NURS 3000 - Professional Nursing Mobility Needs PDF

NURS 3000 - Professional Nursing Mobility Needs Mobility Needs HardiName: Sean Whitfield Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respond to any case studies and client scenarios. All of these ac...

NURS 3000 - Professional Nursing Mobility Needs Mobility Needs HardiName: Sean Whitfield Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respond to any case studies and client scenarios. All of these activities will assist in your preparation for exams, help you plan and implement care in the clinical setting, and facilitate your development as a Christian nurse servant. You will submit your completed guide to the instructor at the end of the week. The completed learning guide will be worth a maximum of 10 points. If you have questions or are unsure about your answers; or you may email your instructor for clarification. Note: The Active Learning Guide provides a general outline of topics covered in this module; it is not all inclusive of all information needed for the exam. You are responsible for all content in readings and activities throughout the module. I. Mobility Needs: Chapter 44: Activity and Exercise 1. List and discuss factors that affect mobility: Growth and Development: An individual’s age and musculoskeletal and nervous system development affect posture, body proportions, body mass, body movements, and reflexes. Newborn movements are reflexive and random. All extremities are generally flexed but can be passively moved through a full range of motion. As the neurologic system matures, control over movement progresses during the first year. Gross motor development precedes fine motor skills. Gross motor development occurs in a head-to-toe fashion, that is, progression from head control, to crawling, to pulling up to a standing position, to standing, and to walking, usually after the first birthday. The contralateral motion of crawling, however brief, is an important building block for walking. Initially, walking involves a wide stance and unsteady gait, thus the term toddler. From ages 1 to 5 years, both gross and fine motor skills are refined. For example, preschoolers master riding a tricycle, running, jumping, using crayons to draw, fastening or using zippers, and brushing their teeth. Immobility can impair the social and motor development of young children. Nutrition: Both undernutrition and overnutrition can influence body alignment and mobility. Poorly nourished people may have muscle weakness and fatigue. Vitamin D deficiency causes bone deformity during growth. Inadequate calcium intake and vitamin D synthesis and intake increase the risk of osteoporosis. Obesity can distort movement and stress joints, adversely affecting posture, balance, and joint health. See Chapter 46 for more information about nutrition. Personal Values and Attitudes: Whether individuals value regular exercise is often the result of family influences. In families that incorporate regu NURS 3000 - Professional Nursing Mobility Needs External Factors: Many external factors affect an individual’s mobility. Excessively high temperatures and high humidity discourage activity, whereas comfortable temperatures and low humidity are conducive to activity. Proper hydration needs vary according to the individual, health status, activity levels, and environment. Water is the best fluid to replace loss incurred through metabolic processes and exercise. Prescribed Limitations: Limitations to movement may be medically prescribed for some health problems. To promote healing, devices such as casts, braces, splints, and traction are often used to immobilize body parts. Clients who are short of breath may be advised not to walk up stairs. Bedrest may be the therapeutic choice for certain clients, for example, to relieve edema, to reduce metabolic and oxygen needs, to promote tissue repair, or to decrease pain. 2. What is osteoporosis? How does it affect mobility status? Osteoporosis is a condition in which the bones become brittle and fragile due to calcium depletion. Osteoporosis is common in older women and primarily affects the weight-bearing joints of the lower extremities and the anterior aspects of spinal bones, causing compression fractures of the vertebrae and hip fractures. All of these changes affect older adults’ posture, gait, and balance. Posture becomes forward leaning and stooped, which shifts the center of gravity forward. To compensate for this shift, the knees flex slightly for support and the base of support is widened. Gait becomes wide based, short stepped, and shuffling. 3. What is activity tolerance? Activity tolerance is the type and amount of exercise or ADLs an individual is able to perform without experiencing adverse effects. Why is it important for the nurse to be aware of the client’s activity tolerance? The care plan that is created for the patient needs to be customized to the individual. The interventions will be tailored to the individuals specific goals and needs. The patient is part of an on-going assessment and the care plan will continuously be evaluated and the care plan will change to fit their needs. 4. What are the benefits of exercise on the major body systems? In general, regular exercise is essential for maintaining mental and physical health. Musculoskeletal System NURS 3000 - Professional Nursing Mobility Needs The size, shape, tone, and strength of muscles (including the heart muscle) are maintained with mild exercise and increased with strenuous exercise. With strenuous exercise, muscles hypertrophy (enlarge), and the efficiency of muscular contraction increases. Joints lack a discrete blood supply. It is through activity that joints receive nourishment. Exercise increases joint flexibility, stability, and range of motion. Bone density and strength are maintained through weight bearing. The stress of weight-bearing and high-impact movement maintains a balance between osteoblasts (bone-building cells) and osteoclasts (bone-resorption and breakdown cells). Examples of non–weight-bearing exercise include swimming and bicycling. Cardiovascular System The American Heart Association (2018) places great emphasis on physical activity by recommending at least 150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise, or a combination of moderate and vigorous activity. Adequate moderateintensity exercise increases the heart rate, the strength of heart muscle contraction, and the blood supply to the heart and muscles through increased cardiac output. Exercise also promotes heart health by reducing the harmful effects of stress. The types of exercise that will provide cardiac benefit vary. They include aerobic exercise such as walking and cycling. Research evidence supports the benefits of yoga practice on cardiovascular health. Respiratory System Ventilation (air circulating into and out of the lungs) and oxygen intake increase during exercise, thereby improving gas exchange. More toxins are eliminated with deeper breathing, and problem-solving and emotional stability are enhanced due to increased oxygen to the brain. Adequate exercise also prevents pooling of secretions in the bronchi and bronchioles, decreasing breathing effort and risk of infection. Attention to exercising muscles of respiration (by deep breathing) throughout an activity as well as rest enhances oxygenation (improving stamina) and circulation of lymph (improving immune function). Gastrointestinal System Exercise improves the appetite and increases gastrointestinal tract tone, facilitating peristalsis. Activities such as rowing, swimming, walking, and sit-ups work the abdominal muscles and can help relieve constipation. Endocrine System and Metabolism Exercise elevates the metabolic rate, thus increasing the production of body heat and waste products and calorie use. During strenuous exercise, the metabolic rate can increase to as much as 20 times the normal rate. This elevation lasts after exercise is completed. Exercise increases the use of triglycerides and fatty acids, resulting in a reduced level of serum triglycerides, glycosylated hemoglobin A1C (HbA1C) levels, and cholesterol. Weight loss and exercise stabilize blood sugar and make cells more responsive to insulin. Urinary System NURS 3000 - Professional Nursing Mobility Needs With adequate exercise, which promotes efficient blood flow, the body excretes wastes more effectively. In addition, stasis (stagnation) of urine in the bladder is usually prevented, which in turn decreases the risk for urinary tract infections (UTIs). Immune System As respiratory and musculoskeletal effort increase with exercise and as gravity is enlisted with postural changes, lymph fluid is more efficiently pumped from tissues into lymph capillaries and vessels throughout the body. Circulation through lymph nodes where destruction of pathogens and removal of foreign antigens can occur is also improved. Psychoneurologic System Mental or affective disorders such as depression or chronic stress may affect an individual’s desire to move. The depressed client may lack enthusiasm for taking part in any activity and may even lack energy for usual hygiene practices. Lack of visible energy is often seen in a slumped posture with head bent down. Chronic stress can deplete the body’s energy reserves to the point that fatigue discourages the desire to exercise, even though exercise can energize the client and facilitate coping. By contrast, clients with eating disorders may exercise excessively in an effort to prevent weight gain. Cognitive Function Current research supports the positive effects of exercise on cognitive functioning, in particular decision-making and problem-solving processes, planning, and paying attention. Physical exertion induces cells in the brain to strengthen and build neuronal connections. Spiritual Health Yoga-style exercise improves the mind–body–spirit connection, relationship with God, and physical well-being by establishing balance in the internal and external environment. The combination of mind, body, and breath awareness is likely to have an impact on psychophysiologic functioning. The emphasis on breathing in is thought to soothe the nervous and cardiorespiratory systems, promoting relaxation and preparedness for a contemplative experience. 5. Effects of Immobility on Major Body Systems Be familiar with all terms r/t each system. Musculoskeletal: Disuse osteoporosis. Without the stress of weight- bearing activity, the bones demineralize. They are depleted chiefly of calcium, which gives the bones strength and density. Regardless of the amount of calcium in an individual’s diet, the demineralization process, known as osteoporosis, continues with immobility. The bones become spongy and may gradually deform and fracture easily. Disuse atrophy. Unused muscles atrophy (decrease in size), losing most of their strength and normal function. NURS 3000 - Professional Nursing Mobility Needs Contractures. When the muscle fibers are not able to shorten and lengthen, eventually a contracture (permanent shortening of the muscle) forms, limiting joint mobility. This process eventually involves the tendons, ligaments, and joint capsules; it is irreversible except by surgical intervention. Joint deformities such as foot drop (Figure 44.34), wrist drop, and external hip rotation occur when a stronger muscle dominates the opposite muscle. Stiffness and pain in the joints. Without movement, the collagen (connective) tissues at the joint become ankylosed (permanently immobile). In addition, as the bones demineralize, excess calcium may deposit in the joints, contributing to stiffness and pain. Cardiovascular: Diminished cardiac reserve. Decreased mobility creates an imbalance in the autonomic nervous system, resulting in a dominance of sympathetic activity that increases heart rate. Rapid heart rate reduces diastolic pressure, coronary blood flow, and the capacity of the heart to respond to any metabolic demands above the basal levels. Because of this diminished cardiac reserve, the immobilized client may experience tachycardia with even minimal exertion. Increased use of the Valsalva maneuver. The Valsalva maneuver refers to holding the breath and straining against a closed glottis. For example, clients tend to hold their breath when attempting to move up in a bed or sit on a bedpan. This builds up sufficient pressure on the large veins in the thorax to interfere with the return blood flow to the heart and coronary arteries. When the client exhales and the glottis again opens, pressure is suddenly released, and a surge of blood flows to the heart. Cardiac arrhythmias can result if the client has preexisting cardiac disease. NURS 3000 - Professional Nursing Mobility Needs Orthostatic (postural) hypotension. Orthostatic hypotension is a common result of immobilization. Under normal conditions, sympathetic nervous system activity causes automatic vasoconstriction in the blood vessels in the lower half of the body when a mobile client changes from a horizontal to a vertical posture. Vasoconstriction prevents pooling of the blood in the legs and effectively maintains central blood pressure to ensure adequate perfusion of the heart and brain. During any prolonged immobility, however, this reflex becomes inactive. When the immobile client attempts to sit or stand, this reconstricting mechanism fails to function properly in spite of increased adrenalin output. The blood pools in the lower extremities, and central blood pressure drops. Cerebral perfusion is seriously compromised, and the client feels dizzy or lightheaded and may even faint. This sequence is usually accompanied by a sudden and marked increase in heart rate, the body’s effort to protect the brain from an inadequate blood supply. Venous vasodilation and stasis. The skeletal muscles of an active client contract with each movement, compressing the blood vessels in those muscles and helping to pump the blood back to the heart against gravity. The tiny valves in the leg veins aid in venous return to the heart by preventing backward flow of blood and pooling. In an immobile client, the skeletal muscles do not contract sufficiently, and the muscles atrophy. The skeletal muscles can no longer assist in pumping blood back to the heart against gravity. Blood pools in the leg veins, causing vasodilation and engorgement. The valves in the veins can no longer work effectively to prevent backward flow of blood and pooling (Figure 44.35). This phenomenon is known as incompetent valves. As the blood continues to pool in the veins, its greater volume increases venous blood pressure, which can become much higher than that exerted by the tissues surrounding the vessel. NURS 3000 - Professional Nursing Mobility Needs Dependent edema. When the venous pressure is sufficiently great, some of the serous part of the blood is forced out of the blood vessel into the interstitial spaces surrounding the blood vessel, causing edema. Edema is most common in parts of the body positioned below the heart. Dependent edema is most likely to occur around the sacrum or heels of a client who sits up in bed or in the feet and lower legs of a client who sits in a chair. Edema further impedes venous return of blood to the heart, causing more pooling and more edema. Edematous tissue is uncomfortable and more susceptible to injury than normal tissue. Thrombus formation. Three factors collectively predispose a client to the formation of a thrombophlebitis (a clot that is loosely attached to an inflamed vein wall): impaired venous return to the heart, hypercoagulability of the blood (sometimes caused by medications such as oral contraceptives), and injury to a vessel wall. Respiratory: Decreased respiratory movement. In a recumbent, immobile client, ventilation of the lungs is passively altered. The body presses against the rigid bed and decreases chest movement. The abdominal organs push against the diaphragm, restricting lung movement and making it difficult to expand the lungs fully. An immobile, recumbent client rarely sighs, partly because overall muscle atrophy also affects the respiratory muscles and partly because there is no stimulus of activity. Without these periodic stretching movements, the cartilaginous intercostal joints may become fixed in an expiratory phase of respiration, further limiting the potential for maximal ventilation. These changes produce shallow respirations and reduce vital capacity (the maximum amount of air that can be exhaled after a maximum inhalation). Pooling of respiratory secretions. Secretions of the respiratory tract are normally expelled by changing positions or posture and by coughing. Inactivity allows secretions to pool by gravity (Figure 44.36), interfering with the normal diffusion of oxygen and carbon dioxide in the alveoli. The ability to cough up secretions may also be hindered by loss of respiratory muscle tone, dehydration (which thickens secretions), or sedatives that depress the cough reflex. Poor oxygenation and retention of carbon dioxide in the blood can, if allowed to continue, predispose the client to respiratory acidosis, a potentially lethal disorder. Pooling of secretions in the lungs of an immobile client. See below: NURS 3000 - Professional Nursing Mobility Needs Atelectasis. When ventilation is decreased, pooled secretions may accumulate in a dependent area of a bronchiole and effectively block it. Because of changes in regional blood flow, bedrest decreases the amount of surfactant produced. (Surfactant enables the alveoli to remain open.) The combination of decreased surfactant and blockage of a bronchiole with mucus can cause atelectasis (the collapse of a lobe or of an entire lung) distal to the mucous blockage. Immobile older, postoperative clients are at greatest risk of atelectasis. Hypostatic pneumonia. Pooled secretions provide excellent media for bacterial growth. Under these conditions, a minor upper respiratory infection can evolve rapidly into a severe infection of the lower respiratory tract. Pneumonia caused by static respiratory secretions can severely impair oxygen–carbon dioxide exchange in the alveoli and is a fairly common cause of death among weakened, immobile clients, especially heavy smokers. Metabolism: Decreased metabolic rate. Metabolism refers to the sum of all the physical and chemical processes by which living substance is formed and maintained and by which NURS 3000 - Professional Nursing Mobility Needs energy is made available for use by the body. The basal metabolic rate (BMR) is the minimal energy expended for the maintenance of these processes, expressed in calories per hour per square meter of body surface. In immobile clients, the basal metabolic rate and gastrointestinal motility and secretions of various digestive glands decrease as the energy requirements of the body decrease. Negative nitrogen balance. In an active client, a balance exists between protein synthesis (anabolism) and protein breakdown (catabolism). Immobility creates a marked imbalance, and the catabolic processes exceed the anabolic processes. Catabolized muscle mass releases nitrogen. Over time, more nitrogen is excreted than is ingested, producing a negative nitrogen balance. The negative nitrogen balance represents a depletion of protein stores that are essential for building muscle tissue and for wound healing. Anorexia. Loss of appetite (anorexia) occurs because of the decreased metabolic rate and the increased catabolism that accompany immobility. Reduced caloric intake is usually a response to the decreased energy requirements of the inactive client. If protein intake is reduced, the nitrogen imbalance may become more pronounced, sometimes so severely that malnutrition ensues. Negative calcium balance. A negative calcium balance occurs as a direct result of immobility. Greater amounts of calcium are extracted from bone than can be replaced. The absence of weight bearing and of stress on the musculoskeletal structures is the direct cause of the calcium loss from bones. Weight bearing and stress are also required for calcium to be replaced in bone. Urinary stasis: Urinary stasis. In a mobile client, gravity plays an important role in the emptying of the kidneys and the bladder. The shape and position of the kidneys and active kidney contractions are important in completely emptying the urine from the calyces, renal pelvis, and ureters (Figure 44.37A). The shape and position of the urinary bladder (the detrusor muscle) and active bladder contractions are also important in achieving complete emptying. NURS 3000 - Professional Nursing Mobility Needs When the client remains in a horizontal position, gravity impedes the emptying of urine from the kidneys and the urinary bladder. To urinate, the client who is supine (in a backlying position) must push upward, against gravity (Figures 44.37B). The renal pelvis may fill with urine before it is pushed into the ureters. Emptying is not as complete, and urinary stasis (stoppage or slowdown of flow) occurs after a few days of bedrest. Because of the overall decrease in muscle tone during immobilization, including the tone of the detrusor muscle, bladder emptying is further compromised. Renal calculi. In a mobile client, calcium in the urine remains dissolved because calcium and citric acid are balanced in appropriately acidic urine. With immobility and the resulting excessive amounts of calcium in the urine, this balance is no longer maintained. The urine becomes more alkaline, and the calcium salts precipitate out as crystals to form renal calculi (stones). In an immobile client in a horizontal position, the renal pelvis filled with stagnant, alkaline urine is an ideal location for calculi to form. The stones usually develop in the renal pelvis and pass through the ureters into the bladder. As the stones pass along the long, narrow ureters, they cause extreme pain and bleeding and can sometimes obstruct the urinary tract. Urinary retention. The immobile client may suffer from urinary retention (accumulation of urine in the bladder), bladder distention, and occasionally urinary incontinence (involuntary urination). The decreased muscle tone of the urinary bladder inhibits its ability to empty completely. In addition, the discomfort of using a bedpan or urinal, the embarrassment and lack of privacy associated with this function, and the unnatural NURS 3000 - Professional Nursing Mobility Needs position for urination combine to make it difficult for the client to relax the perineal muscles sufficiently to urinate while lying in bed. When urination is not possible, the bladder gradually becomes distended with urine. The bladder may stretch excessively, eventually inhibiting the urge to void. When bladder distention is considerable, some involuntary urinary “dribbling” may occur (retention with overflow). This does not relieve the urinary distention, because most of the stagnant urine remains in the bladder. Urinary infection. Static urine provides an excellent medium for bacterial growth. The flushing action of normal, frequent urination is absent, and urinary distention often causes minute tears in the bladder mucosa, allowing infectious organisms to enter. The increased alkalinity of the urine caused by the hypercalcuria supports bacterial growth. The organism most commonly causing urinary tract infections is Escherichia coli, which normally resides in the colon. The normally sterile urinary tract may be contaminated by improper perineal care, the use of an indwelling urinary catheter, or occasionally urinary reflux (backward flow). During reflux, contaminated urine from an overly distended bladder backs up into the renal pelvis to contaminate the kidney pelvis as well. Gastrointestinal System: Constipation is a frequent problem for immobilized clients because of decreased peristalsis and colon motility. The overall skeletal muscle weakness affects the abdominal and perineal muscles used in defecation. When the stool becomes very hard, more strength is required to expel it. The immobile client may lack this strength. This can lead to impaction. A client’s unnatural and uncomfortable position on a bedpan does not facilitate elimination. The backward-leaning posture does not promote effective use of the muscles used in defecation. Some clients are reluctant to use the bedpan in the presence of others. The embarrassment, lack of privacy, dependence on others to assist with the bedpan, and disruption of normal bowel habits may cause the client to postpone or ignore the urge for elimination. Repeated postponement eventually suppresses the urge and weakens the defecation reflex. Some clients may make excessive use of the Valsalva maneuver by straining at stool in an attempt to expel the hard stool. This effort dangerously increases intra- abdominal and intrathoracic pressures and places undue stress on the heart and circulatory system. Integumentary System: Reduced skin turgor. The skin can atrophy as a result of prolonged immobility. Shifts in body fluids between the fluid compartments can affect the consistency and health of the dermis and subcutaneous tissues in dependent parts of the body, eventually causing a gradual loss in skin elasticity. NURS 3000 - Professional Nursing Mobility Needs Skin breakdown. Normal blood circulation relies on muscle activity. Immobility impedes circulation and diminishes the supply of nutrients to specific areas. As a result, skin breakdown and formation of pressure injuries can occur. Psychoneurologic System: Due to a decline in production of mood-elevating substances such as endorphins, individuals experience negative effects on mood when unable to engage in physical activity. Clients who are unable to carry out the usual activities related to their roles (e.g., as employee, husband, mother, or athlete) become aware of an increased dependence on others. These factors lower the client’s self-esteem. Frustration and the decrease in self-esteem may in turn provoke exaggerated emotional reactions. Emotional reactions vary considerably. Some clients become apathetic and withdrawn, some regress, and some become angry and aggressive. Because the immobilized client’s participation in life becomes much narrower and the variety of stimuli decreases, the client’s perception of time intervals deteriorates. Problem-solving and decision-making abilities may deteriorate as a result of lack of intellectual stimulation and the stress of the illness and immobility. In addition, the loss of control over events can cause anxiety. 6. Table 44.3 Assessing Problems of Immobility p. 1101  Review areas of assessment in each body system. Word the assessment ideas as independent nursing interventions. MUSCULOSKELETAL SYSTEM Position Change Mobility Therapy CARDIOVASCULAR SYSTEM Assess Vital Signs RESPIRATORY SYSTEM Assess Vital Signs METABOLIC SYSTEM Promote fluid and food consumption URINARY SYSTEM Promote ambulation and fluid intake. GASTROINTESTINAL SYSTEM Promote ambulation INTEGUMENTARY SYSTEM Promote skin care, use of lotion PSYCHONEUROLOGIC SYSTEM Promote exercise, reading, thinking games and socialization NURS 3000 - Professional Nursing Mobility Needs 7. What would be important to assess about a client’s mobility status as you are admitting them to your unit? Remember that it is your responsibility to maintain their safety while in your care. The most important thing to assess for a patients mobility status would be their need for assistance. Do they need help transferring, during ambulation and do we need to implement fall precautions for the individual. Safety comes first for the patient and they are under a continuous assessment and evaluation. The care plan will be changed and tailored to the patient.