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nursing 20030 > immobility > Flashcards

immobility Flashcards

1
Q

describe adduction

A

lateral movement of a body part toward the midline of the body

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2
Q

describe abduction

A

lateral movement of a body part away from the midline of the body

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3
Q

describe rotation

A
  • internal rotation: a body part turning on its axis toward the midline of the body
  • external rotation: a body part turning on its axis away from the midline of the body
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4
Q

describe flexion

A

the state of being bent

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5
Q

describe extension

A

the state of being in a straight line

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6
Q

describe supination

A

the assumption of the supine position

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7
Q

describe pronation

A

the assumption of the prone position

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8
Q

describe inversion

A

movement of the sole of the foot inward (occurs at the ankle)

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9
Q

describe eversion

A

movement of the sole of the foot outward (occurs at the ankle)

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10
Q

describe trendelenburg position

A

requires lowing the torso and raising the feet

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11
Q

describe prone position

A

person lies on abdomen and turns head to the side, body is straight

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12
Q

describe supine position

A

person lies flat on back with legs extended and knees slightly flexed

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13
Q

describe dorsal recumbent position

A

patient lays on back with legs separated, knees flexed, and soles of feet on the bed

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14
Q

describe bone

A

the hard largely calcareous connective tissue of which the adult skeleton of most vertebrates is chiefly composed

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15
Q

describe muscles

A

an organ that is essentially a mass of muscle tissue attached at either end to a fixed point and that by contracting moves or checks the movement of a body part

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16
Q

describe ligaments

A

a tough fibrous band of tissue connecting the articular extremities of bones or supporting an organ in place

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17
Q

describe tendons

A

a tough cord or band of dense white fibrous connective tissue that unites a muscle with some other part (such as a bone) and transmits the force which the muscle exerts

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18
Q

describe joints

A

the point of contact between elements of a skeleton with the parts that surround and support it

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19
Q

describe alignment

A
  • in the standing position, a straight line can be drawn from the ear through shoulder and hip; in bed, head, shoulders, and hips are aligned
  • correct alignment permits optimal musculoskeletal balance and operation and promotes physiologic functioning
  • deviations from body alignment result from chronic poor posture, trauma, muscle damage, or nerve dysfunction. Pain, fatigue, and a persons mental status may also influence alignment
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20
Q

describe posture

A
  • the position or bearing of the body
  • head erect, vertebrae straight, knees and feet point forward, arms at side with elbows flexed
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21
Q

describe balance

A

stability produced by even distribution of weight on each side of the vertical axis

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22
Q

describe gait

A
  • the way a person walks
  • arms swinging freely in alternation with legs swings, while one leg is in the stance phase the other is in the swing phase
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23
Q

describe coordination

A

the harmonious functioning of parts for effective results

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24
Q

describe range of motion (ROM)

A

the maximum degree of movement of which a joint is normally capable

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25
Q

name some factors that influence mobility

A
  • lifestyle and habits
  • musculoskeletal function
  • nervous system control
  • circulation and oxygenation
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26
Q

how could lifestyle and habits influence mobility?

A
  • are they sedentary or active?
  • what is their motivation to move?
  • what habits do they have?
  • what is their living environment and community like?
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27
Q

describe how musculoskeletal function may influence mobility

A

need adequate structure and function in order to mobilize properly

28
Q

describe how nervous system control may influence mobility

A
  • spinal cord injury - paralysis below the level of injury
  • afferent and efferent nerves connect to the CNS to the periphery and back again
  • pain is managed and mediated by the nervous system, pain can impede mobility (anticipate pain on movement and administer pain meds before movement)
29
Q

describe efferent nerves

A

impulses move from CNS back to periphery

30
Q

describe afferent nerves

A

nerves that help to move impulses from the periphery to CNS

31
Q

describe how circulation and oxygenation can influence mobility

A
  • skeletal muscle contraction requires significant energy and oxygenation
  • any alteration will limit ability to have purposeful movements
32
Q

what findings during assessment may indicate limited mobility?

A
  • decreased muscle strength and tone
  • lack of coordination
  • altered gait
  • falls
  • decreased joint flexibility
  • pain on movement
  • impact in every body system
33
Q

how can immobility impact the cardiovascular system?

A
  • increased cardiac workload = skeletal muscles dont help push the blood back to the heart = makes the heart work harder to pump = faster heart rate
  • orthostatic hypotension = baroreceptors in the brain are sluggish to respond to body position changes
  • thrombus formation and embolism = venous stasis = increase risk of formation of blood pools (venous stasis) in the extremities
34
Q

what is the difference between a thrombus and embolism

A

thrombus is a clot, embolism is a moving clot

35
Q

what are some abnormal findings r/t immobility in the cardiovascular system

A
  • increased HR
  • hypotension, particularly with position changes
  • edema of extremities
  • assessment findings indicating DVT or clot (unilateral edema, redness, swelling, pain, low grade fever)
36
Q

what interventions can be used to prevent complications of immobility r/t cardiovascular system

A
  • orthostatic VS
  • gradual position changes
  • DVT prevention (early ambulation, TED hose, SCD pumps)
37
Q

what impacts does immobility have on the respiratory system

A
  • decreased lung expansion (partially because of a decreased need for oxygen by the body)
  • atelectasis - micro collapse of functional unit of the lung (alveoli) where exchange of O2 and CO2 happens
  • retained secretions
  • pulmonary embolus (thrombus that has moved to circulatory system surrounding the lungs)
38
Q

describe abnormal assessment findings r/t the respiratory system with immobility

A
  • diminished lung sounds, especially in the bases of the lungs
  • increased need for supplemental oxygen or decreased SPO2
  • cough or rhonchi
  • SOB
  • chest pain and tachycardia along with SOB may cause concern for pulmonary embolus (can be life threatening)
39
Q

what interventions can be used to prevent complications of immobility r/t respiratory system

A
  • coughing, deep breathing
  • incentive spirometry
  • increase fluid intake
  • positioning
  • promote activity
40
Q

describe the impact immobility has on the musculoskeletal system

A
  • muscle atrophy and weakness, impaired endurance
  • contractures and joint pain
  • disuse osteoporosis = OP is the weakened state of bone structure. without weight bearing activity, bone breaks down faster than it is repaired
41
Q

describe some abnormal assessment findings with immobility r/t the musculoskeletal system

A
  • atrophy
  • impaired strength
  • impaired ROM
  • pain on movement
  • frequent fractures
42
Q

describe interventions to prevent complications of immobility r/t musculoskeletal system

A
  • turning schedules and positioning aides
  • logrolling
  • mobility restrictions on recent orthopedic surgery pts
  • change positions gradually
  • joint mobility maintenance/ROM exercises (support joint being exercised, use of automatic ROM equipment)
  • early and progressive mobilization
  • dangling
  • protect yourself and the pt (transfer and gait belts)
  • pt can perform isometric exercises in bed to maintain or improve muscle tone even if unable to get oob
43
Q

differentiate between active and passive ROM

A

active - pt moves extremities on their own

passive - pt is assisted to move

44
Q

what are some different devices used to assist with musculoskeletal interventions for immobility

A
  • foot board
  • high top sneakers/boots to prevent plantar flexion (foot drop)
  • hand rolls
  • trochanter rolls
  • transfer/gait belts
45
Q

what impact does immobility have on the neurologic system

A
  • sensory deprivation
  • altered sleep/wake cycles
46
Q

what are some abnormal assessment findings with immobility r/t neurologic system

A
  • confusion
  • impaired short term memory
  • irritability
  • insomnia
  • excessive drowsiness
47
Q

what are some interventions used to prevent complications of immobility r/t neurologic system

A
  • meaningful stimuli
  • promote natural/normal sleep patterns
  • mobilize
48
Q

describe the impact immobility has on psychological/social functioning

A
  • helplessness
  • body image disturbance
  • exaggerated emotional responses
49
Q

describe interventions to prevent complications of immobility r/t psychological/social functioning

A
  • give choices
  • encourage even limited self care
  • mobilize
50
Q

describe the impact immobility has on the integumentary system

A
  • impaired peripheral circulation
  • can lead to impaired skin integrity
51
Q

describe some abnormal assessment findings with immobility r/t integumentary system

A
  • reddened areas of skin at pressure points
  • pressure injuries
  • rashes
52
Q

what are some interventions to prevent complications of immobility r/t integumentary system

A
  • turn q2 for high risk pts, use natural alignment, pillows for support
  • keep dry, wrinkle free linens
  • progressive mobility (oob as soon as possible)
53
Q

describe the impact immobility has on the gastrointestinal/metabolic system

A
  • decreased metabolic rate
  • cellular demand for O2 decreased, leading to decreased metabolic rate
  • negative nitrogen balance (other factors- fever, trauma, illness - cause increased metabolic rate and tissue breakdown occurs faster than can be replaced)
  • constipation due to decreased muscle tone in GI organs (decreased peristalsis)
  • anorexia/decreased appetite
54
Q

describe some abnormal assessment findings with immobility r/t GI/metabolic system

A
  • nausea
  • appetite decrease
  • weight loss
  • evaluation of bowel elimination or constipation
55
Q

describe some interventions that can be used to prevent complications of immobility r/t GI/metabolic system

A
  • increase fluids
  • offer frequent toileting
  • oob for meals and elimination
  • progressive mobility
56
Q

describe the impact immobility has on the urinary system

A
  • urinary stasis (pooling)
  • UTI
  • renal calculi (when bone breaks down faster than it can repair, calcium is released into the bloodstream)
57
Q

describe some abnormal assessment findings with immobility r/t urinary system

A
  • urinary retention
  • frequent urination
  • cloudy or amber urine
  • back or flank pain
58
Q

describe some interventions used to prevent complications of immobility r/t urinary system

A
  • oob for elimination
  • increase fluids
  • progressive mobility
59
Q

describe some subjective data used when assessing for mobility alterations

A
  • normal pattern identification r/t activity
  • risk identification (patients on bedrest or risk for falls)
  • dysfunction identification (inability to tolerate activities, what causes the mobility issues?)
60
Q

describe some objective data used for assessing for mobility alterations

A
  • general survey (posture, alignment, gait)
  • neurological
  • cardiovascular
  • respiratory
  • GI
  • urinary
  • musculoskeletal
61
Q

what are some nursing diagnoses r/t immobility

A
  • impaired physical mobility
  • ineffective tissue perfusion
  • ineffective breathing pattern
  • impaired wheelchair mobility
  • activity intolerance
  • constipation
  • urinary retention
  • risk for disuse syndrome
  • acute pain
  • risk for impaired skin integrity
  • impaired bed mobility
62
Q

what does SMART stand for

A

Specific

Measurable

Attainable

Realistic

Time Based

63
Q

describe planning and implementing with immobility

A
  • establish measurable patient centered goals and outcomes
  • health promotion (physical fitness, injury prevention, osteoporosis prevention)
  • systemic interventions
64
Q

describe systemic interventions

A
  • interventions that affect the whole person
  • ex. encouraging frequent and early mobilization, increased fluid intake
  • affective learning - seeing what pts believe about immobility
65
Q

describe implementing progressive mobility

A
  • personalize how much activity a pt participates in based on how much they can tolerate
  • dangle at side of bed
  • must use nonslip socks
  • use transfer belts and ambulation devices
  • isometric exercises to enhance muscle strength
  • obtain proper equipment and assistance
66
Q

describe evaluation with immobility

A
  • have goals and outcomes been met?
  • supporting documentation of progress, stagnation, or recession
  • modify or discontinue the care plan as needed

nursing 20030 (31 decks)

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