1. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Chapter 47 Mobility and Immobility

2. 2Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Scientific Knowledge Base: Nature of Movement Body mechanics Coordinated efforts of the musculoskeletal and nervous systems Alignment and balance Also refers to posture Gravity Weight force exerted on the body Friction Force that occurs in a direction opposite to movement

3. 3Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Physiology and Regulation of Movements  Skeletal system  Provides attachments for muscles and ligaments and protects vital organs  Provides leverage for movement  Bones are long, short, flat, or irregular.  Coordination and regulation of muscle groups depend on muscle tone; activity of antagonistic, synergistic, and antigravity muscles; and neural input to muscles.

4. 4Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Skeletal System  Joints connect bones.  Four classifications:  Synostotic, cartilaginous, fibrous, synovial

5. 5Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Skeletal System (cont’d)  Ligaments bind joints together and connect bones and cartilage.

6. 6Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Skeletal System (cont’d)  Tendons connect muscles to bone.

7. 7Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Skeletal System (cont’d)  Cartilage is a supportive tissue.  Located in joints, thorax, trachea, larynx, nose, and ears  Can be temporary or permanent

8. 8Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Skeletal Muscle  Muscle movement and posture  Leverage  Posture  Muscle regulation of posture and movement  Muscle tone

9. 9Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nervous System  Regulates movement and posture  Motor fibers from the right motor strip initiate voluntary movement for the left side of the body.  Motor fibers from the left motor strip initiate voluntary movement for the right side of the body.

10. 10Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Pathological Influences on Mobility Postural abnormalities Impaired muscle development Damage to central nervous system (CNS) Musculoskeletal trauma

11. 11Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Knowledge Base: Safe Patient Handling  Ergonomics assessment protocol  Patient assessment criteria  Algorithms for patient handling and movement  Special equipment  Back injury resource nurses  “After-action review”  No-lift policy

12. 12Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Factors Influencing obility/Immobility  Mobility  Ability to move about freely  Immobility  Inability to move about freely  Bed rest  An intervention that restricts patients for therapeutic reasons

13. 13Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Systemic Effects Metabolic Endocrine, calcium absorption, and GI function Respiratory Atelectasis and hypostatic pneumonia Cardiovascular Orthostatic hypotension Thrombus Musculoskeletal changes Loss of endurance and muscle mass and decreased stability and balance Muscle effects Loss of muscle mass Muscle atrophy Skeletal effects Impaired calcium absorption Joint abnormalities Urinary elimination Urinary stasis Renal calculi Integumentary Pressure ulcer Ischemia

14. 14Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 1.You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with A. Atelectasis. B. Hypertension. C. Orthostatic hypotension. D. Coagulation of blood.

15. 15Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Metabolic Changes

16. 16Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Respiratory Changes

17. 17Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study  Ms. Eileen Thomas, who is 82, is admitted for a fractured right hip. She is on complete bed rest in Buck’s traction.  Sergio is the nursing student assigned to Ms. Thomas.

18. 18Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Cardiovascular Changes  Orthostatic hypotension  Increased cardiac workload  Thrombus formation

19. 19Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Musculoskeletal Changes  Muscle effects  Patient loses lean body mass.  Muscle weakness/ atrophy  Skeletal effects  Disuse osteoporosis  Joint contracture

20. 20Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Urinary Elimination Changes  Urinary stasis  Renal calculi  Infection

21. 21Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Integumentary Changes  Pressure ulcers  Inflammation  Ischemia  Older adults at greater risk

22. 22Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Psychosocial Effects  Emotional and behavioral responses  Hostility, giddiness, fear, anxiety  Sensory alterations  Altered sleep patterns  Changes in coping  Depression, sadness, dejection

23. 23Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Developmental Changes Infants, Toddlers, Preschoolers Prolonged immobility delays gross motor skills, intellectual development, or musculoskeletal development Adolescents Delayed in gaining independence and in accomplishing skills Social isolation can occur Adults Physiological systems are at risk Changes in family and social structures Older Adults Decreased physical activity Hormonal changes Bone reabsorption

24. 24Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Ms. Thomas’ mitral valve was replaced 2 months ago, and since the time of the surgery, she has been on anticoagulants. She has had type 2 diabetes mellitus for the past 10 years and is a smoker. She weighs 195 lbs and is 5′7″ tall. She lives by herself, and she attends Mass daily.  Her pain is 6 on a scale of 1 to 10.

25. 25Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Critical Thinking  Knowledge  Experience  Patient data  Attitudes  Intellectual and professional standards

26. 26Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Assessment  See through the patient’s eyes.  Mobility  Range of motion  Planes of the body  Sagittal  Transverse  Frontal

27. 27Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Assessment (cont’d)  Mobility  Gait (a particular manner or style of walking)  Exercise (physical activity for conditioning the body, improving health, and maintaining fitness)  Activity tolerance Physiological Emotional Developmental

28. 28Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Assessment (cont’d)  Mobility  Body alignment is used for: Determining normal physical changes Identifying deviations in body alignment Patient awareness of posture Identifying postural learning needs of patients Identifying trauma, muscle damage, or nerve dysfunction Obtaining information on incorrect alignment (i.e., fatigue, malnutrition, psychological problems)

29. 29Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Assessment (cont’d)  Body alignment  Standing

30. 30Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Assessment (cont’d)

31. 31Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Assessment (cont’d)  Body alignment  Sitting

32. 32Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Assessment (cont’d)

33. 33Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Assessment (cont’d)  Body alignment  Lying

34. 34Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Assessment (cont’d)  Immobility  Metabolic  Respiratory  Cardiovascular  Musculoskeletal  Integumentary  Elimination  Psychosocial  Developmental

35. 35Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Diagnosis and Planning Impaired physical mobility Risk for disuse syndrome Ineffective airway clearance Ineffective coping Risk for injury Risk for impaired skin integrity InsomniaSocial isolation

36. 36Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Diagnosis and Planning (cont’d)  Planning  Goals and outcomes  Setting priorities  Teamwork and collaboration

37. 37Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation: Health Promotion  Prevention of work-related musculoskeletal injuries  Exercise  Bone health in patients with osteoporosis

38. 38Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation: Acute Care  Metabolic  Provide high-protein, high-calorie diet with vitamin B and C supplements.  Respiratory  Cough and deep breathe every 1 to 2 hours.  Provide chest physiotherapy.

39. 39Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Based on Eileen Thomas’ medical history of type 2 diabetes mellitus, heart valve replacement surgery 2 months ago, and being an active smoker, list three nursing interventions that you will initiate to prevent respiratory complications related to her immobility.

40. 40Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation  Cardiovascular  Progress from bed to chair to ambulation.  SCDs, TED hose, and leg exercises  Musculoskeletal  Passive ROM  CPM  Active ROM CPM, Continuous passive motion; ROM, range of motion; SCD, sequential compression device; TED, thromboembolic deterrent.

41. 41Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Applying Sequential Compression Devices

42. 42Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Applying Sequential Compression Devices (cont’d)

43. 43Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Applying Sequential Compression Devices (cont’d)

44. 44Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Applying Sequential Compression Devices (cont’d)

45. 45Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Applying Antiembolitic Elastic Stockings

46. 46Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Applying Antiembolitic Elastic Stockings (cont’d)

47. 47Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Applying Antiembolitic Elastic Stockings (cont’d)

48. 48Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 2.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 A. “I can remove them at night.” B. “I can roll them no lower than my calf muscle.” C. “I wear them no longer than 4 hours at a time.” D. “I can remove them for 30 minutes every 8 hours.”

49. 49Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation  Integumentary system  Reposition every 1 to 2 hours.  Provide skin care.  Elimination system  Provide adequate hydration.  Serve a diet rich in fluids, fruits, vegetables, and fiber.

50. 50Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation (cont’d)  Psychosocial changes  Developmental changes

51. 51Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation (cont’d)  Positioning aids

52. 52Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation (cont’d)  Positioning techniques  Supported Fowler’s  Supine  Prone  Side-lying  Sims’

53. 53Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation (cont’d)  Transfer techniques  Moving/repositioning patients From bed to chair From bed to stretcher

54. 54Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Transferring Patient from Bed to Chair

55. 55Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Transferring Patient from Bed to Chair (cont’d)

56. 56Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Transferring Patient from Bed to Chair (cont’d)

57. 57Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Transferring Patient from Bed to Chair (cont’d)

58. 58Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Transferring Patient from Bed to Stretcher  Determine patient’s ability to assist.  Communicate actions to patient.  Use appropriate resources.

59. 59Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Implementation  Restorative and continuing care  IADLs  ROM exercise  Walking IADLs, Instrumental activities of daily living; ROM, range of motion.

60. 60Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Evaluation  Have the patient’s goals been met?  Have outcomes been met? If not, ask questions:  Are there ways we can assist you to increase your activity?  Which activities are you having trouble completing right now?  How do you feel about not being able to dress yourself and make your own meals?  Which exercises do you find most helpful?  What goals for your activity would you like to set now?

61. 61Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Safety Guidelines  Communicate clearly.  Mentally review transfer steps.  Assess patient mobility and strength.  Determine assistance needed.  Raise side rail on opposite side of bed.  Arrange equipment.  Evaluate body alignment.  Understand use of equipment.  Educate patient.