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NURS 175 - Nursing Practice Foundations > Lesson 8 - Understanding Mobility and Immobility > Flashcards

Lesson 8 - Understanding Mobility and Immobility Flashcards

1
Q

Potential Causes of Immobility

A

-direct injury (ie. sprain)
-CNS damage (ie. stroke)
-illness (ie. cancer)
-surgery complications
-advanced age

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2
Q

What is a developmental consideration for immobile school age children?

A

-delay in gross motor skills, intellectual or musculoskeletal development

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3
Q

What is a developmental consideration for immobile adolescents?

A

-growth patterns
-ability to gain independence
-social isolation

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4
Q

What is a developmental consideration for immobile adults?

A

-risk for physiological systems
-change in family and social structure

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5
Q

Which group is at the most risk of immobility?

A

older persons

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6
Q

What is a developmental consideration for immobile older adults?

A

-loss of bone mass and muscle strength
-increased dependence of other
-loss of capacity for self-care

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7
Q

How can you make older persons feel more independent and decrease immobility risk?

A

encouraging them to do as much self-care as possible

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8
Q

How do nurses contribute to loss of self-care?

A

by doing too much for patients

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9
Q

What are some of the “benefits” of bed rest?

A

-reduced activity and oxygen needs
-reduces pain
-promotes safety
-allows rest

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10
Q

Bed rest is a ______-_______ immobility.

A

medically-imposed

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11
Q

Deconditioning

A

when you have not used something in a while, your body forgets how to use it

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12
Q

What is deconditioning a result of?

A

prolonged bed rest

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13
Q

Etiology (reasons behind) deconditioning

A

-sleep
-pain
-depression
-immobility
-medical and surgical conditions
-inflammation
-nutrition

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14
Q

Atelectasis

A

-collapse of alveoli
-can lead to lung collapse
-impaired gas exchange

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15
Q

Hypostatic Pneumonia

A

-inflammation of the lung from pooling of secretions
-good medium for bacterial growth

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16
Q

Dyspnea

A

-difficulty breathing

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17
Q

Orthostatic Hypotension

A

-blood pressure drops when the patient changes from lying to standing

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18
Q

Why does orthostatic hypotension happen from bed rest?

A

-diminished cardiac output
-heart can’t keep up with changing vertical position

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19
Q

Why is orthostatic hypotension dangerous?

A

-dizziness may lead to falls

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20
Q

Thrombus

A

-blood clot that forms in a vessel as a result of vessel injury, slow blood flow, increase in viscosity

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21
Q

What is the most common type of thrombus?

A

DVT - Deep Vein Thrombosis

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22
Q

Embolus

A

-dislodged venous thrombus
-can travel and cause an eschemic event (ie. stroke)

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23
Q

Constipation

A

-may result from decreased GI mobility

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24
Q

Pseudodiarrhea

A

-may result from a fecal impaction
-liquid stool passes around the impaction
-may lead to mechanical bowel obstruction

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25
Q

Fecal Impaction

A

accumulation of hardened feces

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26
Q

Urinary Stasis

A

urine stoppage due to no help from gravity

27
Q

What are the risks of urinary stasis?

A

-UTI
-kidney stones

28
Q

Residual Urine

A

-urine left in the bladder may increase infection risk

29
Q

Muscular Atrophy

A

-decrease in size of muscle tissue
-muscle strength drops 3%/day

30
Q

Bone Loss

A

-increased with osteoporosis
-risk for fractures

31
Q

Disuse Osteoporosis

A

-less dense bones
-increased fracture risk

32
Q

Joint Contracture

A

-abnormal and possibly permanent condition characterized by joint fixation

33
Q

Foot Drop

A

-damage to peroneal nerve
-consistent flexion as a result of poor support

34
Q

Pressure Injury

A

-bed sores
-caused by pressure and a lack of sensation

35
Q

How does friction lead to pressure injury?

A

-weak skin deteriorates
-due to linens
-may be during transfers

36
Q

How does shear lead to pressure injury?

A

-sliding down in bed
-creases in clothes, socks, linens

37
Q

How does hygiene contribute to pressure injury?

A

-skin breakdown from not clean and moist

38
Q

What can delay wound healing?

A

-malnutrition
-bed rest

39
Q

Psychosocial Effects of Immobility

A

-social isolation
-sensory deprivation
-changes in coping
-depression

40
Q

Depression

A

affective disorder characterized by sadness, melancholy, worthlessness, emptiness

41
Q

The nurse is caring for a patient with the nursing diagnosis of impaired physical mobility. The nurse needs to be alert for which of the following complications? SATA
a. pulmonary emboli
b. pneumonia
c. impaired skin integrity
d. fatigue
e. increased socialization

A

a, b, c, d

42
Q

A patient has been on prolonged bed rest, the nurse is observing for signs associated with immobility. While assessing the patient the nurse is alert to which of the following signs?
a. increased bp
b. decreased hr
c. increased urinary output
d. decreased peristalsis

A

d

43
Q

Immobility is a major risk factor for pressure ulcers. In caring for an immobile patient, the nurse needs to be aware of which of the following?
a. breaks in the skin integrity are easy to heal
b. preventing a pressure ulcer is less expensive than treating one
c. a 30 degree lateral position is recommended for patient positioning
d. pressure ulcers are caused by a sudden influx of oxygen to the tissue

A

c

44
Q

The nurse is caring for a patient who has suffered a stroke and is partially immobile. As part of ongoing care, what should the nurse do?
a. encourage the patient to perform as many self-care activities as possible
b. provide a complete bed bath to promote patient comfort
c. place the patient on bed rest to prevent fatigue
d. understanding that the patient will not eat because energy needs are decreased

A

a

45
Q

Subjective Mobility Assessment

A

-degree of mobility
-how long has disability been present?
-is the patient fearful
-use of assistive device?
-pain assessment
-effect on lifestyle
-coping

46
Q

Objective Mobility Assessment

A

-ROM
-gait
-exercise
-body alignment
-physical deformities
-AOx4
-mood

47
Q

Active ROM

A

-on own

48
Q

Passive ROM

A

-with help

49
Q

Mobility Expectations Assessment

A

-address unrealistic expectations
-do they understand own limitations?

50
Q

What is important when planning for immobility?

A

interdisciplinary team collaboration

51
Q

Nursing Interventions: Respiratory

A

-deep breathing exercises
-semi/high fowlers position
-couching exercises
-supplementary oxygen

52
Q

Nursing Interventions: Cardiovascular

A

-slow position changes
-frequent position changes
-anti-clotting medications
-exercise
-fluids
-TED stockings
-positioning

53
Q

What do TED stockings do?

A

increase venous return to the heart

54
Q

Nursing Interventions: GI System

A

-nutritional intake
-small meals more frequently
-ambulation to aid in peristalsis

55
Q

Nursing Interventions: Urinary System

A

-hydration/fluid intake
-upright elimination position
-increased sitting upright in general

56
Q

Nursing Interventions: Musculoskeletal

A

-pillows for positioning
-handrolls
-splints for foot drop
-ROM exercises
-TED stockings
-sequential compression device
-use of mobility aids

57
Q

Nursing Interventions: Integumentary

A

-skin integrity assessment
-braden scale assessment
-reposition every 1-2 hours
-hygiene care

58
Q

Nursing Interventions: Psychosocial

A

-socialization
-maximize patient participation in care
-activities
-teaching
-self-care

59
Q

Hemiplegia

A

muscle paralysis

60
Q

Hemiparesis

A

muscle weakness

61
Q

Muscle Atrophy

A

loss of muscle tone and joint stiffness

62
Q

Disease Atrophy

A

tendency of cells and tissue to reduce in size and function in response to prolonged inactivity

63
Q

Negative Nitrogen Balance

A

when an immobile patient’s body excretes more nitrogen than it ingests in proteins

NURS 175 - Nursing Practice Foundations (11 decks)

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