Module 8: MedSurg Impaired Mobility Flashcards Preview

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Flashcards in Module 8: MedSurg Impaired Mobility Deck (73)
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1

What is "Alteration of Mobility"?

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

2

Top 3 Causative Factor Types for Altered Mobility

1. Congenital
2. Internal Factors
3. Acquired

3

What does Congenital cause of Altered Mobility mean?

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

4

What does Internal factors for altered mobility mean?

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

5

What does Acquired cause of altered mobility mean?

Stiffness/Physical Maladies and Disease

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

6

Types of Altered Mobility

1. New and Short Term/Limited

2. New and Long Term/Continuing/Worsening

3. Life Long (Congenital)

7

New and Short Term/Limited Altered Mobility

Things that temporarily will alter mobility

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

8

New and Long Term/Continuing/Worsening

Things that will chronically cause altered mobility

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

9

Life Long Altered Mobility

Altered mobility that is permanent and usually since birth

ex: Cerebral Palsy and Muscular Dystrophy

10

Benefits of Mobility

Psychological well being

Cardiac efficiency

Pulmonary function

Muscle tone

Renal/GI functions

Decrease bone/mineral loss

11

Benefits for Immobility

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*

12

Consequences of Immobility

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

13

How to minimize the consequences of immobility

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

14

What is Nursing Care?

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

15

Examples of Activity and Exercise Nursing Diagnoses

Activity intolerance

Risk for activity intolerance

Impaired physical mobility

Sedentary Lifestyle

Risk for disuse syndrome

16

Examples of Mobility Decline Nursing Diagnoses

risk for falls

fear of falling

ineffective coping

low self esteem

powerlessness

self care deficit

17

Examples of Prolonged Immobility Nursing Diagnoses

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

18

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

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*

19

Cardiovascular System Responses to Impaired Mobility

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

20

Assessments for the Cardiovascular System when the Patient has Impaired Mobility

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

21

Interventions for the Cardiovascular System when the Patient has Impaired Mobility

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

22

What medicines are used in low dose anticoagulation therapy?

Heparin

Coumadin

Lovenox (enoxaparin sodium)

Xarelto (rivaroxaban tablets)

23

Heparin (Admin, Antidote, Lab Test)

Admin - SubQ

Antidote - Protamine Sulfate

Lab Test - PTT

*Given as a preventative measure*

24

Coumadin (Admin, Antidote, Lab Test)

Admin - PO

Antidote - Vit K

Lab Test - PT/INR

*"Warfarin"*

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