NURS3802 Module 20: Care of the Patient with Mobility Challenges

the degree of movement

Define range of motion.

low muscle tone, flaccidity

Define hypotonicity.

high muscle tone, rigid, spastic

Define hypertonicity.

no control of voluntary movement

Define ataxia.

paralysis of one side of the body (right or left)

Define hemiplegia.

paralysis below the waist

Define paraplegia.

paralysis of all four limbs

Define quadriplegia.

weakness on one side of the body

Define hemiparesis.

wasting away of muscle due to lack of use

Define atrophy.

increase in muscle size

Define hypertrophy.

- hypertrophy of muscle cells and prevention of atrophy

- increases endurance

- decreases activity intolerance

- promotes joint mobility

- prevents contractures

- slows or prevents osteoporosis

- burns calories

- reduces feelings of stress

- promotes well-being by increasing endorphins

What are benefits of exercise?

weight bearing

What type of exercise helps prevent osteoporosis?

exercise that requires oxygen metabolism for energy

What is aerobic exercise?

- running

- biking

- swimming

- brisk walking

- dancing

What are examples of aerobic exercise?

- some chronic illnesses limit blood flow needed for aerobic exercise

- anemia limits oxygenation of muscle fibers

How can chronic illnesses affect an individual's ability to perform aerobic exercise?

exercise that starts as aerobic until the muscles can't get enough oxygen

What is anaerobic exercise?

- weight lifting

- sprinting

- high-intensity interval training

What are examples of anaerobic exercise?

converting stored glycogen into energy which produces lactic acid

How do anaerobic pathways provide energy?

exercise with constant muscle contraction, flexion and extension of joints

What is isotonic exercise?

isotonic

Carrying out ADLs is an example of what kind of exercise?

- increases muscle tone

- increases muscle mass

- increases strength

What are benefits of isotonic exercise?

exercise where the muscles tense and relax without flexion or extension of the joints

What is isometric exercise?

- plank

- leg lifts

- wall sits

What are examples of isometric exercise?

no, but it can help improve some risks of immobility

Will isometric exercise prevent contractures?

- medications

- surgery

- mobility limitations

- dementia and confusion

- orthostatic hypotension

What makes a patient at risk for falls?

flexion

extension

hyperextension

rotation

circumduction

abduction

adduction

supination

pronation

- disuse osteoporosis

- disuse atrophy and muscle weakness

- decreased endurance

- contractures

- joint weakness and pain

How does immobility affect the musculoskeletal system?

- risk for injury

- risk for falls

- activity intolerance

- impaired mobility

- pain

What are musculoskeletal nursing diagnoses related to immobility?

- orthostatic hypotension

- thrombus and embolism formation

- dependent edema

How does immobility affect the cardiovascular system?

blood pools in the veins when the patient is supine which causes decreased cerebral blood flow when the patient stands

How does immobility cause orthostatic hypotension?

- dyspnea

- tachycardia

- discomfort

- weakness/fatigue

- elevated respirations

- elevated BP

What are signs and symptoms of activity intolerance?

- decreased cardiac output

- activity intolerance

- decreased tissue perfusion

- risk for volume overload

- risk for impaired skin integrity

What are cardiovascular nursing diagnoses related to immobility?

- checking vital signs

- change positions slowly

- have patient dangle legs before standing

- assess for DVT: redness, swelling, pain

- assess RBC, hematocrit, hemoglobin values

- compression socks

- sequential compression devices (SCDs)

- point and flex the feet

- elevate extremities

- anticoagulants

What are cardiovascular nursing interventions related to immobility?

- altered breathing pattern

- hypoventilation

- atelectasis

- pooling of pulmonary secretions

- hypostatic pneumonia

- low CO2 production

How does immobility affect the respiratory system?

- impaired gas exchange

- ineffective airway clearance

- impaired tissue perfusion

What are respiratory nursing diagnoses related to immobility?

- assess respiratory rate

- assess O2 sat

- assess lung sounds

- incentive spirometer

- deep breathing

- suctioning

What are respiratory nursing interventions related to immobility?

- decreased metabolic rate

- decreased thyroid hormone production

- decreased ACTH

- decreased aldosterone

- decreased insulin production

- decreased drug metabolism

- weight loss

- negative nitrogen balance leads to poor wound healing

- anorexia

- negative calcium balance leads to osteoporosis

How does immobility affect metabolism and nutrition?

- imbalanced nutrition

- impaired tissue perfusion

- risk for fluid overload

- activity intolerance

- unstable blood glucose

- risk for injury

- impaired healing

What are metabolism and nutrition nursing diagnoses related to immobility?

- offer small frequent meals

- offer supplements

- prioritize protein and calcium

- daily weights

- intake and output monitoring

- blood glucose monitoring

- monitor for drug toxicity

What are metabolism and nutrition nursing interventions related to immobility?

- decreased peristalsis

- weal abdominal and perineal muscles

- conscious decision to delay BM

- hard to pass stool

- narcotics lead to constipation

How does immobility affect the gastrointestinal system?

constipation

What is the main gastrointestinal nursing diagnosis related to immobility?

- increase fiber

- increase fluids

- stool softeners

What are gastrointestinal nursing interventions related to immobility?

- incomplete emptying of bladder

- increased serum calcium levels causes calcium crystals in kidney or bladder

- urine stagnates which increases risk for UTI

- increased bladder capacity and urinary retention increases risk for UTI and causes overstretching of the bladder

- cauterization causes increased risk of UTI

How does immobility affect the urinary system?

- risk for urinary retention

- risk for urinary incontinence

- acute pain

- impaired urinary elimination

What are urinary nursing diagnoses related to immobility?

- voiding schedule

- external catheter

- monitoring intake and output

What are nursing interventions for the urinary system with immobility?

- decreased skin turgor

- increased risk for pressure injuries

How does immobility affect the integumentary system?

impaired skin integrity

What is the nursing diagnosis for the integumentary system related to immobility?

- assess risk with Braden scale

- increase vitamins A, C, & E

- increase protein

- high-calorie diet and increase hydration

- turn q 2 hrs

What are integumentary nursing interventions related to immobility?

- self-esteem

- body image

- sensory deprivation

- sensory overload

How does immobility affect the psychosocial system?

- self-esteem disturbance

- risk for situational low self-esteem

- risk for powerlessness, hopelessness

- ineffective role performance

- disturbed body image

- impaired memory

- disturbed thought process

What are psychosocial nursing diagnoses related to immobility?

- pain management

- assist with hygiene

- repositioning

- ensure adequate sleeping environment

- encourage independence

- cluster care

- reorient patient

What are psychosocial nursing interventions related to immobility?

excessive sleepiness

What is hypersomnia?

inability to sleep

What is insomnia?

- assess for depression

- provide rest periods

What are nursing interventions for hypersomnia?

- quiet environment

- decrease day-time napping

- maintain preferred evening routine

- no caffeine after noon

- assess for pain

What are nursing interventions for insomnia?

- need for adaptation

- depression

- anxiety

- anger

What can immobility cause regarding coping and stress?

- bed in lowest position

- side rails up

- call bell within reach

- use signs to tell patient to call for help

- door open

- grippy socks

- hourly rounding

- proactive toileting

- night lights

- medication awareness

How can falls be prevented?

a. Lower the height of the bed and the bottom two side rails before leaving the room.

Which action should be taken when attempting to decrease falls in the hospital setting?

a. Lower the height of the bed and the bottom two side rails before leaving the room.

b. Ask patients on first encounter to use the bathroom and every 4 hours thereafter.

c. Instruct patients to use the call light only if they think they need help getting out of bed.

d. Encourage patients to not take any prescribed medicine that could cause drowsiness or light headedness.

d. Include hourly rounding in the plan of care.

What actions should be taken when caring for an 80-year-old postoperative patient with a history of Parkinson's disease?

a. Ensure that all four side rails are elevated.

b. Instruct family that they cannot leave the room.

c. Place wrists in soft restraints to protect invasive lines.

d. Include hourly rounding in the plan of care.

b. Remove rugs that can slip; use rubber mats instead.

c. Use your walker or cane even if only moving short distances.

e. Put frequently used items in easy-to-reach places.

f. Use handrails when available.

The nurse is providing discharge instructions on ways to prevent falls at home. Which of the following guidelines are helpful in preventing falls? (Select all that apply.)

a. Always wear socks when walking to protect your feet when ambulating.

b. Remove rugs that can slip; use rubber mats instead.

c. Use your walker or cane even if only moving short distances.

d. Use lightweight, easily moveable chairs to assist with mobility.

e. Put frequently used items in easy-to-reach places.

f. Use handrails when available.

c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP).

An uncooperative 70-year-old male with right-sided paralysis from a recent cerebrovascular accident (CVA) has to be transferred from the bed to a wheelchair. Which action indicates the best method to transfer this patient?

a. A two-person lift is performed, with one person on each side of the patient.

b. The patient is steadied under the arms and pivoted on his left leg.

c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP).

d. A stand assist lift is used with the help of another nurse.

a. Early ambulation after surgery

What nursing action would be most effective in preventing flaccidity in a hospitalized patient?

a. Early ambulation after surgery

b. Administering calcium with vitamin D

c. Coughing and deep breathing exercises

d. Referring the patient to occupational therapy

a. Bilateral elbow contractures

Which cue during an admission assessment of a patient transferred from a long-term care facility does the nurse recognize as the result of immobility?

a. Bilateral elbow contractures

b. Increased muscle tone

c. Decreased cardiac workload

d. Orthostatic hypertension

primary aging:

- the genetically determined part of aging

- incudes puberty and menopause

- unavoidable

secondary aging:

- interaction between influences of personality, lifestyle behaviors, society, environment, disease, and accidents

Compare primary and secondary aging.

- absence of disease and disability

- high cognitive functioning

- high physical functioning

- active engagement with life

What is optimal aging?

- what Matters

- Medication

- Mentation

- Mobility

What are the 4 Ms of aging?

a theory that states that biological tissues will respond in a predictable way to changes in physical stress

What is the physical stress theory?

- loss of physiologic reserve

- loss of muscle mass and bone mass

- increased risk of injury and falls

- increased risk of chronic disease

What are consequences of aging?

- accelerated aging

- mobility disability

- physical frailty

- lower quality life

- increased mortality

- pressure injuries

- contractures

What are consequences of immobility?

- decreased muscle strength

- orthostatic hypotension

- decreased endurance

- osteoporosis

- decreased oxygen exchange

- altered mental state

- inability to perform ADLs

What are consequences of bedrest?

- use good body mechanics

- know your patient's abilities

- recognize your limitations

What are 3 ways to ensure safe patient handling?

to widen the base of support

What is the purpose of assistance devices?

pushing

Which uses better body mechanics: pushing or pulling?