Comprehensive Guide to Mobility, Posture, and Nursing Interventions in Healthcare

Mobility

A nursing goal is to assist in preserving, maintaining, and restoring as much mobility and function as possible.

Assessment of Mobility

The assessment of mobility includes ROM, gait, and exercise.

Range of Motion (ROM)

Includes Active and Passive types.

Activity intolerance

An inadequate amount of physical or physiological energy to undergo or complete a necessary activity.

Activity tolerance

The capacity to successfully complete a necessary activity without distress.

Activities of daily living (ADL)

Basic essential skills that a person does independently every day and are usually related to personal care.

Cardiac Muscle

Only located in the heart and functions involuntarily.

Smooth Muscle

Located in the blood vessels and the visceral organs and functions involuntarily.

Skeletal Muscle

Attached to the skeleton (bones) by tendons and functions voluntarily.

Lordosis

Increased lumbar curvature.

Kyphosis

Increased thoracic curvature.

Scoliosis

Lateral curvature that can be thoracic, lumbar, or both - rarely cervical.

Torticollis

A postural abnormality affecting the neck.

Congenital hip dysplasia

A postural abnormality affecting the hip.

Knock-knee

A postural abnormality where knees go inward.

Bowlegs

A postural abnormality where legs curve outward.

Club foot

A postural abnormality affecting the foot.

Foot drop

A postural abnormality where the foot drags.

Immobility

A state of being unable to move, which can be due to bed rest or other factors.

Disuse atrophy

Muscular deconditioning due to lack of use.

Systemic Effects of Immobility

Includes metabolic changes, decreased appetite, electrolyte imbalances, and increased risk of bone fracture.

Gastrointestinal (GI) system functions

Can be affected by immobility, leading to constipation risk and pseudodiarrhea.

Respiratory changes

Includes atelectasis and hypostatic pneumonia as effects of immobility.

Nursing Interventions for Metabolic Changes

Includes high-protein, high-calorie diet, with Vitamin B and C, and may require enteral feedings.

TCDB

A nursing intervention that stands for Turn, Cough, Deep Breathe, used to prevent atelectasis and pneumonia.

Incentive spirometer

A device used to encourage deep breathing and lung expansion.

PO hydration

Oral hydration that helps keep skin moist and prevents breakdown.

TEDS

Compression stockings used to prevent blood clots.

SCDS

Sequential Compression Devices used to promote venous return and prevent blood clots.

Dangle legs prior to standing

A method to prevent orthostatic hypotension before standing.

Heparin

An anticoagulant medication used to prevent blood clots.

Lovenox

A low molecular weight heparin used to prevent blood clots.

ROM exercises

Range of Motion exercises to maintain joint flexibility and prevent atrophy.

Muscle atrophy recovery

It takes approximately 4 weeks to recover from atrophy due to immobility.

Skin assessment

Involves palpating for induration and assessing for color changes.

Abnormal reactive hyperemia characteristics

1) An area that does not blanch; 2) A reddened area that remains red for longer than 1 hour.

Proper Positioning

The process of intentionally placing the body in a specific way to promote comfort and prevent injury.

Common Patient Positions

Positions such as Trendelenburg and Reverse Trendelenburg used for patient care.

Devices Used For Positioning

Includes pillows, footboards, trochanter rolls, and wedge pillows.

Crutch Walking

Involves techniques like 2-point gait, 3-point gait, and 4-point gait.

Walker Walking

Sizing the walker while the patient is standing erect, with elbows flexed 15-30 degrees.

Cane Use

Should be used on the strong side, with specific measurements for placement and height.

Nursing Diagnosis Examples

Includes Risk for Disuse Syndrome, Impaired mobility, and Risk for Impaired Skin Integrity.