Mobility

Question 1

regulation of movement

Answer 1

• skeletal system: bones and joints
• muscles
• nervous system
• problem with any of these affects mobility

Question 2

Factors that affect mobility: age

Answer 2

1. Infant
   a. Spine flexed, no anteroposterior curve until infant raises head
   b. Thoracic spine straightens
   c. Lumbar spinal curve appears allows sitting & standing
   d. Posture awkward–head & upper trunk carried forward–child off balance,
   falls easily
2. Toddler
   a. Posture slightly swayback with protruding abdomen
   b. Walk–legs & feet far apart & feet slightly everted
3. School age
   a. By third year taller, slimmer & better balanced
   b. Improved posture &  muscle strength  fine motor coordination
4. Older adult
   a. Bones—osteoporosis  risk of fx of wrist, vertebrae & neck.
   b. Muscles–Regeneration slowed, atrophied tissue replaced with fiber
   c. Joints Breakdown in component of joint capsule–arthritis
   d. Posture–Height  1.2 cm/20 yrs, long bones remain same length

Question 3

Factors that affect mobility: physical health

Answer 3

1. Congenital disorders—cerebral palsy, spina bifida
2. NS disorders—Parkinson’s disease, Spinal cord injury, stroke
3. MS disorders—arthritis, fractures. Amputations
4. Inner ear injections–vertigo

Question 3

Factors that affect mobility: mental health

Answer 3

1. Depression –> can affect posture
2. Chronic stress –> fatigue, decrease in exercise

Question 4

Factors that affect mobility: nutrition

Answer 4

1. Poor nutrition –> muscle weakness, fatigue
2. Vitamin D deficiency –> bone deformity
3. Calcium deficiency –> Osteoporosis
4. Obesity –> altered posture, balance

Question 4

Factors that affect mobility: personal values

Answer 4

1. Sedentary vs active lifestyle
2. Value of personal appearance

Question 5

Factors that affect mobility: external factors

Answer 5

1. Weather
2. Availability of recreational facilities

Question 6

Factors that affect mobility: prescribed limitations

Answer 6

1. Casts, braces, splints, traction
2. Ordered immobility

Question 7

nursing history: subjective data

Answer 7

• height/wt (pt report)
• activity & rest patterns
• diet: intake of calcium and vit D –> affects bone health
• meds
  
  • arthritis, CNS depressants, sedatives
• do they use a walker, a cane, do they have difficulty ambulating

Question 8

nursing history

Answer 8

• Functional status
  o Walking, standing, sitting up, getting into/ out of bed or chair, ADLs
  o Assistive devices—crutches, walker, braces, feeding or grooming aids
  o Activity tolerance
• Environmental barriers/ aids
• Past history of falls/ injuries
• Symptoms associated with MS problems
• pain/stiffness with movement
• weakness
• dominant hand

Question 9

physical assessment: objective data

Answer 9

• Height, weight, stature, posture
• Body alignment
• Movement
• In bed, lying –> sitting –> standing
• Get idea of flexibility, agility,
  control
• gait – steady?
• get up and go test

Question 10

times get up and go test

Answer 10

• begin timing
• rise from standard arm chair
• walk to line on floor (approximately 10 ft away from chair)
• turn and return to chair
• sit in chair again
• end timing
• should take 7 to 10 seconds

Question 11

joints

Answer 11

• Swelling, redness, deformity, contractures (unable to stretch their arm out), crepitation (crackling)
• ROM
• Use of cane, walker, crutches, prosthesis
• evidence of past injuries
  
  • any bruises, scratches, scrapes

Question 12

functional status

Answer 12

• Dressing, bathing, feeding, toileting
• NOC Scale:
  0–completely independent
  1—requires use of an assistive device
  2—needs minimal help
  3—needs assistance or some supervision
  4—needs total supervision
  5—needs total assistance or unable to assist

Question 13

diagnostics

Answer 13

• X-rays
  
  • Fracture sites—old or new
• DXA (or DEXA) Scan (bone density scan)
  
  • Dual-emission X-ray absorptiometry
  • Bone density
• white = more dense

Question 14

impaired physical mobility

Answer 14

• difficulty or inability to facilitate movement
• Ex: older adult who has experienced a fracture
• someone who broke their leg in their 20s and isn’t able to move around adequately

Question 15

self-care deficit syndrome

Answer 15

• the state in which an individual experiences an impaired motor fxn or cognitive fxn causing a decreased ability in performing each of the 5 self-care activities (feeding, bathing, toileting, dressing, instrumental things like cooking)
• ex: someone who had a stroke –> cog motor fxn = altered

Question 16

sedentary lifestyle

Answer 16

• reports a habit of life that is characterized by a low physical activity level
• couch potato, lots of work from a computer

Question 17

principles of body mechanics

Answer 17

• use proper body mechanics and equipment to protect pt and self
• maintain a wide stable base with ur feet
• put the bed at the correct height
  
  • waist level when providing care
  • hip level when moving a pt
• try to keep the work directly in front of u to avoid rotating the spine
• keep the pt as close to ur body as possible to minimize reaching

Question 18

lifting risks in nursing

Answer 18

• Awkward postures/reaching
• Heavy loads
  
  • No nurse should lift over 35 pounds
• Excessive pushing/ pulling
• Frequent/ repeated lifting and
  moving
• Tasks that take a long time
• Lack of help
• Lack of equipment
• pt should be able to assist you or you need some medical equipment
• if you had 2 nurses and pt was 100 lbs

Question 19

Nursing interventions

Answer 19

• do this after you figure out the cause
• should not be lifting more than 35 lbs
• Use mechanical equipment whenever necessary for moving patients
• Increase limb mobility
  • ROM exercise 4x/day
  • Support extremity to reduce swelling
• Medicate for pain
• Positioning
  • Maintain body alignment

Question 20

Active ROM

Answer 20

• they move around themselves
• best form of ROM

Question 21

Passive ROM

Answer 21

• we assist them to move around if they are unable to do it themselves

Question 22

Positioning

Answer 22

• Maintain body alignment
• Use the appropriate position: Fowler’s, Semi-Fowler’s, Dorsal Recumbent, Prone, Lateral, Sim’s

Question 23

Fowler’s position

Answer 23

- bad for ppl who are immobile bc they are @ an increased risk for getting a pressure ulcer - sitting @ a 45° angle

Question 24

Prone position

Answer 24

- laying on belly - best for assisting with breathing

Question 25

Sim’s position

Answer 25

- laying on side but also partially prone - one leg up - pts are placed in this position for an enema

Question 26

Dorsal recumbent

Answer 26

- laying flat on back

Question 27

Right lateral position

Answer 27

- laying on right side

Question 28

Semi-Fowler

Answer 28

- laying on back at a 15-45° angle

Question 29

Different types of nursing interventions

Answer 29

- assess casts, traction devices, Ace bandages for proper fit (circulation, sensation, motion) - if something is on too tight, it causes circulation issues - can assess by doing capillary refill to finger or toes —> <3 seconds - sensation: Ask if pt is experiencing any numbness or tingling - motion: Can they wiggle fingers or toes

Question 30

Provide for progressive ambulation

Answer 30

• Involve Interprofessional Team—PT, OT • Non-ambulatory - ROM exercises at least tid - Out of bed and into chair tid with appropriate equipment • Ambulatory - Ambulate with or without assistance in hallway as tolerated (at least tid) - Get out of bed and into chair for all meals

Question 31

Health teaching

Answer 31

• OT/ PT consult for assistive devices • Reinforce teaching done in therapy • Safety practices

Question 32

Nursing interventions classification

Answer 32

• Ambulation • Joint mobility • Positioning

Question 33

Which of the following are physiological effects of exercise on the body systems? Select all that apply.

Answer 33

- Decreased cardiac output - Increased respiratory rate and depth (Correct) - Increased muscle tone, size and strength (correct) - Change in metabolic rate (correct)

Question 34

While assisting the client with a bath, the nurse encourages full range of motion in all the client's joints. Which activity would best support range of motion in the hand and arm?

Answer 34

- Give the client a washcloth to wash the face. (little movement) - Move the wash basin farther toward the foot of the bed so the client must reach. (safety issue) - Have the client brush hair and teeth. (Correct. Has the most ROM) - Move each of the client's hand and arm joints through passive range of motion. (active ROM = better)

Question 35

The nurse recognizes that the older adult's progressive loss of total bone mass and tendency to take smaller steps with feet kept closer together will most likely:

Answer 35

A. Increase the patient's risk for falls and injuries (CORRECT) B. Result in less stress on the patient's joints. C. Decrease the amount of work required for patient movement. D. Allow for mobility in spite of the aging effects on the patient's joints.

Question 36

A nursing assistant asks for help to transfer a patient who is 125 lbs (56.8 kg) from the bed to a wheelchair. The patient is unable to help. What is the nurse’s best response?

Answer 36

A. “As long as we use proper body mechanics, no one will get hurt.” B. “The patient only weighs 125 lbs. You don’t need my assistance.” C. “Call the lift team for additional assistance.” (CORRECT) D. “The two of us can lift the patient easily.”

Question 37

Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.)

Answer 37

A. Patient’s weight (CORRECT) B. Patient’s level of cooperation (CORRECT) C. Patient’s ability to assist (CORRECT) D. Presence of medical equipment (CORRECT. IV, cast on, etc) E. Nutritional intake

Question 38

Which of the following is a principle of proper body mechanics when moving patients or lifting objects? (Select all that apply.)

Answer 38

A. Keep the knees in a locked position. B. Bend at the waist to maintain a center of gravity. C. Maintain a wide base of support. (CORRECT) D. Hold objects away from the body for improved leverage. E. Encourage patient to help as much as possible. (CORRECT)