Mobility

Nursing interventions performed when caring for a patient who is blind

-Ask about any cultural practices as treatments -Ask permission before touching -Ask preferred method for teaching (audio material or written material in large print)

What is crepitus and how does it relate to osteoarthritis?

-When one bones grates against another (usually results from a fracture or cartilage breakdown) -May be elicited during ROM testing for osteoarthritis

A 12-year-old boy taken to the emergency department after a soccer injury cries out, "Look, my leg is bigger now!" How will the nurse respond to the boy? A. "Swelling is a normal response from your body to prepare for healing." B. "Yes. it is supposed to. This is a good thing." C. "Let me look at that. We may need to have the doctor examine you." D. "No need to worry. Soccer is a dangerous sport."

A. "Swelling is a normal response from your body to prepare for healing."

The physician has ordered that the client should ambulate three times a day. The nurse enters the room to ambulate the client and the client complains of pain. What is the nurse's most appropriate action? A. Medicate the client and wait to ambulate later. B. Ambulate the client and medicate later. C. Emphasize to the client the importance of following the treatment plan. D. Explain to the client the benefits of ambulation.

A. Medicate the client and wait to ambulate later

The nurse observes the client and notes a shuffling gait. The nurse recognizes this finding is consistent with: A. Parkinson's disease B. Lower motor neuron disease C. Scoliosis D. Paget's disease

A. Parkinson's disease

Which therapeutic exercise is done by the nurse without assistance from the patient? A. Active B. Passive C. Resistive D. Isometric

B. Passive

A nurse is assessing a patient with a primary immunodeficiency. Afterward she documents that the patient displayed ataxia. Which statement explains the documentation? A. The patient has vascular lesions caused by dilated blood vessels. B. The patient has an inability to understand the spoken word. C. The patient has uncoordinated muscle movements. D. The patient has difficulty swallowing.

C. The patient has uncoordinated muscle movements

How does immobility affect comfort?

Immobility can lead to joint and muscle stiffness

Nursing interventions that can help a patient who is immobile and constipated

-Assist to the bathroom; provide bedpan or bedside commode, as indicated. -Encourage increased fluid and fiber intake -Develop a bowel program specific to the patient. -Educate about meds that affect bowel function and on actions that promote regular bowel function. -Encourage and assist the patient with activities -Encourage the use of easily removable clothing on outings. -Identify factors that contribute to the patient's constipation and assist in developing a plan to alter those factors.

How is a hip fracture diagnosed?

-Blood tests may find the underlying cause of the fracture -X-rays show the location of the fracture -CT scan or MRI shows abnormalities in complicated or occult fractures -Bone scans reveal occult fractures

How should a nurse assist a blind patient to walk?

-Hold onto his or her arm -Walk at a relaxed pace -Indicate changes in terrain (stairs, slopes, etc) -Give directions (to the R/L, etc)

What is important to teach when teaching a patient how to walk with a walker?

-How to sit, stand, and walk -How to go up and down steps and curbs

Positive clinical outcomes related to mobility

-Independence -Physical activity -Weight control

Common symptoms of a patient with osteoarthritis

-Joint pain is predominant symptom and worsens with joint use -Joint stiffness occurs after periods of rest or static position -Early morning stiffness usually resolves w/in 30 mins -Heberden's and Bouchard's nodes

What should a nurse assess for when a patient has arthritis?

-Joint pain or tenderness upon palpitation -Pain after exercise or is relieved by rest -Stiffness in the morning or after exercise (<30 mins) -Limited joint movement -Joint swelling -Contractures -Abnormal gait -Decreased ROM -Hard nodes that may be red, swollen, and tender

Nursing interventions for those with joint replacement?

-Monitor the surgical site, vital signs, pulse oximetry -Administer meds and IVs as ordered -Maintain bed rest then assist with exercises -Assess pain level

What important factors should the nurse teach when teaching a patient how to walk with a cane?

-Move the cane and weaker leg at the same time -Place cane to the side and about one step ahead of you -Step through with stronger leg

Conditions that place one at risk for altered mobility

-Musculoskeletal conditions -Inadequate energy or muscle strength -Neuromuscular discoordination -Age

How to walk using crutches

-Stand up straight with feet apart -Crutches should be 6-8" apart on side -Weight should be on leg that isn't hurt. -Lean forward slightly and move both crutches ~6-12" (one step length) forward. -Keep elbows slightly bent. -Put your weight on your hands -Move body and hurt leg towards crutches. -Finish step normally with leg that isn't hurt. -Keep hurt leg off the floor (you may bend knee or put leg in front of you) -Repeat the motions. -Don't put weight on hurt leg or foot unless the doctor says it's OK. -Take time to rest if feeling tired

Negative clinical outcomes related to mobility

-Swelling of lower extremities -Dyspnea on exertions -Contractures -Skin breakdown -Constipation -Incontinence -Loss of self-worth

The nursing assistant is preparing to help the patient make a lateral transfer from the bed to a stretcher. The patient informs the nurse that he is able to move onto the stretcher without her help. What is the nurse's best response? A. "You are free to move onto the stretcher without assistance, but I will supervise for your safety." B. "I can only allow you to transfer without assistance based upon a physician's order, so I will now help you." C. "You cannot transfer without my help because you need a friction-reducing device to prevent harm to your skin." D. "That is fine if you want to transfer without my help, so ring your call bell after you have transferred and are ready to go."

A. "You are free to move onto the stretcher without assistance, but I will supervise for your safety."

A patient with a long arm cast continues to complain of unrelieved throbbing pain even after receiving opioid pain medication. Which of the following is the priority action by the nurse? A. Assess for complications. B. Assess for previous opioid drug use. C. Reposition the patient for comfort. D. Teach relaxation techniques.

A. Assess for complications

Which of the following is the most common joint affected in gout? A. Metatarsophalangeal B. Tarsal area C. Ankle D. Knee

A. Metatarsophalangeal

Which of the following are usually the first choice in the treatment of rheumatoid arthritis (RA)? A. Nonsteroidal anti-inflammatory drugs (NSAIDs) B. Disease-modifying antirheumatic drugs (DMARDS) C. Tumor necrosis factor (TNF) blockers D. Glucocorticoids

A. NSAIDs

An elderly patient informs the nurse, "I just don't feel like myself. I cry so easily and my mobility is so bad from my degenerative disc disease in my back." What factor is most likely contributing to the patient's depression? A. Pain B. Shortness of breath C. Hearing loss D. Diminished vision

A. Pain

A nurse is giving post-operative care to a client after knee arthroplasty. Which of the following is a possible short-term goal for this client? A. To ambulate the client to a bedside chair B. To help the client return to activities of daily life C. To maintain a healthy and active lifestyle D. To prevent repeat surgery in the client

A. To ambulate the client to a beside chair

Definition of mobility

Ability to move or be moved freely and easily

Which body movement involves moving toward the midline? A. Pronation B. Adduction C. Abduction D. Eversion

B. Adduction

A nurse is repositioning a patient who has physical limitations due to recent back surgery. How often would the nurse turn the patient in bed? A. Every hour. B. Every two hours. C. Every four hours. D. Every shift.

B. Every 2 hours

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do? A. Have the UAP keep a steady pull on the client to promote forward ambulation. B. Explain how to overcome a freezing gait by telling the client to march in place. C. Assist the UAP with getting the client back in bed. D. Give the client a muscle relaxant.

B. Explain how to overcome a freezing gait by telling the client to march in place.

The nurse is caring for a patient diagnosed with Parkinson's disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination? A. Use of a bedpan B. Use of a raised toilet seat C. Sitting quietly on the toilet every 2 hours D. Following the outlined bowel program

B. Use of a raised toilet seat

Definition of osteoporosis

Bone disease caused by loss of calcium and phosphate from bones, resulting in decreased bone density

Definition of muscle atrophy

Breakdown of muscle resulting from denervation or prolonged muscle disuse

The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown in the accompanying image. Which finding is expected when assessing this client? a. inability to move his arms b. loss of sensation in his hands and fingers c. dysfunction of bowel and bladder d. difficulty breathing

C. Dysfunction of bowel and bladder

The nurse is preparing a patient to be turned in bed. In what position would the nurse place the patient to begin this procedure? A. Sitting up. B. Lying prone. C. Lying flat. D. Lying flat with feet raised slightly.

C. Lying flat

A nurse's assessment of a teenage girl reveals that her shoulders are not level and that she has one prominent scapula that is accentuated by bending forward. The nurse should expect to read about what health problem in the patient's electronic health record? A. Lordosis B. Kyphosis C. Scoliosis D. Muscular dystrophy

C. Scoliosis

The nurse is assessing the infant shown in the figure. On observing the client from this angle, the nurse should document that this infant has which finding? A. Ortolani's "click" B. Limited abduction C. Galeazzi's sign D. Asymmetric gluteal folds

D. Asymmetric gluteal folds

A patient will be ambulating for the first time since his cardiac surgery. What should the nurse consider when assisting this patient? A. Patients who are fearful of walking should be told to look at their feet when walking to ensure correct positioning. B. Patients who can lift their legs only 1 to 2 inches off the bed do not have sufficient muscle power to permit walking. C. Nurses should never assist patients with ambulation without a physical therapist present. D. If an ambulating patient whom a nurse is assisting begins to fall, the nurse should slide the patient down his or her own body to the floor, carefully protecting the patient's head.

D. If an ambulating patient whom a nurse is assisting begins to fall, the nurse should slide the patient down his or her own body to the floor, carefully protecting the patient's head.

How does immobility affect functional ability?

Decreases functional ability, so the patient may require assisted devices or assistance from other people

Definition of disuse syndrome

Deterioration of body systems due to immobility or inactivity

What safety concerns are associated with mobility?

Falls and fractures (ie hip fractures)

How does immobility relate to tissue integrity?

Immobility can lead to skin breakdown, poor skin turgor, pressure ulcers

How does immobility affect elimination?

It can lead to constipation and/or incontinence

How does a patient correctly use a walker?

Move the walker forward first and set all 4 legs down. If both legs are strong, you can step forward with either leg to line up with the back legs of the walker. Do not step all the way to the front of the walker. If one leg is weaker, step forward with your weaker leg, then step forward with your stronger leg. Repeat, moving the walker, then your weaker leg, then your stronger leg. Always take small steps when you turn and move slowly.

What is degenerative joint disease?

Osteoarthritis

Realistic goal for a patient with osteoporosis

Pain control

Difference between passive and active ROM

Passive ROM is with the assistance from another person or object, while active ROM is done without

Why is early ambulation after a surgery important for a post op patient?

Prevent DVT or PE

Definition of osteoarthritis

Slowly progressive noninflammatory disease of the diarthrodial joints

How are patients evaluated for risk of falling?

Use a standardized, facility-approved assessment tool, such as the Hendrich II Tool, Morse Fall Scale, Johns Hopkins Tool, or STRATIFY tool. These tools identify risk factors for falls and then assign those factors a score to determine a specific patient's risk for falling and the appropriate precaution measures to implement based on that score.

What activities are helpful for patients with osteoporosis?

Weight-bearing exercises for 30 mins 3x/week