Mobility/Immobility

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?

Fowlers

When recovering from a hip replacement, what should the nurse do?

Place a pillow between the legs to keep the hip from popping out of place

Lab values to monitor with immobility

- urine output <30cc / hr = bad - monitor BUN albumin protein electrolytes

How do we use crutches?

1. distance between crutch pad an axilla must be 2 inches 2. dont rest on armpits 3. use shoulders and arms for stregnth 4. slight bend through the elbows (slide two fingers)

Musculoskeletal changes with immobility

1. muscle atrophy 2. skeletal effects - disuse osteoporosis contractures and foot drop

How are we assessing the cardiovascular system when dealing with immobility?

1. vital signs monitoring 2. assess for orthostatic changes 3. peripheral pulse assessment 4. assessment of EDEMA 5. Prevent thrombus formation 6. Assessment of VTE/DVT (calf circumference)

What is high fowlers position?

60-90 degrees

A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client?

Occupational therapist

A nurse is caring for a client who is at risk for developing atelectasis. Which actions should the nurse take?

Remind the client to use the incentive spirometer

a nurse is completing the mobility assessment tool (MAT) for a client and determines that the client is at level 1 mobility. What task can't the client perform?

Sit on the edge of a bed for 1 min

What are we assessing on a patient for dehydration?

Skin turgor, mucous membranes

What is a nurse independent intervention

Suctioning

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches?

The client has the crutches resting 5cm (2in) below their axilla

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?

The use of ergonomics increases job satisfaction

What are early mobility exercises prescribed for patients that cannot tolerate increased activity?

isometric exercises

If the bladder is palpable what does this mean?

it is full

a nurse is caring for a client who requires total assistance with mobility. When using the mobility assessment tool (MAT) what piece of equipment should the nurse use to transfer the client?

mechanical lift

When should the gait belt be used?

minimal assistance required

When should the sit to stand be used?

moderate assistance required

Cardiovascular changes with immobility

orthostatic hypotension increased workload of heart due to decrease in venous return to heart risk for thrombus

During an exercise session, the nurse assists the client to dorsiflex and plantarflex the foot, explaining the client needs to exercise the foot to maintain function. The nurse recognizes this type of exercise activity as

passive range of motion

What can we use to adjust positioning as nurses?

pillows trapeze bar foot board splints abductor pillow ROM exercises

Which nursing assessment of the immobilized client would prompt the nurse to take further action?

absence of bowel sounds

What is prescribed for patients who can tolerate movement but are recovering from being immobile?

active, active assisted, walking

A nurse in a long-term care facility is caring for an older adult client and notes their muscles have become smaller and weaker. What is the client experiencing?

atrophy

What is important when caring for patients with immobility and their progression?

promote patient independence as much as possible

Integumentary changes and immobility

skin breakdown - have high protein diet, turn patient position every 2 hrs.

When transferring patients, what must be locked

the bed and the wheelchair

What gives the least amount of walking assistance?

the cane

a nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. What info should the nurse plan to include regarding flexion of a joint?

the contraction of a muscle results in flexion of a joint

What is isometric exercises

there is muscle contraction without moving the joint (planks) maintains strength in immobilized muscle

What should nurses look for in the elimination system during immobility

- I&O each shift - assess for fluid and electrolyte imbalances - bowel assessment - adequate hydration - incontinence

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include?

- a stable center of gravity increases stability and balance - a wide base lowers the center of gravity - proper body alignment involves tightening the abdomen

How do we use a cane?

- can goes to unaffected side - slight bend at elbow - cane moves forward 6-10 inches - affected leg moves forward with cane - unaffacted leg moves past the cane

What are SPH aids

- powered mechanical full body lifts -powered mobile sit to stand lifts - friction reducing devices - transfer belts

How do we prevent thrombus formation?

1. anticoagulants 2. TED stockings 3. Calf pumping exercises 4. Sequential compression stockings - measure for right fit, covered by insurance

What is low fowlers

15-30 degrees

What is the capacity of the bladder?

500-600 mL capacity

when moving a patient in a wheel chair, what must the nurse make sure of?

the foot rests must be down

when transferring a patient, what must the nurse make sure of regarding the patients neurological status?

the person must be able to follow commands

How do we confirm DVT?

ultrasound / sonogram

How can we prevent drop foot?

with Range of motion exercises

a nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for what?

Diminished awareness of body position and balance

A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. What condition should the nurse suspect the client is experiencing?

Foot drop

After completing preoperative teaching for a surgical patient, you can evaluate the patient's understanding of the use of elastic stockings when the patient states

I can remove them for 30 minutes every 8 hours

A nurse is performing a focused assessment on an older client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing an age-related change to their musculoskeletal system?

Increased curvature of the thoracic spine

What is simms position?

Left lateral for enema, however this increases intracranial pressure

A nurse is preparing to transfer a client from a bed to a wheelchair. Which of the following actions by the nurse demonstrates proper use of body mechanics?

Looking at the client face to face when transferring the client, the nurse should bend at the knees

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?

Mechanical lift

What is isotonic exercises

Muscle shortens to produce contraction and active movement (running walking swimming) maintains joint flexibility and circulation

A nurse preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?

Muscles assist with thermoregulation in the body

You notice a respiratory change in your immobilized postop patient. The change you note is most consistent with

atelectasis

Lack of exercise and movement put client at risk for

atelectasis - collapse of alveoli leading to partial collapse of lung hypostatic pneumonia - inflammation of lung tissue from stasis or pooling of secretions - both decr oxygenation, prolong recovery, and add to discomfort

What is HIT in regards to heparin?

it is an allergic reaction which is severe and occurs with heparin. Heparin is derived from pork (pig blood). The cure to heparin is protamine sulfate. Never give heparin again after an allergic rxn

Which of the following is true concerning the physiologic effects of immobility

secretions may block bronchioles

Finger glove

stops fingers from bending, must be removed every few hrs

a nurse is teaching a client who has an unsteady gait about how to use a walker. What instructions should the nurse include?

the top of the walker should be at the level of the wrist elbows should be placed at 15 degrees move the walker before taking a step

Trenddenburg position

upside down - contraindicated in BRAIN INJURY

How are we handling the respiratory system when it comes to immobility

- frequent respiratory assessment - auscultate lung sounds - inspect chest wall movement - promote lung expansion + stasis of pulmonary secretions - deep breathing and coughing exercises - incentive spirometer - suctioning / hydration / reposition every 2 hrs

What are some common errors with the walker?

- hunching over - pushing walker too far in front - picking up walker - pushing walker with one arm only

Immobility and associated systemic changes

- metabolic changes - endocrine metabolism - decreased BMR - disrupts metabolic functioning - functioning of GI tract

What are we assessing in the musculoskeletal system during immobility?

- muscle tone, strength, loss of mass, contractures - assess for risk of disuse osteoporosis - assess ROM - PASSIVE ROM FOR ALL IMMOBILIZED JOINTS should be provided

What should we monitor for DVT

- platelets (20-30% drop)

What are some urinary changes with immobility

1. kidney stone high risk 2. stasis/pooling of urine in renal pelvis. leads to increases risk for infection and renal calculi 3. dehydration + decr urine output 4. UTIs from foley cath (given because of incontinence)

What are the Safe patient handling core principles?

1. maintain a wide stable base with your feet 2. bend the knees when lifting, watch the back 3. push pull or roll objects rather than lifting 4. put bed at correct height 5. try to keep work directly in front of you to avoid rotating the spine 6. keep patient close to body as possible to minimize reaching

A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics?

1. stand as close to object as possible 2. keep abdominal muscles contracted and lower back straight 3. look straight ahead w/ shoulders raised up 4. bend hips slightly and squat 5. push up from the knees when lifting the object

How do we use a walker?

1. stand in center of walker, slide walker forward 6-8 inches 2. keep all 4 feet of walker on ground 3. step forward with affected side 4. keep weight on walker and unaffected leg 5. bring unaffected leg up to walker

What is a good respiratory sign with immobility?

Coughing + deep breathing

A nurse is providing teaching for a client who has kyphosis. Which of the following info should the nurse include?

Kyphosis is a rounded upper back with the pelvis tilted forward.

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture?

Muscles

Which of the following patients is most at risk for thrombus formation?

Patient with total hip replacement because of IMMOBILITY

A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL

Toileting

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage?

Damage into the skin layer

a nurse is caring for a client who had a stroke and is immobile. The nurse should identify that the client is at risk for what?

DVT

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage?

Prone

A patient with a long history of arthritis complains of sensitivity and warmth in the knees. To determine the degree of limitation, the nurse should assess...

Range of joint motion

A nurse is providing teaching for a client who injured their ankle. Which of the following info should the nurse include?

Tendons connect muscle to bone