Chapter 32: Activity

The nurse would like to elevate the client's arms to promote ventilation in a client with chronic obstructive pulmonary disease. What intervention should the nurse implement?

Place a small pillow under each arm. A small pillow may be used to elevate the extremities, shoulders, or incisional wounds. Instructing the client to place the arms on the side rails will place pressure on the arms and affect circulation to the extremity. Elevating the head of the bed (Fowler) will not elevate the arms. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward.

A nurse is preparing to turn a hospitalized client age 65 years. Which action is a recommended guideline for performing this skill?

Position a friction-reducing sheet under the client. After placing the bed in a comfortable working position (usually elbow height of the caregiver), position a nurse on either side of the bed, put a friction-reducing sheet under the client, and use the leg muscles to pull the client to the side.

A nursing student has entered a patient's room on a night shift and observes that the patient is likely experiencing rapid eye movement (REM) sleep. What additional conclusion can the student draw from this observation?

REM sleep is characterized by heightened brain activity; paralysis of voluntary muscles; and rapid, shallow breathing. The individual is usually difficult to rouse during this stage of sleep.

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?

Raise the head of the bed to a sitting position. When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair.

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

Shift their weight back and forth, from back leg to front leg. The nurses would use a rocking motion to counteract the client's weight. The nurses would shift their weight back and forth, from back leg to front leg, count to three, and then move the client up toward the head of the bed.

When assessing for proper body alignment of a standing client, what is a normal finding?

The weight of the body is distributed on the soles and heels. A client's body is in correct body alignment while standing when the weight of the body is distributed on the soles and heels. The chest is held upward and forward. The abdominal muscles are held upward and the buttocks downward. The line of gravity goes midline through the center of the knees and in front of the ankle joints.

The oblique position, a variation of the side-laying position, is recommended as an alternative to the side-laying position because it places significantly less pressure on the trochanter region.

True (instead of having a pillow in front of you it's behind you)

Braces

Used to support weakened leg muscles Can cause skin irritations

Transferring a Patient From the Bed to a Stretcher

Using sheet to roll patient away from stretcher. Positioning transfer board under patient. Transferring patient onto stretcher. Securing patient on stretcher.

nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient?

When a patient complains of fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the nursing care plan, and assess the patient for further symptoms. The exercises could then be scheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day.

Side-lying or lateral position will ensure

airway patency and reduce risk of aspiration if vomiting occurs **** this is a comfortable alternative to the supine position for the patient on bed rest. Although it relieves pressure on the scapulae, sacrum, and heels and allows the legs and feet to be comfortably flexed, support pillows are needed for correct positioning ****** The oblique position***** *****COMPLICATION TO BE PREVENTED******* 1.) Lateral flexion of the neck 2.) Inward rotation of the arm and interference with respiration 3.) Extension of the finger and abduction of the thumbs 4.) Internal rotation and adduction of the femur 5.) Twisting of the spine ******* SUGGESTED PREVENTIVE ACTIONS******* 2.)Place a pillow under the upper arm; lower arm should be flexed and positioned comfortably. 4.) Use one or two pillows as needed to support the leg from the groin to the foot. 5.) Ensure that both shoulders are aligned with both hips.

When a client is lifted or held by a nurse, the additional weight becomes a part of the nurse's weight and should be:

balanced over the center of gravity. Maintaining balance involves keeping the spine in vertical alignment, the feet positioned for a broad base of balance, and the body weight close to the center of gravity.

range of motion

complete extent of movement of which a joint is normally capable Eve attention to the joints that are not being used active exercise: joint movement activated by the pt active-assistive exercise, the nurse may provide minimal support passive exercise, the patient is unable to move independently, and the nurse moves each joint through its range of motion. isotonic exercise- contraction of the joint (joint change) Isometric- in joint change, we are maintaining joint angle while increasing the workload

What is a benefit of regular exercise over time?

decreased heart rate Regular physical activity over time results in cardiovascular conditioning, thus decreasing heart rate. Regular exercise increases circulating fibrinolysin that serves to breakup small clots, thus decreasing the risk for blood clots. Over time, regular exercise leads to improved pulmonary function, including decreased work of breathing. Venous return is improved when contracting muscles compress superficial veins and push blood back to the heart against gravity.

A nurse applies padded boots to maintain the foot in dorsiflexion on a client who is comatose. The nurse is protecting the client from:

footdrop. A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Footdrop is a contracture in which the foot is fixed in plantar flexion.

When an older adult client walks with her knees slightly flexed and body leaning, the nurse determines that the client:

is demonstrating a common gait for the older adult. Many older people have more difficulty overcoming inertia and using gravity efficiently. One contributing factor is the shift in the center of gravity. To compensate for this shift, the knees flex slightly for support.

When logrolling a client, the nurse should use supportive devices in turning the client in order to:

maintain the natural alignment of the client's body. Logrolling is a technique used for turning clients who have had surgery or an injury involving the back or spine. It maintains spinal alignment, thus preventing injury. It is not performed for the purpose of maximizing the client's participation or preventing blood stasis.

A 65-year-old woman has come in for her annual physical exam. She has asked the nurse what to expect in terms of aging. The nurse tells her that an abnormal sign of aging is:

osteoporosis. Osteoporosis is not a normal part of aging, though it is more common in older adults, particularly women.

A nurse is conducting a home assessment of a 90-year-old male client with a history of several minor strokes that have left him with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.

removal of clutter on the floor placing a nightlight in the bathroom and the hallways moving the bedroom to the ground floor Each of these activities will reduce the risk of falling and encourage the client to increase his mobility.

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?

supine Supine position is recommended as a way to reduce the incidence of sudden infant death syndrome (SIDS) among newborns. Other positions are inappropriate for placing the infant to sleep.

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?

supporting the client's back The nurse would place the pillow under the client's back to provide support and help maintain the proper position. More than one pillow under the client's head is not necessary.

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?

thrombus formation Prolonged sitting can increase a client's risk for thrombus formation. The nurse will emphasize this, and teach stretching exercises. Skeletal contractures, pooling of secretions, and oliguria are not risk factors associated with flying (prolonged sitting).

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?

trochanter rolls Trochanter rolls prevent the legs from turning outward. The trochanters are the bony protrusions at the head of the femur near the hip. Placing a positioning device at the trochanters helps to prevent the leg from rotating outward. Other devices are inappropriate for this client.

The occupational nurse is teaching an administrative assistant about proper posture when sitting. Which teaching will the nurse include?

"Both of your feet should rest on the floor." Proper sitting posture includes using the buttocks and upper thighs as the base of support, keeping both feet resting on the floor, and the knees bent with the back of the knees away from the chair to avoid distal circulation concerns. Other choices are unsafe practices.

The nurse has been teaching a client about health promotion and exercise. The nurse knows that the education has been successful when the client states:

"I will invite a friend to exercise with me." Exercising with a friend will add the support of a buddy. Joining a spa, health club, or exercise group is also recommended to provide support to exercise. Exercise sessions should be introduced gradually to prevent overexertion and injury to muscles. Clients should be encouraged to exercise for 30 to 45 minutes 3 to 4 times per week. Alternating types of exercise will help to prevent boredom.

The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include?

"Picture yourself with good posture standing; that is how good lying posture works." The best posture lying down will be the same as standing posture, except the client is horizontal. Knees should be slightly flexed; feet should be at a right angle from the legs; the head and neck muscles should be in a neutral position centered between the shoulders. It is not correct to say to keep the knees and legs very straight, to position feet at a 45-degree angle from the legs, or to sleep with the head tilted to one side.

exercise affects the respiratory system

*EFFECTS OF EXERCISE ↑Depth of respiration ↑Respiratory rate ↑Gas exchange at alveolar level Pooling of secretions ↑Rate of carbon dioxide excretion *EFFECTS OF IMMOBILITY ↓Depth of respiration ↓Rate of respiration Pooling of secretions

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?

"Put your arm in this sleeve." When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions. "Put your arm in this sleeve" gives one step in the process of getting dressed. "Put on your shirt" involves many steps and should be broken down into the steps of putting on a shirt. "Put your pants on and zip the zipper" should be broken down into steps and given in clear, short sentences. Furthermore, putting on pants and zipping a zipper involves many steps and may be too complicated for the client with dementia to follow. Instructions should be phrased positively as the client may not register the "Don't"; the client may put the shoes on if the nurse states "Don't put on your shoes yet."

A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

"To prevent the legs from rotating outward." Trochanter rolls prevent the legs from rotating outward. The other statements do not describe trochanter rolls. Hand rolls preserve the client's functional ability to grasp and pick up objects, and help the client avoid contractures. Foot boards prevent foot drop.

Psychological Well-Being

****************Exercise Energy, vitality, general well-being Improved sleep Improved appearance Improved self-concept Positive health behaviors *********Immediately ↑Sense of powerlessness ↓Self-concept ↓Social interaction ↓Sensory stimulation Altered sleep-wake pattern ↑Risk for depression Risk for learned helplessness

How exercise affects the musculoskeletal system

***********Effects of exercise ↑Muscle efficiency(strength) and flexibility ↑Coordination ↑Efficiency of nerve impulse transmission Reduce bone loss *********effects of immobility ↓Muscle size, tone, and strength ↓Joint mobility, flexibility Bone demineralization ↓Endurance, stability ↑Risk for contracture(shorting of the muscle or tissue around the joint preventing joint movement)formation.

Gastrointestinal System on exercise and immobility

***********Exercise ↑Appetite ↑Intestinal tone(gut muscle) ********immobility Altered protein metabolism Change in appetite Constapation ↓Peristalsis ( the involuntary construction and relaxation of muscles of the intestine;creates wavelike movement that push the the content of the canal forward)

How exercise affects the Metabolic system

***********effects of exercise ↑Efficiency of metabolic system ↑Efficiency of body temperature regulation **************effects of immobility ↑Risk for electrolyte imbalance Altered exchange of nutrients and gases

Urinary System

**********Exercise ↑ Blood flow to kidneys ↑Efficiency in maintaining fluid and acid-base balance ↑Efficiency in excreting body wastes ********immobility ↑Urinary stasis ↑Risk for renal calculi (kidney stones) ↓Bladder muscle tone

equipment and assistive devices for moving patients

*******Gait Belts******** The gait belt is used to help the patient stand and provides stabilization during pivoting. Gait belts also allow the nurse to assist in ambulating patients who have leg strength, can cooperate, and require minimal assistance. Do not use gait belts on patients with abdominal or thoracic incisions. ******** Stand-Assist and Repositioning Aids ******** Some patients need minimal assistance to stand up. With an appropriate support to grasp, they can lift themselves. Many types of devices can help a patient to stand. These devices can be freestanding or attached to the bed or wheelchair. Other aids have a pull bar to assist the patient to stand, and then a seat unfolds under the patient. After the patient sits on the seat, the device can be wheeled to the toilet, chair, shower, or bed. ********Lateral-Assist Devices******* an inflatable lateral-assist device is a flexible mattress that is placed under the patient. An attached, portable air supply then inflates the mattress, which provides a layer of air under the patient. This air cushion allows nursing staff to perform the move with much less effort. Another example is a transfer board, usually made of smooth, rigid, low-friction material (such as coated wood or plastic). The board, which is placed under the patient, provides a slick surface for the patient during transfers, reducing friction and the force required to move the patient. A third type of lateral sliding aid is made of a special fabric that reduces friction. Some devices have long handles that reduce reaching by staff to improve safety and make the transfer easier ******** Friction-Reducing Sheets***** Get close to the pt and left the sheet. these sheets may require excessive force by the caregiver ******Mechanical Lateral-Assist Devices******** A portion of the device moves from the stretcher to the bed, sliding under the patient, bridging the bed and stretcher. The device is then returned to the stretcher, effectively moving the patient without any pulling by staff members. ******Transfer Chairs******* Chairs that can convert into stretchers are available. These are useful with patients who have no weight-bearing capacity, cannot follow directions, and/or cannot cooperate. The back of the chair bends back, and the leg supports elevate to form a stretcher configuration, eliminating the need for lifting the patient. Some of these chairs have built-in mechanical aids to perform the patient transfer, as detailed previously. ****** Powered Stand-Assist and Repositioning Lifts******* These devices can be used with patients who can bear weight on at least one leg, can follow directions, and are cooperative. A simple sling is placed around the patient's back and under the arms. Some devices come with breathable slings that can remain under the patient, reducing the risk for the nurse in turning the patient to position the sling. The patient rests the feet on the device's footrest and places the hands on the handle. The device mechanically assists the patient to stand, without any assistance from the nurse. Once the patient is standing, the device can be wheeled to a chair, the toilet, or bed. Some devices have removable footrests and can be used as a walker. Some have scales incorporated into the device that can be used to weigh the patient. The duration of time spent in slings should be limited to reduce risk for pressure injury, especially for vulnerable populations. ******Powered Full-Body Lifts****** These devices are used with patients who cannot bear any weight to move them out of bed, into and out of a chair, and to a commode or stretcher. A full-body sling is placed under the patient's body, including head and torso, then the sling is attached to the lift. As mentioned previously, some of these slings are made to stay under the patient to decrease strain on the staff during placement. The device slowly lifts the patient. Some devices can be lowered to the floor to pick up a patient who has fallen. These devices are available on portable bases and ceiling-mounted tracks. The duration of time spent in slings should be limited to reduce risk for pressure injury, especially for vulnerable populations.

How Exercising affects the cardiovascular system

*EFFECTS OF EXERCISE. ↑Efficiency of heart ↓Resting heart rate and blood pressure ↑Blood flow and oxygenation of all body parts. ↑circulating fiberinolysin (substance that brakes up small clots) improved venous return *EFFECTS OF IMMOBILITY. ↑Cardiac workload (your hearts having to work harder) ↑Risk for orthostatic hypotension ↑Risk for venous thrombosis

The framework of bones, the joints between them, and cartilage that protects our organs and allows us to move is called the skeletal system. Functions of this system include:

-Supporting the soft tissues of the body (maintains body form and posture) -Protecting crucial components of the body (brain, lung, heart, spinal cord) -Furnishing surfaces for the attachments of muscles, tendons, and ligaments, which, in turn, pull on -the individual bones and produce movement -Providing storage areas for minerals (such as calcium) and fat -Producing blood cells (hematopoiesis)

The nurse uses gait belts when assisting patients to ambulate. Which patient would be a likely candidate for this assistive device?

A patient who has leg strength and can cooperate with the movement The gait belt is used to help the patient stand and provides stabilization during pivoting. Gait belts also allow the nurse to assist in ambulating patients who have leg strength, can cooperate, and require minimal assistance. A gait belt is not used on clients who have either an abdominal or thoracic incision. A gait belt would not be used on a client who is confined to bedrest.

A patient who is obese and who leads a sedentary lifestyle admits to being a "heavy snorer." His frequent complaints of fatigue led to diagnostic testing and an eventual diagnosis of sleep apnea. When planning this patient's care, the nurse should include which of the following?

Assess the patient's readiness to start a weight loss program. For many patients, weight loss achieves partial relief of sleep apnea symptoms. The patient may need naps because of poor nighttime sleep quality, but these are not a solution or treatment. There is no need to limit activity to the first half of the day, and sleeping in a semi-Fowler position can be beneficial.

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?

Fowler's Fowler's position, a semi-sitting position, will assist the client with dyspnea because this position allows the abdominal organs to drop away from the diaphragm. Other position choices do not promote oxygenation.

A client is lying on their back with their arms at their side and knees supported with a pillow. What nursing documentation is most appropriate for this client?

Client is in supine position with arms in functional position and pillow support under the knees. In the supine position, the client is lying on the back. All other options are incorrect, as prone is lying on the stomach, lateral oblique is a side-lying position, and Sims' position is a semi-prone position that allows for rectal and/or vaginal examination.

The nurse has asked the client to grasp his overbed trapeze and pull his torso up off the surface of the bed. What movement will the client perform with his arms?

Flexion Flexion is achieved when a body part is bent, as when the elbow is bent and the upper arm and forearm are brought together. Adduction and abduction denote lateral movement to and from the body, and dorsiflexion is backward bending of the hand or foot.

A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient:

If a patient being ambulated starts to fall, you should place your feet wide apart with one foot in front, rock your pelvis out on the side nearest the patient, grasp the gait belt, support the patient by pulling her weight backward against your body, gently slide her down your body toward the floor while protecting her head, and stay with the patient and call for help.

Moving a patient up in bed

If the patient is fully able to assist in moving up in the bed, allow the patient to complete the movement independently, with safe supervision. The patient assists movement either by pushing with the feet flat against the bed or by using an overbed trapeze. Place bed in a Trendelenburg position (all the way flat) Remove all pillows from under the patient. Leave one at the head of the bed, leaning upright against the headboard. Position at least one nurse on either side of the bed, and lower both side rails. Ask the patient (if able) to bend his or her legs and put his or her feet flat on the bed to assist with the movement. Have the patient fold the arms across the chest. Have the patient (if able) lift the head with chin on chest. One nurse should be positioned on each side of the bed, at the patient's midsection, with feet spread shoulder width apart and one foot slightly in front of the other. Grasp the friction-reducing sheet securely, close to the patient's body. Flex your knees and hips. Tighten your abdominal and gluteal muscles and keep your back straight. If possible, the patient can assist with the move by pushing with the legs. Shift your weight back and forth from your back leg to your front leg and count to three. On the count of three, move the patient up in bed. Repeat the process, if necessary, to get the patient to the right position.

Turning the Patient in Bed

If the patient is unable to assist with movement, a full-body sling and two or more caregivers are required. When turning the patient, the bed should be at the height of the caregivers' elbows to ensure a comfortable working height.

Benefits of exercise to musculoskeletal system

Increased muscle efficiency (strength) and flexibility Increased coordination Reduced bone loss Increased efficiency of nerve impulse transmission

The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action?

Move the client to edge of the bed opposite the side that client will be turning. When turning a client in bed, the nurse would use a friction-reducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Consult a Safe Patient Handling Algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client.

The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response?

Osteoarthritis is a common disorder as people age. It is a noninflammatory, progressive disorder of movable joints (particularly weight-bearing joints) characterized by the deterioration of articular cartilage and pain with motion. Cartilage acts as a shock absorber and provides a smooth surface that reduces friction between the moving parts of the joint. If the client experienced a fall and subsequent hip fracture, mobility would be more impaired. The client would have difficulty walking. Also, this does not address the client's question of why pain accompanies osteoarthritis. Although it is true that osteoarthritis is painful and common as people age, this response does not answer the client's question of why there is pain. Furthermore, while it is also true that loss of muscle tone is common as people age, it may cause weakness, but does not necessarily cause pain with walking.

Transferring a Patient From the Bed to a Chair

Place the bed in the lowest position. Raise the head of the bed to a sitting position or as high as the patient can tolerate. Make sure the bed brakes are locked. Put the chair next to the bed. If available, lock the brakes of the chair. If the chair does not have brakes, brace the chair against a secure object. Encourage the patient to move to the side of the bed and to a side-lying position, facing the side of the bed on which the patient will sit. stand near the patient's hips. Stand with your legs shoulder width apart with one foot near the head of the bed, slightly in front of the other foot. ask the patient to swing his or her legs over the side of the bed. At the same time, pivot on your back leg to lift the patient's trunk and shoulders. Keep your back straight; avoid twisting. Stand in front of the patient and assess for any balance problems or complaints of dizziness. Allow the patient's legs to dangle a few minutes before continuing. Wrap the gait belt around the patient's waist Stand facing the patient. Spread your feet about shoulder width apart and flex your hips and knees. Ask the patient to slide his or her buttocks to the edge of the bed until the feet touch the floor. Position yourself as close as possible to the patient, with your foot positioned on the outside of the patient's foot. If a second staff person is assisting, have him or her assume a similar position. Grasp the gait belt Rock back and forth while counting to three. On the count of three, using the gait belt and your legs (not your back), assist the patient to a standing position. If indicated, brace your front knee against the patient's weak extremity as he or she stands. Assess the patient's balance and leg strength. If the patient is weak or unsteady, return the patient to bed. Ask the patient to use his arm to steady himself on the arm of the chair while slowly lowering to a sitting position. Continue to brace the patient's knees with your knees and hold the gait belt. Flex your hips and knees when helping the patient sit in the chair

protective supine or dorsal position

Prevent exaggerated curvature of the spine and flexion of the hips by providing a firm, supportive mattress Prevent flexion contracture of the neck by placing pillows under the upper shoulders, neck, and head Prevent internal rotation of the shoulders and extension of the elbows(hunch shoulders) by placing pillows or arm supports under the forearms so that upper arms are alongside the body and the forearms are pronated slightly Prevent flexion of lumbar curvature by placing rolled towel or small pillow under lumbar curvature Prevent external rotation of the femurs by placing sandbags or a trochanter roll alongside the hips and the upper half of the thighs Prevent hyperextension of the knees by placing a pillow under the lower legs from below the knees to the ankles Prevent extension of the fingers and abduction of the thumbs(clawhand) with hand-wrist splints Prevent footdrop by supporting the feet in dorsal flexion with foot board; high top sneakers

The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination?

Sims' Sims' position, a semi-prone position, can be used for certain examinations of the rectum and vagina. Other positions do not allow for adequate examination of this area.

The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table?

The client is aware of spatial relationships to avoid the table. The client has awareness of spatial relationships (where objects are located in space). This ability comes from the visual or optic reflexes. The labyrinthine sense relates to the sensory organs in the inner ear and provides a sense of position, orientation, and movement. It does not contribute to where objects are in space. When the extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture, such as when the knee buckles under, the reflex contraction aids the person to straighten the knee. This does not contribute to perception of where objects are in space.

Using proper body mechanics, which motions would the nurse make to move an object?

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The internal girdle is made by contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward. It is helped further by making a long midriff by stretching the muscles in the waist. The nurse would not relax the stomach muscles or use the muscles of the back when moving an object. The nurse would not lift an object when it can be safely slid, rolled, pushed, or pulled.

A client has stated to the community health nurse that she is having prolonged sleep latency and frequent nighttime awakenings. When assessing the potential role that the patient's medication regimen may have on her sleep, the nurse should address which of the following?

The patient takes furosemide (Lasix) at bedtime each night to treat symptoms of heart failure.

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement is correct regarding logrolling?

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight alignment when the client is being turned. The nurse should avoid twisting the client's head, spine, shoulders, knees, or hips while logrolling. The nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement.

Fowler's position

The semi-sitting position, or Fowler's position, calls for the head of the bed to be elevated 45 to 60 degrees. This position is often used to promote cardiac and respiratory functioning because abdominal organs drop in this position, providing maximal space in the thoracic cavity. This is also the position of choice for eating, conversation, and urinary and intestinal elimination. Variations of Fowler's position include high-Fowler's and low-Fowler's, or semi-Fowler's position. In the high-Fowler's position, the head of the bed is elevated 90 degrees. When a bedside table with a pillow on top of it is placed in front of the patient in high-Fowler's position, the patient can lean forward and rest the arms on the pillow, assuming a posture that allows for maximal lung expansion. In low-Fowler's or semi-Fowler's position, the head of the bed is elevated only 30 degrees. In Fowler's position, the buttocks bear the main weight of the body. In this position, the heels, sacrum(lower back), and scapulae(shoulder blade) are at risk for skin breakdown and require frequent assessment. ****** COMPLICATION TO BE PREVENTED***** 1.) Flexion contracture(shortening and harding) of the neck. 2.) Exaggerated curvature of the spine 3.) Dislocation of the shoulder 4.) Flexion contracture of the wrist 5.) Edema of the hand 6.) Flexion contractures of the fingers and abduction of the thumbs 7.) Impaired lower extremity circulation and knee contracture, pressure on heels 8.) External rotation of the hips Use trochanter roll. 9.) Footdrop ***** SUGGESTED PREVENTIVE ACTIONS******* 1.) Allow the head to rest against the mattress or be supported by a small pillow only. 2.) Use a firm support for the back; position the patient so that the angle of elevation starts at the hips. 3.) Support the forearms on pillows to elevate them sufficiently so that no pull is exerted on the shoulders. 4.) Support the hand on pillows so that it is in natural alignment with the forearm. 5.) Support the hand so that it is slightly elevated in relation to the elbow. 6.) Provide hand-wrist splints if necessary. 7.) Elevate the knees for only brief periods; place one or two pillows under the lower legs from below the knees to the ankles; avoid pressure on the popliteal vessels; avoid using the knee gatch. 8.) Use trochanter roll. 9.) Support the feet in dorsal flexion. Use footboard; high-top sneakers can also be used.

Walker

Wheeled walkers are best for patients who need minimal weight bearing from the walker. elbows should be flexed about 30 degrees patients lift the walker without wheels ahead of themselves and step into it. Wear nonskid shoes or slippers. When rising from a seated position, use the chair arms for support. Once standing, place one hand at a time on the walker and move forward into it. Begin by pushing the walker forward, keeping the back upright. Place one leg inside the walker, keeping the walker in place. Then, step forward with the remaining leg into the walker, keeping the walker still. Repeat the process by moving the walker forward again. Caution the patient to avoid pushing the walker out too far in front and leaning over it. Patients should always step into the walker, rather than walking behind it, staying upright as they move. Never attempt to use a walker on stairs.

Which type of mobility aid would be most appropriate for a client who has poor balance?

a cane with four prongs on the end (quad cane) Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold, but are not recommended for clients with poor balance. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.

Protective position

correct body alignment and regular position changes when on prescribed bed rest. Reposition the every 2hr. So they don't get pressure injuries. Massage anything that's against the bed for a long time(do not massage if red)

When moving a client up in bed with the assistance of another caregiver, the nurse should:

have the client fold the arms across the chest. Positioning the arms across the chest improves assistance, reduces friction, and prevents hyperextension of the neck. Before attempting to move a client up in bed, the nurse should review the medical record and the nursing plan of care. This validates the correct client and correct procedure, identification of limitation, and ability. Reviewing the medical record and plan of care also identifies use of an algorithm to prevent injury and it assists in determining the best plan for client movement. The head of the bed should be flat, or as low as the client can tolerate; this will help to decrease the gravitational pull of the upper body. If tolerated, a slight Trendelenburg position aids in movement. Pillows should be removed from under the client's head; this facilitates movement.

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed?

near the client's hip, with legs shoulder-width apart and one foot near the head of the bed When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder-width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight, to assist the client to a sitting position safely.

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate?

placing a small towel under the neck Kyphotic changes can cause pressure on cervical vertebrae when someone is in a supine position. Effects of this can be minimized by placing a small towel or cervical pillow under the neck. Placing the client on the stomach is incorrect, and a muscle relaxer will not help reduce the pressure caused by the kyphosis. Contacting the physician is unnecessary.

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

the 24-month-old child who is unable to walk unassisted At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raise the head, but this is not expected at this age. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month-old infants. Stacking blocks is accomplished by most 3-year-olds, but doing so at 18 months is considered early.

The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care?

trapeze bar Promoting client independence with movement and activity is an important intervention for clients with musculoskeletal problems. Unlike log rolling and pull sheets, which are nurse-initiated methods, the overhead trapeze is used by the client.

A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as:

tremor Tremors are rhythmic, repetitive movements that can occur at rest or when movement is initiated. A tremor usually interferes with fine motor control, but in Parkinson's disease it also can interfere with coordinated ambulation. Athetosis is movement characterized by slow, irregular, twisting motions. Dystonia is similar to athetosis but usually involves larger areas of the body. Ataxia is a general term used to describe impaired muscle coordination.

integumentary system

*********Exercise Improved tone, color, and turgor, resulting from improved circulation. ***********immobility ↑Risk for skin breakdown and formation of pressure injuries (pressure ulcers)

Physical assessment for mobility

*******GENERAL EASE OF MOVEMENT AND GAIT- starts the moment the pt walks in the room. Note whether the patient's body movements are quick and sure or slow and deliberate. These observations communicate both a sense of the person's emotional status and self-care abilities. ***********ALIGNMENT Joint and balanced problems when alignment is off ************JOINT STRUCTURE AND FUNCTION Use inspection and palpation to examine joints, their range of motion, and the surrounding tissue. Range of motion is the maximum degree of movement of which a joint is normally capable. *******MUSCLE MASS, TONE, AND STRENGTH ********* ENDURANCE Ability to turn in bed, maintain correct alignment when sitting and standing, ambulate, and perform self-care activities Physiologic or psychological inability to tolerate an increase in activity:

Factors influencing mobility

*Developmental considerations Older people-lose muscle tone, loss of fat, arthritis joint pain *Physical health *Mental health *Lifestyle *Attitude and values *Fatigue and stress *External factors

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

*Developmental: able to support self, balanced, coordinated, center of gravity, activity levels -older people: Increased convexity in the thoracic spine (kyphosis) from disk shrinkage and decreased height • Loss of muscle tone • Subcutaneous fat loss • Arthritic joint changes may be present *Physical Health: neuro, CNS, congenital, musculoskeletal, nervous system, problems involving other body systems *Mental Health: depression (don't want to get up and move) *Lifestyle: inactive, active *external factors: weather *Fatigue and Stress: exercise helps with stress or over stresses the body

A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones?

By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.

A nurse is caring for clients with alterations in mobility. Which nursing interventions are recommended for these clients? Select all that apply.

For orthostatic hypotension, have the client sleep sitting up or in an elevated position. For constipation, increase fluid intake and roughage. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours. The nurse would implement the following nursing interventions when caring for clients with alterations in mobility: Have the client sleep sitting up or in an elevated position for orthostatic hypotension; have the client increase fluid intake and roughage (if not contraindicated) to address constipation concerns; reposition the client in correct alignment at least every 1 to 2 hours to address impaired skin integrity issues. The client would decrease the cardiac workload if lying in the prone position. Shallow breathing would not be encouraged with a client with ineffective breathing patterns. Range of motion (ROM) exercises would not be performed as often as every 2 hours for a client with impaired physical mobility.

Crutches

Forearm crutches are used for patients requiring long-term support for ambulation. Axillary crutches are used to provide support for patients who have temporary restrictions on ambulation. These crutches require significant upper body and arm strength to use. Do not use in the axillary area, support body weight with hands and arms

Moving a Patient from Bed to Stretcher

Have patient fold arms against chest and move chin to chest. Use the friction-reducing sheet to move the patient to the side of the bed where the stretcher will be placed. Alternately, place a lateral-assist device under the patient. Position the stretcher next (and parallel) to the bed. Lock the wheels on the stretcher and the bed. Two nurses should stand on the stretcher side of the bed. A third nurse should stand on the side of the bed without the stretcher. The nurse on the side of the bed without the stretcher should grasp the friction-reducing sheet at the head and chest areas of the patient. The nurse on the stretcher side of the bed should grasp the friction-reducing sheet at the head and chest, and the other nurse on that side should grasp the friction-reducing sheet at the chest and leg areas of the patient. At a signal given by one of the nurses, have the nurses standing on the stretcher side of the bed pull the friction-reducing sheet. At the same time, the nurse (or nurses) on the other side push, transferring the patient's weight toward the transfer board, and pushing the patient from the bed to the stretcher

protective sims position

Helps to prevent respiratory complications, pressure ulcers, and contractures r/t complications of immobility. Facilitates oral drainage. Reduces pressure over the sacrum and greater trochanter. Prevent lateral flexion of the neck by placing a pillow under the head and the neck Prevent footdrop by supporting the feet in dorsal flexion with a sandbag Prevent twisting of the spine by ensuring that both shoulders are aligned with both hips Prevent internal rotation and adduction of the hip by placing a pillow under the upper flexed leg from the groin to the foot Prevent damage to nerves and blood vessels in the axillae of the lower arm by carefully positioning lower arm behind and away from the patient's back Prevent internal shoulder rotation and adduction by abducting the upper shoulder slightly so that the shoulder and elbow are flexed; place a pillow between the chest and upper arm

Pneumatic compression devices

Intermittent pneumatic compression devices may be used in conjunction with graduated compression stockings or alone. They are composed of an air pump, connecting tubes, and extremity sleeves that apply intermittent or sequential pressure to the legs to enhance blood flow and venous return, stimulating the normal muscle-pumping action in the legs. They require a prescriber's order and are often prescribed for high-risk surgical patients, those with decreased mobility or chronic venous disease, and patients at risk for deep vein disorders.

Positioning Patients in Bed

Positioning that maintains correct body alignment. (Having correct alignment won't cause discomfort or won't cause pressure on parts of the body.) The force of gravity pulls parts of the body out of alignment unless adequate support is provided. ******Foam Wedges and Pillows- used to help for proper alignment. ****Mattresses-A mattress must be firm but have sufficient "give" to permit proper body alignment. *****Adjustable Beds ****Trapeze- device makes it possible for the patient to lift part of the body from the bed, facilitating turning and moving up in bed. It can also be used when a patient needs to perform exercises that strengthen some muscles of the upper extremities ****** Additional Equipment The use of a foot support, such as a foot board, foot boot, or high-top sneakers, helps avoid this complication. (Without this Plantar flexion occurs. This happens when the foot is not supported. When high-top sneakers support the feet, the dorsiflexion position is maintained. Because of plantar flexion pt can develop footdrop( pt will experience extreme difficulty in walking) *******Trochanter rolls- are used to support the hips and legs so that the femurs do not rotate outward. *****=hand-wrist splints or hand rolls may be necessary to provide a means for keeping the thumb in the correct position, that is, slightly adducted and in apposition to the fingers. A hand roll can be created by folding a washcloth and rolling it. ********Side rails can assist the patient in rolling from one side to the other or to sitting up without calling for assistance. Using the side rails.

A nurse is caring for a patient whose health history includes narcolepsy. When planning this patient's care, which of the following risk nursing diagnoses is most likely?

Risk for Injury Narcolepsy is a neurological disorder that causes people to fall asleep at any given time of day when they want to be awake. This unpredictable pattern of sleep creates a significant risk for injury. However, it is less likely that the individual would develop an infection or aspirate. Quality of life is affected, but this may or may not result in delayed development.

A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient?

Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet.

A nurse is leading a "chair aerobics" class with a group of older adults who reside in a long-term care facility. One of the regular participants in the class suddenly winces and begins rubbing her shoulder. What is the nurse's most appropriate action?

Tell the woman to stop the exercise and then assess her shoulder. If a person experiences pain while exercising, he or she should immediately stop. The nurse should assess the woman's shoulder for any obvious signs of injury and refer appropriately. Performing passive ROM exercises may cause further injury. TAKE A PRACTICE QUIZ

A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side?

The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses.

The nurse is observing an unlicensed assistive personnel (UAP) transferring a client with left-sided weakness from the bed to the chair. The nurse should intervene when the UAP does which of the following? Select all that apply.

instructs the client to hold on to the side rail when standing to move into the chair stands next to the client when the client is sitting on the side of the bed stands near the client's head and shoulders before sitting the client up in bed The nurse keeps the client in good body alignment and protects the client from injury while being moved. Safety and comfort are key concerns when assisting a client out of bed. The side rails should be down when transferring a client out of bed. The client should be instructed to use an arm to steady himself on the arm of the chair when getting out of bed for support and stability. The nurse should stand in front of, not next to, the client when the client is sitting on the side of the bed; this will prevent falls or injuries from orthostatic hypotension. When assisting the client to sit up on the side of the bed, the nurse should stand near the client's hips. The nurse's center of gravity is placed near the client's greatest weight to assist the client to a sitting position safely. The head of the bed should be elevated to place the client in a sitting position, or as high as the client can tolerate. The amount of energy needed to move from a sitting position or elevated position to a sitting position is decreased. Bracing the knees against a weak extremity prevents a weak knee from buckling and the client from falling.

Protective Prone Position

lies on abdomen with head turned to side, helps to prevent flexion contractures of hips and knees, can't use for spinal injuries Prevent footdrop by supporting the feet in dorsal flexion by moving the patient down in the bed so that the feet are over the mattress, or support the lower legs on a pillow just high enough to keep the toes from touching the bed Prevent flexion on the cervical spine by placing a small pillow under the head Prevent hyperextension of the spine (impaired respirations) by placing some suitable support under the patient between the end of the rib cage and the upper abdomen

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

predisposition to renal calculi In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.

Using Graduated Compression Stockings and Pneumatic Compression Devices

prevents Venous stasis and deep vein thrombosis and pulmonary embolism and prevent phlebitis (Phlebitis Vein disease that is characterized by inflammation of a vein)(immobility people) available in either knee or thigh-high length By applying pressure, graduated compression stockings it increase the velocity of blood flow in the superficial and deep veins and improve venous valve function in the legs, promoting venous return to the heart. By preventing pooling of the blood, clot formation is less likely. An order is required from the patient's health care provider for their use. When assisting with graduated compression stockings. Be prepared to apply the stockings in the morning before the patient is out of bed and while the patient is supine. If the patient is sitting or has been up and about, have the patient lie down with legs and feet elevated for at least 15 minutes before applying the stockings. Otherwise, the leg vessels are congested with blood, reducing the effectiveness of the stockings. Do not massage the legs. If a clot is present, it may break away from the vessel wall and circulate in the bloodstream. checking the legs at least once every 8 hours; others recommend twice a day. Remove once a day

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene?

raising the height of the bed to the waist level prior to moving the client Raising the height of the bed to the waist level is an incorrect action that would require the nurse to intervene. The bed should be raised to the height of the caregiver's elbow prior to positioning the client. All other options are appropriate positioning techniques.

Canes

single-ended canes with half-circle handles (recommended for patients requiring minimal support and those who will be using stairs frequently), single-ended canes with straight handles (recommended for patients with hand weakness because the handgrip is easier to hold but not recommended for patients with poor balance), or canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support (recommended for patients with poor balance). the cane extends from the floor to the crease in the patient's wrist. The elbow should be flexed 15 degrees when holding the cane. walking with a cane and not to lean out over the cane. The patient stands with weight evenly distributed between the feet and the cane. The cane is held on the patient's stronger side and is advanced one small stride ahead. Supporting weight on the stronger leg and the cane, the patient advances the weaker foot forward, parallel with the cane. Supporting weight on the weaker leg and the cane, the patient brings the stronger leg forward to finish the step.

The nurse has been educating the client about how to use a walker safely. The nurse knows the education has been effective when the client:

steps into the walker when walking. A walker is mechanical aide that enhances the client's balance and ability to bear weight. Education is usually done by physical medicine or physical therapy, but the nurse should continue to assess the client's ability to use it properly. The client should step into the walker when walking, rather than walking behind it. When rising from a seated position, the arms of the chair should be used for support, not the walker. The client should be cautioned to avoid pushing the walker out too far in front. Also, the client should avoid leaning over the walker, but should stay upright as he moves.