-Vital signs Tachycardia? Orthostatic hypotension? Any disses? - Palpate for edema and skin warmth - Observe perfusion and DVT

- Assist increase activity ASAP - Change position often as possible - Dangling and slow transitions - Teach ROM - Use elastic stocking

- Early ambulation (especially after surgery) - leg, foot ankle exercise - ROM q1h - Promote fluid intake - Avoid crossing leg, prolonged sitting - ROM q1h

What is the goal of the _psychosocial_ aspect? 3

- Maintain a sleep/wake pattern - Archive socialization - Complete self independently

Mobility/Immobility Flashcards by Yuko Porter

System effect

Integument

Increase pressure skin
Decrease circulation causing ischemia
pressure injury

ischemia
-reduce blood flow

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System effect

Respiratory

Decrease oxygenation and carbon dioxide exchange
Weekend respiratory muscle
Risk for atelectasis and pneumonia
Decrease cough response
*Atelectasis**
the collapse of part or all of a lung, is caused by a blockage of the air passages

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Cardio

System effect

Decrease cardiac output
Poor effectiveness, leads to increased cardiac workload
Increased oxygenation requirement
Increase risk for thrombus

Thrombus-blood clot

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System effect

Elimination

Urinary stasis(inactivity)
Decreased intake, use catheter result UTI
Decrease peristalsis
Constipation-increased fecal impaction

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System effect

Musculoskeletal

Impaired balance
Atrophy of muscle
Altered Ca metabolism(osteoporosis)
Foot drop
Altered joint mobility

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Assessment

Respiratory system

-Assess full respiratory cycle
for observing chest wall and symmetry

Auscultate all lung fields
Observe cough with or without sputum production

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Intervention

Respiratory

We want open lungs and get air through

Deep breathing exercises
Use an incentive spirometer

-Controlled coughing
3 deep breathes then forced cough

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Assessment

Cardio

-Vital signs
Tachycardia? Orthostatic hypotension?
Any disses?

Palpate for edema and skin warmth
Observe perfusion and DVT

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Intervention

Cardio

Assist increase activity ASAP
Change position often as possible
Dangling and slow transitions
Teach ROM
Use elastic stocking

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DVT prevention

Early ambulation (especially after surgery)
leg, foot ankle exercise
ROM q1h
Promote fluid intake
Avoid crossing leg, prolonged sitting
ROM q1h

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An older adult has limited mobility as a result of a surgical repair of a fractured hip. During assessment, you note that the patient cannot tolerate lying flat. 許す

Which of the following assessment data support a pos

sible pulmonary problem related to impaired mobility? (Select all that apply.)

A. B/P = 128/84
B. Respirations 26 per minute on room air
C. HR 114
D. Crackles heard on auscultation
E. Pain reported as 3 on scale of 0 to 10 after medication

B. C. D

Patients with reduced mobility are at risk for retained pulmonary secretions, and this risk increases in postoperative patients. As a result of retained secretions, the respiratory rate increases.

The heart rate also increases because the heart is trying to improve oxygen levels.

These symptoms are of concern for older adults because, if left untreated, further complications such as heart failure can occur.

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A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, “It hurts when I try to breathe, and I can’t catch my breath.”

Your first action is to:
A. Call the health care provider to report this change in condition.
B. Give the patient a paper bag to breathe into to decrease her anxiety.
C. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen.
D. Explain that this is normal after such trauma and administer the ordered pain medication.

C.
These are signs of possible pulmonary emboli, which can be life-threatening. You must assess your patient, be prepared to start oxygen, and have someone call the surgeon while you stay with the patient to continue to monitor her status.

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The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to:

A. Prevent varicose veins.
B. Prevent muscular atrophy.
C. Ensure joint mobility and prevent contractures.
D. Promote venous return to the heart.

Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous return to the heart.

This increase in venous return helps reduce the stasis of blood and in turn reduces the risk for deep vein thrombosis (DVT) formation in the lower extremities.

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A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education?

A. “I usually go swimming with my family at the YMCA 3 times a week.”
B. “I need to ask my doctor if I should have a bone mineral density check this year.”
C. “If I don’t drink milk at dinner, I’ll eat broccoli or cabbage to get the calcium that I need in my diet.”
D. “I’ll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill. “

Just because a multivitamin has calcium in it does not mean that the woman is receiving enough to meet her needs. She must know her requirement and make the decision based on that rather than on the value for calcium on the label.

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The patient at greatest risk for developing multiple adverse effects of immobility is a:

A. 1-year-old child with a hernia repair.
B. 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA).
C. 51-year-old woman following a thyroidectomy.
D. 38-year-old woman undergoing a hysterectomy.

The older the patient and the greater the period of immobility, which can be significant following a hemorrhagic stroke, the greater is the number of systems that can be affected by the immobility.

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Immobility type 4

Temporary
Permanent
Sudden onset(fracture arm, trauma)
Slow onset

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Assessment

Musculoskeletal

ROM capability
Muscle tone and mass
Observe contractures
Monitor gait
Monitor intake of Ca
Monitor assist device with ADLs

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Intervention

Musculoskeletal

Make sure to reposition q2
Encourage active or passive ROM
Assist ambulation with assistive devices

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What is the goal of the psychosocial aspect?

Maintain a sleep/wake pattern
Archive socialization
Complete self independently

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Assessment

Psychosocial

Emotional, mental status
Behavior and decision making skills
Coping skills
sleep cycle
Level of consciousness
Family functioning
ADL
Social activities

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Consequences of immobility

Infants to school age

Slower progression in the development
Body aligned with the line of gravity
(unbalanced posture)

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Intervention

Infants to school age

Incorporate play
Provide socialization
Encourage self-care
prevent fall

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Consequences of immobility

Adolescents

Imbalanced growth possible altered with immobility
Delayed development of independence
Social isolation

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Intervention

Adolescents

Facilitate independence
Involve in decision making
Promote socialization

facilitate 促進する

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***Consequences of immobility*** Adults

- Every physiological system - Family and social system - Alteration in job identity and self-esteem

***Intervention*** Adults

- Promote activity in all system - Promote family engagement - Discuss social involvement - Discus the meaning of care and job

***Consequences of immobility*** Older adults

- Alterations in the balance * *RISK for FALLS!!!** - Loss of bone mass - Slower walk with smaller steps - Increased dependence

**Intervention** Older adults

- Promote social interaction - Encourage independence with self-care and ADLs - Promote family involvement

***Consequences of immobility*** Disuse atrophy

**Losing muscle** - Permanent or temporary impairment - Atrophy from disuse/not being used * *-Increase RISK FOR FALLS!!!**

***Consequences of immobility*** Osteoporosis

Increased risk for pathologic fractures Increase osteoclast activity

Consequences of immobility Footdrop

- Permanent planter flexion - From a stroke impaired ambulation Easy to prevent. Wear boots!!!

**Sim's position** lies on side with the hips and knees flexed and parallel -Prevents aspiration of fluids(unconscious pt) -Reduces lower body pressure reduces pressure over the sacrum(paralyzed pt) - Rectal examination - Enemas - Examining women for vaginal wall

* *low Fowler’s (15 to 30 degrees)** * *semi-Fowler’s (30 to 45 degrees)** * *high Fowler’s (nearly vertical)** - Promotes lung expansion(gravity pulls the diaphragm downward) - For patients who have a nasogastric tube in place. - prepare the patient for dangling or walking

* *Prone position** * *lies on the abdomen with the head turned to one side and the hips are not flexed.** -Full extension of the hip and knee joints -Drainage from the mouth (unconscious or those recovering from surgery) -improve breathing (severe cases of COVID-19)

* *Supine position** * *Lies flat on the back** - Provides comfort in general - Assess for skin breakdown

* *Orthopneic or Tripod Position** * *-Sitting position with an overbed table in front to lean** - Maximum lung expansion(pt who has difficulty breathing/maximum expansion of the chest) - Helps in exhaling(press the lower part of the chest)

* *Lateral position** * *Lies on one side of the body** * *The top leg in front of the bottom leg and the hip and knee flexed** - Relieves pressure on the sacrum and heels - Bodyweight distribution

Heat application

- Increased blood flow - Increase tissue metabolism - Relaxes muscles - Eases joint stuffiness and pain

Cold application

- Decreases inflammation - Prevent swelling - Reduces bleeding - Decrease pain by decreasing nerve conduction

Assessment Thrombus

-Bilateral calf circumference If one side is swallow/ DVT -Tenderness pr clamping ## Footnote **DO NOT palpate if suspected thrombus**

Intervention Thrombus

- Notify the provider immediately - Leg elevated - Avoid any pressure at the site of the inflammation - Medication/Anticoagulants - Use warm and moist

A nurse is caring for a client who had been sitting in a chair for 1 hr. Which of the following **complications** is the greatest risk to the client? A: Decreases subcutaneous fat B: Muscle atrophy C: Pressure injury D: Fecal impaction

C Because of unrelieved pressure over a bony prominence from prolonged sitting in chair. Need to change every 15 mins **complications/合併症**

A nurse is caring for a client who is postoperative. Which following interventions should the nurse take to reduce the risk of thrombus development? SATA A: Instruct the client not to perform the Valsalva maneuver. B: Apply elastic stocking C: Review lab values for total protein level D: Place pillow under the client's knees and lower extremities E:Assisted the client to change the position often

B and E

A nurse is planning care for a pt who is on bed rest. Which of the following interventions should the nurse plan to implement? A: Encourage the pt to perform antiembolic exercise q2h. B: Instruct the pt to cough and deep breathe q4h. C: Restrict pt fluid intake. D: Reposition the pt q4h.

A ## Footnote B: Reduce the risk of atelectasis C: Never restricted D: q2h

A nurse is evaluating a pt's understanding of the use of a sequential compression device. Which of the following pt statements indicates pt understanding? A: "This device will keep me from getting sored in my skin" B: "This device will keep the blood pumping through my leg" C: "With this device on, my leg muscle won't get weak" D: "This device will keep my joints in good shapes"

A nurse is instructing a pt, who has an injury of the left lower extremity, about the use of a cane. Which following instructions should the nurse include? SATA A: Hold the cane on the right side B: Keep two points of support on the floor. C: Place the cane 38cm in front of the feet before advancing D: After advancing cane, move the weaker leg forward E: Advance the stronger leg so that it aligns evenly with the cane

A,B,D

Why we cannot massage or palpate the site of **DVT?**

Because it maybe leads dislodging clot and the clot may be travel to lung cause ## Footnote **Pulmonary embolus**

A pt has been on prolonged bed rest. And the nurse is observing for sing associated with immobility. In the assessment of the pt the nurse is alert to 1: Increased BP 2: Decreased HR 3: Increased urinary output 4: Decreased peristalsis

4 Immobility everything slows down **#1 worry is BLOOD CLOT**

A 61 years old pt recently suffered left-sided paralysis from a cerebrovascular accident(stroke). In planning care for this pt, the nurse implements which of following? A: Encourage an even gait when walking in place. B: Assess the extremities for unilateral swelling and muscle atrophy. C: Teach the use of two-point crutch technique for ambulation

B unilateral=one side

A pt leaving for surgery and because of preoperative sedation needs complete assistance to transfer from the bed to the stretcher. Which following should be the nurse do first? A: Elevate the head of the bed. B: Explain the procedure to the client. C: Assess the situation for any potentially unsafe complications

C ## Footnote **ADPIE!!!!**

The best approach for the nurse to use to assess the pt of thrombosis in an immobilized pt to a: Measure the calf and thing circumference b: attempt to client Homans's sing c: Palpate the temprature of the feet d: Observe for a loos of hair and skin turgor in the lower legs

D Decrease circulation makes hair loos.

Skin turgor?

the elasticity of the skin

Homan's sing?

Test for Deep Vein Thrombosis (DVT) Calf pain on passive ankle dorsiflexion Calf　ふくらはぎ

A pt gets up for the first time after a period of bed rest. The nurse should first do? 1: Assese respiratory function 2: Obtain a baseline BP 3: Assist the pt with sitting at the edge of the bed 4: Ask the pt if he or she feels light-heated

2 being on bed rest means the pt's BP is already low. Making them stands up make BP lower **Risk for Orthostatic hypotension**

It has been determined that all of the following clients are at risk of falling. Which one required the nurse's priority for ambulation? 1: A 16-year-old with a sprained ankle is being discharged from the emergency department 2: A 54 years old who has taken the initial dose of an antihypertensive medication 3: A 45 year old postoperative up for the first time since knee surgery 4: An 81 years old who is asthmatic and had a hip replacement 18 months ago

3 ## Footnote Postoperative patients automatically equal Risk for falls!!! (unconscious) Knee surgery-we use knee to walk

Postoperative pt a) 3 things worry b) Intervention

a) Infection DVT hemorrhage(bleeding) b) assist ambulate ASAP To prevent DVT and pulmonary embolism Moving=circulation up= blood goes up to the heart

Which of the following statements may be a nurse caring for a pt who expected a myocardial infarction(heart attack)8 hours ago shows the greatest insight as to the purpose to keeping the pt on bed rest? 1: "This has been exhausting,she needs a period of uninterrupted rest" 2" "The pain she experienced os exhausting: it's imperative that the rest" 3: "Keeping her on bed rest decreases the need for her body oxygen"

3 Need to rest for decrease demand for oxygen. Think about when you exercise we need oxygen. This means that the heart is working to pump blood in and out more than we rest.

Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest? 1. Isometric exercises 2. Administration of low-dose heparin 3. Suctioning every 4 hours 4. Use of incentive spirometer every 2 hours while awake

An older adult pt had been bedridden for 2 weeks. Which of the complaints be the pt indicates to the nurse that he or she is developing a complication of immobility? a) Increase of appetite b) Gum soreness c) Difficulty in swallowing d) Left ankle joint stiffness

d bedridden/confined to bed by sickness or old age confined/限られた

The effect of immobility on the cardiac system includes which of the following? SATA 1: Thrombus formation 2: Increased cardiac workload 3: Weak peripheral pulse 4: Irregular heartbeat 5: Orthostatic hypotension

1,2,5

A 46 years old pt is admitted to the emergency for the trauma. The pt has a pelvic fracture and is ordered o bed rest and placed in an immobilization device t limit further injury. Which measures would be appropriate for this pt to prevent complications of bed rest? 1: Administer intravenous incentive spirometry. 2: Have pt perform incentive spirometry 3: Support pt in active ROM exercises for upper body 4: Provide low-calorie diet 5: Apply sequential compression devices to legs

2,3,5

What is the difference between Sims position and left lateral position?

In Sims position, the patient's undermost arm is positioned laterally and parallel to the patient's back

Mobility/Immobility Flashcards

(62 cards)