Health Assessment Foundations Exam 2

Mobility Definition

Purposeful physical movement, including gross + fine motor and coordination

Interrelated Concepts (Causes) of Mobility

1. Intracranial Regulation

2. Nutrition

3. Pain

4. Gas Exchange

5. Perfusion

Interrelated Concepts (Effects) of Mobility

1. Tissue Integrity

2. Elimination

Motion Definition

Mechanisms that facilitate and impair mobility

Interrelated Concepts of Motion

1. Oxygenation of blood to tissues

2. Intracranial regulation by brain, spinal cord, and peripheral nerves

3. Pain from motion can limit movement

4. Nutrition must be adequate (excess weight damages joints)

5. Elimination: increases risk of constipation d/t limited mobility

Activity Intolerance

Inadequate amount of physical/physiological energy to undergo/complete necessary physical activity

Activity Tolerance

Capacity to successfully complete a necessary activity without distress

Activities of Daily Living (ADLs)

Basic essential skills that a person does independently every day and are usually related to personal care (bathing, dressing, eating)

Increased Likelihood of Injuries/Disease Processes Impacting Movement

1. CNS Disorders

2. Disorders of Bones, Joints, Muscles

3. Musculoskeletal Trauma (ex: fractures)

Activity Orders

How much the patient is allowed to do themselves

Principles of Mobility

1. Alignment (Posture)

2. Balance (Stable Center of Gravity)

3. Coordinated Movement

What is essential when a patient is unable to assist during tranfer?

Mechanical Lifts and Lift Teams

The wider the base of support AND the lower the center of gravity, …

The greater the stability of the nurse

The equilibrium of an object is maintained as long as…

The line of gravity passes through its base of support

Facing the direction of movement prevents…

Abnormal twisting of the spine

Dividing balanced activity between arms and legs reduces the risk of…

Back Injury

What requires less work than lifting?

Leverage, rolling, turning, pivoting

When friction is reduced between the object to be moved and the surface on which it is moved, …

Less force is required to move it

What are some assistive devices when patients are unable to maintain proper positioning?

1. Trochanter Rolls/Towels

2. Lift Sheets

3. Trapeze Bar

Physiological Effects of Immobility (Perfusion)

Decreased activity l/t reduced cardiac capacity, orthostatic hypotension, increased risk of DVT, increased HR at rest, venous pooling

Physiological Effects of Immobility (Gas Exchange)

Reduced lung expansion, atelectasis (alveolar collapse l/t less room for gas exchange: higher risk of pneumonia)

Physiological Effects of Immobility (Elimination)

Decreased activity l/t decreased peristalsis, increased constipation risk, urinary calculi, increased UTI risk

Physiological Effects of Immobility (Integumentary)

Decreased mobility l/t increased pressure (especially when patient can’t move themselves from bed) l/t decreased blood flow and breakdown in skin

Proper Positioning of Standing

Head erect, body parts symmetrical, wide base of support, midline center of gravity

Proper Positioning of Sitting

Sit without any device holding up, thighs parallel, neck and spine in alignment

Proper Positioning of Laying (Recumbent)

Vertebrae straight, extremities in alignment and not crossed over

Proper Positioning of Gait

Regular smooth rhythm, length of leg swing is symmetrical, smooth arm swing

Trochanter Rolls/Towels

Roll towel placed under hip to maintain and prevent external rotation of hip when patient is laying down in bed

Lift Sheets

Sheet underneath patient that a nurse can manually use to reposition a patient (not always the safest for the nurse or patient)

Trapeze Bar

Goes above patient and allows patient to use their upper body to move

Passive Range of Motion

Unable to move joint/extremities on their own, we use a head to toe sequence

Active Range of Motion

When a patient is unable to do it on their own (requiring assistance), bathing is a good place to test for ROM for these patients

What is important to incorporate to prevent deconditioning?

Assessing ROM using a head to toe sequence

Assistive Devices

Walkers, canes, crutches, wheelchairs, gait belts

What does cultural awareness/cultural humility begin with?

In-depth self-examination of own culture

Functional Ability

How well our patient is able to function (how are we able to tailor our care?)

Spirituality Definition

Speaks to what gives ultimate meaning and purpose to one’s life. It is that part of people that seeks healing and reconciliation with self and others

What interrelated concept is a barrier for new nurses for spirituality/diversity?

Grief and Loss

Essential Components of Cultural and Spiritual Competence

1. Desire

2. Awareness

3. Knowledge

4. Skill

5. Encounters

Culturally Sensitive Assessment Tool

1. Respect

2. Explanatory

3. Sociocultural Context

4. Power

5. Empathy

6. Concerns and Fears

7. Therapeutic Alliance/Trust

Spiritual Assessment Tool

1. Faith and Belief

2. Importance

3. Community

4. Address in Care

Nursing Responsibility for Diversity/Spirituality

1. Asking patients about beliefs, practices, values, and attitudes

2. Be aware of patients’ behaviors during the interview

3. Ask 1 question at a time and allow for an adequate response, avoiding medical jargon

Musculoskeletal System Composed of…

1. Bones

2. Muscles

3. Joints

4. Tendons

5. Ligaments

6. Cartilage

7. Bursae

Bones

Continually changing and remodeling

Joints

2+ bones come together allowing for extension + flexion

Tendons

Connect Muscle + Bone

Ligaments

Bone to Bone

Cartilage

Support weight and facilitate movement

Bursae

Sacs within joint, reducing friction and pain

Musculoskeletal System

Provides support and mobility for the body and the protection of our internal organs

What supports bone health?

Calcium and Vitamin D

Elimination Definition

Excretion of waste products; passage of stool through the intestinal tract or urine through the urinary tract

Elimination Interrelated Concepts

1. Nutrition

2. Fluid and Electrolytes

3. Acid-Base Balance

4. Mobility

5. Cognition

Largest Body Cavity

Abdominal Cavity

Abdominal Cavity Contains…

Stomach, SI, LI, Liver, Gallbladder, Pancreas, Spleen, Kidneys, Ureters, Bladder, Adrenal Glands, Major Vessels, Uterus, Fallopian Tubes, Ovaries

Upper Left Quadrant

Stomach

Lower Left Quadrant

Small Intestine, Descending Colon, Sigmoid Colon

Lower Right Quadrant

Ascending Colon

Upper Right Quadrant

Liver, Transverse Colon