class 11

Mobility

a person’s ability to move about freely

Immobility

the inability for a patient or person to move about freely

Bed Rest

an intervention that restricts patients to bed for therapeutic reasons and is sometimes prescribed for selected patients

Clients experience____ ___ in the healthcare setting due to deconditioning

functional decline

What is functional decline?

The loss of the ability to perform self-care or activities of daily living.

What is deconditioning?

physiological changes after a period of inactivity

Body Mechanics

the coordinated efforts of the musculoskeletal and nervous systems [to initiate and control movement] how the brain communicates to the musculoskeletal system to promote movement

Balance and Alignment

_________is the ability to maintain the body's center of gravity over the base of support.

__________refers to the positioning of joints, muscles, and bones to promote optimal

Gravity

the force that pulls objects toward the center of the earth, affecting balance and movement

Friction

a force that occurs in a direction to oppose movement [force that resists motion between two surfaces, providing traction to prevent slips and falls during movement]

What does the Skeletal system do?

provides structural support, protects vital organs, enables movement, produces blood cells, and stores minerals.

What are bones made of? What are the types of bones?

composed of a collagen matrix reinforced with calcium phosphate minerals. 

The types are long (e.g., femur), short (e.g., carpals), flat (e.g., ribs), and irregular (e.g., vertebrae). 

What is a joint?

the area where two or more bones are attached, allowing varying degrees of movement

How does the nervous system regulate movement and posture?

regulates movement and posture through the integration of sensory input from proprioceptors in muscles and tendons with motor output from the brain and spinal cord to coordinate muscle contractions

An Intact and ______ and _____systems are necessary for optimal physical mobility and functioning.

 

musculoskeletal and nervous

Kyphosis

An exaggerated outward curvature of the thoracic spine can limit mobility, cause pain, and restrict breathing due to compression of the chest cavity

Lordosis

An abnormally accentuated inward curvature of the lumbar spine can lead to back pain, difficulty standing upright, and impaired mobility due to muscle imbalances and postural strain.

Scoliosis

The lateral curvature of the spine in scoliosis can cause muscle imbalances, pain, restricted range of motion, and potential impingement on organs like the lungs and heart in severe cases, limiting physical abilities.

Muscle abnormalities (impact on mobility)

muscular dystrophy, myasthenia gravis, or muscle atrophy can severely limit mobility due to progressive muscle weakness, fatigue, and loss of strength and coordination

Damage to the CNS (impact on mobility)

conditions like stroke, traumatic brain injury, or spinal cord injury can impair mobility by disrupting the neural pathways controlling voluntary movement, balance, and posture

Musculoskeletal trauma (impact on mobility)

fractures, sprains, or tears can temporarily or permanently restrict joint range of motion and weight-bearing ability, limiting independent mobility and increasing fall risk. 

Joint Disease (impact on mobility)

rheumatoid arthritis, osteoarthritis, or gout can cause joint pain, stiffness, deformity, and inflammation, progressively limiting joint flexibility and mobility over time.

What is orthostatic hypotension?

a drop in blood pressure (systolic pressure by at least 20 millimeters of mercury or drop in the diastolic pressure by at least 10 millimeters of mercury) [changing positions] upon standing due to blood pooling, can occur with immobility. 

thrombus

a blood clot formed from platelets, fibrin, and cellular blood components that attaches to the interior wall of a vein or artery, potentially obstructing blood flow.

Describe the impact hospitalization has on the older adult’s functional ability?

enforced immobility, unfamiliar environments, and acute illness. Prolonged bed rest leads to deconditioning, loss of muscle strength and endurance, and increased risk of falls upon discharge. The hospital routine may disrupt normal sleep-wake cycles and self-care abilities.

How does nutrition affect the patient’s functional ability?

Malnutrition causes muscle wasting, weakness, fatigue, impaired wound healing, and increased susceptibility to infections - all of which hinder physical function and independence with activities of daily living.

How can a nurse assess a client’s mobility status?

Observe the client's gait, balance, use of assistive devices, and ability to perform activities like transfers and ambulation. Interview the client about any limitations, pain, weakness, or dizziness affecting mobility. Perform functional assessments like the Timed Up and Go test, assessing range of motion, strength, and ability to complete activities of daily living. Evaluate environmental factors like obstacles or safety hazards. Consider the client's age, medical conditions, medications, and psychosocial factors that may impact mobility

See through the client’s eyes

Is the limitation in mobility sudden and unexpected, causing the client to be fearful or full of questions?

Mobility

range of motion

activity tolerance

Gait

Manner or Style of Walking

Exercise Pattern

Exercise History

Body Alignment

Observe the appearance and position of your' client’s extremities

Immobility

-Thrombus Formation

-Pressure injuries

-Respiratory Complications

Define ROM (range of motion)

maximum amount of movement available at a joint in one of the three planes of the body

What are the three types of ROM exercises?

The three types are active (client moves joint independently), passive (nurse/caregiver moves joint for client), and active-assistive (client initiates movement with help).



~Active (patient does the ROM, but they need prompting or reminding), ~Active assisted (providing support for a patient who is weak and assist a patient while they perform most of the joint movement, but you’re only assisting them), 

~passive (you are actually doing the ROM for the patient). 

How do we perform ROM?

moving each joint through its full, available range. 

What is a contracture?

is a permanent shortening and hardening of muscles, tendons, or other tissues around a joint, limiting joint mobility. 

Where are contractures normally found?

occur in joints immobilized for prolonged periods

How do we prevent client’s from getting a contracture?

through regular ROM exercises

Define Activity tolerance

the type and amount of exercise or work that a patient is able to perform without undue exertion or injury.

-need to know your limitations with the patient

What are some factors that influence activity tolerance?

age, fitness level, motivation, pain, respiratory status, and cardiovascular function.

What are some assessment findings that indicate the client is not tolerating the activity?

excessive shortness of breath, dizziness, pallor, diaphoresis, and marked increases in heart rate or blood pressure. 

How can an abnormality in gait contribute to a fall?

shuffling, asymmetry, or poor balance and coordination increase the risk of tripping and falling, especially when combined with muscle weakness, visual impairments, or environmental hazards.

What are some nursing diagnoses for a client with impaired mobility?

Impaired Physical Mobility related to factors like pain, muscle weakness, joint stiffness, or deconditioning.

Risk for Impaired Skin Integrity related to immobility and pressure on bony prominences.  

Risk for Falls related to gait disturbances, muscle weakness, or environmental hazards.

Deficient Knowledge regarding assistive devices, exercise, or safety precautions 

Disturbed Sleep Pattern related to discomfort, immobility, or medication side effects.

Activity Intolerance related to imbalance between oxygen supply and demand.

diagnoses that can apply for patients’ immobility:

-impaired physical mobility

-ineffective airway clearance

-impaired urinary elimination

-risk for disuse syndrome

-risk for constipation

-risk for impaired skin integrity because risk for pressure injuries

-social isolation especially if patient can’t get out, can’t socialize

Implementation:

increase patient mobility

reduce the impact that the immobility has on the patient’s outcome

What are some nursing interventions that promote mobility and prevent the complications of immobility?

- Encouraging early and frequent ambulation as tolerated

- Assisting with active range of motion exercises

- Providing mobility aids like walkers or canes

- Implementing a scheduled toileting program

- Repositioning immobile patients frequently

- Applying sequential compression devices

- Ensuring adequate nutrition and hydration

- Providing diversional activities and socialization

- Educating on the importance of mobility and ways to stay active

Falls are the leading cause of both _____ and ______injuries for those 65 years and older. 

fatal and nonfatal

intrinsic factors

age, chronic illnesses, cognitive impairment, vision problems, gait/balance deficits, muscle weakness, medications that cause dizziness or drowsiness, and a history of previous falls

extrinsic factors

hospital environment and care processes, such as cluttered rooms, poor lighting, incorrect bed height, lack of mobility aids, restraint use, and staffing issues.

universal fall precautions

to create a safe environment and include interventions like keeping beds low, removing tripping hazards, using non-slip footwear, ensuring adequate lighting, keeping essential items within reach, utilizing mobility aids appropriately, providing patient education, implementing hourly rounds, using bed/chair alarms for high-risk patients, and ensuring call lights are accessible.

fall risk factors

-alcohol or substance use, non-proper fitting shoes, underlying medical conditions such as neurological, cardiac (orthostatic hypotension), or other disabling conditions, polypharmacy   and side effects of medications

-physical inactivity and loss of balance, particularly among older adults,

-poor mobility (impaired balance, gait, coordination), cognition, and vision)

-unsafe environments (broken stairs, icy sidewalks, inadequate lighting, throw rugs, exposed electrical cords, barriers along walking paths, and improper devices for ambulation

Interventions associated with universal fall precautions

Keeping the bed in a low position with brakes locked

Removing potential fall hazards from the environment 

Using non-skid footwear

Ensuring proper lighting

Keeping frequently used items within reach

Using appropriate mobility aids like canes or walkers

Providing patient education on fall prevention strategies

Implementing hourly rounding to proactively address needs

Utilizing bed/chair alarms for high-risk patients

Ensuring call lights/assistive devices are accessible

Walker

lightweight, movable device that stands about waist high with four widely placed sturdy legs. Used by patient who has lower extremity weakness or has problems with balance

-useful for patients who have difficulty lifting and advancing the walker as they walk bc of limited balance or endurance

Canes

-provides less support than a walker and are less stable

-most common cane is the straight-legged, the length of which should be equal to the distance between the greater trochanter and floor

*Have the patient keep the cane on the stronger side of the body

How do you assist a client that you are walking that is having a syncopal episode or is becoming too weak to ambulate?

immediately assist them to the floor in a controlled manner to prevent falls and injury. Call for help. Keep the client flat and elevate their legs if possible to promote blood flow to the brain. Loosen any restrictive clothing. Monitor vital signs and level of consciousness. Provide supplemental oxygen if needed.

Stay with the client until they regain consciousness and strength, or until additional personnel arrive to assist in transferring them safely back to bed

Explain how the physiological changes in older adults affect their safety.

-significantly impact an older adult's safety. Sensory changes like impaired vision, hearing loss, and decreased sensitivity to temperature extremes increase accident risks.

-Slowed reaction time and cognitive changes make it harder to recognize and respond to hazards. Gait and balance problems elevate the risk of falls. Decreased muscle strength and coordination affect mobility.

-Thermoregulatory issues make older adults more prone to hypothermia and hyperthermia. Medication effects like dizziness or drowsiness are also contributing factors.

safety devices

variety of physical restraints to partially or fully limit patient’s mobility

chemical restraints

medications administered to agitated patients to control unsafe physical movements and behaviors; medications: Haldol (elderly population), Ativan, Versed.

-Ativan sometimes causes idiosyncratic effect on elderly population, can make them more excited instead of more sedative

physical restraints

wrapped, buckled, or tied to a patient’s arms, legs, or trunk of the body to limit or restrict movement (waist, ankles, wrist)

-least restrictive forms of restraint must be tried first before the most restrictive

 

Discuss instances when restraints are necessary for the healthcare setting

when patients are at risk of harming themselves or others, or repeatedly attempting to remove life-sustaining medical devices.

Explain the differences between chemical and physical restraint.

________immobilize or restrict a patient's movement, while ____________ restraints involve medications to manage behavior.

What should the nurse monitor if a patient is in physical restraints?

the nurse should closely monitor vital signs, skin integrity under the restraint, circulation, range of motion, nutrition/hydration, hygiene needs, cognitive and psychological status, and the ongoing need for restraint use.

Restraint alternatives and least restrictive forms of restraints must be tried ___

before using more restrictive restraints

What is a seizure? Who is at risk?

an abnormal, excessive electrical discharge of neurons in the brain causing involuntary movements, sensory disturbances, and altered behaviors

Anyone can experience a seizure, but those at higher risk include people with seizure disorders, brain injuries, infections, tumors, or metabolic disturbances.

What are seizure precautions?

include keeping the area safe by removing objects that could cause injury, protecting the patient's airway, not restraining movements, staying with the patient, and timing the seizure. 

What do you do if a patient experiences a seizure?

-remain calm,

-protect them from injury,

-loosen tight clothing,

-do not place anything in their mouth,

- turn them on their side if possible, and

-time the duration.

-Seek emergency care if it lasts over 5 minutes, repeated seizures occur, or injury happens

Patients on bed rest are likely at risk for which

physiologic effects and conditions?

Select all that apply.

A. Tissue ischemia

B. Decreased lung expansion

C. Decreased cardiac workload

D. Atelectasis

E. Pneumonia

A. Tissue ischemia

B. Decreased lung expansion

D. Atelectasis

E. Pneumonia

Patient reports of shortness of breath and

fatigue while performing activities of daily

living are indicative of which alteration?

A. Orthostatic hypotension

B. Deep vein thrombosis

C. Activity intolerance

D. Renal Calculi

C. Activity intolerance

Which evaluative cue alerts the nurse

that a patient with Activity Intolerance is

improving?

A. Ambulates 15 feet with shortness of breath

B. Has a heart rate of 110 beats/min when ambulating

C. Brushes hair while sitting in chair with assistance

D. Has a pulse oximetry reading of 96% when standing to brush teeth

D. Has a pulse oximetry reading of 96% when standing to brush teeth

Which response would the nurse make to an

immobile patient who says, “I am just not hungry.

I don’t understand it. I am always hungry”?

A. “Don’t worry about it, every patient gets that way in the hospital.”

B. “Your loss of appetite is unusual; I will let your health care provider

know.”

C. “You have been immobile for several days, which can decrease your metabolism and appetite.”

D. “Your lack of appetite is your body’s way of telling you that bed rest interferes with your body’s ability to digest food and not to eat too much

D. “Your lack of appetite is your body’s way of telling you that bed rest interferes with your body’s ability to digest food and not to eat too much

Which interventions would the nurse implement

for a patient with lower extremity Paralysis?

Select all that apply.

A. Apply oxygen.

B. Turn every 2 hours.

C. Arrange for a special bed.

D. Use a gait belt for transfers and ambulation.

E. Perform range-of-motion (ROM) exercises at least two times per day

B. Turn every 2 hours.

C. Arrange for a special bed.

E. Perform range-of-motion (ROM) exercises at least two times per day

Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills?

A. Place the patient flat in bed.

B. Encourage the patient to take deep breaths.

C. Assess the patient for signs of deep vein thrombosis.

D. Notify the health care provider that the patient may have pneumonia.

D. Notify the health care provider that the patient may have pneumonia.

In which area would the nurse place a pillow

for a patient in the supine position?

A. Between the legs

B. Under the calves

C. Between the arms

D. Under the scapula

B. Under the calves

Which safety measures would the nurse

implement for a patient who is a fall risk?

Select all that apply.

A. Use a low bed

B. Remind clients to walk around spills

C. Raise all four side rails

D. Frequently orient the patient

E. Keep bed brakes locked

A. Use a low bed

D. Frequently orient the patient

E. Keep bed brakes locked

The nurse is instructing a client who had a stroke

and has weakness on one side how to ambulate

with the use of a cane. Which instruction would

the nurse provide to the client?

A. Hold the cane on the affected (weak) side.

B. Hold the cane on the unaffected (strong) side.

C. Move the cane forward first along with the unaffected (strong) leg.

D. Move the cane and the unaffected (strong) leg down first when going down stairs

B. Hold the cane on the unaffected (strong) side.

Which negative outcomes resulting from

the use of physical restraints would the

nurse identify? Select all that apply.

A. Death

B. Diarrhea

C. Fractures

D. Incontinence

E. Reduced bone mass

A. Death

D. Incontinence

E. Reduced bone mass

The nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which findings noted by the nurse are indicative of impaired circulation? Select all that apply.

A. Areas of pallor

B. Capillary refill <2 seconds in both hands

C. Areas of erythema

D. Impeded pulse on wrists

E. Decreased movement

F. Heightened sensation

G. Decreased temperature

H. Reports of pain or tingling

A. Areas of pallor

D. Impeded pulse on wrists

E. Decreased movement

G. Decreased temperature

H. Reports of pain or tingling

The nurse is providing instructions to the assistive

personnel (AP) who will be caring for a client with hand restraints. The nurse asks the AP to repeat the instructions to ensure that the AP understands the care.

Which statement, if made by the AP, indicates an

understanding of the care for this client?

A. "I need to remove the restraints every 4 hours.”

B. "I need to make sure that the restraints are securely tied to the side rails.”

C. "If the family comes in to visit, I can tell them to take the restraints off if they want to.”

D. "I need to remove the restraints at least every 2 hours to perform range of motion exercises

D. "I need to remove the restraints at least every 2 hours to perform range of motion exercises