mobility and immobility

Start Studying!

Terms

undefined, object

copy deck

Coordinated movement involves integrated functioning of what systems?: -Skeletal system
-skeletal muscle
-nervous system
Postural abnormalities can cause?: -pain
-impair alignment or mobility
Impaired muscle development is caused by?: -injury
-diseases
Name a disorder that causes degeneration of skeletal muscle fibers?: Muscular distrophies
What are the characteristics of muscular dystrophies?: -progressive
-symmetrical weakness
-wasting of skeletal muscles
-increasing disability & deformity
What injury can damage the motor strip in the cerebral cortex?: -trauma from head injury
-CVA(ischemia from a stroke or brain attack)
-bacterial infection (meningitis)
A person with a right-sided cerebral hemorrhage with complete necrosis,what body part will be affected?: -destruction of right motor strip
-left-sided hemiplegia
What results from direct trauma to the musculoskeletal system?: -bruises
-contusions
-sprains
-fractures
Disruption of bone tissue continuity?: Fracture
what can cause fractures?: -direct external trauma
-deformities of the bone
(osteoporosis, pagets disease
What is the treatment for fractures?: -proper alignment
-immobilization
(promotes healing and restores function?
loss of tone and joint stiffness?: muscle atrophy
the inability to move about freely?: immobility
terms frequently used when discussing clients on the mobility immobility continuum are?: -bed rest
-impaired physical mobility
an intervention that restricts clients to bed for therapeutic reasons?: Bed rest
a state in which the individual experiences or is at risk of experiencing limitation of physical movement?: Impaired physical mobility
Name some prescribed restrictions of movement that can alter the level of physical mobility?: -Bed rest
-Physical restriction(cast)
-voluntary restriction
-impairment fo motor or skeletal function
the pathological reduction in normal size of muscle fibers after prolonged inactivity from bed rest, trauma, casting, or local nerve damage?: disuse atrophy
immobility disrupts normal metabolic function, name 3 changes?: -altered endocrine metabolism
-calcium resorption (loss of bones)
-disrupt GI system
What is the function of the endocrine system?: maintains and regulate vital functions
-response to stress and injury
-growth and development
-reproduction
-ionic homeostasis
-energy metabolism
How does the endocrine system maintain homeostasis in the body?: through maintaince of Na,K,water and acid-base balance
How does the endocrine system regulate energy metabolism?: -BMR in increased by thyroid Hormone
-energy made available to cells through GI and Pancreatic Hormones
What results from the disruption of normal metabolic function due to immobility?: -decrease metabolic rate
-alters metabolism of carbs,fats, proteins
-F/E and calcium imbalances
-GI disturbance(low appetite)
If an immobilized client experiencing an infectious process such as fever, or is in the process of wound healing what will happen to his BMR and Why?: -Increases, due to increase in cellular oxygen requirement.
Clients with decrease appetite secondary to immobility have what defiency: -calories
-protein
When more nitrogen is excreted than is ingested in protein the body is said to have?: Negative nitrogen balance
What causes tissue breakdown (catabolism)?: -weight loss
-decreased muscle mass
-weakness
-protein loss
What is a common symptom seen due to impairment of GI function?: constipation
Most common respiratory complication seen in post-operative and immobile clients are?: -Atelectasis(collapse of alveoli)
-hypostatic pneumonia (inflammation of lung from stasis or pooling of secretions)
Immobilization causes what 3 major cardiovascular changes?: -orthostatic hypotension
-increase cardiac workload
-thrombus formation
Name 3 factors that contribute to venous thrombus formation?: -loss of integrity of the vessel wall(injury)
-abnormalities of blood flow
-change in clotting factors
Name an effect of the muscles due to immobilization?: -Protein breakdown
-muscle weakness
What puts a client at risk for falls related to muscle effects?: -loss of endurance
-decreased muscle mass and strenght
-joint instability
Name 2 skeletal effects immobilization cause?: -impaired calcium resorption(bone resorption,
tissue less dense,
atrophied(osteoporosis)
What is the client with disuse osteoporosis at risk for ?: Pathological Fractures
An abnormal and possibly permanent condition characterized by fixation of the joint?: joint contracture
What causes joint contractures?: disuse atrophy
shortening of muscle fibers
Name a common contracture where the foot is permanently fixed in the plantar flexion, ambulation is difficult due to inability to dorsiflex the foot?: Foot Drop
What clients are susceptible to footdrop?: -Hx CVA or brain attacks
-left or right sided hemiplegia
The clients urinary elimination is altered by immobility, when a patient is in a recumbent or flat position, insufficient peristalltic contractions cannot overcome gravity therefor the renal pelvis may fill before urine enters the ureters this condition: Urinary stasis
Calcium stones that lodge in the renal pelvis and pass through the ureters cause hypercalcemia?: Renal calculi
As immobility continues how is urinary elimination effected?: -fluid intake diminish
-fever,causes dehydration
-high concentration of urine cause calculi formation and infectin
-high risk of e.coli in women
Major risk of the integumentary system seen with immobility?: pressure ulcers
Tissue metabolism depends on the body's receipt of ?: -oxygen,nutrients, blood and elimination of wastes
Common emotional changes seen with immobility: -depression
-behavioral changes
-sleep-wake disturbances
-impaired coping
Prolong immobility can delay gross motor skills, intellectual and musculoskeletal development this is mostly seen in what age group?: infants, toddler preschoolers
Alter growth spurt, decrease independence and increase isolation in what age group?: Adolescent
Immobility affects self-confidence and affects adult role regarding family or social structure?: Adults
Immobility increases physical dependence and accelerate functional losses, cna be gradual or sudden?: Older Adults
Assessment of client mobility focuse on 5 factors?: -ROM
-Gait
-Exercise-
-Activity intolerance
-Body alignment
The maximum amount of movement available at a joint?: ROM
Aline that passes through the body from front to back?: Sagittal plane
(divides the body into left and right side)
Passes through the body from side to side and divides the body in front and back?: Frontal plane
a horizontal line that divides the body into upper and lower portions?: transverse plane
Name the joint movements in the sagittal plane?: -flexion and extension(fingers and elbows)
-dorsiflexion and plantar flexion (feet)
-extension ( hip)
Name the joint movements in the frontal plane?: -abduction and adduction(arms and legs)
-eversion, inversion (feet)
Name the joint movements in the transverse plane?: -pronation and supination (hands)
-internal and external rotation(hips)
When assessing ROM, physical examination consist of ?: -stiffness
-swelling
-pain
-limited/unequal movement
The client is able to move all joints through their ROM unassisted?: Active ROM
The client is unable to move independently and nurse moves each joint through its ROM?: Passive ROM
A particular manner or style of walking?: gait
Assessment of gait allow the nurse to draw conclusions about?: -balance
-posture
-safety
-ability to walk w/o assist
How does the gait cycle begin?: -with the heel strike of one lef and continues to the heel strike of the other leg
Physical activity for conditioning the body, improving healt and maintaining fitness?: exercise
The type and amount of exercise or work that a person is able to perform?: activiy tolerance
Assement for activity tolerance is necessary when planning what kind of activities/: -walking
-ROM exercises
-ADL's
The nurse should monitor pt during activity for what symptoms?: -dyspnea
-fatigue
-chest pain
-change of vital signs
The assessment of body alignment has what objective?: -determines normal physiological changes
-Id deviation in body cause by posture
-Learning for clients to maintain alignment
-id trauma,muscle damage,or nerve dysfuntio
What position do you assess body alignment?: -standin
-sitting
-lying
What mesurement is used when assessing metabolic system?: -Ht, Wt, skinfold thickness
-I & O
-Dehydration,edema
-lab data
-lytes,serim protein(albumin),total protein levels, BUN, wound healing
Metabolic system: Interventions for the immobilized client involves:: -High protein,high-calorie diet
-May require Parenteral or enteral feedings
TPN, a central line or IV site is Known as what type of feeding?: -Parenteral
NGT, GT, jejunostomy tube with high protein feeding is known as what type of feeding?: -Enteral
Respiratory system: Name hazards of immobility?: -Assess full insp and exp cycle.
-chest movement may be aymmetrical
-Assess for crackles or wheezez
Interventions for a immobile pt at risk for respiratory disfunction?: -change position every 2hrs
-deep breath and cough q 2hrs
-min.2000ml of fluid/day
-CPT if needed
-Suction PRN
Cardiovascular system: What are some hazards due to immobility?: -edema, poor wound healing
-DVT, Thrombus....Homan signs
-Embolus
-Recumbant position,increases cardiac workload, increases HR
Cardiovascular system: Name NSG Interventions?: -Prevent orthostatic BP:pedangle
-Increase mobility to decrease cardiac workload
-avoid valsalva maneuvar(encourage pt to breath out while moving or positioning
-Prevent DVT(IPC/SCDs,Meds,TED,ROM)
Name interventions to reduce orthostatic hypotension?: -dangling at bedside(to increase venous return)
Name interventions to reduce cardiac workload?: -avoid valsalva maneuvar
-teach client breathing exercises when moving or repositioning
Define valsalva maneuvar?: -used during straining of defecation or moving up in bed
-decreases venous return,C.O
-when strain is release, increase in BP due to increase in venous return
-produces reflex bradycardia, low BP
Name interventions to prevent thrombus formation?: -leg exercises
-encourage fluids
-position changes
-teaching begins when client becomes immobile
Name NSG intervention to prevent thrombus formation that require a physicians order?: -Meds(heparin,LMWH(lovenox)
-Intermittent pneumatic compression(IPC)
-Sequential compression devices(SCDs)
What is common dosage for heparin therapy?: -5000 units subq 2hrs before surgery
-repeated every 8 to 12 hrs until client is fully mobile or discharged.
Clients on Heparin assess for ?: -bleeding
-increase bruising
-guaiac-positive stools
-bleeding gums
Common dosage or lovenox(lMWH)in the prophylaxics of DVT?: -30 to 40 mg subq 2hrs before surgery
-and continue throughout post-op period
What are SCD/IPCs? What's a typycal cycle?: -sleeves or stockings
-wrap around legs, secure with velcro
-sleeves connected to pump
-inflation 10-15 sec(40mmhg)
-deflation 45-60 sec
What's the purpose of the use of SCDs/IPCs?: -decreases venous stasis
-increases venous return through deep veins of legs
Define TED Hose?: -Thromboembolic device hose
-elastic stockings
Name position techniques to aid in reducing compression of the leg veins?: -prevent pressure on posterior knee and deep veins in lower extremities
-
What do you teach a client regarding position techniques to aid in reducing compression of the leg veins?: -avoid crossing legs
-avoid sitting for prolong period of time
-avoid wearing clothing that constricts the legs and waist
-avoid putting pillows under the knees
-avoid massaging the legs
Name specific exercises that help prevent thrombophlebitis?: --anle pumps(alternate plantar flexion and dorsiflexion)
-foot circles(rotate ankle,make letters with feet every 2hrs)
-knee flexion(extend and flex knee
Name hazards of immobility seen in the musculoskeletal system?: -decrease muscle tone and strength
-loss of muscle mass
-contractures
-muscle atrophy due to lack of weight bearing
-osteoporosis
Whose at greater risk for bone demineralization?: -Clients on prolonged bedrest
-postmenopausal women
-clients taking steroids
-clients with increase serum and urine calcium levels
NSG interventions for the immobilized client to improve musculoskeletal system?: -ROM, during hygiene care
-passive ROM or CPM
-commonly used in POst knee surgery
-may need pt consult
Hazard of immobility in the integumentary system?: -assess skin for pallor or redness
-assess every 2hrs
-assess during hygiene care
hazard or immobility seen in the elimination system?: -dehydration(increases risk for skin breakdown, thrombus formation,respiratory infections, constipation)
-inadequate I&O
NSG interventions for maintaining optimal elimation sytem function?: -hydrate(2000-3000ml fl/day
-prevent urinary stasis
-assess I & O
-assess bowels
Diet adequate to facilitate peristalsis movement?: -veggies -stool softener
-fluids -cathartics
-fruits -enemas
-fiber
Abrupt changes in personality may be due to what physiological causes?: -surgery
-medication reaction
-pulmonary embolus
-acute infection
Primary symptom seen in older adults when experiencing pulmonary emboli or an acute infection?: -confusion
Common reactions to immobilization include?: -boredom
-feelings of isolation
-depression
-anger
Name some possible NSG DX related to psychological assessment?: -social isolation
-disturbed sleep pattern
-ineffective individual coping
What's procedure to transfer from bed to chair?: -Chair is placed next to bed with chair back in the same direction as the head of bed
What's procedure to transfer from bed to strecher?: -place beds side to side
-client fold arms over chest
-three-person carry
-lift sheet or transfer pad
-back board if spinal injury
What does the nurse assess when a client is getting ready to walk?: -activity tolerance
-strength
-coordination
-balance
-orientation
Methods used when assisting a client to ambulate?: -place both hands on waist
-use of a gait belt
Name assistive devices for walking: -walkers
-canes
-crutches
Causes mucle contraction and change in muscle length: isotonic contraction
Walking,swimming,dance aerobics,jogging,bicycling,moving arms and legs with light resistance these exercises are called?: -Isotonic exercises
what are the benefits of doing isotonic exercises?: -increases,
circulation and respiratory function
osteoblastic activity(bone forming cells)
muscle tone, mass and strength
tightening or tensing of muscles without moving body parts: isometric contraction
quadriceps sets and contraction of gluteal muscles, for pts who are unable to tolerate an increase in activity expected during isotonic exercises.: Isometric exercises
What are the benefits of isometric exercises?: -increase muscle mass,tone,strengh
-decreases potential for muscle wasting
-increases circulation to involved body part
-increases osteoblastic activity
Name pathological influences on body mechanics?: -congenital defects
-disorders of bones,joints, muscles
-CNS damage
-musculoskeletal trauma
Congenital defects affect what on the body?: -body alignment
-balance
-appearance

Start Studying!

Deck Info

Number of cards 115