Immobility

Question 1

three things you need to move

Answer 1

structure
strength
control

Question 2

physics of motion (4)

Answer 2

alignment
balance
gravity
friction

Question 3

alignment

Answer 3

lining up for best effect
using joints and muscles well
avoiding injury 
proprioception
spacial relationships

Question 4

balance

Answer 4

ear drums
managing weight
avoid falls
flex knees
senses
feet apart
flex knees

Question 5

gravity

Answer 5

weight
lifting
pressure

Question 6

friction

Answer 6

risk factor for skin breakdown
more work
more damage
can use lift or nonfriction sheets

Question 7

Some factors that influence mobility

Answer 7

developmental considerations
physcial health
mental health
lifestyle
attitude and values
fatigue and stress
external factors (temperature, finances, location)

Question 8

patological influence on mobility

Answer 8

postural abnormalities
impaired bone formation or muscle development
problems affecting joint mobility
musculoskeletal trauma
damage to nerves, CNS
problems involving other body systems
psychological
sedentary lifestyles

Question 9

several medical diagnoses, one common nursing diagnosis

Answer 9

stroke
osteoarthritis
post surgery

all cause immobility

Question 10

“functional” nursing diagnosis

Answer 10

nursing diagnoses sometimes relate to ability to function in some way

immobility is a common nursing diagnosis with potential for major preventable complications

Question 11

3 general goals for mobility

Answer 11

• prevent decreased mobility and increase mobility
• safety - avoid injuries
• minimize complications due to immobility

Question 12

“bed rest”

NANDA diagnosis

Answer 12

impaired physical mobility

• intervention that restricts clients to bed for therapeutic reasons
• leads to hazards of immobility
• and disuse atrophy

Question 13

side effects of immobility

metabolic

Answer 13

endocrine, calcium and GO

Question 14

side effects of immobility

cardiovalcular

Answer 14

hypotension
increased cardiac workload (orthostatic hypotension because laying flat for so long)
thrombosis/emboli (travelling blood clot - poor circulation blood is pooling - venous stasis)

Question 15

side effects of immobility

respieratory

Answer 15

hypostatic pneumonia

atelectasis (collapsed lung)

Question 16

side effects of immobility
musculoskeletal changes (contractures)

Answer 16

muscle loss/atrophy
joint instability
weakness

Question 17

side effects of immobility

GI

Answer 17

constipation, gas (pain)

*can gain weight on bed rest because decrease in BMR

Question 18

side effects of immobility

skeletal

Answer 18

calcium loss
osteoporosis
fractures
contractures (hardening of muscles or tendons)
footdrop

Question 19

side effects of immobility

urinatry

Answer 19

urinary stasis (because kidney and ureter are level with each other so are prone to bacteria growth)
IT
stones (calcium)
dehydration

Question 20

side effects of immobility

skin

Answer 20

pressure ulcers

Question 21

side effects of immobility

psychosocial effects

Answer 21

• emotional and behavioral responses
• sensory alterations: deprivation, depression, hostility, poor sleep
• changes in coping

Question 22

Nursing Assessment

• asses the present mobility
• assess body systems

Answer 22

ROM
exercise/activity tolerance
alignment
gait
use of assistive devises

Question 23

SMART goals

Answer 23

Specific, singular
Measurable
Attainable
Realistic
Time limited

Question 24

Long term goal

Answer 24

Mr. J will walk with his cane around the blook each day by January 30th (2 weeks from now)

Question 25

short term goal

Answer 25

Mr. J will demonstrate proper use of his cane by 1:30pm

Question 26

Interventions for immobility

Answer 26

list all possible interventions for increasing mobility - positioning techniques - transfers - ROM - exercise; ambulation

Question 27

dorsal position (dorsal recombant)

Answer 27

lying on back

Question 28

lateral position

Answer 28

lying on side

Question 29

fowlers position

Answer 29

lying head propped up 45-60 degrees

Question 30

tredelenburg postion

Answer 30

head down, legs elevated

Question 31

reverse trendelenburg

Answer 31

head up, legs at a down angle

Question 32

prone position

Answer 32

laying on stomach

Question 33

SIMS position

Answer 33

lying on stomach with knee up at a 90 degree angle

Question 34

cane with a half circle handle

Answer 34

need minimal support | use stairs frequently

Question 35

cane with flat handle one leg

Answer 35

easier to grasp | hand weakness

Question 36

cane with flat handle 4 legs

Answer 36

poor balance

Question 37

Initiate interventions for each system to compensate for immobility: metabolic

Answer 37

diet change good nutrients add calcium iff appropriate

Question 38

Initiate interventions for each system to compensate for immobility: respiratory

Answer 38

incentive spirometer

Question 39

Initiate interventions for each system to compensate for immobility: cardiovascular

Answer 39

compression stockings | move legs/walk

Question 40

Initiate interventions for each system to compensate for immobility: musculoskeletal

Answer 40

ROM

Question 41

Initiate interventions for each system to compensate for immobility: elimination

Answer 41

fiber/laxative | encourage fluid intake

Question 42

Initiate interventions for each system to compensate for immobility: Skin

Answer 42

rotate patient

Question 43

Initiate interventions for each system to compensate for immobility: psychosocial

Answer 43

spend time with them | quiet time

Question 44

Evaluation

Answer 44

use goals to evaluate progress | -continue, stop or revise your plan according to your evaluation