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N353: Practice of Nursing II > Module 8: MedSurg Impaired Mobility > Flashcards

Module 8: MedSurg Impaired Mobility Flashcards

(73 cards)

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1
Q

What is “Alteration of Mobility”?

A

A nursing diagnosis

Defined as a state in which an individual has a limitation (of) independent, purposeful movement of the body or of one or more extremities

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2
Q

Top 3 Causative Factor Types for Altered Mobility

A
  1. Congenital
  2. Internal Factors
  3. Acquired
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3
Q

What does Congenital cause of Altered Mobility mean?

A

Mobility alteration present from birth, may be a muscular, structural, or Neuro issue

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4
Q

What does Internal factors for altered mobility mean?

A

May be mobility impairments from psych concerns - MOBILITY IS NOT JUST PHYSICAL

ex: Pain, fear, anxiety, depression

ex: Do not wanna move when hurt, so fear keeps you from moving

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5
Q

What does Acquired cause of altered mobility mean?

A

Stiffness/Physical Maladies and Disease

ex: Accidents, Aging, Altered Systems (Pathologies), Ailments and Afflictions

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6
Q

Types of Altered Mobility

A
  1. New and Short Term/Limited
  2. New and Long Term/Continuing/Worsening
  3. Life Long (Congenital)
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7
Q

New and Short Term/Limited Altered Mobility

A

Things that temporarily will alter mobility

ex: Bone fracture, surgical pain, flu, joint sprain, high risk pregnancy

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8
Q

New and Long Term/Continuing/Worsening

A

Things that will chronically cause altered mobility

ex: Mult Sclerosis, dementia, Parkinsons, Paralysis from CVA, MVA, Amputations, Arthritis, Polio

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9
Q

Life Long Altered Mobility

A

Altered mobility that is permanent and usually since birth

ex: Cerebral Palsy and Muscular Dystrophy

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10
Q

Benefits of Mobility

A

Psychological well being

Cardiac efficiency

Pulmonary function

Muscle tone

Renal/GI functions

Decrease bone/mineral loss

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11
Q

Benefits for Immobility

A

Relieves pain

Promotes healing

Reduces re-injury of use

Reduces oxygen needs

Reduces threat of miscarriage in some high-risk pregnancies

Sometimes some immobility is a good thing for rest

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12
Q

Consequences of Immobility

A
  1. Generalized deconditioning (can come on fast)
  2. Secondary Disabilities may occur (like contractures)
  3. Severity and Duration can depend on things such as Age, general health and comorbidities, degree of immobility, length of immobility, and rehabilitation strategies
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13
Q

How to minimize the consequences of immobility

A

Early mobilization

Frequent position changes

Good skin care

Maintain all limbs/joints in functional alignment

Active/passive ROM

Maintain clear respiratory system

Maintain nutrition and hydration

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14
Q

What is Nursing Care?

A

The diagnosis and treatment of HUMAN RESPONSES (NOT DIAGNOSES) to actual or potential health problems

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15
Q

Examples of Activity and Exercise Nursing Diagnoses

A

Activity intolerance

Risk for activity intolerance

Impaired physical mobility

Sedentary Lifestyle

Risk for disuse syndrome

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16
Q

Examples of Mobility Decline Nursing Diagnoses

A

risk for falls

fear of falling

ineffective coping

low self esteem

powerlessness

self care deficit

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17
Q

Examples of Prolonged Immobility Nursing Diagnoses

A

ineffective airway clearance

risk for infection

risk for injury

risk for disturbed sleep pattern

risk for situational low self esteem

potential for impaired peripheral circulation

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18
Q

What are the general nursing goals for Impaired/Altered Mobility when caring for a patient?

A
  1. Increased tolerance for physical activity
  2. Restored/improved capability (ambulation, ADLs, etc)
  3. Absence of injury (falling, improper use of body mechanics, etc)
  4. Enhance physical fitness
  5. Absence of complications associated with immobility
  6. Improved social, emotional, intellectual well being

INCREASE FUNCTION, IMPROVE ABILITY, AND AID PSYCHE

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19
Q

Cardiovascular System Responses to Impaired Mobility

A

Decreased HGB

Increased Cardiac Workload (because venous return is less effective)

Increased Resting Heart Rate

Decreased Organ Perfusion

Increased thrombosis formation (could become a pulmonary embolism)

Orthostatic Hypotension

Edema (Swelling) in the legs, hands, or overall venous stasis

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20
Q

Assessments for the Cardiovascular System when the Patient has Impaired Mobility

A
  1. Labs: Hgb&Hct
  2. BP: Lying, Sitting, Standing
  3. Pulse: Apical, Peripheral
  4. O2 Sat
  5. Edema of Extremities Check
  6. Temperature of Extremities Check
  7. Check skin for signs of reduced perfusion
  8. Signs of DVT: Swelling, Redness, Homans Sign, Pain in the Calves
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21
Q

Interventions for the Cardiovascular System when the Patient has Impaired Mobility

A

OOB ASAP w/ ORDER!!!!

ROM Exercises

Change position gradually

Avoid Valsalva maneuver

Encourage fluids

TEDs/SCDs

Do not gatch foot of bed (locks bed angle and can cause blood pooling)

Low does anti coagulation therapy (prevent bleed + clots)

Education

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22
Q

What medicines are used in low dose anticoagulation therapy?

A

Heparin

Coumadin

Lovenox (enoxaparin sodium)

Xarelto (rivaroxaban tablets)

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23
Q

Heparin (Admin, Antidote, Lab Test)

A

Admin - SubQ

Antidote - Protamine Sulfate

Lab Test - PTT

Given as a preventative measure

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24
Q

Coumadin (Admin, Antidote, Lab Test)

A

Admin - PO

Antidote - Vit K

Lab Test - PT/INR

“Warfarin”

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25
Lovenox (Enoxaparin Sodium) (Admin, Antidote, Lab Test)
Admin - Subcutaneous Antidote - Protamine Sulfate Lab - None *Often given to go home with*
26
Xarelto (rivaroxaban tablets) (Admin, Antidote, Lab Test)
Admin - PO Antidote - Andexanet alfa Lab - None *newer and more expensive but you do not need to worry about what you eat or having blood work done when taking it*
27
What patient education should be done regarding low dose anti coagulation therapy?
Inform other PCPs (physicians and professionals) Dietary considerations (like when taking Coumadin) Interactions with other medications (OTC or prescription or herbal preparations) Importance of lab tests if necessary Monitor for S/S of bleeding
28
What are some S/S of bleeding in anti coagulation therapy?
ecchymosis occult blood (hidden blood in stool to test for) sudden numbness or weakness HA (brain maybe) confusion (could be bleeding in brain) problems with vision, speech, or balance (brain maybe) N/V Joint Swelling
29
Respiratory System responses to Impaired Mobility
Decreased HGB Decreased Lung Expansion Increased Secretions Increased risk of Atelectasis Increased Risk of pneumonia Stasis of secretions Impaired gas exchange Anxiety
30
Assessments for the Respiratory System when the patient has impaired mobility
Labs (H&H) Vital signs (including pulse ox) Lung sounds chest movements resp. difficulties s/s of Pulmonary embolism mentation blood gases pulmonary secretions sputum
31
Interventions for the Respiratory System when the patient has impaired mobility
OOB ASAP w/ ORDER!!!! Encourage C-DB and/or incentive spirometer q2h Reposition q2h Raise HOB ROM (active and passive) Supplemental O2 Encourage fluids Specialty beds Education!
32
Skin response to Impaired Mobility
Increased risk of skin breakdown and ulcer formation (protein buildup or infection signs too)
33
Response by the Skin to impaired mobility is compounded by what factors?
Impaired body metabolism Pressure Shearing force Friction Decreased hydration and/or nutrition
34
Assessments for the Skin when the patient has impaired mobility
Signs of compromise: Redness, blanching, temp, sponginess, loss of sensation Labs: H&H, protein, albumin, WBCs
35
Interventions for the Skin when the patient has impaired mobility
OOB ASAP w/ ORDER!!! ROM (active/passive) ID patients at risk for breakdown (Braden Scale Risk) Daily skin inspection (do not rub everything, stimulate circulation with bathing, washcloths, ankle rotation, etc) Keep skin clean and moisturized Protect pressure points Stimulate circulation Adequate Adequate hydration/nutrition turn/resposition q2h Specialty beds Education
36
Risk Areas for Pressure ulcer
*Anywhere you lean or has a bony prominence* 1. Back of Head 2. Shoulder Blade 3. Elbows 4. Spine 5. Hip Bones or (Iliac Crest) 6. Medial knee (Between the Knee; may need a towel) 7. Anywhere the leg touches the but, but especially THE HEELS (float the heels!)
37
When measuring a pressure ulcer, what 4 things need to be documented?
1. Size (LxWxD) 2. Depth 3. Staging 4. Presence of undermining, tunneling, or sinus tract *to measure depth, size, and presence use a sterile, saline damp swab, but never use force
38
What are the 4 Staging levels of Pressure Wounds
1. Redness 2. Partial thickness 3. Full thickness 4. Full thickness past fascia
39
Gastrointestinal responses to impaired mobility in a patient
Decreased Appetite Decreased BMR (Basal metabolic rate) Decreased gastric motility Decreased muscle tone Increased risk of constipation
40
What things are altered in the GI tract if the patient cannot move?
Digestion Utilization of nutrients Proteins Metabolism
41
Assessments for the GI system in a patient with impaired mobility
Labs: Albumin, Protein levels Anxiety and/or embarrassment (maybe inability to get to bathroom) Bowel sounds Defecation pattern Abdominal distention Appetite Nutrition Nausea
42
Interventions for the GI system in a patient with impaired mobility
OOB ADAP w/ ORDER!!! Ambulate to BR (do not use a bed pan if possible, they should be upright to go - its torturous) Record and note bowel elimination pattern Promote regular bowel elimination Record dietary and fluid intake Raise HOB during meals Encourage fluids/fiber/nutrition
43
Genitourinary System responses in a patient with impaired mobility
Decreased Bladder tone Decreased Urine Output Increased urine Stasis Increased risk of UTI Increased risk of renal calculi
44
Assessments for the GU system in a patient with impaired mobility
Anxiety and/or embarrassment barriers Bladder distention (becomes floppy. and doesn't fill right) Vital signs (especially temperature) Labs: BUN, CR (these two may reflect kidney damage) Output q shift: Color, odor, clarity, amount Urine pooling and having urine stasis - increased risk for renal stones and UTI
45
Interventions for the GU system in a patient with impaired mobility
OOB ASAP w/ ORDER!!! Encourage bathroom (v bedpan) use Encourage fluids Discourage "holding" urine Measure and record I&O if ordered Avoid catheterization
46
The most common type of healthcare associated infection is?
Urinary Tract Infection *Accounts for more than 30% of infections*
47
Virtually all healthcare associated UTIs are caused by ...
instrumentation of the urinary tract
48
UTIs are associated with increased what?
1. Morbidity (illness) 2. Mortality (death) 3. Hospital cost 4. Length of stay
49
What are some appropriate uses for Indwelling Urethral Catheter?
Acute urinary retention or bladder obstruction Accurate measurements of output Peri operative use for selected surgery procedures Anticipated prolonged duration of surgery Need for intraoperative monitoring of urinary output To assist in healing of open sacral or perineal wounds in incontinent patients Prolonged immobilization To improve comfort for end of life care if needed
50
What are some inappropriate uses for Indwelling Urethral catheter?
Substitute for nursing care of the pt/residence w/ incontinence As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void For prolonged postoperative duration without appropriate indications (ex: structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc) = Never want no particular reason
51
Musculoskeletal System responses for patients with impaired mobility
Loss of Endurance Decreased stability, muscle mass, skeletal mass, balance w/ posture changes Increased muscle atrophy and contractures Disuse osteoporosis
52
Assessments for the Musculoskeletal system in patients with impaired mobility
Muscle strength and weakness Muscle mass Muscle tone (hyper/hypo tonic) Contractures ROM Gait/stability w/ ambulation
53
Interventions for the Musculoskeletal system in patients with impaired mobility
OOOB ASAP w/ PCP ORDER!!!! ROM (active and passive) Assist with activity as needed PT/OT consults Protective positioning
54
Types of Range of Motion
Resistive Active Active Assist Passive
55
Resistive ROM
patient movement using pulling/pushing forces they move but you give resistance against them
56
Active ROM
patient can move joints independently
57
Active Assist ROM
patient moves joints with some assistance; encourages normal muscle function without stress to distal joint Move independently but need some assistance to prevent stress
58
Passive ROM
Nurse/Caregiver moves joints for the patient - Individual does not do the movement, someone else does
59
Tips for the Nurse doing PROM
Start gradually and work slowly Move joints to points of resistance BUT NOT PAIN Avoid neck hyperextension, especially with the elderly as you can cause spinal cord/nerve issues
60
What is the path from Decondition to Dependence like?
They take a stepwise pattern down toward dependence for mobility and it is steep and rapid and much quicker than one may think
61
What is the pathway from decondition to dependence?
1. weak wobbly legs 2. more muscle weakness 3. less ability to perform 4. more muscle weakness 5. less ability top perform 6. disuse atrophy (muscle shrinkage) 7. NO ability to perform --> Dependence
62
What is the path upward to mobility independence like?
It is a progressive mobilization that is less steep and a little slower than deconditioning to dependence
63
What is the pathway upward to independence?
1. Bed Activities 2. Sitting 3. transferring 4. Standing 5. Walking 6. Climbing 7. Stair (this is commonly point of discharge)
64
What is the Psychosocial response like for patients with impaired mobility
Increased sense of powerlessness Increased risk of depression Altered sleep wake pattern Decreased self concept Decreased social interaction Decreased Sensory stimulation
65
Psychosocial Assessments/What to assess for the patients with impaired mobility
Mood swings Social interactions Mentation and Outlook Ability for abstract thinking Ability to follow commands Ability to assimilate new information Anxiety, Insomnia, Lethargy
66
Psychosocial interventions for patients with impaired mobility
*Do these when possible as they may not be there long* OOB ASAP w/ ORDER!!! Note, record, and report changes in any and all patient thought processes, emotional behavior, increased anxiety, insomnia, and lethargy Establish workable routine for care, rest, and visitors - encourage self care and what they can do on their own (do not take function away from them) Encourage self care Positive feedback for "wellness behaviors"
67
Musculoskeletal Responses to Immobility
Loss of endurance Decreased stability, muscle mass, skeletal mass, balance with posture changes Increased muscle atrophy, contractures Disuse osteoporosis
68
Respiratory Responses to Immobility
Decreased Hgb, lung expansion Impaired gas exchange Increased secretions, risk of atelectasis, risk of pneumonia Stasis of secretions
69
Cardiovascular responses to Immobility
Decreased Hgb, organ perfusion Increased cardiac workload, resting heart rate, venous stasis (leading to thrombosis formation) Edema of the legs, hands, or overall Orthostatic hypotension
70
GU responses to immobility
Decreased bladder tone, urinary output Increased urine stasis, risk for UTI, risk for renal calculi
71
Skin responses to immobility
Increased risk of skin breakdown, and ulcer formation
72
GI responses to immobility
Decreased appetite, BMR, gastric motility, muscle tone Increased risk of constipation Altered digestion, utilization of nutrients, protein, metabolism
73
The most important intervention for impaired mobility, regardless of system, is?
GETTING THEM OUT OF BED AS SOON AS POSSIBLE (WITH ORDER)

N353: Practice of Nursing II (14 decks)

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