ATI Chap. 40 Mobility and Immobility exam}| 57 questions fully solved 2023

_____ is freedom and independence in purposeful movement and refers to adapting to and having self-awareness of the environment. Mobility _____ is the inability to move freely and independently at will. Immobility _____ _____ are designed to maintain mobility and prevent or minimize complications of immobility. Nursing interventions Cutaneous stimulation in the form of ______ and ______ applications helps relieve pain and promote healing. cold / heat Promoting _____ _____ is another key component of reducing the complications of immobility. venous return Immobility time frames/examples Temporary - knee arthroplasty Permanent - paraplegia Sudden onset - fractured arm Slow onset - multiple sclerosis The principles of body mechanics are based on: alignment balance gravity friction Movement depends on: Intact skeletal system Skeletal muscles Nervous system Assessment of the client focuses on: mobility range of motion (ROM) gait exercise status activity tolerance body alignment Factors affecting mobility include: Alterations in muscles Injury to the musculoskeletal system Abnormal posture Impaired central nervous system Health status and age Body systems that can be affected by immobility: See ATI Fundamentals pp400-401 for examples Integumentary Respiratory Cardiovascular Metabolic Elimination Musculoskeletal Neurological/Psychosocial Developmental Nursing Interventions Integumentary Maintain intact skin Nursing Interventions Respiratory Maintain airway patency, achieve optimal lung expansion and gas exchange, and mobilize airway secretions. Nursing Interventions Cardiovascular Maintain cardiovascular function, increase activity tolerance, and prevent thrombus formation. Nursing Interventions Metabolic Reduce skin injury and maintain metabolism. Nursing Interventions Elimination Maintain or achieve normal urinary and bowel elimination patterns. Nursing Interventions Musculoskeletal Maintain or regain body alignment and stability, decrease skin and musculoskeletal system changes, achieve full or optimal ROM, and prevent contractures. Nursing Interventions Psychosocial Maintain an acceptable sleep/wake pattern, achieve socialization, and complete self-care independently. Nursing Interventions Developmental Continue expected development and achieve physical and mental stimulation. Therapeutic effects of heat: Increases blood flow Increases tissue metabolism Relaxes muscles Eases joint stiffness and pain Therapeutic effects of cold: Decreases inflammation Prevents swelling Reduces bleeding Reduces fever Diminishes muscle spasms Decreases pain by decreasing the velocity of nerve conduction Clients at risk for injury from heat/cold applications: Very young, fair-skinned, and older clients have fragile skin. Immobile clients cannot move away from uncomfortable treatments. Clients with impaired sensory perception may not feel pain/burning. Do not over use treatments or response might be opposite. Heat treatment contraindications: Bony prominences are more sensitive to heat. Avoid heat applications over metal devices (ex. pacemakers). Do not apply to abdomen of pregnant women. Do not use under an immobile client due to burn risk. Cold applications are inappropriate for clients with: cold intolerance vascular insufficiency cold aggravated conditions like Reynaud's Make sure heat and cold application orders include: Location Duration and frequency Specific type (moist or dry) Temperature Types of MOIST HEAT applications: Hot compresses Hot soaks Sitz baths Types of DRY HEAT applications: Hot pack Warming blanket Types of MOIST COLD applications: Large basin of ice Cold water Cold pack to be used in place of ice Types of DRY COLD applications: Ice bag, Ice collar, ice glove, or a cold pack Cooling blanket Assess heat and cold treatment sites every _____ to _____ minutes 5 to 10 Symptoms to check for with heat or cold treatments: Redness or pallor Pain or burning Numbness Shivering (with cold application) Blisters Decreased sensation Cyanosis (with cold application) Most heat or cold applications are used from _____ to _____ minutes. 15 to 20 Documentation Heat & Cold Application Location, type, length of application Condition of skin before and after Client's ability to tolerate treatment TED thromboembolic device Elastic stockings, or TED's, help maintain external pressure on the _____ of the lower extremities and promote blood return to the heart. muscles SCD Sequential compression devices IPC Intermittent pneumatic compression TED's, SCD and IPC help promote _____ _____. venous return They require a provider's order. ROM exercises promote blood return and can include: ankle pumps foot circles knee flexion Immobile clients should perform leg exercises, increase their ______ ______, and change positions frequently. fluid intake These can all be implemented without a provider's order. True or False? When poor venous return or possible thrombus is suspected, the provider must be notified and no pressure applied to a thrombus to avoid dislodging it. True Remove compression stockings and reapply them at least _____ a day. twice To reduce compression of leg veins, teach clients to avoid: crossing the legs sitting for long periods of time wearing restrictive clothing on lower extremities putting pillows behind the knees massaging the legs When promoting venous return, ROM exercises are performed _____ while the client is awake. hourly Thrombophlebitis/deep vein thrombosis is an inflammation of a vein (usually in a lower extremity) that results in _____ formation. clot