Mobility
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| Structures of the musculoskeletal system regulating movement | Bones, muscles, joints, joint motion: adduction, abduction, rotation, flexion, extension, supination (up), pronation (down), inversion (towards body), eversion
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| Normal physiologic function | Alignment, posture, Balance and gait, coordinated movement (controlled by cerebellum), body mechanics.
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| Types of Exercise | Aerobic (requires O2), Anaerobic (exchange occurs without O2, Isotonic (muscle contraction with a change in muscle length ex. walking/biking). Isometric (tightening or tensing a muscle with moving muscle length ex. flexing, push, pull)
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| Benefits of exercise | Increase venous return, blood flow, oxygen.
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| Factors affecting mobility | Lifestyle and habits. Intact musculoskeletal system. Nervous control system. Circulation and oxygenation. Pain.
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| Manifestations of Altered mobility | Decreased muscle strength and tone. Lack of coordination. Altered gait. falls. Decreased joint flexibility. Pain on movement.
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| Impact of Immobility on cardiovascular | Increased cardiac workload. Orthostatic hypotension. Thrombus formation and embolism.
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| Impact of Immobility on Respiratory | Decreased lung expansion. Retained secretions. pulmonary embolus.
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| Impact of Immobility on Musculoskeletal System | Muscle atrophy and weakness. Contractures and joint pain. Disuse osteoporosis.
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| Impact of Immobility on Nutrition and metabolism | Decreased metabolic rate and anorexia. Impaired immunity. Pressure ulcers.
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| Impact of Immobility on elimination | Urinary stasis. UTI. Renal calculi (kidney stones). Constipation
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| Subjective Data | Normal pattern identification relating to activity. Risk Identification: pts on bedrest, risk for falls. Dysfunction Identification- activity intolerance
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| Objective Data | Physical assessment, cardiovascular, vital signs including postural BP, edema, presence of thrombus, resp, auscultate lungs, nutrition, elimination, bowel sounds, weight, I
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| Nursing Diagnosis | Impaired physical mobility, ineffective tissue perfusion, ineffective breathing pattern, impaired wheelchair mobility, impaired walking, constipation, risk for injury
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| Planning | Pt's lungs will be clear to auscultation by discharge. Pt will be able to sit in chair for 20 minutes with assist of one within 2 days.
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| Implementation | Health promotion: Physical fitness, exercise programs. Osteoporosis prevention: bone density screenings, calcium and vit D. Injury prevention: Identify falls risk
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| Cardiopulmonary nursing interventions | Cough and deep breath. Incentive spirometer. Increase fluids. Gradually increase activity,
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| DVT prevention | Early ambulation. TEDs and SCDs
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| Positioning interventions for altered mobility | Turning schedules and positioning aids, logrolling, care of pts with hip surgery, change positions gradually.
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| Joint mobility maintenance | General principles of ROM exercises. Automatic ROM equipment. Types of ROM.
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Created by:
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