PREP U 5 HEALTH ASSESSMENT OBJ

Mobility

Ability to move freely and independently.

Ambulation

Walking or moving from place to place.

Functional Ability

Ability to perform activities needed for daily living.

Body Mechanics

Using the body correctly and safely when moving, lifting, or positioning.

Ergonomics

Adjusting how work is performed and using equipment correctly to prevent injury.

Range of Motion (ROM)

Movement of a joint through its normal range.

Active ROM

The CLIENT moves the joints independently. Maintains muscle strength and joint mobility and helps prevent contractures.

Passive ROM

The NURSE/PT moves the client's joints. Maintains joint mobility and prevents contractures but does NOT maintain muscle strength.

Contracture

Permanent tightening or shortening of muscles that limits joint movement.

Foot Drop

Inability to keep the foot in a normal position; the toes point downward.

Weight Bearing

The amount of body weight a client is allowed to place on an extremity.

Orthostatic Hypotension

A drop in blood pressure when changing positions that can cause dizziness or fainting.

Assistive Device

Equipment that helps a client move safely, such as a cane, walker, crutches, gait belt, or mechanical lift.

Gait Belt

A belt placed around the client's waist to provide stability during transfers or ambulation.

SCD (Sequential Compression Device)

Inflatable sleeves that intermittently squeeze the legs to promote venous return and prevent DVT.

Antiembolism Stockings

Elastic stockings that provide continuous compression to prevent blood from pooling in the legs.

DVT (Deep Vein Thrombosis)

A blood clot that forms in a deep vein, usually in the leg.

Bones

Support the body and protect organs.

Joints

Where bones meet and allow movement.

Muscles

Contract to create movement and maintain strength.

Tendons

Connect muscle to bone.

Ligaments

Connect bone to bone.

Tendon vs. Ligament

Tendon = muscle to bone. Ligament = bone to bone.

Benefits of Movement

Maintains muscle strength, joint flexibility, bone strength, balance, and coordination.

Mobility and Circulation

Improves blood flow and helps prevent blood pooling and DVT.

Mobility and Respiratory System

Promotes lung expansion.

Mobility and GI System

Stimulates intestinal movement and helps prevent constipation and paralytic ileus.

Mobility and Skin

Reduces prolonged pressure and helps prevent pressure injuries.

Effects of Aging on Mobility

Decreased muscle mass/strength, decreased bone density, stiffer joints, decreased flexibility and balance, and slower mobility.

Mobility Risks in Older Adults

Increased risk for falls, fractures, weakness, and limited mobility.

Complications of Immobility

Muscle weakness/atrophy, decreased joint mobility, contractures, foot drop, pressure injuries, DVT, constipation, and paralytic ileus.

Best Way to Prevent Complications of Immobility

Encourage safe mobility as early as possible.

Mobility Assessment

Assess muscle strength, ROM, balance, gait, activity tolerance, weight-bearing status, upper-extremity strength, ability to sit/stand, ability to follow directions, assistance needed, assistive devices, dizziness, and pain.

Main Question Before Moving a Client

Can the client move safely alone, do they need assistance, or do they need equipment/additional staff?

Before Ambulating After Bed Rest

Sit up → Dangle → Stand → Ambulate.

Why Dangle Before Ambulating?

Helps determine if the client develops dizziness, weakness, or orthostatic hypotension before walking.

Early Ambulation

Getting a client safely moving as soon as possible after illness, injury, or surgery.

Benefits of Early Ambulation

Maintains strength and joint flexibility, improves circulation and breathing, stimulates the GI tract, and helps prevent complications of immobility and DVT.

Best DVT Prevention When Possible

Early ambulation.

DVT Prevention When Client Cannot Ambulate

Antiembolism stockings, SCDs, venous foot pumps, and ROM/exercises as appropriate.

Antiembolism Stockings Compression

CONTINUOUS compression.

Purpose of Antiembolism Stockings

Prevent blood pooling, promote venous return, and help prevent DVT.

Antiembolism Stocking Safety

Correct size, no wrinkles, do NOT roll down the top, and assess skin and circulation.

When Are Antiembolism Stockings Usually Applied?

In the morning before the client gets out of bed.

SCD Compression

INTERMITTENT compression.

Purpose of SCDs

Promote venous return and help prevent DVT.

SCD Contraindication

Do NOT use with severe arterial disease.

Correct SCD Fit

You should be able to fit 2 fingers between the sleeve and the client's leg.

SCD Too Tight

Can impair circulation.

SCD Too Loose

Does not provide enough compression.

SCD Nursing Care

Remove at least every 8 hours or per facility policy and assess skin and circulation.

SCD Tubing Safety

Do not place tubing underneath the client's leg because it can cause pressure injury or device malfunction.

Antiembolism Stockings vs. SCDs

Antiembolism stockings = continuous compression. SCDs = intermittent compression.

Purpose of Correct Positioning

Maintains body alignment and helps prevent pressure injuries, contractures, and foot drop.

Repositioning an Immobile Client

At least every 2 hours or according to facility policy.

Pillows

Support body alignment and protect pressure areas.

Footboard

Keeps feet dorsiflexed and helps prevent FOOT DROP.

Trochanter Roll

Keeps the hips in a neutral position, especially with weakness or paralysis.

Hand Roll

Maintains hand/wrist position and helps prevent contractures.

Supine Position

Lying flat on the BACK.

Prone Position

Lying on the ABDOMEN/STOMACH.

Prone Position Risks

Can cause difficulty breathing, lower-back hyperextension, and foot drop.

Lateral/Side-Lying Position

Lying on the SIDE. Helps relieve pressure from the sacrum.

Lateral Position Nursing Care

Place pillows for alignment, especially between the legs.

Left Lateral Position

Client lies primarily on the LEFT SIDE. Commonly used for enemas and examination of the perineal area.

Orthopneic Position

Client sits upright and leans forward over a table or pillows. Helps with difficulty breathing and allows maximum chest expansion.

Fowler's Position

Head of bed about 45°. Improves ventilation and comfort.

Semi-Fowler's Position

Head of bed about 30°. Helpful for cardiac, respiratory, or neurological problems and often useful with an NG tube.

Trendelenburg Position

HEAD DOWN, FEET UP. Promotes venous return.

Reverse Trendelenburg Position

HEAD UP, FEET DOWN. Can help decrease esophageal reflux.

ROM Exercises

Help maintain joint mobility and prevent contractures.

Active vs. Passive ROM

Active = CLIENT moves. Passive = NURSE/PT moves.

Passive ROM Technique

Support the joint above and below and gently move it through its ROM.

When Should You Stop Passive ROM?

Stop if the client experiences pain or discomfort. Never force a joint.

Safe Body Mechanics

Use a wide base of support, bend knees, use leg muscles, keep the client close, keep center of gravity low, and avoid twisting.

Wide Base of Support

Keep your feet apart to improve stability.

Correct Way to Lift

Bend at the knees and use your LEG muscles, not your back.

Position of Client/Object When Lifting

Keep the client or object close to your body.

Bed Height for Care

Raise the bed to a comfortable working height to reduce injury.

How to Turn Safely

Face the direction you are moving and move your entire body/feet instead of twisting your back.

Mechanical Assistance Safety

Do NOT manually lift a client who requires mechanical assistance.

Before a Transfer

Assess strength/ability, determine assistance needed, explain the procedure, gather equipment/staff, check equipment, and lock brakes.

Transfer Safety: Brakes

Lock the brakes on beds, wheelchairs, and stretchers before transferring.

Gait Belt Purpose

Provides balance and stability during ambulation and transfers.

Transfer Board

Reduces friction and helps move clients between surfaces, such as bed to stretcher or wheelchair.

Draw/Transfer Sheet

Helps reposition a client in bed and reduces pulling directly on the client's body.

Mechanical Lift

Supports the client's body weight when the client cannot safely assist enough with the transfer.

Grab Bars

Help clients maintain balance near toilets, showers, and tubs.

Weak or Paralyzed Extremities During Transfer

Support weak or paralyzed extremities to prevent injury.

What Should You Do If a Client Starts to Fall?

Do NOT try to catch or hold them upright. Gently lower them to the floor.

Safely Lowering a Falling Client

Hold the gait belt/waist, widen your stance, bend your knees, use your leg for support, and gently lower the client to the floor.

Mobility Critical Thinking

ASSESS → SAFETY → ASSIST → REASSESS → DOCUMENT.

Before Mobility: Weight Bearing

Determine whether the client can safely bear weight.

Before Mobility: Strength

Assess how strong the client is and how much they can assist.

Before Mobility: Directions

Determine whether the client can understand and follow directions.

Before Mobility: Dizziness

Assess for dizziness or orthostatic hypotension.

Before Mobility: Activity Tolerance

Determine how much activity the client can safely tolerate.

Before Mobility: Equipment

Determine what equipment and how many staff members are needed.

Ambulation Documentation

Document distance walked, level of assistance, balance/gait, assistive device used, and client's response.

Transfer Documentation

Document type of transfer, client participation, level of assistance, balance/pivot ability, equipment used, and client response.