2 Mobility Mobility refers to a person’s ability to move about freely. Immobility refers to a person’s inability to move about freely.Mobility & immobility are the endpoints of a continuum with many degrees of partial immobility in between.mobility immobilitySome clients move back and forth, some clients remain absolute.
3 Ability to MoveThe ability to move & function is a function most people take for granted.The level of mobility has a significant impact on an ind.’s physiological, psychosocial, & developmental well-being (Hamilton & Lyon, 1995).When there is an alteration in mobility, many body systems are at risk for impairment.Cardiovascular functioning – orthostatic hypotensionPulmonary complications – pneumoniaPromote skin breakdown, muscle atrophy etcSuch changes can lead to altered self-concept & lowered self-esteem.
4 Medical Conditions that can Alter Mobility Fractures/sprainsNeurological conditions – spinal cord injury, head injuryDegenerative neurological conditions – Myasthenia gravis, Huntington’s chorea
5 Nursing Measures Guidelines: Attempt to maintain and/or restore optimal mobility as well as to decrease the hazards assoc. with immobility.DB & C exercisesMuscle & joint exercisesFrequent repositioning – q 2 hrsfluid intake/fiber intakeGuidelines:Check activity orderKnow client’s past medical history & limitationsBaseline vital signs are necessaryBecome familiar with assistive devices
6 Major concern during transfer = Safety of both the client and the nurse
7 Range of Motion Exercise (ROM) ROM exercises, in which a body part is moved through a range of motion, are carried out to promote circulation, maintain muscle tone & promote flexibility. In doing this, joint stiffness & debilitating contractures are prevented. Active ROM is range of motion carried out by the patient. It is a form of isotonic exercise & as such, it maintains strength, tone & flexibility. In patients unable to move body parts due to paralysis or extreme illness, ROM is performed by someone else. This is called passive ROM exercise. Passive exercise helps to maintain joint flexibility & prevent stiffness & contractures. Because this type of exercise involves no active movement on the part of the muscles, it does not contribute to muscle tone or strength.
8 ROM(cont.)ROM exercises are planned as a regular part of nursing activities. During a bath, for example, the nurse has an excellent opportunity to move the patient’s limbs through their full range of motion. The patient is encouraged to exercise actively those muscles that can be used. However, in certain cases, the nurse may need to assist the patient in performing ROM (active assisted ROM), or to perform passive ROM.
9 ROM (cont.)The maximum movement that is possible for a joint is it’s range of motion.If a joint is not moved sufficiently it begins to stiffen within 24 hrs & eventually becomes inflexible, flexor muscles contract & pull tight causing contractures or fixed joint flexion.To prevent joint contractures & muscle atrophy (wasting or decrease in size of a normally developed organ or tissue), exercise must be performed – ROM exercise.Contracture – abnormal flexion & fixation of joints caused by the disuse, shortening & atrophy of muscle fibers.Correcting contractures requires intensive therapy over a prolonged period of time, and may be impossible. Prevention is the key.
10 Two Purposes of ROM Maintain joint function Restore joint function Do not exercise joints beyond the point of resistance or to the point of fatigue or pain
11 Contraindications to ROM ROM requires energy & increased circulation, any illness/disorder where increased use of energy or increased circulation is hazardous is contraindicated; puts strain/stress in soft tissues of the joint & bony structures, therefore not done with swollen, inflamed joints.
12 Perform Exercises in Head to Toe Format Start with the head and move down, always do bilaterallyDo not grasp the joint directlyCup the joint gently (prevents pressure)Do not grasp fingernail or toenailImportant joints – thumb, hip, knee, ankleReturn to correct anatomic positionMove joint through movement 5 times/session
13 Start at the Neck P&P p. 830 Neck Flexion – look @ the toes Extension – look straight aheadHyperextension – look ceilingLateral flexion – look straight ahead, tilt head to shoulderShoulderFlexion – raise arm forward & overheadExtension – return arm to side of bodyAbduction – raise arm to side to position above head with palm away from head.Adduction – return arm & bring across chestInternal rotation – elbow flexed, rotate the shoulder by moving arm til thumb is turned inward & toward the back (fingers to the floor)External rotation – elbow flexed, move arm until thumb is upward & lateral to head. (fingers point up)Circumduction – move arm in full circle (arm straight out, move hand as if to draw a circle.
14 Elbow Elbow Flexion – bend elbow Extension – straighten elbow Hyperextension – bend lower arm back as far as possibleForearmSupination – turn lower hand so palm is upPronation - turn lower hand so palm is downWristFlexion – bend wrist forwardExtension – straighten wrist (fingers, wrist & arm in same plane)Hyperextension – bring dorsal surface of hand as far back as possibleAbduction (radial flexion) – bring wrist medially towards the thumbAdduction (ulnar flexion) – bend wrist laterally towards 5th finger
15 Fingers & Thumb Fingers & thumb Flexion – bend fingers & thumb into palm make a fistExtension – straighten fingers & thumbHyperextension – bend fingers as far back as possibleAbduction – spread fingers apart / extend thumb laterallyAdduction – bring fingers together/ thumb back to handCircumduction – move finger/thumb in circular motionOpposition – touch thumb to each finger of same hand
16 Hip Hip Knee Flexion – move leg forward (ROM 90-120 deg) Extension – move leg back beside other legHyperextension – move leg backwards (ROM deg)Abduction – move leg laterally away from body (ROM deg)Adduction – move leg back to medial position & beyond if possible (ROM deg)KneeFlexion – bring heel toward back of thigh ( deg)Extension – return leg to floor
17 Ankle Ankle Foot Dorsiflexion – move foot so toes are pointed upward Plantarflexion – move foot so toes are pointed downwardFootInversion – turn sole of foot medially (ROM 10 deg)Eversion – turn sole of foot laterally (ROM 10 deg)Flexion – curl toes downward (ROM deg)Extension – straighten toes (ROM deg)Abduction – spread toes apartAdduction – bring toes together
18 Spine Spine Flexion – when standing – bend forward from the waist Extension – straighten upHyperextension – bend backwardLateral flexion – bend to the sideRotation – twist from the waist
19 Types of ROM exercisesActive – exercises the client is able to perform independently.Passive – exercises performed for the client by someone else.Active assisted – performed by a client with some assistance – client can move a limb partially through its ROM, but needs help completing the ROM.
20 Isometric/Isotonic Exercises In addition to ROM exercises, some immobilized clients may be able to perform muscle-strengthening exercises.Isotonic – cause muscle contraction & change in muscle length – walking, aerobics, moving arms & legs against light resistance.Isometric – tightening or tensing of muscles without moving body parts. This increases muscle tension but do not change the length of muscle fibers. Isometric exercises are easily performed by an immobilized patient in bed.Isotonic and isometric exercises help to prevent muscular atrophy and combat osteoporosis.
21 Applying Antiembolism Stockings (Elastic) P&P p. 842 Thromobophlebitis – the development of a thrombus or clot along with the inflammation of the vein & may be classified as superficial or deep.Three elements contribute to the development of a clot.Hypercoagulability of the bld – clotting disorders, dehydration, pregnancy & 1st 6 weeks postpartum if the woman was confined to bed, oral contraceptives.Venous wall damage – local trauma, orthopedic surgeries, major abdominal surgery, varicose veins, arteriosclerosisBlood stasis – immobility, obesity, pregnancy
22 Antiembolism stockings Promote venous return by maintaining pressure on superficial veins to prevent venous pooling.Prevent passive dilation of veinsApplication of antiembolism stockings (refer to p. 845 P&P)
23 Orthostatic hypotension A drop in blood pressure that occurs when the client rises from lying to sitting or from sitting to standing. (A decrease in systolic pressure >15 mmHg or decrease diastolic pressure >10 mmHg.)At risk clientsImmobilized clientsProlonged bed redMeasures to minimized Orthostatic HypotensionMaintain muscle toneIncrease venous return to the heartDecrease stasis of bld in the lower extremitiesROM/isometric exercises/TED’sMobilize ASAP
24 Therapeutic Positions Chair – feet flat on floor, footrest if unable to reach floor, knees & hips flexed degrees. Buttocks at back of the chair, spine straight, pillows at side to prevent leaning.Fowlers – supine, HOB elevated 45 deg. Promotes lung expansion, decrease ICP, comfortable for eating.High fowlers – same as above, with HOB elevated deg. Utilized for clients experiencing difficulty breathing.Semi fowlers – as above with HOB elevated less than 45 deg.Orthopneic – sit on side of bed with over bed table across lap, pillow on table, lean forward & rest head & arms on table. Utilized for patients with extreme difficulty breathing – promotes lung expansion.
25 Therapeutic positions cont. Lithotomy – supine flex both knees so that feet are close to hips, separate legs, feet in stirrups. Utilized for perineal & vaginal examinationsTrendelenburg – supine, entire bed frame tilted down with head 30 deg below horizontal.Postural drainageIncrease venous return in case of shock
26 Benefits of Proper Positioning Maintains body alignment & comfortPrevents injury to musculoskeletal system, prevents strainProvides sensory, motor & cognitive stimulationPrevents pressure sore (decubitus ulcer) & joint contractures
27 TransfersTransferring is a nursing skill that helps the client with restricted mobility attain/maintain mobility & independence.Benefits of transfersMaintains & improves joint motionIncreases strengthPromotes circulationRelieves pressure on the skinImproves urinary/respiratory functionIncreases social activityIncreased mental stimulation
28 Transfers - SafetySafety is a major concern when transferring. Falls are a common hazard. If a patient starts to fall – do not try to stop the fall, instead assist the patient to the floor while protecting the head from injury. This will reduce the risk of patient as well as staff injury.Complete a thorough nursing assessment before you move the patient to determine if she/he has suffered any injuries.Prevention of injury is the key, be aware of the client’s motor deficit, ability to support their body weight and use effective body mechanics & lifting techniques.When in doubt regarding the patient’s ability-GET ASSISTANCE
29 Nursing Process - Transfers AssessmentActivity ordersClient capabilitiesPlanningDecide appropriate transfer techniqueExplain procedure to the patientImplementationWash handsPosition chair 45 deg angle to bed on clients stronger sideLock bed brakes, lower bed, raise HOB as high as patient toleratesLower side railAssist to sitting (lift upper body & swing legs around)Assist with robe & slippersPosition feet on floorTake wide stance, bend knees, grasp patient“1 2 3 stand”Pivot to chair
30 Nursing Process (cont.) EvaluationOf note:Body in alignment, patient comfortable, no injuriesNurse maintains good body alignmentTwo person lift (same as above) except one nurse is on each side of the patientNever lift under the axilla – can damage nervesMechanical lifts – enables you to lift heavy patients, or those unable to help. (Use 2 people)(
31 AmbulationClients who have been immobile even for a short time may require assistanceA client may require the use of an assistive device to aid in ambulation.Assistive devicesIncrease stabilitySupport a weak extremityReduce the load on weight bearing structures; hip, knees
32 Assisting the patient Simple assist Place arm near patient under the arm & at the elbow & grasp pt’s hand, synchronize walking with the pt (move inside foot forward at same time as pt’s inside foot)Grasp pt’s left hand in nurses’ left hand & encircle pt’s waist with the rt hand & synchronize walking as aboveUsing a transfer belt (held at the waist from the rear by the belt – helps maintain balance)Nurse to stand on the pt’s weak side. The nurse provides support with his/her leg to the pt’s weakened one if necessary. Do not allow the pt. to place their arm around your shoulder.Walk slowly, even gait, synchronize your steps.
33 Cane Stand from sitting Helps maintain balance by widening the base of support increases a pt’s security.Should be held on stronger sideShould have rubber tip – prevent slippingHeight (from greater trochanter to the floor allowing deg of elbow flexion.Gait – place cane 6-10 inches ahead, move affected leg ahead to cane, place weight on affected leg and cane, move unaffected leg ahead of cane.Stand from sittingCane in hand opposite affected leg, grasp arm of chair & cane in other, push to stand, gain balanceSitting back to chair with a cane – reach back with free hand grasp arm of chair, lower self, cane under chair.Stairs (up with strong leg first, down with affected leg first)
34 WalkerWide base of support, provides great stability & security. Used for clients who are weak or who has problems with balance.Patient should have at least one weight bearing leg and armPick up walker is more stable, walker with wheels easier for pt’s who have difficulty with lifting or balance, however can roll forward when weight is applied.Height – upper bar of walker should be slightly below the client’s waist with arms flexed deg
35 Walker (cont.)To stand – walker in front of seat, push up off arms of chair (walker is less stable, chair is lower pt. can push with more force. Hands move to walker one at a time.To sit – back up to chair, reach back with one arm to arm of chair, then with the other arm and lower to chair.Gait – walker ahead 6-8 inches, weight on arms. Partial weight on affected leg first.
36 CrutchesWooden or metal staff that reaches from the ground to 11/2 – 2 inches below the axilla. When standing tip of crutch rests 4-6 inches in front & 4-6 inches to side of foot.Do not rest on top of crutches – pressure on axilla nerves – can lead to paralysis called crutch paralysis (numbness, tingling, muscle weakness)
37 Crutches (cont.) P&P p.8593 point gait – able to wt. bear on one foot, full wt. on unaffected leg then on both crutches – begin in tripod position, move crutches & affected leg ahead, move stronger leg forward and repeat.4 point gait – (most stable crutch walk) weight on both legs and both crutches – muscular weakness, improves balance by providing a wide base of support, lack of coordination, move each independently – rt crutch-lt foot-lt crutch-rt leg