Transcript Principles of Mobility and Immobility

NURS 230/Spring 2014
Professor Sporbert
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Overview of exercise and activity:
◦ Body alignment
 Relationship of one body part to another
◦ Body balance
 Achieved by low center of gravity; enhanced by
posture
◦ Coordinated body movement
 A result of weight, center of gravity, and balance
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Overview of exercise and activity:
◦ Friction
 Force that occurs in a direction to oppose
movement
◦ Exercise and activity
 A patient’s individualized exercise program
depends on the patient’s activity tolerance or the
type and amount of exercise or activity that the
patient is able to perform.
 Isotonic exercises
 Isometric exercises
Skeletal
system
Muscles
concerned
with
movement
Joints
Ligaments,
tendons,
cartilage
Skeletal
muscle
Muscles
concerned
with posture
Muscle
groups
Nervous
system
Proprioception
Balance
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Developmental changes
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Infants through school-aged children
Adolescence
Young to middle adults
Older adults
Behavioral aspects
◦ Patients are more likely to incorporate an
exercise program if those around them are
supportive.
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Environmental issues
◦ Work site
◦ Schools
◦ Community
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Cultural and ethnic influences
Family and social support
Assessment
Diagnosis
Planning
Implementation
Evaluation
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Mobility
◦ The ability to move about freely
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Immobility
◦ Inability to move about freely
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Bed rest
◦ An intervention that restricts clients for therapeutic
reasons
Postural abnormalities
Scoliosis
Congenital defects such as:
•Spina Bifada
Damage to CNS
Damage to component that
regulates voluntary movement
Musculoskeletal trauma
Bruises, contusions, sprains, and
fractures
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Standing: head erect and midline; body
symmetrical; spine straight; abdomen tucked;
knees straight; hips and ankles flexed; feet
flat
Sitting: head erect; neck straight; weight on
buttocks and thighs; feet on the floor;
forearms supported
Recumbent: lateral position; vertebrae
straight without curves
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Recumbent position
Mobility
◦ Range of motion
◦ Gait
◦ Exercise
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Activity tolerance
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Activity intolerance
Ineffective coping
Impaired gas exchange
Risk for injury
Impaired physical mobility
Imbalanced nutrition: more than body
requirements
Acute or chronic pain
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Goals and outcomes
◦ Participates in prescribed physical activity while
maintaining appropriate heart rate, blood
pressure, and breathing rate
◦ Verbalizes an understanding of the need to
gradually increase activity based on tolerance
and symptoms
◦ Expresses understanding of balancing rest and
activity
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Setting priorities
Teamwork and collaboration
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Health promotion
◦ Teach patients to calculate maximum heart rate.
◦ Body mechanics
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Acute care
◦ Musculoskeletal system
◦ Joint mobility
◦ Walking
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Restorative and continuing care
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When moving a patient, knowledge of safe
transfer and positioning is crucial.
Pathological influences on body alignment
and mobility:
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Congenital defects
Disorders of bones, joints, and muscles
Central nervous system damage
Musculoskeletal trauma
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Range of joint motion
◦ Used to determine limitation/injury to a joint
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Gait
◦ Manner or style of walking, including rhythm and
speed
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Exercise/activity tolerance
◦ Physical activity for conditioning body, improving
health, maintaining fitness, therapy- includes
physical and/or occupational
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Range of joint motion
◦ Active: patient is able to move his or her joints
◦ Passive: nurse moves the patient’s joints
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Walking
◦ Canes
◦ Crutches
◦ Measurements
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Immobilized patient
◦ Use of proper body mechanics moves patients safely and protects
nurse from injury
Dependent patient
◦ Assists patient with regaining optimal independence, joint
movement, increases strength, promotes circulation, relieves
pressure on skin, improves respiratory and urinary function
What types of Equipment are available to you:
Hoyer Lifts
EZ-stands
Gait Belts
Wheelchairs
Walkers
Canes
Crutches
As the nurse you have to assess the mobility status of your patientsto determine the safest transfer technique and equipment
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Fowler’s
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◦ HOB elevated, support
and align hips and spine
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Supine
◦ Back lying, support with
pillows, trochanter rolls,
splints
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Prone
◦ Face down
Lateral
◦ Side lying with proper
spine alignment
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Sims’
◦ Semiprone on right or left
side with weight placed
on Ilium, humerus, and
clavicle
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Physiological
Psychological
Psychosocial
Developmental
◦ Very young
◦ Older adult
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Sociocultural –refer to box 47-5
Environmental Factors
◦ Surrounding conditions
Metabolic
Respiratory
Endocrine, calcium absorption, and GI
function
Atelectasis and hypostatic pneumonia
Cardiovascular
Musculoskeletal changes
Orthostatic hypotension
Thrombus
Loss of endurance and muscle mass
and decreased stability and balance
Muscle effects
Skeletal effects
Loss of muscle mass
Muscle atrophy
Impaired calcium absorption
Joint abnormalities
Elimination- GI and GU
Urinary stasis
Renal calculi (kidney stones)
Constipation
Integumentary
Pressure ulcer
Ischemia
 Immobility
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can cause emotional changes.
Depression
Sleep-wake disturbances
Impaired coping
Infants, Toddlers,
Preschoolers
Prolonged immobility delays gross
motor skills, intellectual development
or musculoskeletal development
Adolescents
Delayed in gaining independence and
in accomplishing skills
Social isolation can occur
Adults
Older Adults
Physiological systems are at risk
Changes in family and social
structures
Decreased physical activity
Hormonal changes
Bone reabsorption
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Immobility can cause an excessive amount of
time and energy for the care-giver; as well as,
financial constraints.
Living conditions for the client:
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Hospitalization.
Extended care facility.
Rehabilitation facility
Home Care.
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Must assess the patient’s past and present mobility and the potential
effects of immobility.
Health History
Physical Examination of Mobility
What is their ROM? What exercises can they do for
themselves, assess their ability to move
extremities- are there strengths and weaknesses?
◦ Body alignment
◦ Gait
◦ Joints
◦ Skeletal muscles
◦ Neurovascular function
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Physiological Systems Continued
◦ Respiratory system
◦ Metabolic system – Fluid & Electrolytes/nutrition
◦ Cardiovascular system
◦ Musculoskeletal system
◦ Skin Integrity
◦ Elimination system
◦ Skeletal system
◦ Muscle effects/systems
Psychological condition
Developmental state
Sociocultural factors
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Group
Group
Group
Group
1-Respirtory changes
2-Cardiovascular changes
3-Elimination/Bowel and Bladder
4-Integumentary changes
Assessment
1. What is the subjective data
2. What is the your objective data
B. Nursing diagnosis: Primary diagnosis? Why?
 C. Planning: order or rank the nursing diagnosis and
interventions in prioritiesD. 1-2 Nursing Interventions pick and rationales-why?
E. Evaluating patient care outcomes
◦ What are 1-2 expected patient outcomes from your
interventions
 Include in your care plans if applicable:
 6.Think about the benefits of therapy and how it could impact
improving mobility
 7. Should you incorporate physical and/or occupational therapies
and why
A.
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Mr. WW is an 87 year old male admitted to The Woodland
for fracture of C1-C2 secondary to fall at home. He has
end stage COPD. History of depression, DJD, and chronic
back pain. He has an unproductive cough, increased
congestion noted. Lung sounds diminished at the bases. Is
dependent for all ADL’s and has limited mobility, needs 2
for transfers. Patient has PT ordered. Ordered 3L of
oxygen via NC His vital signs are: BP 130/80, RR 14, pulse
ox 88% on 3LNC, T 98.7.
Identify subjective and objective data
What other nursing assessments should you collect
Without using impaired physical mobility as a primary
diagnosis; identify patient’s risk factors- create a care plan
that identifies the respiratory risks you have identified.
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Mrs. VL is a 67 year old female, resident of the woodland.
Her primary diagnosis is Congestive heart failure. Her past
medical history includes: AMS, Parkinson’s, HTN,
depression, dementia, cardiac arrhythmias, and status
post (s/p) fall. Her morning vital signs are: BP 110/60 RR
22, P 88, 90% at rest on RA, T 97.5. Mrs. VL typically
spends her day in the wheelchair or in bed. She has bed
and fall alarms in place. Transfers with assistance of one
and becomes short of breath with exertion and activity.
She has a poor appetite, is on thickened liquids, and
needs to be reminded to drink fluids.
Identify subjective and objective data
What other nursing assessments should you collect
Without using impaired physical mobility as a primary
diagnosis; identify cardiac risk factors- create a care plan
that identifies the risks you have identified.
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Mrs. CR is a 79 year old female admitted to the woodland s/p fall
at home. She has a medical diagnosis of head trauma as a result
of the fall. Past medical history includes HTN, Depression, CVA,
Osteoporosis, PVD and CAD. She is out of bed to chair with the
use of a rolling walker and ambulates short distances in her
room. She needs the assistance of one for transfers. There are
no physician orders for therapy. She is reported to sleep several
hours of day in bed or chair and needs frequent stimuli by staff.
Her appetite is fair and she needs to be encouraged to drink
fluids. She complains of facial pain and is ordered hydrocodone
q4hrs for pain. Her prn meds include colace 1 tab BID po. MOM
30cc as needed if no BM in 3 days. Last BM documented 3/4/11.
BP 108/66 P 66 RR 16 T: 98.1 pulse ox 92%RA. Pain is 5/10.
What other nursing assessments should you collect
Without using impaired physical mobility as a primary diagnosis;
identify elimination risk factors- create a care plan that identifies
the risks.
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Mr. RH is a 71 year old male admitted to the woodland following a right hip fx with
nailing s/p fall. Hx of DVT with IVC filter, HTN, heart murmur, dementia, and DM. He is
alert and occasionally disoriented. He is on oxygen 2L NC prn. Orders are for pulse ox
<90% to resume 02 as directed. He has a 3 surgical sites to anterior portion of right
thigh. Staples removed with steri strips intact. Scant amount of serosangious blood to
one surgical site. Right thigh is swollen and warm to the touch.
Patient is continent and uses the urinal, but shift report notes resident was incontinent
during the night. Patient was admitted to the woodland with a stage 2 pressure ulcer to
coccyx. Physician orders are for xenoderm topically bid to stage 2 pressure ulcer. Patient
is also to receive physical therapy 2-3 x a day x 5 days. Patient did not have physical
therapy yesterday and has not gotten out of bed (OOB). Patient needs an assist of 2 for
all personal care, meal set-up, and transferring to w/c. Patient is toe touch weight
bearing to right leg. Patient complains of pain to right leg and is ordered hydrocodone
2 tabs q 4 hours for pain. VS: 130/66 P 66 RR 16 pulse ox 89% RA, T 99.0. pain 6/10
What other nursing assessments should you collect
Without using impaired physical mobility as a primary diagnosis; identify integumentary
risk factors- create a care plan that identifies the risks.
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1.
A client who was in a car accident and broke his femur has
been immobilized for 5 days. When the nurse gets this client out of
bed for the first time, a nursing diagnosis related to the safety of
this client will be:
A. Pain
B. Impaired skin integrity
C. Altered tissue perfusion
D. Risk for activity intolerance
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Risk for activity intolerance
RationaleBeing on bed rest limit cardiac function, moving
the client from a lying or supine position to an
upright position will require an immediate
cardiac workload, increase oxygen demand and
will cause your patient to be short of breath and
exhibit an intolerance to activity. If you get your
client up to fast, without allowing time for
positional changes to their cardiac system- the
risk of falls increases.
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2.
The nurse is caring for a client who has right-sided weakness.
The nurse needs to help the client walk. What should the nurse do
while walking with the client?
A. Hold the client’s left hand while walking
B. Hold the client’s right hand while walking
C. Put a gait belt on the client and provide support on the left side
D. Put a gait belt on the client and provide support on the right side
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Put a gait belt on the client and provide
support on the right side
Rationale:
With right-sided weakness this is the side
that needs support during ambulation,
transfers, etc.
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#3 A client is diagnosed with osteoarthritis (OA), tells a clinic nurse
about the inability to ambulate and staying on bed rest because of
hip stiffness. In addition to teaching the client measures to reduce
joint stiffness, which referral for the client should the nurse plan to
discuss with the health care provider?
A. Social worker
B. Occupational therapy
C. Arthritis Foundation
D. Physical Therapy
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Physical Therapist- rationale:
The P.T. can assist the client in adopting
self-management strategies and teach
isometric, postural, and other exercises that
prevent joint overuse.
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#4. A client is admitted to the rehab unit following a Right total hip
replacement (THR). The client is 3 days post-op. Doctor order
states: activity is weight bearing as tolerated with assistance. Which
nursing intervention should be implemented?
A. Assisting the client to get out of bed on the left side so the client
can stand to use the urinal
B. Assisting the client using a gait belt to the commode
C. Log rolling client on the right side to assist the client out of bed
D. Assisting the client to the bathroom, which has grab bars , an
elevated toilet seat, using a walker, and partial weight bearing of the
right leg.
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Assisting the client to the bathroom, which
has grab bars ,elevated toilet seat, using a
walker, and partial weight bearing of the right
leg.
Rationale: on the second day post-op your
patient should be up and walking with a
walker and have doctor orders that
stipulating weight bearing restrictions. An
elevated toilet seat is used to prevent hip
flexion of >90 degrees when the client sits.
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#5
To prevent circulatory compromise after a right
total knee replacement, a nurse should ensure
that the client is:
A. flexing both feet and exercising uninvolved
joints every hour while awake
B. using the CPM machine every 2 hours for 30
minutes
C. Assisted up to the chair as soon as the effects
of anesthesia have worn off
D. Using the trapeze to life the buttocks off the
bed and then rotating each leg intermittently
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flexing both feet and exercising uninvolved
joints every hour while awake- the flexing will
promote muscle contraction and reduce the
risk of DVT
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#6
The nurse is assessing a resident who is 3 days
post-op following a right total hip replacement.
In assisting the resident up to the chair- which of
the following findings require the nurse to
intervene immediately?
A. Reddened area on the Sacrum
B. Voiding concentrated urine, 50ml/hr
C. Capillary refill 3 seconds, dorsiflexon and
sensation intact, pedal pulses palpable
D. Hip incision well approximated with 5 steristrips in place.
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Reddened area on sacrum is indicative of a
pressure ulcer, damage to underlying tissues
has already occurred.
Urinary output is 30ml/hr indicates adequate
kidney function.
These assessments indicate good circulation
and perfusion
Assessment of incision suggests good
healing process