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How does the nurse assess a client's mobility in relation to:
- Range of motion: is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, or transverse
- Gait: particular manner or style of walking
- Exercise or Activity tolerance: physical activity for conditioning the body, improving health, and maintaining fitness
- Body alignment: identifies deviations, learning needs, identifies trauma, risk factors
How are each of the following systems impacted by immobility: respiratory, cardiovascular, musculoskeletal, urinary and bowel elimination and integumentary system?
- Respiratory: Do respiratory assessment at least q2hrs for pts with restricted activity. Inspect chest wall movements during full; -atelectasis (collapse in alveoli)
- -hypostatic pneumonia (inflammation of lungs from pooling of secretions)inspiratory-expiratory cycle. If pt has atelectatic area, chest movement is asymmetrical. Auscultate entire lung region for diminished breath sounds, crackles or wheeze. Focus auscultation on dependent lung fields because pulmonary secretions tend to collect in loer regions.
- Cardiovascular: check blood pressure, evaluate pical & peripheral pulses and look for signs of venous stasis; -orthostatic hypotension (drop in 20 mmHg in systolic or 10 mmHg in diastolic
- -increased cardiac workload
- -thrombus (blood clot) formation
- Musculoskeletal: identify decreased muscle tone & strength, loss of muscle mass and contractures. Early ROM is important to help identify later measurements to see if joint mobility is less.
- -loss of endurance, strength, muscle mass
- -impaired joint mobility (foot drop)
- -increased risk of falls
- -impaired calcium metabolism
- Urinary and bowel elimination: evaluate elimination status each shift and total intake & output q 24 hrs. Make sure pt is receiving correct amount & type of fluids. Dehydration increases risk of skin breakdown, thrombus formation, respiratory infectin and constipation;
- -increased risk of UTI
- -renal calculi
- -decreased fluid intake/dehydration
- -inability to void
- Integumentary system: continually assess pts skin for breakdown and color changes. Use Braden scale for risk for impaired skin integrity; -skin breakdown/pressure ulcers
How does immobility impact the following functions: metabolic, psychosocial and developmental?
- Metabolic function: decreases the metabolic rate; alters the metabolism of CHO, fats, and proteins; causes fluid and electrolyte and calcium imbalances; and causes GI disturbances
- a. emotional and behavioral responses
- b. sensory alterations
- c. changes in coping
- Developmental: body alignment and mobility; the greatest impact of physiological changes on the musculoskeletal system is observed in children and older adults.
What nursing assessment is related to complications of immobility for each of the previously listed body systems?
- Metabolic function: use anthropometric measurements (height, weight, skinfold thickness) to evaluate muscle atrophy. Also use I&O for fluid balance. Lab tests (electrolyte levels, serum protein, BUN;
- -negative nitrogen balance
- -decreased GI mobility
- -calcium resorption (loss from bones)
- Psychosocial: observe pts behavior on a daily basis. If changes occur determine cause and evaluate changes, Identify the cause helps nurse design appropriate intervention. Listen to family if they report emotional changes;
- -decreased social interaction
- -sensory deprivation
- -sleep wake alterations
- Developmental: in children determine if they are able to meet developmental tasks and progressing normally. Provide physical and psychosocial stimuli after identifying a childs developmental needs and assure parents that delays are usually temporary.
- In older adults assess for ability to meet needs independently and adapt developmental changes such as declining physical functioning and altered family and peer relationships.
Interventions for each complication
- -attempt to move patient asap
- -change position slowly/gradually
- -sit with HOB upright 10 min before standing
- -dangle before standing
- -ask about dizziness
- -ROM and isometric exercises
- -proper support/ alignment
- -use of assistive devices
- -high protein, high calorie diet with vitamin C and Zinc
- -monitor weight
- -position change every 2 hrs
- -adequate hydration
- -chest physio
- -suction secretions when needed
- -asses respirations/breath sounds/sputum
- -diet rich in fruits and vegetables
- -stool softeners/ laxatives
- -positioning every 2 hrs
- -skin care
- -offloading devices
- -therapeutic sleep surfaces (higher sleep elevation-risk of pressure ulcers)
- -routine and informal socialization
- -minimize sleep interruption
How do nurses protect themselves from injury when lifting, positioning, and transferring clients?
- Assess if you can safely do the task yourself or need help
- 1. Keep weight to be lifted as close to the body as possible
- 2. Bend knees
- 3. Tighten abdominal muscles and tuck pelvis
- 4. Maintain the trunk erect and knees bent so multiple muscle groups work together in a coordinated way
What techniques are used to assist clients in: moving up in bed, repositioning, achieving a sitting position, and transferring from a bed to a chair, or bed to stretcher?
- moving up in bed:
- achieving a sitting position:
- transferring from a bed to a chair, or bed to stretcher:
What devices are used to assist clients in proper positioning?
- Folded sheets, blankets or towels
- Trochanter rolls
- Positioning boots
- Trapeze bar
- Transfer belt
How do active and passive range-of-motion exercises differ?
- Passive Range of Motion: patient makes NO effort in moving
- Active Range of Motion: the therapist stabilizes the proximal joint (and sometimes supports the distal joint) while the patient performs AROM
What nursing diagnoses are applicable to impaired physical mobility?
- Ineffective airway clearance
- Ineffective coping
- Risk for injury
- Risk for impaired skin integrity
- Social isolation