Unit 9 Musculoskeletal System

Circumduction

moving the arm in a circle around the shoulder

Rotation

moving the head around a central axis

toddler's

A _______ posture is awkward because of the slight swayback and protruding abdomen. Toward the end of this age period, posture appears less awkward, curves in the cervical and lumbar vertebrae are accentuated, and foot eversion disappears. The musculoskeletal system continues to grow and develop as they grow into adolescence. Greater coordination enables them to perform tasks such as washing hands and brushing teeth, which require fine motor skills.

middle-age adult

A _________ should normally have full musculoskeletal function. An adult with correct posture and body alignment feels good, looks good, and generally appears self-confident. They also have the necessary musculoskeletal development and coordination to carry out ADLs and physical exercise.

Polydactyly: an extra digit (extra toes or fingers). Syndactyly: the fusion of one or more fingers or toes.

Assessing Infant Musculoskeletal - Hands/arms: what to assess for

• Inspection and palpitation of joints integrated with each body region • Observation of ROM as person proceeds through motions necessary for examination • Age-specific screening measures, e.g. scoliosis screening for adolescent

A screening musculoskeletal examination includes...

• Elevates our mood and attitude. • Keeps us physically fit. • Helps one to quit smoking and stay tobacco-free. • Boosts your energy level so you can get more done. • Helps in the management of stress. • Promotes a better quality of sleep. • Improves your self-image and self-confidence.

According to the American Heart Association activity and exercise has the following benefits:

Advantages • Wide base of support • Good stability and security • Better for patients who have problems with balance Disadvantages • Requires some coordination to life and advance walker forward

Advantages & Disadvantages of Walkers

Normal, single C-curve. By 2 months, can lift head while prone. Assess for signs of spina bifida, such as a tuft of hair on the lower back.

Assessing Infant Musculoskeletal - Spine: what to assess for

isotonic contraction isometric contraction concentric tension eccentric tension

An __________ is mobilizing, causing the body to move. In contrast, an _________ is stabilizing, causing the body to hold a stable position. In __________ increased muscle contraction causes muscle shortening, resulting in movement, such as when a patient uses an overhead trapeze to pull up in bed. _________ causes lengthening of a muscle to control the speed and direction of movement.

family or social structure. Some adults lose their jobs, which affects their self-concept

An adult who has correct posture and body alignment feels good, looks good, and generally appears self-confident. The healthy adult also has the necessary musculoskeletal development and coordination to carry out ADLs. When periods of prolonged immobility occur, all physiological systems are at risk. In addition, the role of the adult often changes with regard to the __________

Assess for lordosis Lordosis, or swayback, is an increased lumbar curvature. It is marked with muscular dystrophy and rickets

Assessing Preschool & School-Age Children Musculoskeletal - Back: what to assess for

Subluxation of the elbow ("nursemaid's elbow") - subluxation of the head of the radius with entrapment of the annular ligament in the radiohumeral joint

Assessing Preschool & School-Age Children Musculoskeletal - Elbow: what to assess for

A toddler's posture is awkward because of the slight swayback and protruding abdomen. Toward the end of toddlerhood, posture appears less awkward, curves in the cervical and lumbar vertebrae are accentuated, and foot eversion disappears. • Broad-based gait initially, with arms out • By age 3, base narrows with arms closer to side • Assess for limp

Assessing Preschool & School-Age Children Musculoskeletal - Gait: what to assess for

balance

Body ______ occurs when a person is properly aligned with a relatively low center of gravity balanced over a wide, stable base of support. In the case of standing, a vertical line falls from the center of gravity through the base of support. This is necessary to stand, walk, turn, lift, or perform ADLs.

1. Walk (with shoes on) - shuffling patterns, swaying; arms out to help balance, broader base of support, person may watch feet 2. Climb up stairs - person holds handrail; may haul body up with it; may lead with stronger leg 3. Walk down the stairs - Holds handrail, may descend sideways. 4. Pick up object from the floor - bends at waist instead of knees; holds furniture for support 5. Rise up from sitting in a chair - uses arms to push off chair arms; upper trunk leans forward before body straightens; feet are planted wide in broad base of support 6. Rise up from lying in bed - may roll to one side, push with arms to lift up torso, grab bedside table for leverage

Common adaptation to aging changes 1. Walk (with shoes on) 2. Climb up stairs 3. Walk down the stairs 4. Pick up object from the floor 5. Rise up from sitting in a chair 6. Rise up from lying in bed

reduces strain on musculoskeletal structures, aids in maintaining adequate muscle tone, promotes comfort, and contributes to balance and conservation of energy

Correct body alignment does what?

heart, lungs, and muscles tired/fatigue and weakness an exercise program in which activity is increased slowly

Deconditioning happens in the ________ Symptoms include ________ Treatment includes _______

For those with advanced aging changes, arthritic changes, or musculoskeletal disability, perform a functional assessment for ADLs. This applies the ROM and muscle strength assessments to the accomplishment of specific activities. 1. Walk (with shoes on) 2. Climb up stairs 3. Walk down the stairs 4. Pick up object from the floor 5. Rise up from sitting in a chair 6. Rise up from lying in bed

Describe functional assessment

Test the strength of the prime mover muscle groups for each joint. Repeat the motions you elicited for active ROM. Ask the person to flex and hold as you apply opposing force. Muscle strength should be equal bilaterally and should fully resist your opposing force.

Describe muscle testing portion of musculoskeletal examination

Palpate each joint, including its skin for temperature, its muscles, bony articulations, and area of joint capsule. Notice any heat, tenderness, swelling, and masses. Joints are normally not tender to palpation

Describe palpation of musculoskeletal examination

developmental changes behavioral aspects environmental issues family and social support cultural and ethnic origin

Factors influencing activity and exercise include...

isometric exercise

During __________, a patient tightens or contracts a muscle group for 10 seconds and then completely relaxes for several seconds. Repetitions are increased gradually for each muscle group until the exercise is repeated 8 to 10 times. Instruct patients to perform the exercises slowly and to increase repetitions as their physical condition improves. A patient needs to do this exercise for quadriceps and gluteal muscle groups, which are used for walking, 4 times a day until the patient is ambulatory.

Changes in mobility alter endocrine metabolism, calcium resorption, and functioning of the gastrointestinal (GI) system

Effects of Immobility on Metabolic/Endocrine system

urinary stasis urinary tract infection (UTI) renal calculi

Effects of immobility on urinary elimination? -In the upright position urine flows out of the renal pelvis and into the ureters and bladder because of gravitational forces. When a patient is recumbent or flat, the kidneys and ureters move toward a more level plane. Urine formed by the kidney needs to enter the bladder unaided by gravity. Because the peristaltic contractions of the ureters are insufficient to overcome gravity, the renal pelvis fills before urine enters the ureters. This condition is called _________ and increases the risk of ________ (also caused by indwelling catheter) and _________, calcium stones that lodge in the renal pelvis or pass through the ureters. (due to hypercalcemia)

gait belt incisions, stitches, tubes, or intravenous lines pregnant patient

For those who can bear weight easily provide support at the waist with a _________ so that the patient's center of gravity remains midline. Helps you to stabilize patients if they lose their balance. It is not to be used in lifting or carrying a patient by the waist. It encircles a patient's waist below the belly button, snugly, being sure two fingers fit between the device and patient's body. Don't place one over __________ and never use one on a _________ When using this, hold the device behind the patient, with your palms facing up, but avoid trying to lift or catch patients by mistake, causing you a back injury. If the person is unable to walk under his or her own power or has too high a risk of falls, something more protective should be utilized

Complete ROM against gravity, with full resistance

Grade 5 muscle strength (normal) 100%

No evidence of muscle contractility

Grade 0 muscle strength (zero) 0%

Evidence of slight contractility with no joint motion

Grade 1 muscle strength (trace) 10%

Complete ROM with gravity omitted

Grade 2 muscle strength (poor) 25%

Complete ROM against gravity, with no resistance

Grade 3 muscle strength (fair) 50%

- Constipation is a common symptom. - Pseudodiarrhea often results from a fecal impaction (accumulation of hardened feces). This finding is not normal diarrhea, but rather liquid stool passing around the area of fecal impaction. - Left untreated, fecal impaction results in a mechanical bowel obstruction - The resulting fluid in the intestine produces distention and increases intraluminal pressure. - Over time intestinal function becomes depressed, dehydration occurs, absorption ceases, and fluid and electrolyte disturbances worsen.

How does immobility affect GI function?

- Calcium resorption (loss) from bones - Causes the release of calcium into the circulation. Normally the kidneys excrete the excess calcium. However, if they are unable to respond appropriately, hypercalcemia results

How does immobility affect calcium resorption?

As the workload of the heart increases, so does its oxygen consumption. Therefore the heart works harder and less efficiently during periods of prolonged rest. As immobilization increases, cardiac output falls, further decreasing cardiac efficiency and increasing workload.

How does immobility affect cardiac workload?

Virchow's triad Three factors contribute to venous thrombus formation: (1) damage to the vessel wall (vessel wall injury) (2) alterations of blood flow (stasis of blood) (3) alterations in blood constituents (hypercoagulability of blood)

How does immobility lead to thrombus formation? What do you look for in patients?

- Give the immobilized patient a high-protein, high-calorie diet. - A high-calorie intake provides sufficient fuel to meet metabolic needs and replace subcutaneous tissue. - Ensure that the patient is taking vitamin B and C supplements when necessary. Supplementation with vitamin C is needed for skin integrity and wound healing; vitamin B complex assists in energy metabolism.

How to reduce effect of immobility on metabolic system?

Exercises to prevent excessive muscle atrophy and joint contractures help maintain musculoskeletal function. Active ROM should be encouraged for any patient at risk for reduced musculoskeletal strength or functionality by improving joint mobility. When a patient has muscle weakness, fatigue, or pain, active assisted ROM exercises are more appropriate.

How to reduce effect of immobility on musculoskeletal system?

raise the leg (straight) to assess for low back pain

How to test for low back pain related to nerve root sensitivity

assume a wide base of support with one foot in front of the other, thus supporting the patient's body weight. While holding the gait belt, try to extend one leg, let the patient slide against the leg, and gently lower him or her to the floor, protecting the head

If the patient has a fainting (syncope) episode or begins to fall...

Adolescents

In __________, growth is often sporadic and uneven. As a result, the adolescent appears awkward and uncoordinated. Girls usually grow and develop earlier than boys. Hips widen, and fat deposits in the upper arms, thighs, and buttocks. The boy's changes in shape are usually a result of long-bone growth and increased muscle mass.

lower level of education and minority racial/ethnic groups culturally diverse populations

Individuals with a __________ tend to have higher levels of physical activity at work but lower levels of nonwork physical activity. The difference may limit the positive effects of physical activity on an individual's health because nonwork physical activity has a stronger positive association with health relative to work physical activity. When developing a physical fitness program for __________, consider their education regarding the value of exercise and learn about what motivates individuals to exercise and which activities are appropriate and enjoyable.

Impaired physical mobility Risk for disuse syndrome Ineffective airway clearance Ineffective coping Impaired urinary elimination Risk for impaired skin integrity Social isolation

Nursing Process: Nursing Diagnoses for Immobility

Inspection Palpation Range of Motion Muscle Testing

Order of the musculoskeletal examination

posture alignment

Proper ________ enhances body balance. It means maintaining optimal body position or alignment that favors function. It requires the least muscular work to maintain, and places the least strain on muscles, ligaments, and bones Nurses maintain patient _______ when positioning patients and when turning or moving them

Immobilization often leads to emotional and behavioral responses, sensory alterations, and changes in coping. Illnesses that result in limited or impaired mobility can cause social isolation and loneliness - depression

Psychosocial Effects of Immbility

increase inpatients' activity and mobility levels as soon as possible

Recently concerted efforts have been made in hospitals to _____________ to prevent deconditioning and other complications of immobilization

• Staying in the hospital bed or being on bedrest • Obesity • Poor nutrition • Being an older adult • Having an illness or injury that affects your movement and activity

Risk factors for deconditioning include...

- Use the client's strength when lifting, transferring, or moving when possible - "SAVE YOUR BACK": Elevate work surfaces to approximately waist height - Work with gravity whenever possible - Decrease friction between client & surface - Bend at the knees rather than the waist when liftingFace the direction of movement to avoid twisting motions

Safe Transfer Techniques include...

Tendons

Skeletal system _________ are white, glistening fibrous bands of tissue that occur in various lengths and thicknesses. They connect muscle to bone and are strong, flexible, and inelastic. Ex: achilles

4 curves double S absorb shock balance and center of gravity

Spine • Lateral view shows vertebral column has __________, a _________-shape • Balanced or compensatory nature of curves, together with intervertebral disks, allow spine to _________ Spine is responsible for _________

gaining independence and accomplishing certain skills, such as obtaining a driver's license. Social isolation

The adolescent stage usually begins with a tremendous increase in growth. When the activity level is reduced because of trauma, illness, or surgery, the adolescent is often behind peers in _____________ ________ is a concern for this age-group when immobilization occurs.

• Activity Intolerance • Risk for Injury • Impaired Mobility in Bed • Impaired Mobility • Acute or Chronic Pain

The following are examples of nursing diagnoses related to activity and exercise:

4 humerus dull, deep pain in the shoulder, inability to sleep

The rotator cuff consists of ___ muscles that hold the ________ in place A rotator cuff injury is indicated by ____________

8 radius and ulna

The wrist has ___ carpal bones that are attached to the ________

crutches height, the angle of elbow flexion, and the distance between the crutch pad and the axilla.

Use of _________ is usually temporary (e.g., after ligament damage to the knee). Must be appropriate height. Measurements include the patient's _____________

increases joint mobility

Walking ___________ and can be measured by length of time or distance walked, such as down a hospital hallway or actual number of feet walked. Measure distances walked in estimated feet or yards instead of charting "ambulated to nurses' station and back." Some hospital or rehab units will have markers along floorboards designating distances. Illness or trauma usually reduces activity tolerance, resulting in the need for help with walking or the use of assistive devices such as crutches, canes, or walkers. Patients who increase their walking distance before discharge improve their ability to independently perform basic ADLs, increase activity tolerance, and have a faster recovery after surgery

tai chi, walking, hiking, jogging, climbing stairs, playing tennis, and dancing

Weight-bearing exercises

• Weight-bearing exercise (walking, tai chi) • Calcium/Vitamin D

What lifestyle changes can improve musculoskeletal health?

ALWAYS keep cane on stronger side of the body • Place cane forward 6-10", keeping body weight on both legs • Weaker leg is moved forward, divide weight between cane and stronger leg • Stronger leg is advanced past cane; divide weight between cane and weaker leg

What to educate the client on about using a cane

Plantar flexion Dorsiflexion

________ - bending of the sole of the foot by curling the toes toward the ground ________ - bending of the foot or the toes upward

Inversion Eversion

________ - moving the sole of foot inward at the ankle ________ - moving the sole of foot outward at the ankle

bed rest

an intervention that restricts patients to bed for therapeutic reasons and is sometimes prescribed for selected patients. The therapeutic reasons for it include decreasing the oxygen needs of the body, reducing cardiac workload and pain, and allowing a debilitated patient to rest.

keep both wrists at 90o flexed for 60 seconds; a positive test is defined as pain or paresthesia in at least 1 finger innervated by the median nerve carpal tunnel

describe Phalen's test and what it tests for

tap lightly (percuss) over the carpal tunnel nerve at the wrist to elicit a tingling sensation of "pins & needles". The test is positive when the tingling sensation is present in the distribution of the nerve carpal tunnel

describe Tinel's sign and what it tests for

deconditioning

involves physiological changes in the body following a period of inactivity (i.e. bedrest or sedentary lifestyle)

Canes single straight-legged quad cane

lightweight, easily movable devices approximately waist high, made of wood or metal. Less stability than walker Two types: _________ provide support and balance for patients who have mild balance or strength impairments. _________ are often used for patients who have unilateral weakness from a neurological event/disease (i.e., stroke) and require more support than a straight cane.

Body alignment ("posture")

refers to the positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying means that an individual's center of gravity is stable

newborn infant's

A _______ spine is flexed and lacks the anteroposterior curves of an adult. As growth and stability increase, the thoracic spine straightens, and the lumbar spinal curve appears, which allows sitting and standing. As they grow, musculoskeletal development permits support of weight for standing and walking, allowing them to explore its environment.

work sites Schools Community

A common barrier for many individuals to being physically active is the lack of time needed to engage in a daily exercise program. Some _______ help their employees overcome the obstacle of time constraints by offering physical activity opportunities at the work site, reminders, and rewards for those committed to physical fitness. Children today are less active, resulting in an increase in childhood obesity. _________ are excellent facilitators of physical fitness and exercise. Strategies for physical activity incorporated early into a child's daily routine often provide a foundation for lifetime commitment to exercise and physical fitness. _________ support of physical fitness is instrumental in promoting the health of its members (e.g., providing walking trails and track facilities in parks, maps to guide access, and physical fitness classes). Success in implementing physical fitness programs depends on collaboration among public health agencies, parks and recreational associations, state and local.

for people with articular disease, a history of musculoskeletal symptoms, or any problems with ADL • Numbness or weakness in one or more limbs that typically occurs on one side of the body at a time • Electric-shock sensations that occur with certain neck movements (especially bending the neck forward) • Tremor, lack of coordination or unsteady gait More comprehensive, head-to-toe, proximal to distal

A complete musculoskeletal examination is for... More comprehensive, head-to-toe, _______ to _______

loss of total bone mass accelerates functional losses

A progressive _________ in older adults results from decreased physical activity, hormonal changes, and bone resorption. The effect of this is weaker bones. Older adults often walk more slowly, take smaller steps, and appear less coordinated. The outcomes of a fall include not only possible injury but also hospitalization, loss of independence, psychological effects, and quite possibly death Older adults often experience functional status changes secondary to hospitalization and altered mobility status Immobilization of older adults increases their physical dependence on others and __________ Immobilization of some older adults results from degenerative diseases, neurological trauma, or chronic illness. In some it occurs gradually and progressively; in others, especially those who have had a stroke, it is sudden. When providing nursing care for an older adult, encourage the patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient's immobility by providing unnecessary help with activities such as bathing and transferring.

older adults

A progressive loss of total bone mass occurs with __________. Some of the possible causes of this loss include physical inactivity, hormonal changes, and increased osteoclastic activity (i.e., activity by cells responsible for bone tissue absorption). The effect of bone loss is weaker bones, causing vertebrae to be softer and long shaft bones to be less resistant to bending, making an individual prone to fractures and muscle injuries. They may walk more slowly and incorrectly and appear less coordinated. Many are afraid of falling. They often take smaller steps and keep their feet closer together, which decreases the base of support and thus alters body balance. Physical exercise can improve endurance, coordination, and muscle stability and reduce the risk for falls and injuries

Bathing Toileting Dressing Eating Mobility

ADLs include...

1. bathing/showering, grooming, nail care, oral care 2. being able to make appropriate clothing decisions and physically dress and undress oneself) 3. the ability to feed oneself, though not necessarily the capability to prepare food 4. being able to mentally & physically use a restroom. This includes the ability to get on and off the toilet & cleaning oneself 5. being able to stand from sitting position, as well as get out of bed. The ability to walk independently from one location to another.

Activity of daily living (ADLs): a series of basic activities necessary for independent living at home or in the community. • They are to be performed daily: 1. Personal hygiene: 2. Dressing 3. Eating 4. Maintaining continence 5. Transferring/Mobility

gross motor skills, intellectual development, and musculoskeletal development.

As a baby grows, musculoskeletal development permits support of weight for standing and walking. Posture is awkward because the head and upper trunk are carried forward. Because body weight is not distributed evenly along a line of gravity, posture is normally off balance, and falls occur often. When an infant, toddler, or preschooler becomes immobilized, it is usually because of trauma or the need to correct a congenital skeletal abnormality Prolonged immobilization delays a child's __________

• Pay special attention to spinal posture • Kyphosis, , or hunchback, is an exaggeration of the posterior curvature of the thoracic spine. It's common during adolescence because of chronic poor posture • Scoliosis (lateral spinal curvature) screening only if indicated. To screen, seat yourself behind the standing child and ask them to touch their toes. - Be aware of risk of sports injuries

Assessing Adolescent Musculoskeletal

- Postural changes include a decrease in height, "lengthening of the arm-trunk axis" - Osteoporosis is common in postmenopausal women, it is a decrease in skeletal bone mass leading to low bone mineral density, increases risk of fractures - Kyphosis, or hunchback, is common with a backward head tilt to compensate and maintain the level of vision - Bony prominences become more marked - Do functional assessment

Assessing Aging Adult Musculoskeletal

Distinguish if any foot deformities are flexible or fixed

Assessing Infant Musculoskeletal - Feet/legs: what to assess for

Ortolani maneuver tests for congenital hip dislocation.

Assessing Infant Musculoskeletal - Hips: what to assess for, what test can you do?

• Genu varum ("bow-leggedness") • Genu valgum ("knocked-knees") • Toeing in ("pigeon toes")

Assessing Preschool & School-Age Children Musculoskeletal - Legs: What to assess for

• Head: erect, midline • Spine: straight with normal curvatures • Abdomen: tucked•Knees: slightly flexed • Feet: pointed forward and slightly apart • Arms: at sides • Center of gravity: midline

Assessment cues - Standing • Head: • Spine: • Abdomen: • Feet: • Arms: • Center of gravity:

Readiness to Exercise Nature of the Problem Signs and Symptoms Onset and Duration Severity Barriers to Exercise and Activity Patient Values Effect on Patient

Assessment questions for exercise

acute care

Because patients in ________ are at risk for deconditioning, the encouragement of early ambulation and performing exercises that involve stretching and active ROM is important. The level of exercise allowed will depend on the patient's physical condition. Physical therapists will collaborate on an exercise plan, including progressive walking, walking with assist devices, and isometric exercises. If needed, provide patients ordered analgesics for pain 30 minutes before exercise. Do not administer an analgesic that makes the patient feel dizzy.

- Inspect gait and posture: Observe a patient's gait when he or she enters the examination room. Later have the patient walk in a straight line away from and returning to the point of origin. Note how the patient walks, sits, and rises from a sitting position. - Compare corresponding paired joints. inspect for symmetry of structure and function - Note size and contour of the joint - Inspect skin and tissues over the joints for color, swelling, and masses or deformities

Describe Inspection of musculoskeletal examination

Ask for active ROM while stabilizing the body area proximal to that area being moved. If you see a limitation, gently attempt passive motion. Anchor the joint with one hand while your other hand slowly moves it to its limit. Joint motion normally causes no tenderness, pain, or crepitation (don't confuse with a normal, discrete "crack")

Describe range of motion part of musculoskeletal examination

pressure injury

Effects of Immobility on Integumentary System A __________ is an impairment of the skin as a result of prolonged ischemia (decreased blood supply) in tissues. It is characterized initially by inflammation and usually forms over a bony prominence. Ischemia develops when the pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin

atelectasis hypostatic pneumonia

Effects of Immobility on Respiratory System __________: Secretions block a bronchiole or a bronchus, and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. The site of the blockage affects the severity. Sometimes an entire lung lobe or a whole lung collapses. At some point in the development of these complications, there is a proportional decline in the patient's ability to cough productively. Ultimately the distribution of mucus in the bronchi increases, particularly when the patient is in the supine, prone, or lateral position. Mucus accumulates in the dependent regions of the airway. ___________, inflammation of the lung from stasis or pooling of secretions, frequently results because mucus is an excellent place for bacteria to grow. Usually results from the collection of fluid in the dorsal region of the lungs and occurs especially in those (as bedridden or elderly) confined to a supine position for extended periods.

Immobilization frequently results in orthostatic hypotension, increased cardiac workload, and thrombus formation

Effects of Immobility on the Cardiovascular system

Loss of endurance Loss of muscle mass Decreased stability & balance Muscle atrophy Impaired calcium absorption

Effects of Immobility on the Musculoskeletal System

Complete ROM against gravity, with some resistance

Grade 4 muscle strength (good) 75%

• Determining normal physiological changes in body alignment resulting from growth and development for each patient • Identifying deviations in body alignment caused by incorrect posture • Providing opportunities for patients to observe their posture • Identifying learning needs of patients for maintaining correct body alignment • Identifying trauma, muscle damage, or nerve dysfunction • Obtaining information concerning other factors that contribute to incorrect alignment, such as fatigue, malnutrition, and psychological problems

Help a patient feel at ease when assessing body alignment. Your aim is to not have the patient assume an unnatural or rigid position. You will assess a patient's alignment during standing, sitting, and then lying down as a patient is able. The assessment of body alignment has the following objectives:

- Decreases the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing GI disturbances such as decreased appetite and slowing of peristalsis. - When the patient is immobile, his or her body often excretes more nitrogen (the end product of amino acid breakdown) than it ingests in proteins, resulting in negative nitrogen balance.

How does immobility affect endocrine function

Because of protein breakdown, a patient loses lean body mass during immobility. The reduced muscle mass makes it difficult for patients to sustain activity without increased fatigue. If immobility continues and the patient does not exercise, there is further loss of muscle mass. Prolonged immobility often leads to disuse atrophy. Loss of endurance, decreased muscle mass and strength, and joint instability place patients at risk for falls

How does immobility affect muscle?

Orthostatic hypotension is a drop in systolic pressure by at least 20 mm Hg or a drop in diastolic pressure by at least 10 mm Hg within 3 minutes of rising to an upright position Patients also experience symptoms of dizziness, light-headedness, nausea, tachycardia, pallor, or fainting when changing from the supine to standing position In the immobilized patient decreased circulating fluid volume, pooling of blood in the lower extremities, and decreased autonomic response occur.

How does immobility affect orthostatic hypotension?

- disuse osteoporosis - joint contracture - footdrop

How does immobility affect skeleton? - Because immobilization results in bone resorption, the bone tissue is less dense or atrophied, and ________ results. When this occurs, a patient is at risk for pathological fractures. - Immobility can lead to a ____________, which is an abnormal and possibly permanent condition characterized by fixation of a joint. One common and debilitating contracture is ______, which is when the foot is permanently fixed in plantar flexion.

The skeletal system provides attachments for muscles and ligaments and the leverage necessary for mobility. Bones are important for mobilization because they are firm, rigid, and elastic. Firmness results from inorganic salts such as calcium and phosphate that are in the bone matrix. It is related to the rigidity of the bone, which is necessary to keep long bones straight, and enables bones to withstand weight-bearing Consists of joints, ligaments, tendons, cartilages

How does the skeletal system support regulation or movement?

- Point toes toward the floor: Plantar flexion - Point toes towards your nose: Dorsiflexion - Turn soles of feet out and in (stabilize ankle with one hand and hold heel with other to test the subtalar joint): Eversion, Inversion - Flex and straighten toes

How to assess ankle and foot ROM. Inspect and compare both feet, noting position of feet and toes, contour of joints, and skin characteristics. The ankles are smooth, bony prominences. Note locations of any calluses or bursal reactions. Ask client to...

- Touch chin to chest: Flexion - Lift chin toward the ceiling: Hyperextension - Touch each ear toward the corresponding shoulder: Lateral bending - Touch chin toward each shoulder: Rotation

How to assess cervical spine ROM. Inspect the alignment of head and neck. The spine should be straight and head erect. Palpate the spinous processes and the sternomastoid, trapezius, and paravertebral muscles. They should feel firm, with no muscle spasm or tenderness. Ask client to...

- Bend and straighten elbow: Flexion, Extension - Hold the hand midway; then touch front and back sides of hand to table: Pronation, Supination

How to assess elbow ROM. Inspect size and contour of elbow in both flexed and extended positions. Look for deformity, redness, or swelling. Ask client to...

- Raise each leg with knee extended: hip flexion - Bend each knee up to the chest while keeping the other leg straight: hip flexion, opposite thigh remains on table - Flex knee and hip to 90 degrees, Stabilize by holding the thigh with one hand and the ankle with the other. Swing foot outward, swing foot inward. Foot and thigh move in opposite directions: Internal rotation, external rotation - Swing leg laterally, then medially, with knee straight. Stabilize pelvis by pushing down on the opposite anterior superior iliac spine: Abduction, Adduction - When standing, swing straight leg back behind body. Stabilize pelvis to eliminate exaggerated lumbar lordosis. Hyperextension

How to assess hip ROM. Inspect spine & hip together as client stands. Note symmetric levels of iliac crests, gluteal folds, and equally sized buttocks. A smooth, even gait reflects equal leg lengths and functional hip motion. In supine position, palpate hip joints, should feel stable and symmetric. Ask client to...

- Bend each knee: flexion - Extend each knee: straight line or hyperextension in some people - Check knee ROM during ambulation

How to assess knee ROM. Inspect lower leg alignment. Inspect the knee's shape and contour. Normally there are concavities (hollows) on either side of the patella. Check for signs of fullness or swelling. Check quadriceps muscle (prime mover of knee extension). Ask client to....

- With arms at sides and elbows extended, move both arms forward and up in a wide vertical arcs. then move them back: Forward flexion & Hyperextension - Rotate arms internally behind back; place back of hands as high as possible toward the scapulae: Internal rotation - With arms at sides and elbows extended, raise both arms in wide arcs in the coronal place. Touch palms together above head. Abduction & Adduction - Touch both hands behind the head, with elbows flexed and rotated posteriorly: External rotation

How to assess shoulder ROM. Inspect and compare both shoulders posteriorly and anteriorly. Check size and contour of the joint, and compare equality of bony landmarks. Palpate both shoulders, noting any muscular spasm or atrophy, swelling, heat, tenderness. Ask client to... (while cupping hand over shoulder)

- Bend sideways: Lateral bending - Bend backward: Hyperextension - Twist shoulders to one side then the other: Rotation

How to assess spine ROM. check ROM of spine by asking the person to bend forward and touch the toes. Look for flexion and smoothness and symmetry of movement. Note that the concave lumbar curve should disappear with this motion and the back should have a single, convex, C-shaped curve. Stabilize pelvis with your hands. Ask client to...

- Bend hand up at the wrist: Hyperextension - Bend hand down at the wrist: Palmar flexion - Bend fingers up and down at metacarpophalangeal joints: Flexion, Hyperextension - With palms flat on table, turn them outward and in: Ulnar deviation, Radial deviation - Spread fingers apart; make a fist: Abduction - Touch thumb to each finger and to base of little finger: person able to perform, bilaterally

How to assess wrist & hand ROM. Inspect the hands and wrist on dorsal and palmar sides, noting position, contour, and shape. Palpate each joint in the wrist and hands with gentle but firm pressure. Ask client to...

Nursing care should provide the mental and physical stimulation appropriate to a patient's age and developmental status. In the case of young children, incorporate play activities into the care plan. Encourage older immobilized patients to perform as many ADLs as independently as possible.

How to care for immobility according to developmental stage

- Sequential compression devices (SCDs) and intermittent pneumatic compression (IPC) are used to prevent blood clots in the lower extremities. - Thromboembolic disease (TED) hose - Leg exercises - Early ambulation - Fluid

How to reduce effect of immobility on cardiovascular system? • Preventing thrombus formation

Instruct patients to avoid using a Valsalva maneuver when moving up in bed, defecating, or lifting household objects. During a Valsalva maneuver a patient holds his or her breath and strains, which increases intrathoracic pressure and in turn decreases venous return and cardiac output.

How to reduce effect of immobility on cardiovascular system? • Reducing cardiac workload

Mobilize the patient as soon as the physical condition allows, even if this only involves dangling at the bedside or moving to a chair. This activity maintains muscle tone and increases venous return. Isometric exercises (i.e., activities that involve muscle tension without muscle shortening) have no beneficial effect on preventing orthostatic hypotension, but they improve activity tolerance.

How to reduce effect of immobility on cardiovascular system? • Reducing orthostatic hypotension

- Normal hydration (e.g., 800 to 2000 mL of noncaffeinated fluids daily) helps prevent renal calculi and UTIs. - Provide a diet rich in fluids, fruits, vegetables, and fiber to facilitate normal peristalsis.

How to reduce effect of immobility on elimination system?

- Turning and positioning and the use of therapeutic support surfaces and devices (e.g., low air loss mattresses, heel boots, flotation mattresses) to relieve pressure - Reposition every 2 hours - Regular skin care (cleansing of soiled areas and use of moisturizers) aims to maintain the condition of the skin.

How to reduce effect of immobility on integumentary system?

- Encourage an immobile patient to deep-breathe and cough every 1 to 2 hours. Teach alert patients to deep breathe or yawn every hour or to use an incentive spirometer (when ordered). - Controlled coughing, a common therapy for postoperative patients, involves taking in three deep breaths and then coughing with the third exhalation. - Chest physiotherapy (CPT) (percussion and postural drainage) helps the patient drain secretions from specific segments of the bronchi and lungs into the trachea so that he or she is able to cough and expel them. - Ensure that patients who are immobile have an adequate fluid intake. An adult needs to drink at least 1100 to 1400 mL of noncaffeinated fluids daily. This helps keep mucociliary clearance normal.

How to reduce effect of immobility on respiratory system? • Cough & deep breathe • Incentive spirometer • Provide chest physiotherapy • Hydration

Anticipate changes in a patient's psychosocial status, and provide routine and informal socialization. Involve family or significant others when appropriate. Observe the patient's ability to cope with restricted mobility. Plan nursing activities so that a patient is able to talk and interact with staff. Involve patients in their care whenever possible.

How to reduce psychosocial effects of immobility

has multiple chronic diseases. Symptoms of one chronic condition (e.g., difficulty in breathing related to asthma) may interfere with another condition (diabetes), preventing the patient from engaging in needed regular exercise. readiness to change their behavior

It is important to consider your patients' knowledge of exercise and activity, their values and beliefs about exercise and health, barriers to a program of exercise and physical activity, and current exercise behaviors or habits. One barrier to exercise is whether a patient _____________. Patients are more open to developing an exercise program if they are at the stage of ____________. Patients' decisions to change behavior and include a daily exercise routine in their lives often occur gradually with repeated information individualized to their needs and lifestyle.

Any limitations on ADLs due to joint, muscle, or bone problems? Screen for safety in the home Use functional assessment history questions to elicit any loss of function, self-care deficit(s), or safety risks Have you had any increase in falls or stumbling in the past months? - Rugs and other environmental hazards - Reduced vision - Cognitive impairment - Diminished sensory awareness Do you use any mobility aids to help you get around such as a cane or walker?

Nursing Process: Assessment & Recognizing Cues- Functional Assessment of ADLs

• Joint, muscle, or bone pain? • Joint stiffness? • Heat, swelling, redness of any joints? • Muscle weakness? • Describe how injury occurred (if applicable) • Limited ROM in any joints? • Any joint or bone deformities? • Any back pain? • Numbness or tingling in legs?

Nursing Process: Assessment & Recognizing Cues- Health History Questions (Subjective Cues)

1. Assess client's ability to walk safely - Assess the patient's strength, coordination, baseline vital signs, and balance to determine the type of assistance needed. Also assess his or her orientation and determine whether there are any signs of distress. 2. Evaluate environment for safety - (e.g., removal of obstacles, a clean and dry floor, and the identification of rest points in case the patient's activity tolerance becomes less than expected or if the patient becomes dizzy). Also have the patient wear supportive, nonskid shoes. 3. Help the patient to a position of sitting at the side of the bed and dangling the legs over the side of the bed for 1 to 2 minutes before standing. Some experience orthostatic hypotension 4. For those who can bear weight easily provide support at the waist with a gait belt so that the patient's center of gravity remains midline.

Nursing Process: Implementation and Taking- Action; Assisting Patients to Walk steps

skeletal muscle fibers

Skeletal muscle cells have the ability to be stimulated, or excited, and thus can respond to regulatory mechanisms such as nerve signals. Skeletal muscles are composed of bundles of _________ that generally extend the entire length of the muscle. They contract when stimulated by an electrochemical impulse that travels from the nerve to the muscle across the neuromuscular junction. The electrochemical impulse causes the filaments (predominantly protein molecules of myosin and actin) within the to slide past one another, with the filaments changing length.

joint Fibrous joints Cartilaginous joints Synovial joints

Skeletal system The region where two or more bones attach is referred to as a _____ _______ fit closely together and are fixed, permitting little if any movement, such as the syndesmosis between the tibia and fibula _______ have little movement but are elastic and use cartilage to unite separate bony surfaces, such as the synchondrosis that attaches the ribs to the costal cartilage. When bone growth is complete, the joints ossify (see Fig. 38.1B). ________ or true joints, such as the hinge type at the elbow, are freely movable and the most mobile, numerous, and anatomically complex body joints

Ligaments

Skeletal system _________ are white, shiny, flexible bands of dense fibrous tissue that bind joints and connect bones and cartilage. A type of collagenous fiber that intertwines in irregular, swirling arrangements to form thick connective tissue. They are predominantly elastic fibers and are thus somewhat elastic in nature. Some serve a protective function.

Sitting: Note whether a patient can sit on the side of the bed or in a chair upright. Standing: A patient should be able to raise the buttocks off the bed and hold for a count of five Range of motion: Assess ROM to clarify the extent of joint stiffness, swelling, pain, limited movement, and unequal movement. Gait: 1. Observe the patient entering the room, and note speed, stride, and balance. 2. Ask the patient to walk across the room, turn, and come back. 3. Ask the patient to walk heel-to-toe in a straight line. This may be difficult for older patients even in the absence of disease, so stay at the patient's side during the walk. Exercise: determine a patient's preferred form of exercise, level of intensity, and frequency of exercise

The adequacy of a patient's mobility affects his or her coordination and balance while walking, the ability to carry out ADLs, and the ability to participate in an exercise program. The assessment of mobility has five components:

active, active assisted, and passive active range of motion (AROM)

The easiest intervention to maintain or improve joint mobility for patients and one that can be coordinated with other activities is the use of ROM exercises. There are three types of range of motion exercise: _____________. In __________ exercises patients move specific joints independently based on their muscular weakness and the type of activity that needs strengthening. The exercise moves the joint and soft tissues through the available physiological ranges of motion. These exercises are used when a patient is able to voluntarily contract, control, and coordinate a movement when such a movement is not contraindicated

Cartilage

_______ is nonvascular (without blood vessels) supporting connective tissue located chiefly in the joints and thorax, trachea, larynx, nose, and ear. It has the flexibility of a firm, plastic material. Because of its gristlelike nature, it sustains weight and serves as a shock absorber between articulating bones. Permanent is unossified (not hardened), except in advanced age and diseases such as osteoarthritis, which impairs mobility.

Elevation Depression

________ - raising a body part ________ - lowering a body part

Pronation Supination

________ - turning forearm so the palm is down ________ - turning forearm so palm is up

Muscle tone, or tonus

________, is the normal state of balanced muscle tension. The body achieves tension by alternating contraction and relaxation without active movement of neighboring fibers of a specific muscle group. It helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles.

Protraction Retraction

_________ - moving a body part forward and parallel to the ground _________ - moving a body backward and parallel to the ground

Abduction Adduction

_________ - moving limb away from midline of the body _________ - moving limb towards midline of the body

Flexion Extension

_________ bending a limb at a joint _________ straightening a limb at a joint

Proprioception

__________ is a muscle sense that makes us aware of the position of the body and its parts, including body movement, orientation in space, and muscle stretch. For example, if you close your eyes and bend your elbow, you will know where your hand and lower arm are even if you cannot see them. Stretch receptors associated with muscles, joint capsules, and tendons are classified as this. Receptors located within muscle spindles

Social support

__________ is one motivational tool to encourage and promote exercise and physical fitness. In a systematic review that studied the association between this and physical activity among older adults, it was found that people with greater amounts of this for physical activity are more likely to do leisure time physical activity, especially when it comes from family members

Banner Mobility Assessment Tool (BMAT) Level 4: "Call Don't Fall" Level 3: Gait Belt, Walker, Cane, Sit to Stand, crutches, walker harness lift Level 2: Ceiling lift, mobile lift, chair sling, powered sit to stand, friction reducing roll board Level 1: Ceiling lift, mobile lift, chair sling, friction reducing roll board

an assessment tool to guide a patient through 4 functional tasks in order to identify the level of mobility the patient can achieve