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Edapts Mobility and
Immobility
Mobility and Immobility Adam, a 54-year-old client on bed rest, has a Stage 1 pressure injury on the coccyx. Which interventions should the nurse implement? Provide proper skin care. Reposition the client every 1 to 2 hours. Get the client a specialty air or foam mattress. A 77-year-old is recovering from spinal surgery and using a walker as an assistive device. The client states, "I don't want any visitors or to go anywhere. No one should see me using a walker. I want to be left alone." What is the most appropriate nursing diagnosis? Social isolation An 80-year-old fell at home and was not found for three days. The client was admitted to the hospital with a fractured hip. Which complications can occur due to immobility? Embolus Urinary retention Muscle atrophy The nurse is assessing a client who recently had surgery. Lung sounds on the right base are diminished and there are no breath sounds in the left base. What complication does the nurse suspect? Atelectasis Kari Ann (preferred pronouns: she, her), a 32-year-old female, is hospitalized with multiple sclerosis. Her condition has worsened and she will need a wheelchair from now on. She is divorced with four children. Which statement indicates a need for immediate follow-up by the nurse? "I won’t need any help at home." A client has been on prolonged bed rest but now is able to get up. What should the nurse assess for? Activity tolerance Gait Range of motion (ROM) Strength Carol (preferred pronouns: she, her) is a new resident of a long-term care facility. She has severe arthritis and is wheelchair-bound. Recent complications led Carol to be hospitalized and then transferred to a care facility. She appears very depressed and withdrawn. What is the nurse's best action? Bring Carol to the common area to meet other residents.
Edapts Mobility and
Immobility
Mary Brenner is a 60-year-old client who is less than 24 hours post-operative from abdominal surgery. To prevent immobility complications, what priority nursing intervention should be implemented? Ambulate the client in the hall. The nurse notices that a client with impaired mobility in the lower extremities has decreased skin turgor and hypoactive bowel sounds. Which factor may contribute to these signs in the immobilized client? Inadequate fluid intake A nurse works on an orthopedic surgical floor in a hospital. The nurse understands that clients are at risk of which physiological complication of immobility? Decreased lung expansion An unlicensed assistive personnel (UAP) is putting compression stockings on a client following major surgery. The client asks why they have to wear them. What is the UAP's best answer? "They promote circulation to the heart." An 18-year-old victim of a motor vehicle crash with a fractured femur has been immobilized for six days. The nurse is getting the client out of bed for the first time. Which nursing diagnosis is applicable to this action? Risk for activity intolerance Marissa is a 4-year-old with cerebral palsy. In the nurse's assessment, which finding would indicate a developmental complication? Marissa cannot say their first and last names and speaks unclearly sometimes. The nurse has four clients on the unit with impaired mobility. Which client is at greatest risk of developing complications from immobility? 82-year-old woman who has suffered a cerebrovascular accident (CVA) Range of Motion A client arrives for physical therapy with limited motion of the right knee. How does the therapist know the extent of the limitation? Measure using a goniometer. The client is experiencing pain during range of motion exercises. What is the nurse's best action?
Edapts Mobility and
Immobility
The nurse is reviewing orders for a new post-operative client. Which provider order is most appropriate? Range of motion 2x/day on left knee; 3-5 repetitions When working with a goniometer , it is important to place the fulcrum on the joint. The stationary arm is placed on the proximal segment of the body while the moving arm is placed on the distal.
Edapts Mobility and
Immobility
Positioning The nurse sees that the client's bottom arm is extended more than 90 degrees in a lateral position. The nurse knows that this may put the client at risk for which of the following? Injury to the brachial plexus When in a prone position, the nurse knows to examine the client for skin breakdown on which areas? Ears Knees Toes To prevent complications, what is the maximum amount of time the nurse should wait to reposition a client? Every two hours Age, weight, and diagnosis would be pertinent information that must be reviewed before determining the best position for the client. A nurse is observing an unlicensed assistive personnel (UAP) reposition a client on their side. What action would indicate that the UAP needs more education? The UAP slides the client up in the bed and then onto their side. Semi-Fowler's position the head of the bed elevated about 45 degrees low-Fowler's - 15 to 30 degrees and high-Fowler's - 60 to 90 degrees Supine is flat on the spine. Lateral position
- Hips should be aligned with the spine.
- Top leg needs to be bent and supported by a pillow.
- Left arm should be bent and supported by a pillow.
- Bottom leg needs to be straight so weight is on the right hip. 5. Lithotomy is a supine position but with the legs elevated and thighs apart. This is a position for pelvic surgeries and gynecological examinations.
Edapts Mobility and
Immobility
The nurse has four clients. Which client should the nurse ask for assistance with repositioning? A client who is fully dependent The nurse knows educating the client about the position and encouraging assistance with positioning themselves can benefit the client in what ways? Increases control Increases maintenance of position Increases self-esteem Promotes exercise Transferring The nurse is reviewing a staff education module on safe client handling. Which tips should be corrected? Keep muscles relaxed and maintain a slouched position when lifting. The nurse is preparing to transfer a client from a bed to a stretcher. What items will the nurse need? Pillow Friction-reducing device An unlicensed assistive personnel (UAP) needs to boost a client up in bed prior to transferring. Which technique makes it easier to boost a client in bed? Ask the client to lift their head, cross their arms, and bend their knees. A newly hired unlicensed assistive personnel (UAP) is working in a long-term care facility. They have been transferring multiple clients every day without assistive devices, stating they are "strong enough to do it." A nurse observes the UAP using poor body mechanics and demonstrates the correct way to transfer clients. The UAP says they prefer to transfer their way. Which risk factors increase the UAP's chances of injury? Transferring is repetitive. Not using assistive devices. Poor body mechanics are used. The nurse needs to move a client from the bed to a stretcher for transport for an x-ray. How should the nurse prepare for transfer? Use a friction-reducing device. Move the client on the count of three. Educate the client about the transfer.
Edapts Mobility and
Immobility
Two unlicensed assistive personnel (UAPs) are using a mechanical lift to transfer a client to a wheelchair. Which statement demonstrates a best practice when using a sling? Move the client’s body into the correct position prior to releasing the sling. A post-operative client is coming from the post-anesthesia care unit (PACU) on a stretcher and will need to be transferred to an intensive care unit (ICU) bed. What is the minimum number of people needed to safely transfer this client? 3 When operating lifts:
- Prepare the environment—clear a path, get assistance if needed, and position the lift correctly.
- Prepare the equipment—ensure the battery is charged, the controls work, and proper items are selected.
- Prepare the client—educate the client, position the client correctly, and complete safety checks.
- Lift the client—do not leave the client unattended.
- Position the client—ensure the client is positioned properly. The nurse has four clients. Which clients would require the use of a mechanical lift? A client with a spinal cord injury A client who is a hemiplegic A bariatric client with chronic obstructive pulmonary disease (COPD) Injuries to healthcare workers mainly occur to the lower back and shoulders. What type of transfer causes the most musculoskeletal injuries? Manual transfer of a dependent client When transferring a client from a bed to a wheelchair, what should the nurse prompt the client to do before sitting down? The client reaches the back of the wheelchair to guide themselves into a seated position. The nurse needs to transfer a totally dependent client from a stretcher to a bed. What is the best action the nurse could take to reduce integumentary risk factors for the client? Use a friction-reducing device.
Edapts Mobility and
Immobility
A client has an injured left foot with partial weight-bearing abilities. How would the nurse instruct the client to use a walker? Walker, left foot, right foot, walker A client is using crutches and has partial weight-bearing on both feet. The client moves the left crutch at the same time as the right foot. The right crutch moves with the left foot. How would this gait be documented? 2-point gait The nurse is watching an unlicensed assistive personnel (UAP) use a gait belt to transfer a client. Which action taken by the UAP should be corrected? The belt is left on the client after transferring. A 76-year-old client (preferred pronouns: she, her) has a provider order to ambulate. She had a total hip replacement two days ago. Which factors should be considered prior to ambulating this client? Client’s strength Provider's order for activity Assistive devices needed Range of motion Tolerance for activity Prep for ambulation
- Verify the provider order for ambulation.
- Gather assistive devices and a gait belt.
- Move the client to a sitting position.
- Place the gait belt on the client.
- Move the client to a standing position.
- Walk as far as the client will tolerate.
- Return the client to bed and remove the gait belt.
- Document the client's ambulation. A client has bilateral weakness in the lower extremities but can bear weight. Which assistive devices should the client use? Gait belt Cane Walker Safety Restraint Devices
Edapts Mobility and
Immobility
According to the Centers for Disease Control and Prevention (n.d.), 1356 3 million older adults are treated in the emergency department for fall-related injuries (falls are serious and costly). In the hospital, when do most falls occur? Transfer What is the leading cause of injuries in older adults? Falls The Centers for Disease Control and Prevention (CDC) created a program called Stopping Elderly Accidents, Deaths and Injuries (STEADI) to decrease falls and injuries in the older population. What are the three (3) major components of this program that should be the goals of any falls prevention program? Identify modifiable risk factors. Offer effective interventions. Identify clients at risk. When should a fall assessment screening take place? Admission Change in condition While caring for a client using a safety reminder device (SRD), the nurse goes into the client’s room every two (2) hours to remove the wrist restraint, check distal circulation, assess the client’s pressure points, and massage the client’s skin. What key safety issue has the nurse failed to address for this client? The nurse has not been checking distal circulation every 30 minutes, which puts the client at risk. The nurse has finished applying a safety reminder device (SRD) on the client to immobilize both arms and prevent the client from pulling out an endotracheal tube. When the nurse documents, what must be included? Client response Type of device Client and family teaching Comprehensive assessment Need for SRD The client’s caregiver asks about the risks of using a safety reminder device (SRD). What should be included in the nurse’s response? Increased anxiety Disorientation Skin breakdown
Edapts Mobility and
Immobility
4 m/s Which action should the medical professional perform in order to lift a client? Hold the client so that the center of mass is over the feet. How much torque does a 20 N box create when it is two meters from the pivot point? 40 N x m Torque is equal to the force times the distance to the pivot. 20 N x 2 m = 40 N per m What is being calculated when mass is multiplied by the acceleration? Newton’s Second Law If two cars collide, what do the laws of physics tell us? The momentum before the collision is the same as the momentum after the collision. What is the equation for torque? force x distance A 100 kg client felt 100 N of force. What was the acceleration of the client? 1 m/s^2 100 N = 100 kg x acceleration. So, acceleration = 100 N ÷ 100 kg = 1 m/s^2 If two medical professionals can lift 500 N each, what is the maximum force they can lift together? 1000 N A person of 100 kg is moving at 0.5 m/s. What is their momentum? 50 kg per m/s M x V = 100 kg x 0.5 m/s = 50 kg per m/s Where is the best place to have one’s center of mass? Directly over their feet
Edapts Mobility and
Immobility
If a box on a lever has 100 N/m of torque and is 60 N, how far is it from the pivot point? 1.67 meters 100 N per m = 60 N x distance 100 N per m ÷ 60 N = 1.67 m Nursing Application: Mobility A client had a stroke, has right-sided hemiparesis, and was admitted to the hospital. What complications can result from immobility? Disuse osteoporosis Deep vein thrombosis Constipation The nurse is preparing to transfer a client with right-sided weakness from the bed to a wheelchair. How would the nurse prepare the environment? Obtain a gait belt. Put footwear on the client. Lock the brakes on the wheelchair. A client with right-sided hemiparesis needs to be repositioned every 2 hours. Which positions can the client be placed in?. Prone Supine Paul had an ischemic stroke in the rear portion of the left frontal lobe—the area that controls motor function. If a person has a left-sided stroke, in which areas would motor weakness occur? Right arm Right face Right leg Diagnosis: impaired physical mobility related to neuromuscular impairment as evidenced by right-sided hemiparesis and lack of strength. Diagnosis: impaired verbal communication related to loss of facial muscle control as evidenced by speech impairment. Diagnosis: i neffective coping related to situational crisis as evidenced by anger and frustration. During Paul's hospitalization, the nurse observes Paul sliding down in the bed and he appears uncomfortable. How should the nurse reposition Paul?
Edapts Mobility and
Immobility
Fiber Paul McKinney, (preferred pronouns: he, him, his), is 77 years old, 6’2”, and 215 Ibs. He has right-sided hemiparesis and difficulty communicating with his wife. Strength is +1 on the right lower extremity and absent on the right upper extremity. Paul has full strength on the left side extremities. Paul is visibly frustrated. What interventions can the nurse implement to help prevent the risk of negative psychological effects due to immobility? Implement social activities Encourage visitors to the room Have the client participate in care Paul McKinney, (preferred pronouns: he, him, his), is 77 years old, 6’2”, and 215 Ibs. He has right-sided hemiparesis and difficulty communicating with his wife. Strength is +1 on the right lower extremity and absent on the right upper extremity. Paul has full strength on the left side extremities. Paul is visibly frustrated. A desired outcome for Paul was to increase his strength on the affected right side. Which statement meets the expected outcome? Paul completes active range of motion (ROM) on the right hand. When operating lifts:
- Prepare the environment—clear a path, get assistance if needed, and position the lift correctly.
- Prepare the equipment—ensure the battery is charged, the controls work, and the proper items are selected.
- Prepare the client—educate the client about the lift, apply, and position the client correctly on the sling.
- Complete safety checks.
- Lift the client—do not leave the client unattended.
- Move the lift with the client from the bed to the chair.
- Position the client—ensure the client is positioned properly.
- Remove the sling from the client.
