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NUR151-Immobility
Movement and Mobility - Immobility Danger
| Question | Answer |
|---|---|
| Long bones | contributes to height (femur, fibula, & tibia) & length (e.g., phalanges of fingers & toes) |
| Short bones | (e.g., carpal bones & patella the knee) occur in clusters & when combined w/ligaments & cartilage, permit movement of extremities. |
| flat bones | bones in skull & ribs, provide structural contour.” |
| irregular bones | make up vertebral column & mandible |
| Synostotic joints | bones jointed by bones - no movement - bony tissue between bones provides strength & stability - skull, where fusion of joint occurs later in life |
| Cartilaginous joints or synchondrosis joint | cartilage unites bony components - allows for bone growth while providing stability - when bone growth is complete, joints ossify – 1st sternocostal |
| Fibrous joints or syndesmosis joint | ligament or membrane unites 2 bony surfaces - fibers of ligaments flexible & stretch, permitting limited movement - paired bones of lower leg (tibia and fibula) |
| Synovial joints or true joint | a freely movable joint - contiguous bony surfaces covered w/articular cartilage & connected by ligaments lined w/synovial membrane - joining of humeral radius & ulna by cartilage & ligaments forms pivotal joint |
| Other types of synovial joints are | ball-and-socket joints, such as the hip joint, and the hinge joints such as the interphalangeal joints of the fingers |
| Ligaments | bind joints & connect bones and cartilage |
| Tendons | connect muscle to bone – Achilles tendon (tendo calcaneus) is thickest and strongest in body. |
| Cartilage | nonvascular, supporting connective tissue located mainly in joints, thorax, trachea, larynx, nose & ears |
| Skeletal muscle | helps us move and holds us together |
| How nervous system regulates movement and posture | During voluntary movement, impulses descend from motor strip to spinal cord - exits through efferent motor nerves & travels through the nerves, |
| P | Pattern - onset, duration, what relieves or exacerbates – do anti-inflammatory agents help? |
| A | Area - Location of pain |
| I | Intensity - 0-10 scale, smiley faces, or terms pt. can understand |
| N | Nature - throbbing, burning, aching, crushing, pressure |
| Gait | Conformity, Symmetry, Rhythm of gait & arm swing - begins w/heel strike of one leg & continues to heel strike of the other leg. |
| Assessing a client's gait allows you to draw conclusions about | balance, posture, safety, and ability to walk without assistance. |
| Body alignment & symmetry | 2 arms, 2 legs, etc. |
| Posture | sitting, standing - Muscles associated primarily with maintaining posture are short and - converge obliquely at a common tendon. |
| Which muscles primarily associated with posture? | Muscles of the lower extremities, trunk, neck, and back are concerned primarily |
| Posture | the position of the body in relation to the surrounding space |
| Torticollis | Inclining of head to affected side, in which sternocleidomastoid muscle is contracted |
| Footdrop | Inability to dorsiflex & invert foot - nerve damage – foot fixed in plantar flexion - ambulation difficult - unable to lift toes off ground |
| Pigeon toes | Internal rotation of forefoot or entire foot, common in infants |
| Contractures | can begin to form after only 8 hours of immobility in the older adult client |
| Range of motion joints | flexion, extension, rotation |
| Fasciculation | Localized muscle twitching of a single muscle group |
| Spasms | neuralized involuntary muscle contractions |
| Ecchymosis | bruise |
| The individual of average weight and height and without a chronic illness on bed rest loses muscle strength | from baseline levels at a rate of 3% a day. |
| Immobility disrupts normal metabolic functioning: decreasing | metabolic rate; altering met of carb, fats, & proteins; causing fluid, electrolyte, & Ca imbalances; GI disturbances - decreased appetite & slow peristalsis |
| When the client is immobile, client's body often excretes more | nitrogen (end product of amino acid breakdown) than it ingests in proteins, resulting in neg nitrogen balance |
| Immobility causes release of Ca into circulation | if kidneys unable to respond appropriately, hypercalcemia results - Pathological fractures occur if Ca reabsorption continues |
| The heart therefore works __ during periods of prolonged rest | harder and less efficiently |
| Immobilization causes two skeletal changes | impaired calcium metabolism and joint abnormalities. |
| When disuse osteoporosis occurs | client is at risk for pathological fractures |
| Renal calculi occurs often because immobilized clients | frequently have hypercalcemia. |
| metabolic effects of immobility | Altered endocrine, calcium absorption, and GI function |
| Cardiovascular effects of immobility | Increases Cardiac workload, Orthostatic hypotension, Thrombus |
| GI Effects of immobility | Decreases appetite, stress ulcers, Decreases peristalsis, constipation |
| Urinary elimination effects of immobility | Urinary stasis, UTI, Renal calculi |
| Respiratory effects of immobility | Increase resp. effort, altered gas exchange, Atelectasis and hypostatic pneumonia |
| Musculoskeletal changes in immobility | Decrease endurance, stability, balance, Muscle atrophy, joint abnormalities, Dec. bone density, risk of fx & fall |
| Integumentary effects of immobility | Pressure ulcers, Ischemia, shearing |
| Psych effects of immobility | Anxiety, depression, helplessness, hopelessness, dependency |
| Lordosis | anterior flexion of neck, slumping of shoulders – pregnant women and toddlers |
| Kyphosis | hunchback – elderly |
| Crepitus | grating sound/feel) breakdown of joint when the bones grate together |
| Tenderness Grading Scale | 0 No Tenderness; 1+ Client says it is tender, 2+Client complains of pain & winces;3+Client complains of pain, winces and pulls back; 4+Client will not allow palpation |
| Assess CMS (Circulation, Motion, Sensation) to extremities | routine assessment for knee replacements, fractures, - Circulation – Color, temperature, cap refill, pulses; Motion – ROM; Sensation – numbness or tingling to hands or feet |
| Because people are not geometrically perfect, their centers of gravity are | usually at 55% to 57% of standing height and are located in the midline |
| Face direction of movement to | avoid twisting |
| Metabolic interventions for immobility | high-protein, high-caloric diet with vitamin B and C supplements - Dehydration and edema increase the rate of skin breakdown - monitor lab electrolytes, serum protein (albumin and total protein), and (BUN) |
| Turn, cough and deep breathe every | 1 to 2 hours |
| If a client has an atelectatic area, chest movement | is often asymmetrical |
| SCDs | sequential compression devices |
| signs of venous stasis | edema and delayed wound healing |
| Lying down increases heart rate and can create | 3rd heart sound indicating CHF |
| Measure bilateral calf circumference, and record it daily as an alternative assessment | for DVT |
| Unilateral increases in calf circumference are an early indication of | thrombosis |
| CPM = continuous passive motion | machines used after joint surgeries to provide passive range of motion to avoid stiffening |
| Continually assess the client's skin for breakdown and color changes such as | pallor or redness |
| Complete | through the bone |
| Incomplete | partially through the bone |
| Simple | (closed): fracture of bone with no skin break |
| Compound | (open): fracture causes break in skin |
| Pathological | sight pressure or minimal trauma fractures bone. Bone is weak r/t osteoporosis, bone cancer, osteomyelitis |
| Greenstick | splinters on the top, but the bottom just bends – common in children. |
| Stress fracture | r/t prolonged or repeated low-level stress. Also called fatigue fractures |
| Displaced | fragment is over-riding other bone fragment |
| Spiral | the line of the fracture extends in a spiral direction along the shaft of a bone |
| Transverse | a fracture in which the line of the break extends across the bone shaft at a right angle to the longitudinal axis |
| Longitudinal or oblique fracture | Parallel or at an angle to longitudinal axis |
| Signs & Sx Fracture | Pain, Swelling, Ecchymosis, Impaired mobility, Unnatural position (deformity), Impaired sensation, numbness, tingling, Loss of distal pulse indicates vascular complication, Crepitus |
| fracture hematoma | Fibrin clot forms at break |
| Order of events of bone healing | Bone cells die, inflammation, fracture hematoma, osteoblastic activity forms immature bone called callus, true bone replaces callus in 4-6 weeks |
| Reduction | Realignment of bones - can be open (surgery) or closed - Allows recovery of normal position and range of motion (ROM). |
| Open Reduction - Internal Fixation (ORIF) | open the skin and re-aline the bone |
| The two diagnoses most directly related to mobility problems are | impaired physical mobility & risk for disuse syndrome. |
| The diagnosis of impaired physical mobility | applies to the client who has some limitation but is not completely immobile. |
| The diagnosis of risk for disuse syndrome | applies to the client who is immobile and at risk for multisystem problems because of inactivity |
| Delayed union | not as fast as normal – healing will occur, though |
| Non-union | fracture fails to heal even though appropriate interventions – usually an underlying pathology |
| mal-union | bones don’t heal right and so bone must be broken again and replaced |
| Fat Embolus | Can travel to lungs and cause a PE or travel to heart and cause MI |
| Complications of Fractures – Compartmental Syndrome | Nerve and blood vessel damage or destruction from swelling and edema in a confined space - in arms/leg where expansion limited by fascia - Risk greater if muscle damage occurred w/fracture |
| 5 Ps | Pain, pallor, parasthesia, paralysis, decreased perfusion - Neurovascular deterioration manifested by this |
| Treatment of Hip Fractures | Immobilization in Buck’s traction until surgery can be performed - 24-48 hr. max - Relieves muscle spasm, Surgery is tx of choice - ORIF – open reduction, internal fixation - Permits early mobilization |
| Endoprosthesis | fracture is on the ball of the bone |
| Intracapsular repaired with | endoprosthesis |
| Extracapsular repaired with | nail plates or prosthesis |
| Abductor pillow between legs | abducts the legs – keeps the legs apart and so they can’t cross legs |
| Osteoarthritis – OA - formerly Degenerative Joint Disease (DJD) | Slowly progressive, non-inflammatory disorder of the synovial joints |
| HA injections | into joint (hyaluronic acid) |
| Osteoporosis | Chronic progressive loss of bone tissue, low bone mass, structural deterioration of bone tissue - S/S: Bone loss occurs without symptoms - Bones become weak/fracture easily with strain, bump or fall |
| Common sites of osteoporosis | hip, vertebrae, and wrist - Collapsed vertebrae leads to back pain, loss of height, spinal deformities such as Kyphosis. |
| Bone mineral density | assesses bone mass |
| DEXA | BMD test measures bone density of spine, hips and forearm |
| Interventions for osteoporosis | Proper nutrition, exercise, weight bearing, prevention of fractures, drugs, Calcium 1000-1500 mg/day and Vitamin D 400-800 Units, Estrogen replacement, Fosmax or Evista |
| Osteoporosis | 8x more common in women - lower Ca intake, less bone mass because of smaller frame, Resoprtion begins @ earlier age - accelerated @ menopause – Pregnancy/breast feeding deplete skeletal reserve |
| Pallor | temperature changes |
| C-reactive protein | inflammation, infections, wide spread malignancy. Normal-negative – if positive, we know there is an infection, but don’t know where. |
| Rheumatoid Factor | Presence of autoantibody in serum. Not specific for RA, seen in other connective disorders. Normal is negative or titer <1:20 – tests for autoimmune disorders. |
| ESR: Erythrocyte Sedimentation Rate Sed Rate | Non-specific index for inflammation. Number of RBC’s that settle in 1 hour - Seen w/inflammatory response. Normal: <20 mm/hr - not specific to disease, but general |
| Serum Protein Electrophoresis | infection, neoplasm, rheumatoid-collagen disorders, inflammatory disorders |
| Radiography | density of bone, changes in bones and joints |
| Nuclear medicine | Use of radioactive isotopes to evaluate muscles bones, joints |
| Bone Scan | Injection of radioisotopes so evaluate perfusion of blood through bones. |
| Avascular necrosis | when you have decreased blood supply and RBCs break down. |
| MRI: Radio waves and magnetic fields used to view | soft tissue & cartilage. Useful in DX avascular necrosis, disk disease, tumors, osteomyelitis, ligament tears, cartilage tears |
| Flexion | toward body |
| Abduction | away |
| Adduction | toward |
| Pronation | palm down |
| Supination | palm up |
| Circumduction | arm around in circle |
| Inversion | ankle in – a lot with club feet |
| Eversion | ankle out |
| Rotation | head |
| Protraction | forward& = |
| Retraction | back & = |
| Fosamax | bone reabsorption inhibitor – prevents and treats Osteoporosis |
| NURSING IMPLICATIONS of Fosamax | Take with full glass of water & remain upright 30 minutes to avoid esophageal damage |
| Force exerted on body by gravity | weight |
| Froce that opposes movement | friction |
| Type of joint that is freely moveable | synovial |
| Normal state of balanced muscle tension | tonus |
| Motor strip located in the cerebral cortex | precentral gyrus |
| Lateral S curvature of the spine | scoliosis |
| Internal rotation of the foot | pigeon toe |
| Measures of attributes such as height, weight, and skinfold thickness | antropometric measurements |
| Max amount of movement at a joint | range of motion |
| Which of the following laboratory values would the nurse expect to see for a client experiencing prolonged immobility?Calcium 11.5 mg/dl | |
| Having the client __ can help prevent Orthostatic hypotension. | sit for 2 minutes before standing |
| Hematuria is a sign that the client | is possibly bleeding out. |
| Nurse caring for pt w/r-sided weakness - What should nurse do while walking w.pt? | Put a gait belt on the client and provide support on the right side - should always stand on pt affected side to support pt |
| Ligaments are elastic and | provide joint flexibility and support. |
| Tendons are fibrous bands of tissue that | connect muscle to bone. |
| Cartilaginous tissue is | nonvascular supporting connective tissue located in the joints, thorax, trachea, larynx, nose, and ear. |
| When a client is immobilized, which position is preferred to prevent skin breakdown? | Semi-Fowler's - head of bed elevated 30 degrees, Side-lying w/knees flexed puts press on greater trochanter area, supine = pressure on the scapula, buttocks, calf, & heels, prone puts pressure on anterior pelvis, knees, and elbows. |
| The most significant hazard of restricted mobility is | Deep vein thrombosis |
| most important for preventing deep vein thrombosis in an immobilized client? | Ensuring that compression devices are fitted correctly and pumping |
| The immobilized client should be instructed to | Take in a minimum of 2000 ml of water per day |
Created by:
Ladystorm