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ATI Module
Mobility (Exam 2)
| Question | Answer |
|---|---|
| active range of motion | Voluntary movement of a joint. |
| activities of daily living (ADLs) | Basic essential skills, usually related to personal care, that a person performs every day. |
| activity intolerance | Inadequate amount of physical or psychological energy to undergo or complete a necessary activity. |
| atelectasis | Collapse of airways and small sections of the lung as a result of shallow breathing. The collapsing of the lung during expansion |
| atrophy | Become smaller and weaker often from disuse. |
| body alignment | The positioning held by the various parts of the body while performing activities or during rest. |
| body mechanics | Combined effort from the musculoskeletal and nervous systems to maintain posture, alignment, and balance. |
| cardiac deconditioning | Atrophy of the heart muscle that results in a decreased amount of blood being ejected from the heart during contraction. |
| cartilage | Flexible connective tissue that coats bony areas, allowing them to glide over each other and absorbs shock. |
| constipation | A condition in which the client has infrequent bowel movements where the stool is hard, lumpy, and difficult to pass. |
| deep vein thrombosis (DVT) | A condition that results from a blood clot inside a deep vein, usually within the extremities. |
| disuse osteoporosis | Loss of skeletal mass, density, and strength caused by immobility. |
| ergonomics | Study of body mechanics in relation to the demand and design of the work environment and the equipment used. |
| fecal impaction | A hardened mass of stool that creates a blockage in the intestines. |
| foot drop | A type of joint contracture that results in the foot and toes permanently pointing downward. |
| fragility fractures | Fractures that occur following stress on a bone that would not typically result in a break. |
| gait | Manner or style of ambulation. |
| gastroesophageal reflux | A backflow of gastric fluids into the esophagus that can result in irritation of the tissue. |
| gross motor skills | The use of large muscle groups to perform whole body movements. |
| immobility | An inability to reposition or move self. |
| incentive spirometer | A device utilized to encourage the client to inhale slow, deep breaths. |
| joint contractures | An abnormal fixation of a joint due to changes in muscles and connective tissue. |
| kyphosis | Excessive outward curvature of the upper area of the spine. |
| ligaments | Flexible fibrous connective tissue that attaches bone to bone. |
| mobility | Moving from one position to another. |
| mobility assessment | An objective assessment to determine the amount of assistance required for ambulation and transfers based upon the client's ability to move |
| musculoskeletal | General term used when referring to the muscles and the skeleton. |
| orthostatic hypotension | A decrease in blood pressure that occurs upon standing, especially from a lying or sitting position. A significant drop in the blood pressure caused by a change in position. |
| passive range of motion | The movement of a joint by another individual. |
| peripheral nervous system | Nervous system outside of the brain and spinal cord, which regulates the responses of the body to external stimuli. |
| pneumonia | An infection in the lung tissue. |
| proprioception | Feedback from sensory receptors to coordinate, balance, and fine-tune body positioning and movement. |
| pulmonary embolism | An obstruction of blood flow in a pulmonary artery due to the movement of blood clot from an extremity to the lungs. |
| range of motion (ROM) | The manipulation of a joint within its range of flexion and extension. |
| remodeling | The process of bone breakdown and replacement that occurs throughout a lifespan. |
| renal calculi | Stones that develop in the kidney and usually related to dehydration or an increase of stone-forming substances. |
| sarcopenia | Loss of lean muscle caused by immobility. |
| self-concept | The beliefs one holds regarding their qualities and attributes formed through experiences. |
| splint | Rigid or semirigid device designed to support or stretch an injured or altered part of the body. |
| synovial joints | Fluid-filled capsules that connect bones and enable movement. |
| tendons | Nonflexible fibrous connective tissue that attaches muscle to bone. |
| urinary retention | A condition in which the bladder does not completely empty with urination. |
| Skeletal Muscle Movement (main function): | The skeletal muscles work with the skeleton to create body movements such as texting, sitting, standing, walking, running, and dancing. |
| Skeletal Muscle Posture and Postioning: | The skeletal muscles maintain posture and body positioning without a person’s conscious control. They cause motion through a series of contractions and relaxations, or contract to hold the body in a certain position such as sitting or standing. |
| Skeletal Muscle Generate Body Heat: | Contracting muscles generate heat that assists in maintaining body temperature. Shivering is an example of the muscles working to produce heat. |
| Functions of the Skeletal System | Support: Provide a framework. Protect: Provide mechanical protection for internal organs Produce: Red bone marrow produces red blood cells, white blood cells, platelets, & macrophages. Storage: For calcium, phos, mag, iron, and lipids. Movement: |
| The nervous system consists of two subsystems: | the central nervous system and the peripheral nervous system. |
| The central nervous system includes | the brain and the spinal cord |
| Muscles are attached to | the skeleton and maintain posture and body position. While their main function is to generate movement, they also work to maintain the body temperature by contracting, resulting in shivering. |
| Bones are | hard connective tissues that provide the stable framework for the body, protect internal organs, produce blood cells, store minerals, and work with muscles to produce movement. |
| Synovial joints are | fluid-filled capsules that connect bones. They allow for bending of the limbs |
| Tendons and ligaments | are made of fibrous connective tissue. Tendons fasten muscles to bones, while ligaments attach bones to other bones. |
| Cartilage is | flexible connective tissue that coats bony areas, allowing them to glide over each other and absorb shock. |
| the American Nurses Association (ANA) Safe Patient Handling Campaign advocates | eliminating manual lifting of clients. |
| Optimal posture supports the | spine, muscles, and joints, which increases strength, reduces fatigue, and uses less energy. |
| Using Proper Body Mechanics | Stand or move as close to the object as possible. Keep the abdominal muscles contracted Maintain the head upright with shoulders raised up. Bow the hips slightly and squat. Do not twist the torso. Push up from the knees |
| Risk factors in the workplace can be divided into three areas | - Practice Controls - Physical characteristics - Environmental hazards |
| Risk factors in the workplace: Practice controls | Lighting, noise, transfer lifts, carts, furniture, whole-body vibrations, exposure to heat/cold. |
| Risk factors in the workplace: Physical characteristics: | Posture, duration, force, velocity, heavy exertion, repetition, time, lunch/rest breaks, recovery time. |
| Risk factors in the workplace: Environmental hazards: | Mental stress, physical stress, workload hours (shift, overtime), falls, slips, exposure to hazards. |
| Place the steps for moving a client up in bed in the correct order. | 1.) Assess the client's level of mobility 2.) Get lift assistance 3.) Lock the wheels of the bed 4.) Raise the client's bed 5.) Position the clients' arms 6.) Use the draw sheet to move client 7.) Lower the client's bed to lowest position |
| A nurse is caring for an older adult client who has been on prolonged bed rest. Which of the following findings should indicate to the nurse a potential musculoskeletal complication of immobility? | - Joint stiffness and decreased ROM - Development of a foot-drop deformity - Formation of joint contratures |
| A nurse is caring for a client who is prescribed bed rest. The nurse should recognize that which of the following are complications of bed rest? | - rapid, shallow breathing - reddened areas of skin - resistance to extension of an extremity -manifestation of a blood clot in an extremity - report of heart burn |
| Interventions for Musculoskeletal Reduced Mobility: Disuse osteoporosis | Monitor client for increased pain levels, especially in the vertebral areas; such pain can indicate a fracture. |
| Interventions for Musculoskeletal Reduced Mobility: Sarcopenia | Assess the client for manifestations of fatigue during activity Monitor the client for weakness and unsteadiness and with increased activity. Observe the client for diminishing muscle mass, strength, and coordination. |
| Interventions for Musculoskeletal Reduced Mobility: Joint contractures | Assess the client for increased muscle tone or rigidity of the extremities and joints. Assess the client’s range of motion. Monitor the client for reports of increased stiffness and decreased ability to move the joints. |
| Interventions for Musculoskeletal Reduced Mobility: | Observe the client’s foot position while at rest and the ability to flex the foot upward toward the knee. Monitor the client’s gait for the presence of toe dragging during ambulation. |
| Interventions for Cardiovascular Complications of Immobility: Orthostatic hypotension (Assessment) | Monitor vital signs while the client is lying, sitting, and standing, and compare results. Monitor the client for reports of dizziness or lightheadedness during position changes |
| Interventions for Cardiovascular Complications of Immobility: Orthostatic hypotension (Interventions) | Elevate the head of the bed to promote blood flow to the lower extremities. Assist the client with position changes Teach the client to change positions slowly Apply antiembolism stocking Implement fall precautions to decrease the risk of falls. |
| Interventions for Cardiovascular Complications of Immobility: DVT (Assessment) | Assess the client’s pulses and capillary refill for presence and equality. Observe the client for the presence of unilateral edema, especially in the lower extremities. |
| Interventions for Cardiovascular Complications of Immobility: DVT (Interventions) | lower leg exercises to promote contraction of the lower-extremity muscles Apply antiembolism stockings. Use sequential compression devices Encourage fluid intake to prevent dehydration. Ambulate the client frequently Administer anticoagulant med |
| Interventions for Respiratory Complications of Immobility: Atelectasis (Assessment) | Auscultate the lung fields to confirm air movement throughout all lobes. Observe chest wall movement for symmetry and depth during respirations. |
| Interventions for Respiratory Complications of Immobility: Atelectasis (Intervention) | incentive spirometer to promote lung expansion. perform deep breathing and cough exercises Monitor oxygen saturation levels. Provide supplemental oxygen as prescribed. Elevate the head of the bed at least 30° Q2 Turns |
| Interventions for Respiratory Complications of Immobility: Pneumonia (Assessment) | Auscultate for presence of adventitious sounds (lungs) Observe rate, depth, and effort of respirations. oxygen saturation levels. swallowing difficulties Monitor laboratory reports Assess vital signs for indications of an infection |
| Interventions for Respiratory Complications of Immobility: Pneumonia (Intervention) | Use prone positioning to promote drainage of secretions, if appropriate. Elevate the head of the bed 30° Encourage fluid intake to thin secretions. supplemental oxygen as prescribed. Encourage deep breathing and coughing exercises Q 2 Turns |
| Interventions for Gastrointestinal Complications of Immobility: Constipation (Assessment) | Auscultate bowel sounds Palpate the abdomen. Monitor bowel movements for consistency and regularity. Assess the client for the presence of nausea, vomiting, or abdominal pain, which can indicate constipation or a blockage in the intestines. |
| Interventions for Gastrointestinal Complications of Immobility: Constipation (Intervention) | Encourage fluid intake to soften stools. Encourage the consumption of high-fiber foods, which increases water absorption in stool. Increase the client’s mobility as tolerated to promote peristalsis and move stool to the rectum. |
| Interventions for Gastrointestinal Complications of Immobility: Gastroesophageal reflux (Assessment) | Assess the client for reports of heartburn or regurgitation. |
| Interventions for Gastrointestinal Complications of Immobility: Gastroesophageal reflux (Intervention) | Elevate the head of the bed after meals to promote the collection of gastric secretions in the lower stomach. |
| Interventions for Gastrointestinal Complications of Immobility: Malnutrition (Assessment) | Monitor the client’s appetite and intake. Assess the client’s weight for changes. Monitor laboratory values related to nutrition: serum albumin, serum protein, glucose, and electrolytes. |
| Interventions for Gastrointestinal Complications of Immobility: Malnutrition (Intervention) | Instruct the consumption of high-protein, nutrient-dense foods Help the client select foods based on preferences and nutrients Assist the client during meals Consult a dietitian to provide dietary guidance to address nutritional deficiencies. |
| Interventions for Genitourinary Complications of Immobility: Urinary Retention (Assessment) | Assess the client for the presence of suprapubic pain or incontinence, which can indicate retention. Monitor output to determine if the client is passing adequate volumes of urine. |
| Interventions for Genitourinary Complications of Immobility: Urinary Retention (Intervention) | Encourage fluid intake to increase bladder filling and stimulate the urge to void. upright position during urination to use gravity to promote adequate bladder emptying. Assist the client to use the toilet or bedside commode |
| Interventions for Genitourinary Complications of Immobility: UTI (Assessment) | Monitor the client for the development of urinary urgency, frequency, and burning, which could indicate an infection. |
| Interventions for Genitourinary Complications of Immobility: UTI (Intervention) | Encourage frequent voiding to decrease the pooling of urine. Encourage the client to increase activity in bed Maintain perineal cleanliness to decrease bacterial contamination of the urethra. |
| Interventions for Integumentary Complications of Immobility: Pressure Injury (Assessment) | Assess the client’s skin for manifestations of damage daily. Inspect identified areas of breakdown daily for changes. |
| Interventions for Integumentary Complications of Immobility: Pressure Injury (Intervention) | Q2 Turns pillows support different positions. assistive devices & proper technique w/turns pressure redistribution devices Moisturize dry skin intake of calories & Nutrients Keep skin free from moisture (incontinence, wound drainage, perspiration) |
| Interventions for Psychological Complications of Immobility: Depression (Assessment) | Monitor the client’s emotional status during every shift. |
| Interventions for Psychological Complications of Immobility: Depression (Intervention) | Encourage the client to express feelings. Communicate support and empathy. Report mental health concerns to the provider. |
| Interventions for Psychological Complications of Immobility: Social Isolation (Intervention) | Encourage interactions with family, friends, staff, volunteers, and even other clients. |
| evaluating activity tolerance from the client’s perspective is the Borg Rating of Perceived Exertion (RPE) scale | subjective scale, enabling clients to gauge their level of exertion during activity.lowest level is 6, a state of resting (effortless). highest level 20, maximal effort is required to perform the action. The target zone is between 12 and 14 |
| A standardized bedside mobility assessment tool (BMAT)The BMAT focuses on a client’s ability to | to move, stand, walk, and step. It also evaluates the client’s balance, strength, posture, and any activity intolerances. Implementation of this tool ensures the right equipment is used for the client s by employing sound ergonomic practices |
| The nurse is preparing to conduct a mobility assessment for a client. Place the following steps in the correct order. | 1.) Shake hands 2.) Sit on edge of bed 2min 3.) Extend one leg and point toes and flex ankle 4.) Request clients stand @ bedside 5sec 5.) Walk in place 6.) Few steps forward and then backward |
| nurse should assign the activity level of maximum assist to a client who | who can move self from a semi-reclining position to sit set on the edge of the bed but cannot hold the position |
| The nurse should assign the activity level of moderate assist to a | client who can sit on the side of the bed with their feet on the floor and hold that position. |
| The nurse should assign the activity level of minimal assist to a client who can | rise up from a seated position with an assistive device |
| The nurse should assign the activity level of no assist to a | client who can march in place |
| Age-Related Changes Affecting Mobility in the Older Client: Posture (Age- related change) | Increased thoracic spinal curvature with head protrusion Increased flexion in knees and hips |
| Age-Related Changes Affecting Mobility in the Older Client: Posture (Reason) | Bone loss Degeneration of vertebral discs |
| Age-Related Changes Affecting Mobility in the Older Client: Posture (Effect on Mobility) | Forward leaning or stooped posture Unsteady ambulation |
| Age-Related Changes Affecting Mobility in the Older Client: Reflexes (Age- related changes) | Poor balance |
| Age-Related Changes Affecting Mobility in the Older Client: Reflexes (Reason) | Dysfunction of nervous system |
| Age-Related Changes Affecting Mobility in the Older Client: Reflexes (Effect on Mobility) | Unsteadiness and decreased ability to right oneself |
| Age-Related Changes Affecting Mobility in the Older Client: Joint mobility (Age- related changes) | Slow movement Joint stiffness Ankle and foot weakness |
| Age-Related Changes Affecting Mobility in the Older Client: Joint mobility (Reason) | Changes to the brain and peripheral nervous system Loss of cartilage in joints Changes in bones in joint areas |
| Age-Related Changes Affecting Mobility in the Older Client: Joint Mobility (Effect on Mobility) | Slower steps of varied length with a wider stance |
| Age-Related Changes Affecting Mobility in the Older Client: Muscle Mass (Age- related changes) | Less endurance Decreased strength |
| Age-Related Changes Affecting Mobility in the Older Client: Muscle Mass (Reason) | Loss of muscle mass |
| Age-Related Changes Affecting Mobility in the Older Client: Muscle Mass (Effect on Mobility) | Increased fatigue with ambulation |
| Age-Related Changes Affecting Mobility in the Older Client: Vision (Age- related changes) | Lower vision acuity Reduced depth perception |
| Age-Related Changes Affecting Mobility in the Older Client: Vision (Reason) | Reduced tone of eye muscles Thickening of natural lens in the eye |
| Age-Related Changes Affecting Mobility in the Older Client: Vision (Effect on Mobility) | Slower, hesitant ambulation Increased risk of tripping and falling |
| Goals for client positioning and alignment consist of the two Ps: | promotion and prevention |
| Promotion: | Comfort, safety, dignity, privacy, participation, frequent position changes |
| Prevention: | Strain, injury, and skin breakdown |
| patient positions in bed (Lateral) | Promotes spinal alignment and reduces pressure on the sacrum and heels |
| patient positions in bed (Fowlers) | Promotes lung expansion |
| patient positions in bed (Trendelenburg) | Promotes venous return and drainage of the lower lung lobes |
| patient positions in bed (Prone) | Allows full extension of hip and knee joints; promotes secretion of drainage |
| patient positions in bed (Supine) | Enables visualization of the client during examination |
| patient positions in bed (Lateral semi-prone recumbent) | Reduces pressure on sacrum and hips; promotes drainage of secretions |
| The challenges associated with repositioning, lifting, and transferring clients are based on the following considerations | Variations and differences in body size and shape: height and weight Level of cooperation: willing versus combative Mental function: oriented versus confused Physical disabilities Health-related conditions and equipment |
| A slide board allows the | lateral transfer of a client without imposing the physical exertion of lifting on the staff member |
| Rotation | Moving lengthwise |
| Circumduction | Moving in a circular fashion |
| Extension | Straightening the arm |
| Eversion | Turning soles outward |
| Pronation | Moving the palm of the hand to face downward |
| Adduction | Moving closer to the midline |
| Abduction | Moving away from the midline |
| Flexion | Bending the joint and decreasing the angle between bone |
| Iversion | Turning the sole of the foot inward the midline |
| Orthopneic Position | Maximizes chest expansion, aiding clients with breathing difficulties. It involves sitting upright with an overbed table and pillows for support, promoting easier respiration and comfort. |
| What side do you hold a cane | On the STRONGER side |
| Why hold the cane on stronger side | Holding the cane on the stronger side allows the cane and stronger leg to support the weaker side, improving balance and reducing the risk of falls |
| how to check fit on SCD sleeve | two fingers can fit between the sleeve and the client's leg. |
| correct size of elastic stockings | circumference of the leg |
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