Activity/immobility Flashcards
(83 cards)
1
Q
What are the components to a musculoskeletal review?
A
Gait, alignment, symmetry, muscle mass, muscle tone, range of motion, involuntary movements, inflammatory signs, and gross deformities
2
Q
What is an expected gait?
A
Steady, smooth, and coordinated
3
Q
What is an unexpected gait?
A
Shuffled gait, uncoordinated gait, patient reporting slower or difficulty walking
4
Q
Who is at risk for gait abnormalities?
A
Older adults, patients with neuro conditions, spinal/lower extremity issues
5
Q
Why do we care who about gait abnormalities?
A
They are an increased fall risk
6
Q
Define flexion.
A
Movement decreasing angle between two adjoining bones; bending of limb
7
Q
Define extension.
A
Movement increasing angle between Theo adjoining bones
8
Q
Define hyperextension.
A
Movement of body part beyond its normal resting extended position. (Head)
9
Q
Define pronation.
A
Movement of body part so that the front or ventral surface face downward.
10
Q
Define supination.
A
Movement of body part so that the front or ventral surface faces upward
11
Q
Define abduction.
A
Movement of extremity away from midline of the body.
12
Q
Define Adduction.
A
Movement of extremity toward midline of the body
13
Q
Define inward rotation.
A
Rotation of joint inward
14
Q
Define external rotation.
A
Rotation of joint outward.
15
Q
Define eversion.
A
Turning of body part away from midline (foot)
16
Q
Define inversion.
A
Turning of body part toward midline (foot)
17
Q
Define dorsiflexion.
A
Flexion of toes and foot upward.
18
Q
Define plantar flexion.
A
Bending of toes and foot downward
19
Q
Define kyphosis.
A
Exaggerated curvature of thoracic spine
20
Q
Define lordosis.
A
Exaggerated curvature of the lumbar spine
21
Q
Define socoliosis.
A
Exaggerated lateral curvature
22
Q
Describe a grade 5 for muscle strength.
A
The muscle can move the joint it crosses through a full range of motion, against gravity, and against full resistance applied by the examiner
23
Q
Describe a grade 4 for muscle strength.
A
The muscle can move the joint it crosses though a full range of motion against moderate resistance
24
Q
Describe a grade 3 for muscle strength.
A
The muscle can move the joint it crosses through a full range of motion against gravity but without any resistance
25
Describe a grade 2 for muscle strength.
The muscle can move the joint it crosses through a full range of motion only if the part is properly positioned so that the force of gravity is eliminated
26
Describe a grade 1 for muscle strength.
Muscle contraction is seen or identified with palpation, but it is insufficient to produce joint motion even with elimination of gravity.
27
What is a grade 0 for muscle strength.
No muscle contraction is seen or identified with palpation; paralysis
28
What are nursing implications for using heat or cold?
-Assess the site frequently (5-10 minutes) for signs of irritation
-D/C if irritation occurs, can remove and replace if symptoms resolve
-Document
29
How many back and other injuries occur among nursing employees every year?
35,000
30
What is ergonomics?
Science that focuses on factors or qualities in an object’s design/use that contribute to comfort, safety, efficiency, and ease of use
31
Describe body mechanics.
-Center of gravity: lower the better
-Lifting: use assistive devices when appropriate
-Pushing or pulling: wide base of support
32
What affect mobility?
-Obesity: major risk factor
-Congenital defects
-Bone, joint, and muscle disorders
-Inflammatory joint diseases
-Central nervous system disorder
-Musculoskeletal traumas
-Activity intolerance (deconditioning)
33
Describe fowler’s position.
A bed position where the head and trunk are raised typically between 40-90 degrees. This position is often used for patients who have cardiac issues, trouble breathing, or a nasogastric tube in place.
34
Describe the lateral position.
This position involves the patient lying on either their right or left side. Right lateral means the patients right side is touching the bed, while left lateral means the patient’s left side is touching the bed. A pillow is often placed in between the legs for patient comfort.
35
Describe the lithotomy position.
This position involves the patient lying flat on her back with legs elevated to hoop level or above, often supported but stirrups. It is commonly used for gynecological procedures and childbirth.
36
Describe the prone position.
A position where the patient lies on his stomach with his back up. The head of is typically turned to one side. This position allows for drainage of the mouth after oral or neck surgery. It also allows for full flexion of knee and hip joints.
37
Describe reverse trendelenburg.
The patient is supine with the head of the bed elevated and the foot of the bed down. This position may be used in surgery to help promote perfusion in obese patients. It can also be helpful in treating venous air embolism and preventing pulmonary aspiration.
38
Describe the sim’s position.
A prone/lateral position in which the patient lied on his side with his upper left flexed and drawn in towards the chest, and the upper arm flexed at the elbow. Sim’s position is useful for administering enemas, perineal examination, and for comfort in pregnancy
39
Describe the supine position.
A position where the patient is flat on his back. Supine is considered the most natural “at rest” position, and is often used in surgery for abdominal, facial, and extremity procedures.
40
Describe the trendelenburg position.
This position involves a supine patient and sharply lowering the head of the bed and raising the foot, creating and “upside down” effect. In the past, this position was frequently used to treat hypotension, although this has fallen out of favor in recent years due to studies showing it to be ineffective and potentially dangerous. It is helpful during gynecological and abdominal hernia surgeries, and in placement of central lines.
41
What degree is semi-fowler’s position.
Bed elevated 15-45 degrees (usually 30).
42
What degree is fowler’s position?
Bed elevated to 45-60 degrees.
43
What angle is high-fowler’s position?
Bed elevated to 60-90 degrees
44
Describe a gait belt.
-Assistive device which helps nurses mobilize patients
-Reduces chance patient might fall
-Helps nurses reduce chance of injuring themselves
45
What are the barriers to early mobility?
Lack of staff and pain
46
What does early mobility help with?
Respiratory function, cardiac function, muscle tone, metabolism/gastrointestinal function, every body system is better moving
47
What are the two types of canes?
Signed straight-legged and quad
48
What does a cane do?
Provides support and balance for patients with mild balance or strength impairments
49
Why would a quad can be used?
Used more commonly for patients with unilateral weakness
50
How do you use a cane?
-The cane goes on the strong side
-Handle of cane should be close to the patient’s wrist crease
-Move cane forward first, then weaker side, then stronger leg past the cane.
51
What does a walker do?
Provides a wide base of support, provides lots of stability and security when walking
52
How do you use a walker?
-Do not lean OVER the walker
-Don’t let the walker her too much in front of the patient
-Do NOT use on multiple stairs
-Top of walker in line with patient wrist creases (elbows at 15-30 degrees)
-Make sure patient is stepping inside of the walker
53
What does the acronym COAL stand for when it comes to using a cane?
Cane Opposite Affected Leg
54
What does Wandering Wilma’s Always Late stand for?
Walker with affected leg
55
What are the 2 types of crutches?
Axillary wooden/metal crutch, pro double adjusted Lofstrand (forearm crutch)
56
What are crutches used for?
-Used for temporary issues
-Forearm crutches can be used for longer periods, typically related to some paralysis
57
What are the nursing teaching points for crutches?
-Crutch pads (axilla) should be 2-3 finger lengths from the axilla
-Weight bearing should be on the hand grips
-Elbows should be flexed 15-30 degrees
-Basic crutch position: tripod position, with crutches 6 inches in front of feet and 6 inches to the side
58
Describe a four point gait for crutch use.
-Weight-bearing on both legs
-Each leg moves alternatively, and 3 points of contact/support at all time
59
Describe a three-point gait for crutch use.
-ALL weight-bearing on one leg
-Affected leg not on ground.
60
Describe the two-point gait for crutch use.
-Partial weight-bearing on both feet
-Move opposite crutch and leg alternatively
61
Why is immobility a big deal?
-Immobility affects all body systems
-Systemic and localized affects of immobility can bee seen in days
-Can have a negative effect on psychosocial functioning
-Can have long lasting consequences on health
62
What metabolic changes can be seen with immobility?
Decreases metabolic rate, creates negative nitrogen balance, weight loss, decreased muscle mass
63
What GI changes can be seen with immobility?
Constipation, psuedodiarrhea, overall depressed intestinal function, fluid/electrolyte imbalances
64
What respiratory changes can be seen with immobility?
Atelectasis, increased risk of pneumonia, statins secretions, decreased oxygenation
65
What cardiovascular changes can occur with immobility?
Orthostatic hypotension, increased cardiac workload, thrombus formation
66
At musculoskeletal changes can occur with immobility?
Lose lean muscle mass, disuse atrophy, impaired calcium metabolism, joint abnormalities (disuse osteoporosis), contractures, foot drop
67
What urinary elimination changes can occur with immobility?
Urinary stasis, increased risk of UTI, increased risk of renal calculi (kidney stones), dehydration
68
At integumentary changes can occur with immobility?
Pressure injuries
69
What is joint contracture?
Possible permanent, abnormal fixation of the joint
-Disuse, atrophy, shortening of muscle fibers
-No longer full ROM
-Early prevention is KEY
70
What is foot drop?
-A type of contracture
-Foot permanently flexed in plantar flexion
-Causes extreme difficulty when mobilizing again
-Unable to lift toes off of the ground (FALL RISK)
-Patients with CVA (stroke), with left or right sided weakness are high risk for foot drop
71
What is a pressure injury?
-Impairment of the skin related to prolonged ischemia
-Inflammation over bony prominence leads to ischemia of the tissue (O2 & nutrients cannot get to the skin)
-Longer pressure applies more intense the ischemia areas
72
How do we prevent pressure injuries?
Turning patients, encouraging patients to move around, mobilize if possible, use assistive devices, turning with pillows, or z-flow devices
73
Where are the common areas for pressure injuries?
Coccyx, heels, back of head, elbows
74
What is deep vein thrombosis?
Clot which has detached from the wall
75
What is deep vein thrombosis?
Cloth within the vein blocking flow
76
What are the 3 contributing factors (Virchow’s triad) to thrombus, VTE, DVT?
-Damage to the vessel wall
-Alteration in blood flow (immobility/bed rest)
-Alterations in blood constituents (changed clotting factors, increased platelet activity)
77
What are metabolic nursing preventions that can prevent immobility complications?
-High-protein, high-caloric diet
-Supplement with vitamins B&C
-If patient is not in-taking oral, make sure we are feeding enterally/paternally
78
What are respiratory nursing interventions to prevent immobility complications?
-Pulmonary toilet: turn, cough, deep breathe
-GET UP. Even if they can’t walk, mobilize them to the chair, if that isn’t possible go to chair position in the bed
-Incentive spirometer
-CPT (postural drainage, vibration, cough assist)
-Adequate hydration (thins secretions)
79
What are cardiovascular nursing interventions to prevent immobility complication?
-Reduce orthostatic hypotension (change positions slowly, adequate hydration)
-Mobilize early
-Avoid Valsalva maneuvers (bearing down, avoid constipation, encourage deep breathing)
80
What musculoskeletal nursing interventions can we do to prevent immobility complications?
-In bed exercises
-Passive/active ROM
-Walk the patient
-Encourage activity in any way possible
81
What integumentary nursing interventions can be done to prevent immobility complications?
-Turning q2h is essential
-encourage patients sitting up in the chair to move around, assist with repositioning if weak every hour
-Adequate hydration, nutrition, oxygenation
-Special mattresses
-Special dressing over pressure prone areas
82
What elimination issue nursing interventions can be done to prevent immobility complications/
-Keep well hydrates (800-2000 mL/day of fluid)
-Encourage voiding (up to potty chair or to restroom)
-Stool softeners/laxatives when needed
-High fiber diet, fiber supplementation
83
What psychosocial health nursing interventions can be done to prevent immobility complications?
-Encourage routine when possible
-Sleep cycles
-Provide meaningful stimuli
-Involve patients in care decisions
-Hygiene and grooming
