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1. State nursing guidelines and rationale for use of proper body mechanics. (1043, 1057-1058)
- 1. Body Mechanics: The use of proper body positions to provide protection from the stress of movement and activity, specifically in regard to structure, function, and position of the body
- 1. Proper body movement includes
- a. Body movement in daily activities
- b. The prevention and correction of problems associated with posture
- c. Enhancement of coordination and endurance
- 2. Important to use principles of body mechanics during activity and during rest periods, to prevent injury and soreness in muscles and joints
- 3. The principles of body mechanics also used to assess and maintain the alignment of patients
- 4. Correct body mechanics is a part of ill prevention and health promotion
- 5. Nurses who consciously develop good habits can demonstrate to others proper ways of using the musculoskeletal system
- 2. Application of body Mechanics to Prevent Injury'
- • Nursing strategies designed to promote correct body alignment, mobility, and fitness, as well as interventions to prevent complications from immobility
- • Occupational Safety and Health Administration (OSHA) recommends a no-lift policy for all health care facilities
- > Mechanical lifting devices, or patient handling aids recommended
- • TECHNIQUES TO PREVENT BACK STRESS
- Develop a habit of erect posture (correct posture); slouching can hurt the neck and back muscles; when sitting use the back of the chair to support the whole spine, keeping shoulders back and relaxed; balance the head over the shoulders, avoid leaning forward, and hold in the stomach muscles
- Use the strongest muscles of the arms and legs to help provide the power needed for strenuous activities; back muscles are less strong and can be easily injured
- Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting or pulling
- Work as closely as possible to an object that is to be lifted or moved; this brings the body's center of gravity close to that of the object being moved which puts less strain on the leg and arm muscles rather than the back
- Use the weight o the body to push an object by falling or rocking forward and to pull an object by falling or rocking backward
- Push rather than pull equipment when possible; keep arms close to body and push with your whole body and not just your arms
- Begin activities by broadening your base of support; spread your feet to shoulder width
- Make sure that the surface is dry and smooth when moving an object to decrease the effects of friction; rough, wet, or soiled surfaces can contribute to increased friction, increasing the amount of effort required to move an object
- Flex the knees, put on internal girdle, and come close to an object that is to be lifted
- Break up heavy loads into smaller loads. The National Institute for Occupational Safety and Health (NIOSH) recommends manual load lifting limits of 35 lbs; take breaks from lifting or moving to relax and recover
ii. Patients with injury to CNS often verbalize that no one talks with them (or their families) about how the disease may progress and affect their functioning
- a. Nurse caring for these patients need to be knowledgeable about the pathology an clinical course of these diseases to provide appropriate pt education and counseling
- 5. Problems Involving Other Body Systems
- a. Acute and chronic illnesses - Affect mobility
- b. COPD and conditions such as ascites - may alter posture
- c. Illnesses that interfere with oxygenation - decrease activity tolerance
- i. Anemia, angina, cardiac arrhythmias, heart failure, COPD
- d. Negative nitrogen balance - cancers, anorexia nervosa
- e. Symptoms: fatigue, muscle aches, pain
- f. Nurses need to be vigilant in determining the effects of any injury or illness on mobility and in providing care to facilitate optimal mobility as early as possible
- 3. Mental Health
- 1. Lifestyle
- a. Variables that influence a person's lifestyle and overall mobility include:
- i. Occupation: Sedentary (someone who spends too much time sitting, e.g. computer programmer)
- ii. Leisure activity: reading, debating, crafts, watching tv
- iii. Preferences: Smoking, diet
- iv. Cultural influences
- v. Gender / Age: encourage or discourage exercise
- vi. Geographic location: walking, sometimes walking is not safe in high-crime areas
- b. Important to find physical activities that are congruent with overall lifestyle and cultural context
- i. Makes it easier to incorporate into daily living
- c. Nurse must talk with the pt and family members to determined preferred activities
- d. Nurse must avoid stereotyping
- 2. Attitudes and Values
- a. Family activities differ from family to family
- i. Active families
- a. Children learn the value of regular exercise and as they grow learn to incorporate exercise in their daily routine
- ii. Sedentary families (or less active families)
- a. Watching sports rather than playing sports
- b. People with high values of physical attractiveness may be more committed to regular exercise
- c. Someone with more intellectual pursuits would rather develop the mind than the body
- d. Some may view exercise more as a chore and avoid it
- i. Should suggestions as to how to incorporate exercise into the person's daily routine
- 4. Fatigue and Stress
- 1. Chronic stress may deplete the body of energy to the point that fatigue makes even the thought of exercise overwhelming
- 2. However, regular exercise is energizing and can better equip a person to deal with daily stress
- 3. Excessive exercise may stress the body and lead to injury as well as fatigue
- 5. External Factors
- 1. Weather: Sunny, rainy, windy, humid, etc.
- 2. Financial resources: gym memberships, access to exercise equipment
- 3. Lack of free time
- 4. Insufficient funds
- 5. Air pollution
- 6. Lack of support and reinforcement
• Preventative Actions / Complications to be Prevented
- Pillow under the head unless the drainage of oral secretions is desired
- • Lateral flexion of the neck
- Carefully position lower arm behind and away from patient's back
- • Damage to nerves and blood vessels in the axillae of the lower arm
- Abduct the upper shoulder slightly so that the shoulder and elbow are flexed; place pillow between the chest and upper arm
- • Internal shoulder rotation and adduction
- Place pillow under the upper flexed leg from the groin to the foot
- • Internal rotation and adduction of the hip; lumbar lordosis
- Ensure that both shoulders are aligned with both hips
- • Twisting of the spine
- Support the lower foot in dorsiflexion with a sandbag
- • Footdrop
- Protective Prone position
- • Preventative Actions / Complications to be Prevented
- Place small pillow under head
- • Flexion of the cervical spine
- Place some suitable support under the patient between the end of the rib cage and the upper abdomen if this facilitates breathing and space is available
- • Hyperextension of the spine; impaired respirations
- Move the patient down in bed so that the feet are over the mattress, or support the lower legs on a pillow just high enough to keep the toes from touching the bed
- • Footdrop
Demonstrate supine, lateral and Fowler’s positions.
Refer to #3
Discuss positioning and protective devices and indications for use.
Refer to #3
List nursing guidelines and rationales for patient transfer and ambulation.
- • Activity intolerance
- • Any condition that interferes with the transport of oxygenated blood to tissue.
- • Any condition that causes fatigue
- • Generalized weakness
- • Impaired physical mobility
- • Musculoskeletal impairment (fractures, arthritis)
- • Neuromuscular impairment (MS, Muscular dystrophy)
- • Decreased strength and endurance
- • Pain or discomfort
- • Depression or anxiety
- • Decreased muscle control, mass, or strength.
- • Joint stiffness
- • Pharmaceutical agents (narcotics)
- • Therapy-related restrictions (bed rest orders)
- • Assess the patient. Know the patient’s medical diagnosis, capabilities and any movement not allowed. Apply braces or any devices the patient wears before helping from bed.
- • Assess the patient’s ability to assist with the planned movement.
- • Assess the patient’s ability to understand instructions.
- • Ensure there is enough staff available to assist you in the move.
- • Assess the environmental safety (clutter, accessibility and availability of devices)
- • Decide which equipment to use.
- • Plan carefully.
Demonstrate patient transfer using a gait belt: bed to wheelchair and wheelchair to bed
- • IPIE
- • Position wheel chair at foot or head of bed. Ensure breaks are engaged
- • Position on PTs strong side.
- • Remove the legs (feet holder) of wheel chair.
- • Assess PTs moving capabilites
- • Put PT on sideline position (this can tell you a persons capabilities)
- • in one swift movement sit patient up
- • Assist dizziness or lightheadedness
- • If dizzy, stop.
- • Do not let go of PT
- • Put gait belt on. Nice and snug.
- • Lower bed to lowest position
- • Ensure pt has non-slip socks or shoes
- • Grab gait belt with both hands while patient grabs on to your arms (biceps)
- • Count to 3 (with rocking) and pull up
- • “chin up head up buns in chest out”
- • Baby step to chair have PT reach back with strong hand and sit.
• Kidney stones
- • Incontinence
- • Urinary retention
- • Decreased muscle tone
- • Decreased urine volume
- g. Skin
- • Skin breakdown
- • Increased risk for pressure ulcer
- h. Psychosocial Outlook
- • Increased sense of powerlessness
- • Decreased self-concept
- • Decreased social interactions
- • Decrease sensory stimulation
- • Altered sleep-wake pattern
- • Increased risk for depression
- • Risk for learned helplessness
9. Assess body alignment, mobility, and activity tolerance, using appropriate interview questions and physical assessment skills (1054-1058)
- a. Body alignment
- • Correct body alignment permits optimal musculoskeletal balance and operation, and promotes optimal physiologic functioning
- • Deviations in body alignment may result from:
- a. Chronic poor posture
- b. Trauma
- c. Muscle damage
- d. Nerve dysfunction
- • A patient’s body is in correct body alignment in the standing position when
- a. Head is held erect and in midline
- b. Face is in forward position, same direction as the feet
- c. Chest is held upward and forward
- d. Spinal column is upright, and the curves of the spine are WNL
- e. ABD muscles are held upward with the ABD comfortably tucked in and the buttocks down
- f. Arms hang comfortably at the sides
- g. Knees are extended in a slightly flex position
- h. Feet are at right angles to the lower legs
- i. Line of gravity goes through midline, from the middle of forehead to a midpoint between the feet; laterally the line of gravity runs vertically from the middle of the skull to the posterior of the foot
- j. Base of support is on the soles of the feet, and weight is distributed through soles and heels
- b. Mobility
- • Size, shape, color, and symmetry of joints: note any masses, deformities, or muscle atrophy
- • ROM of each joint
- • Any limitation in the normal ROM or unusual increase in the mobility of a joint; ROM varies with people and decreases with aging
- • Muscle strength when performing ROM exercises against resistance
- • Any swelling, heat, tenderness, pain, nodules, or crepitation
- • Comparison of finding in one joint with those of the opposite joint
- c. Activity Tolerance
- • Evaluate patient’s ability to turn in bed, maintain correct alignment when sitting or standing, AMB, and perform self-care activities
- • Evaluate:
- a. Vital signs while patient is at rest
- b. Ability to perform the activity
- c. Patient’s response during and after activity
- d. Vital signs immediately after the activity
- e. Vital signs after the patient has rested for 3 minutes
- • Significant findings indicating that a person’s exercise tolerance has been reached include:
- a. Increased pulse, respirations, and BP
- b. SOB
- c. Dyspnea
- d. Weakness
- e. Pallor
- f. Confusion
- g. Vertigo
10. Relate nursing guidelines and rationales for performing range of motion exercises.
- • Some patients who are partially immobile or unable to move about freely need the nurse and other health care personnel to assist with passive ROM exercises.
- Follow guidelines and rationales from number 6 above
- • Follow the care plan and know the goals of the resident
- • Find out whether a movement is contraindicated for any joint
- • Become familiar with the diagnosis, abilities, and limitations
- • Use good body mechanics for yourself and the PT. Elevated the bed to a comfortable working height.
- • Be sure the PT is dressed or covered for modesty. Ensure privacy.
- • Ensure area has enough space
- • Move each join as far as possible without causing pain and never force past the resistance point.
- • Do each movement slowly and smoothly
Demonstrate Appropriate ROM to all body site
Document range of motion procedure.
Compare Comfort, Rest and Sleep (1139-1141)
- • The greatest deterrent to rest and sleep is Pain
- Nursing Interventions
- a. remaining with a lonely patient
- b. Use touch and back massage for comfort measures
- c. Obtain an extra blanket
- d. Administer analgesic (MD ordered or OTC)
- Rest & Sleep
- • Discuss Sleep Hygiene: the nonpharmacologic recommendations that help a person get a better nights sleep
- 1. Restrict intake of caffeine, nicotine, alcohol, especially late
- 2. Avoid mental/physical activities after 5pm that are stimulating
- 3. Avoid daytime naps
- 4. Avoid high fluid intake late to minimized waking up for restroom use
- 5. Sleep in a cool dark room
- 6. Eliminate use of bedroom clock
- 7. Take warm bath before bedtime
14. Relate Spiritual needs to comfort
* Review Chapter 45, This Portion is NOT located on Mobility Section
15. Different between NREM and REM sleep? 1121
- • There are two major stages in sleeping NREM and REM
- • They were studied by EEG and which records electrical current from the brain and EOG which records movement of the eyes EMG checks for muscle tone.
- • NREM has four stages I ii iii iv.
- > Stages 1 and 2 consist of 5 and 50 percent of sleep; the person could be waken up fast.
- > Stages 3 and 4 consist of 10 percent of the sleeping time.
- > The threshold is usually greatest at stage 4 which means harder to wake up.
- • The parasympathetic system nervous system dominates bring down RR, B/P metabolic rate and pulse.
- • In REM stage it is difficult to arouse a person.
- > People are usually in this stage 20 to 25 percent of the times.
- • In REM the pulse RR, b/p metabolic rate and body temp increases and skeletal muscle tone and deep tendon reflexes are depressed.
State the relationship of age and sleep requirements Chart on 1123
- Newborn sleep about 16 hour/day pattern are unique.
- Usually by the 8th through the 16th week they sleep through the nigh.
- Toddler sleep about 12 hours/day with two naps sleep about 8 to 10 hours at night.
- Preschooler sleep 9 to 16 hours with an average of 12 hours/day the REM pattern is similar to adults’ daytime napping decreases.
- School age require 10-12 hrs of sleep sleep increases when physical growth peaks.
- Adolescents Sleep, teens vary widely but require 9 to 10 hours of sleep growth spurt that normally occurs at this stage may necessitate the need for more sleep however the stress of school and work may cause restless nights.
- Young adults require about8 hours/day sleep affected by many factors physical health occupation exercise REM sleep averages about 20 percent of sleep.
- Older adults sleep an average of 7to 9 hours/day Sleep is less sound and stage iv is absent considerable decreased. Periods of REM sleep is shorten.
Examine sleep promoting and sleep suppressing factors pg1135
Sleep deprivation could be because one or more of the following things Impaired comfort or pain, changes in bedtime ritual, disruption of circadian rhythm, exercise just before sleep, caffeine, nicotine, alcohol intake after dinner, drug dependency and withdrawal and symptoms of physical illness.
Review drugs that affect sleep 1127
- Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants.
- Diuretics, ant parkinsonian drug, some antidepressants and antihypertensive steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems.