Mobility and Immobility in Patient Care

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Questions and Answers

What is the average inflation pressure for the application of stockings?

  • 40 mm Hg (correct)
  • 30 mm Hg
  • 50 mm Hg
  • 60 mm Hg

Which action should not be performed when using compression stockings?

  • Assess the patient's skin condition periodically
  • Wrap the stocking starting at the ankle
  • Remove the stockings every hour (correct)
  • Place a protective stockinette over the leg

What is the primary condition exhibited by a patient with torticollis?

  • Scapular winging
  • Contracture of the pectoralis major muscle
  • Lordosis of the cervical spine
  • Contracture of the sternocleidomastoid muscle (correct)

After total hip replacement surgery, which device is recommended to maintain leg abduction?

<p>Wedge pillow (B)</p> Signup and view all the answers

Which of the following statements about stockings is false?

<p>The first measurement should be at the knee joint. (A)</p> Signup and view all the answers

Which condition is characterized by an increased convexity of the thoracic spine?

<p>Kyphosis (B)</p> Signup and view all the answers

What should be the primary concern when using sequential compression devices?

<p>Maintaining skin integrity (D)</p> Signup and view all the answers

Which of the following is NOT a characteristic of kyphoscoliosis?

<p>Lumbar spine contracture (C)</p> Signup and view all the answers

What is the primary focus during auscultation in a respiratory assessment for patients with restricted activity?

<p>Dependent lung fields (A)</p> Signup and view all the answers

What is the appropriate action for measuring calf circumference in patients at risk of DVT?

<p>Record measurements daily (B)</p> Signup and view all the answers

Which of the following actions should be avoided when assessing for DVT in a patient suspected of having one?

<p>Assess for Homans's sign (D)</p> Signup and view all the answers

When performing range-of-motion (ROM) exercises, what principle is important for a nurse to teach the patient and family?

<p>Provide support to the extremity (D)</p> Signup and view all the answers

What is a priority nursing intervention for a patient who is immobile to prevent complications related to DVT?

<p>Encourage frequent position changes (A)</p> Signup and view all the answers

In the context of respiratory assessments, what is the nurse inspecting during the inspiratory-expiratory cycle?

<p>Chest wall movements (A)</p> Signup and view all the answers

Which assessment technique is considered least valid for diagnosing DVTs?

<p>Assessing Homans's sign (D)</p> Signup and view all the answers

What should be the nurse's action regarding elastic stockings in patients at risk for DVT?

<p>Remove them every 8 hours for assessment (B)</p> Signup and view all the answers

What is the common misconception regarding calf pain with dorsiflexion in assessing DVT?

<p>It can be present in other conditions as well (A)</p> Signup and view all the answers

How should a nurse approach the mobility assessment of a patient with left-sided hemiparesis after a CVA?

<p>Regularly assess both sides for movement and strength (C)</p> Signup and view all the answers

What is a significant risk factor for the development of pressure ulcers in immobilized patients?

<p>Decreased mobility (B)</p> Signup and view all the answers

When planning care for a patient at risk for pressure ulcers, what position is recommended?

<p>30-degree lateral position (C)</p> Signup and view all the answers

Which statement correctly reflects the cost-effectiveness of preventing pressure ulcers compared to treating them?

<p>Preventing a pressure ulcer is less expensive than treating one. (D)</p> Signup and view all the answers

What misconception might a nurse have regarding breaks in skin integrity for immobilized patients?

<p>They heal faster than other wounds. (C)</p> Signup and view all the answers

In caring for a stroke patient, what is the most appropriate nursing action?

<p>Support the patient in performing self-care activities. (C)</p> Signup and view all the answers

What outcome might result from placing a stroke patient on bed rest without sufficient ambulation?

<p>Loss of mobility and functional decline (A)</p> Signup and view all the answers

What is a possible consequence of insufficient assistance with eating in the context of immobility?

<p>Malnutrition (A)</p> Signup and view all the answers

How does tissue metabolism change in the context of decreased mobility?

<p>It is affected by a lack of oxygen and nutrient supply. (D)</p> Signup and view all the answers

Which statement about the prevention of pressure ulcers is most accurate?

<p>Continuous assessment and preventive interventions are vital for at-risk patients. (A)</p> Signup and view all the answers

What error might be made regarding the nutritional needs of immobile patients?

<p>Underestimating their energy needs. (C)</p> Signup and view all the answers

What characterizes a stage 2 pressure injury?

<p>Partial-thickness skin loss involving the epidermis and/or dermis (D)</p> Signup and view all the answers

What is the first step in assessing a pressure injury in a patient with darkly pigmented skin?

<p>Using halogen light for proper illumination (A)</p> Signup and view all the answers

Which of the following statements is true regarding stage 1 pressure injuries?

<p>The skin appears intact but has nonblanchable redness. (B)</p> Signup and view all the answers

In a stage 3 pressure injury, which of the following is TRUE?

<p>Subcutaneous fat may be visible but there is no exposure of underlying structures. (D)</p> Signup and view all the answers

Which item is LEAST important to use initially during the skin assessment of a pressure injury?

<p>Sterile gloves (B)</p> Signup and view all the answers

What complication can arise from inappropriate use of fluorescent lighting when assessing darkly pigmented skin?

<p>Misleading blue tones affecting assessment accuracy. (C)</p> Signup and view all the answers

What might indicate a stage 4 pressure injury?

<p>Full-thickness tissue loss with visible bone or muscle. (D)</p> Signup and view all the answers

What is the primary reason for not ambulating the 16-year-old with a sprained ankle immediately after discharge?

<p>The patient has not yet demonstrated safe mobility. (D)</p> Signup and view all the answers

Which strategy is essential for the nurse to follow when repositioning a 136.1 kg (300-pound) patient?

<p>Assessing the patient's condition before repositioning. (B)</p> Signup and view all the answers

In managing a patient post-stroke with total paralysis, when is it most appropriate to begin passive range-of-motion exercises?

<p>Immediately after paralysis onset. (C)</p> Signup and view all the answers

Which condition is least likely to prioritize the need for ambulation in a patient?

<p>A 300-pound patient needing repositioning for safety. (C)</p> Signup and view all the answers

What should a nurse prioritize to prevent personal injury while moving a heavy patient?

<p>Determining the number of staff necessary to assist. (A)</p> Signup and view all the answers

What fundamental technique should nurses employ during passive range-of-motion exercises to avoid injury?

<p>Keeping the trunk erect and using multiple muscle groups. (C)</p> Signup and view all the answers

When is it appropriate for a nurse to place a patient in the Trendelenburg position?

<p>When managing a patient with low blood pressure. (C)</p> Signup and view all the answers

What is NOT a recommended approach to assisting a patient who has sustained impaired mobility?

<p>Providing immediate ambulation without prior assessment. (A)</p> Signup and view all the answers

To ensure safety while moving a heavy patient, which posture should a nurse avoid?

<p>Bending at the waist while pulling on assistive devices. (C)</p> Signup and view all the answers

Which factor is most critical in developing an individualized care plan for a patient with impaired mobility?

<p>The severity of the impairment and related comorbidities. (C)</p> Signup and view all the answers

Flashcards

Stockings application

Stockings are applied by wrapping the stocking around the leg, starting at the ankle, with the opening over the patella.

Stockings removal frequency

Stockings should not be removed every hour during application, for optimal results use sequential compression or intermittent pneumatic compression devices.

Torticollis

A condition where the head is tilted to one side due to a contracted sternocleidomastoid muscle.

Lordosis

An exaggeration of the lumbar spine curvature.

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Kyphosis

An increased convexity in the thoracic spine curvature.

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Kyphoscoliosis

An abnormal anterior-posterior and lateral curvature of the spine.

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Post-hip replacement leg position

After total hip replacement, maintain legs in abduction using a wedge pillow.

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Foot boot use

A foot boot supports proper foot position in the dorsiflexion (upward pointing of the foot)

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Priority for Ambulation

Certain patients, like those with sprains, recent medication, or complex conditions (like an 81-year-old asthmatic who had a hip replacement 18 months ago), typically do not get priority for movement assistance.

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Patient Repositioning

When repositioning heavy patients, ensure multiple people are involved to reduce back injury risk. This prevents strain on individual muscles.

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Repositioning Strategy

The safest approach to repositioning a heavy patient is to determine the number of assistants needed before starting, maintaining an upright posture, and bending at the knees, not the waist.

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Passive ROM Exercise Timing

Passive range-of-motion (ROM) exercises for patients with stroke-induced total right-side paralysis should start as soon as the patient loses the ability to move, rather than waiting for the acute phase to pass.

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Respiratory Assessment Frequency

Assess respiratory function at least every 2 hours for patients with limited activity.

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Respiratory Assessment Focus

Inspect chest movement throughout inhalation and exhalation. Listen to the lower lung areas intently because secretions often collect there.

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Immobile Patients & DVT Risk

Immobile patients are more susceptible to deep vein thrombosis (DVT).

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DVT Assessment Method

Measure the circumference of both calves daily to detect early signs of DVT.

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DVT - Assessing Homans's Sign

Avoid using Homans's sign for DVT assessment; it's unreliable and sometimes misleading.

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Post-CVA Hemiparesis

Patients with stroke-related left-sided weakness require ROM and physiotherapy.

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ROM Exercise Principle

ROM exercises should progress from proximal to distal body parts, supporting the extremity.

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Immobility and Pressure Ulcers

Immobility significantly increases the risk of pressure ulcers due to reduced blood flow to tissues. Preventing pressure ulcers is much less costly than treating them.

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30-degree Lateral Position

A 30-degree lateral position is a recommended position for patients at risk of pressure ulcers to prevent pressure on bony prominences.

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Self-Care and Stroke Recovery

Encouraging stroke patients to perform as many self-care activities as possible strengthens their mobility and independence. Avoid unnecessary help.

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Bed Rest and Stroke Recovery

Unnecessary bed rest after a stroke can hinder recovery by decreasing mobility and increasing risks like falls. Balancing rest and activity is key.

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Patient Nutrition and Stroke

Patients who are experiencing a stroke need appropriate assistance with eating. Not eating results in malnutrition.

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Preventing Pressure Ulcers

A critical nursing priority is to prevent pressure ulcers, as prevention is more economically sound than treatment.

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Skin Integrity and Healing

Healing breaks in skin integrity is difficult, especially in the context of immobility.

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Tissue Metabolism

Cellular metabolism, which depends on oxygen and nutrient supply, is affected adversely by pressure, resulting in hindered circulation.

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Staging pressure injury (stage 2)

Partial-thickness skin loss involving epidermis, dermis, or both. Appears as an abrasion, blister, or shallow crater.

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Staging pressure injury (stage 1)

Intact skin with nonblanchable redness over a bony prominence.

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Staging pressure injury (stage 3)

Subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed.

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Staging pressure injury (stage 4)

Full-thickness tissue loss with exposed bone, tendon, or muscle.

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Pressure injury assessment (darkly pigmented skin)

Use proper lighting (natural or halogen) to assess for injuries, as fluorescent light can interfere..

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Study Notes

Mobility and Immobility

  • Prolonged bed rest can lead to decreased appetite, slowed digestion, reduced fluid volume pooling in the lower body, decreased cardiac output (lower blood pressure), increased heart rate, and decreased urine output.
  • Immobilized patients have a higher risk for dehydration and concentrated urine.
  • Cerebrovascular accident (CVA) or stroke patients with left-sided paralysis should use assistive devices like walkers or canes instead of crutches.
  • Assessment of immobilized patients should include checking for unilateral swelling and muscle atrophy in the affected limbs.
  • Sequential compression stockings are used to prevent blood clots and should be measured around the thigh, then wrapped from ankle to mid-thigh, maintaining the opening over the kneecap.
  • Maintaining a 30-degree lateral position is recommended for patients in the recumbent position to reduce pressure on the sacrum and lower the risk of skin breakdown.
  • Immobility can lead to several issues, including hypercalcemia, which increases the risk for renal calculi.
  • Immobility disrupts normal metabolic functioning, leading to reduced metabolic rate, altered metabolism of carbohydrates, fats, and proteins, and often gastrointestinal problems.
  • Immobility increases risk of pressure ulcers.
  • Preventing pressure ulcers is less expensive than treatment.
  • Immobilized patients should be repositioned frequently and assisted to perform as many self-care activities as possible to maintain mobility and function.
  • Patients resuming activity after bed rest should have baseline blood pressure taken before getting up.
  • Passive range-of-motion (ROM) exercises should be started as soon as the patient loses the ability to move a joint or extremity.
  • Assistance from several people is needed for the safe repositioning of immobilized patients.
  • Foot cradles are an option for patients with poor lower extremity circulation to reduce pressure on toes.

Skin Integrity and Wound Care

  • Pressure injuries are caused by pressure intensity, duration, and tissue tolerance.
  • Impaired sensory perception, impaired mobility, shear, friction, and moisture are risk factors for pressure injuries.
  • Unconscious or disoriented patients are very high risk for pressure injuries as they are unable to self-care or communicate discomfort.
  • Stage 1 is nonblanchable redness over a bony prominence.
  • Stage 2 is partial-thickness skin loss.
  • Stage 3 is full-thickness skin loss with damage to subcutaneous tissue.
  • Stage 4 is full-thickness skin loss with exposed bone, tendon, or muscle.
  • Irrigating pressure injuries with normal saline is recommended, not hydrogen peroxide.
  • Wound healing is influenced by factors such as nutrition, tissue perfusion, infection, and age.
  • Primary intention healing is for wounds with minimal tissue loss.
  • Secondary intention healing is for wounds with significant tissue loss.
  • Tertiary intention healing occurs when a wound is left open until it can be closed surgically.
  • A stage 1 pressure injury does not require a dressing.
  • Monitoring for signs of infection, such as increased redness or drainage, is essential for any wound.
  • Laboratory test for nutritional status (serum albumin) is essential when supporting a wound-healing plan.
  • Addressing psychological issues in patients with impaired mobility or skin integrity will improve overall well-being and healing.
  • A consult with the dietician is necessary for wound healing plan.
  • Pain management is a priority in patients with wounds.

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