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Mobility and Immobility chapter 47

Mobility and Immobility chapter 47. The Nature of Movement. Coordination between the musculoskeletal system and the nervous system. Alignment and Balance The positioning of the joints, tendons, ligaments and muscles. Gravity and Friction Gravity is the force of weight downward

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Mobility and Immobility chapter 47

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  1. Mobility and Immobilitychapter 47 NRS 320 S2010

  2. The Nature of Movement Coordination between the musculoskeletal system and the nervous system. Alignment and Balance The positioning of the joints, tendons, ligaments and muscles. Gravity and Friction Gravity is the force of weight downward Friction opposes movement NRS 105.320 S2009

  3. Physiology and Regulation of Movement Please review Anatomy and Physiology text Musculoskeletal system Nervous system NRS 105.320 S2009

  4. Pathological Influences on Mobility Postural abnormalities Impaired Muscle development and strength Damage to the Central Nervous System Trauma to the Musculoskeletal System NRS 105.320 S2009

  5. Safe Patient Handling Protecting the Patient and Health Care worker No lift policies Plan ahead based on patient assessment how much help do you need? Equipment? NRS 105.320 S2009

  6. Mobility and Immobility The effects of Immobility Metabolic changes Respiratory changes Cardiovascular changes Musculoskeletal changes Changes in urinary elimination Integumentary [skin] changes NRS 105.320 S2009

  7. Gait Belt

  8. Wearing a Gait Belt

  9. Using a Gait Belt

  10. Ambulating with a walker

  11. What does it feel like? • Effort • Fear • Do people treat you differently? • Time involved • Obstacles

  12. Positioning

  13. Semi Fowler’s Position

  14. Sim’s or left lateral position

  15. Range of Motion

  16. Assistive Devices for Patient Movement • Canes • Walkers • Wheel chairs • All Devices must be appropriate for patient • Weight limit • Reason for Device • Measured to patient NRS 105.320 S2009

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  25. Risks of ↓ Mobility • Immobility • Unable to move independently • Impaired Perception [numbness, paralysis] • Unable to sense pain/pressure • Altered LOC • Confused – perceive pressure/pain but can’t communicate/ relieve pressure • Coma: no perception + immobility →↑ risk for pressure ulcers

  26. Risks of ↓ Mobility • Weakness, muscle loss • Orthostatic hypotension • Risk for Falls • Circulation impairment [DVT] • Boredom, isolation • Pain • ……etc.

  27. Shearing • Skeleton, muscle slide one way, skin stays or moves the other way • Raising HOB, transferring pt by sliding • stretching of skin, tears capillaries, necrosis leads to undermining of tissues

  28. Friction • Top layers of skin • Sliding across coarse linens, seats • Position changes w/o lifts

  29. Nursing Process for Impaired Mobility Assessment Nursing Diagnosis Planning Implementation Evaluation NRS 105.320 S2009

  30. Pressure Ulcer • Impaired skin integrity (damage to the skin) related to unrelieved, prolonged pressure. • AKA: Pressure sore, decubitus ulcer, bedsore NRS 105.320 S2009

  31. Nursing Diagnosis Impaired Skin Integrity r/t immobility as evidenced by stage III decubitus ulcer on coccyx NRS 105.320 S2009

  32. Plan (stage I ulcer) On-going skin assessment Nutritional assessment Pressure relief for affected areas Preventative care for intact skin NRS 105.320 S2009

  33. Goals Pressure ulcer will not increase in size during hospitalization Infection will not develop in pressure during hospitalization Pt will eat a balanced, high protein diet while in facility Patient and family will develop a plan (with assistance of nursing) for preventing further skin breakdown. NRS 105.320 S2009

  34. Interventions • RN to assess skin q shift • Dietician to complete nutritional assessment and recommend a diet within 24 hours • Offer health shake/ protein cup between meals • Assistive personnel to reposition patient q 2 hours using the following schedule • 8am supine • 10 am left side [6o degrees with pillows] • 12 noon prone • 2pm right side [6o degrees with pillows]… NRS 105.320 S2009

  35. Rationales (with Citations) Decreasing the duration of pressure on skin will prevent further skin breakdown. (Perry and Potter, p. 1281) Wound healing requires proper nutrition. (Perry and Potter, p. 1290) Family caregivers require education and counseling to be effective. (MSU by Joan 2009) NRS 105.320 S2009

  36. Outcome Evaluation • Goal not met: By discharge date, patient had developed stage I ulcer on Rt hip, Coccyx still stage 3 • Revise/ update plan for ulcer prevention • Goal met: Patient has gained 3lbs this month and serum proteins have increased. - Continue w/ plan – it’s working! • Goal met: Family has decided on transfer to LTC for further patient care. - Plan: provide skin history and assessment to LTC facility NRS 105.320 S2009

  37. Additional Nursing DX: • Weakness, muscle loss • Orthostatic hypotension • Risk for Falls • Circulation impairment [DVT] • Boredom, isolation • Pain

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