Chapter 16: Moving and Positioning Patient

constipation

Hard, slow stools that are difficult to eliminate; often a result of too little fiber in the diet

The nurse performs range-of-motion exercises with a patient. Which movement would the nurse perform to supinate the arm?

Turn the patient's lower arm so that the palm is upward to supinate the arm.

renal calculi (kidney stones)

urine becomes concentrated resulting in crystals

Shearing

skin sticks to a surface, while the muscles slide in the direction the body is moving

Decreased level of consciousness

somnolent, Sleepy (drowsy)

Immobility of the Musculoskeletal System

- Decreased muscle endurance/strength/mass - Impaired balance - Atrophy of muscles - Decreased stability - Osteoporosis - Contractures - Foot drop - Altered joint mobility

Immobility of the Gastrointestinal System

- Decreased peristalsis - Decreased fluid intake - Constipation/fecal impactions/diarrhea - Anorexia

Immobility of the Cardiovascular System

- Orthostatic hypotension - Less fluid volume in the circulatory system - Stasis of blood in the legs, - Diminished autonomic response, - Decreased cardiac output - Increased oxygenation requirement - Increased risk of thrombus development. - Deep Vein Thrombosis

Immobility of the nervous system

- lack of stimulation - feelings of anxiety - feelings of isolation - confusion - depression

immobility and urinary system

- reduced kidney function - incontinence - urinary tract infection - urinary retention

Two nurses are moving a patient up in bed with a draw sheet. In which order would the nurses perform this skill?

1)Lower the head of the bed to as flat a position as the patient can tolerate; remove the pillow from under the patient's head and position it vertically next to the headboard. (2) Roll the draw sheet up until it is close to the patient's body. (3) Grasp the draw sheet near the patient's shoulders and hips. (4) Instruct the patient to bend their knees and place their feet flat on the bed. (5) Tell the patient to push against the bed with their feet on the count of three. (6) On the count of three, shift weight from the back foot to the front foot while lifting the patient with the draw sheet and moving the patient up in bed.

Immobility of the Integumentary System

the immobile cannot shift their weight so its important that we move them to prevent skin breakdown

confusion

the inability to think clearly

cardiovascular system immobility affect

50% reduction of blood flow to the legs and contribute to venous stasis.The heart actually has to work harder to pump blood throughout the body .

Osteoporosis

A condition in which the body's bones become weak and break easily.

The nurse is using a sit-to-stand lift. The nurse is most likely caring for which patients? Select all that apply. A)A frail patient B)A paralyzed patient from the waist down C)A malnourished patient D)An 88 y.o. patient E)A post-operative patient recovering from abdominal surgery

A)A frail patient C)A malnourished patient D)An 88 y.o. patient E)A post-operative patient recovering from abdominal surgery

The nurse is preparing to ambulate a patient for the first time after surgery. The nurse checks the patient's vital signs prior to the move. Results are as follows: Pulse-80, Blood pressure (BP)-126/72. The nurse allows the patient to dangle and retakes the pulse and BP with the following results: Pulse-86, BP-120/64. Which action should the nurse take? A)Allow the patient to stand with assistance. B)Assist the patient back to a sitting position. C)In 1 to 3 min, recheck the pulse and BP. D)Place the patient in a wheelchair rather than ambulate.

A)Allow the patient to stand with assistance.

The licensed practical nurse/licensed vocational nurse (LPN/LVN) is assisting the registered nurse (RN) in presenting a staff educational program about the most preventable cause of death during hospitalization. The nurses are describing which condition? A)Embolus B)Hypostatic pneumonia C)Syncope D)Atelectasis

A)Embolus

The nurse is contributing to the plan of care for a patient who is on bedrest. Which cardiovascular interventions should the nurse recommend including in the patient's plan of care? Select all that apply. A)Encourage a range of motion. B)Apply sequential compression devices. C)Use anti-embolism stockings. D)Maintain proper body alignment. E)Place a trochanter roll by the patient's thigh.

A)Encourage a range of motion. B)Apply sequential compression devices. C)Use anti-embolism stockings.

The nurse is using a transfer belt to ambulate a patient. Which actions indicate the nurse has a correct understanding of using a transfer belt? Select all that apply. A)Fasten the belt around the patient's waist. B)Check to make sure that the belt is securely tightened by inserting three fingers between the belt and the patient. C)Replace the transfer belt with a gait belt. D)Place the belt directly against the patient's skin. E)Tuck the catheter inside the belt to prevent entanglement with the tubing.

A)Fasten the belt around the patient's waist. B)Check to make sure that the belt is securely tightened by inserting three fingers between the belt and the patient.

Which movements would the nurse perform while implementing range of motion for a patient's ankle and foot? Select all that apply. A)Invert B)Plantar flex C)Pronate D)Circumduct E)Internal rotation

A)Invert B)Plantar flex D)Circumduct

The nurse is preparing to administer an enema. In which position would the nurse place the patient? A)Left Sims' B)High Fowler's C)Supine D)Trendelenburg

A)Left Sims'

The patient is becoming depressed from being on prolonged bedrest. Which intervention would be appropriate for this patient? A)Offer the patient crossword puzzles. B)Close the window curtains. C)Do as much as possible for the patient. D)Restrict visitors

A)Offer the patient crossword puzzles.

Which positions are appropriate for the nurse to use? Select all that apply. A)Supine, for a patient resting in bed. B)Trendelenburg, for a patient needing perineal care. C)Lateral, for a patient with a pressure ulcer on the coccyx. D)Lithotomy, for a patient needing a vaginal examination. E)Low Fowler's, for a patient with tube feedings.

A)Supine, for a patient resting in bed. C)Lateral, for a patient with a pressure ulcer on the coccyx. D)Lithotomy, for a patient needing a vaginal examination. E)Low Fowler's, for a patient with tube feedings.

Which action should the nurse take when positioning a patient who has limited mobility? A)Place pillows under the patient's upper arms. B)Elevate the patient's knee with three pillows. C)Pull the patient's lower shoulder just slightly forward. D)Keep the heel firmly positioned against the mattress.

C)Pull the patient's lower shoulder just slightly forward.

hypostatic pneumonia

inflammation of the lung from stasis or pooling of secretions

The nurse asks for two other coworkers to assist in turning a patient as a unit. Which patient is the nurse turning? A)One who has severe leg pain B)One who has had the spine fused C)One who is in a coma from a drug overdose D)One who is disoriented to time and place

B)One who has had the spine fused

The nurse is transferring a patient who has right-sided weakness from the bed to the wheelchair. Which action should the nurse take? A)Raise the bed to waist level. B)Place the wheelchair on the patient's left side. C)Apply the transfer belt on the patient's hips. D)Logroll the patient to the side of the bed.

B)Place the wheelchair on the patient's left side.

The nurse wants to internally rotate the patient's shoulder during range-of-motion exercises. Which movement would the nurse implement? A)Move the patient's arm away from the body to a 90° angle. B)Slightly bend the patient's elbow and move the patient's hand to the opposite shoulder. C)Keep the patient's arm straight and lift it up until the inner elbow is even with the patient's ear. D)Return the patient's perpendicular arm back to the side of the body.

B)Slightly bend the patient's elbow and move the patient's hand to the opposite shoulder.

The nurse is performing range-of-motion exercises with a patient. The nurse gently pushes the patient's foot back causing the patient's toes to move toward the patient's head. Which technique did the nurse use? A)Ulnar deviation. B)Radial deviation C)Dorsiflex D)Plantar flex

C)Dorsiflex

A pediatric patient is having an asthma attack. The nurse should place the patient in which position? A)Lithotomy B)Low Fowler's C)Orthopneic D)Dorsal recumbent

C)Orthopneic

The nurse chooses to not use a gait belt when ambulating a patient. Which technique should the nurse use? A)Apply socks to the patient's feet. B)Ambulate a long distance. C)Place an arm around the patient's waist. D)Walk in front of the patient.

C)Place an arm around the patient's waist.

pressure injuries

injuries or wounds that result from skin deterioration and shearing

The nurse is collecting data from a patient who is paralyzed from an accident. The nurse notices high-top sneakers on the patient's feet. How should the nurse interpret this finding? A)The nurse should make sure that the feet are in plantar flexion. B)The nurse should report this to the charge nurse. C)The nurse should assume that they will keep the feet in a natural position. D)The nurse will assume the unlicensed assistive personnel (UAP) forgot to remove them.

C)The nurse should assume that they will keep the feet in a natural position.

Which technique should the nurse use when turning a patient who is paralyzed to the right side? A)First, position the patient on the right side of the bed. B)Place the patient's left arm right next to the patient's body. C)Keep the large plastic bag in place for future turning. D)Move the patient's left leg over their right leg.

D)Move the patient's left leg over their right leg.

orthostatic hypotension

Decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions

Immobility of the Respiratory System

Decreased respiratory movement resulting in atelectasis, hypostatic pneumonia, and decreased cough response.

phycological effects of Immobility

Depression, anxiety, hostility, and Fear

Effects of Immobility

Muscle atrophy Joint dysfunction Atelectasis/pneumonia Venous stasis Increased coagulability Orthostatic hypotension Glucose intolerance

Difference between ROM and PROM

ROM is when the patient does it PROM is when the nurse is doing it

Contractures

Shortening or contraction of a muscle. May be due to spasms or paralysis and may be permanent

Foot drop

The foot falls down at the ankle; permanent plantar flexion

distenstion

The stretching out of intestinal wall that accommodates fecal material as it moves through the sigmoid colon into the rectum, eventually leading the defacation reflex

atrophy

muscle decrease in size, tone, and strength as a result of disuse

embolus (emboli)

clot or other substance that travels to a distant location and suddenly blocks a blood vessel

atelectasis

collapsed lung; incomplete expansion of alveoli

PROM

passive range of motion

ROM

range of motion

hypoxemia

decreased level of oxygen in the blood

flatulence

gas in the stomach or intestines

Compression neuropathy

impaired nerve function

urinary tract infection (UTI)

infection of one or more organs of the urinary tract caused by the presense of pathogens within the urinary tract