mobility Nursing responsibility Need to prevent complications related to immobility Need to evaluate effectiveness of nursing interventions