WEEK 2 (EDAPT)
Mobility and Immobility
If a client is at high risk for or currently has skin breakdown, the nurse should
reposition them every 1 to 2 hours, provide proper skin care, and get a
specialty air or foam mattress for the client.
The client should be on a high-protein diet with vitamin supplements. Fluids
help with decreasing complications of immobility but they do not help with
skin complications.
Not being able to move or having limited mobility can change a client’s daily
routine. Some clients withdraw from participating in events and seeing
friends and family. This is called social isolation.
Complications from immobility include muscle atrophy, embolus, and urinary
retention.
Fever and diarrhea do not result from being immobile.
Atelectasis is the collapse of a portion of a lung. It is a common respiratory
complication of immobility and surgery. It can be prevented by inspiratory
exercises, coughing, and deep breaths.
Immobility in adulthood may change family and social roles. The client will
need to depend on caregivers to assist with household tasks. The other
choices acknowledge the need for help and do not require immediate follow-
up.
A mobility assessment consists of evaluating range of motion, gait, activity
tolerance, body alignment, strength, and assistive devices.
An assessment for depression and skin integrity is important, but not directly
connected with a mobility assessment.
1
,A person with mobility problems should have a high-protein diet with fruits,
vegetables, and fiber. This will decrease the chances of complications.
Salmon, beans, and a salad meet those criteria.
Breads, fries, and rice do not offer the protein that is needed.
Providing an adequate amount of stimulation, encouraging visits, and
offering diversions can help clients psychologically cope with immobility.
Bringing Carol to the common area provides opportunities for interaction and
is a diversion.
It is too early to consider an antidepressant. Sharing information about
additional activities would also be helpful, but taking Carol directly to the
activities is the better choice. Connecting with family could be an additional
action (with the client's approval), but is not the best choice.
Early ambulation reduces complications and length of stay.
Immobility is always a concern on the first post-operative day. Coughing and
deep breathing help with secretions but should be done every 2 hours or as
needed.
Always remind the client to splint the abdomen while completing breathing
exercises. Range of motion (ROM) can be completed but it should be
encouraged twice daily.
Inadequate fluid intake along with immobility can cause decreased skin
turgor and constipation.
Depression and pain medication may contribute to constipation but not
decreased skin turgor. A negative nitrogen balance leads to muscle wasting.
2
, Clients with impaired mobility can be at risk for decreased lung expansion,
increased oxygen demand, decreased metabolism, and increased cardiac
workload.
Compression stockings and sequential compression devices (SCDs) maintain
external pressure on the legs and promote venous return to the heart. By
reducing the stasis of blood, they reduce the risk for deep vein thrombosis
(DVT) formation in the lower extremities.
Compression stockings do not prevent muscle weakness, improve joint
mobility, or prevent varicose veins.
Clients immobilized or on bed rest for an extended amount of time are at risk
for activity intolerance when mobility increases. This increases the risk for
falls.
The data from the scenario does not support other diagnoses, including
impaired circulation, chronic pain, or risk for impaired skin integrity.
For clients with gastrointestinal complaints, encourage fluids, a high-fiber
diet, and administer medications such as stool softeners or laxatives.
For respiratory complaints, have the client cough, deep breathe, and
complete inspiratory respiratory exercises.
For musculoskeletal complaints, have the client complete active or passive
range of motion. Ambulate if possible.
For urinary complaints, review intake and output as well as hydration.
Catheterization is needed.
By age 4, a child should be able to say their name and speak clearly.
Small children with immobility may have delays in gross motor skills, as well
as in musculoskeletal and intellectual development. Marissa may have
psychological complications by realizing they are different from other
children. Being dependent on parents and enjoying stories is to be expected.
3
Mobility and Immobility
If a client is at high risk for or currently has skin breakdown, the nurse should
reposition them every 1 to 2 hours, provide proper skin care, and get a
specialty air or foam mattress for the client.
The client should be on a high-protein diet with vitamin supplements. Fluids
help with decreasing complications of immobility but they do not help with
skin complications.
Not being able to move or having limited mobility can change a client’s daily
routine. Some clients withdraw from participating in events and seeing
friends and family. This is called social isolation.
Complications from immobility include muscle atrophy, embolus, and urinary
retention.
Fever and diarrhea do not result from being immobile.
Atelectasis is the collapse of a portion of a lung. It is a common respiratory
complication of immobility and surgery. It can be prevented by inspiratory
exercises, coughing, and deep breaths.
Immobility in adulthood may change family and social roles. The client will
need to depend on caregivers to assist with household tasks. The other
choices acknowledge the need for help and do not require immediate follow-
up.
A mobility assessment consists of evaluating range of motion, gait, activity
tolerance, body alignment, strength, and assistive devices.
An assessment for depression and skin integrity is important, but not directly
connected with a mobility assessment.
1
,A person with mobility problems should have a high-protein diet with fruits,
vegetables, and fiber. This will decrease the chances of complications.
Salmon, beans, and a salad meet those criteria.
Breads, fries, and rice do not offer the protein that is needed.
Providing an adequate amount of stimulation, encouraging visits, and
offering diversions can help clients psychologically cope with immobility.
Bringing Carol to the common area provides opportunities for interaction and
is a diversion.
It is too early to consider an antidepressant. Sharing information about
additional activities would also be helpful, but taking Carol directly to the
activities is the better choice. Connecting with family could be an additional
action (with the client's approval), but is not the best choice.
Early ambulation reduces complications and length of stay.
Immobility is always a concern on the first post-operative day. Coughing and
deep breathing help with secretions but should be done every 2 hours or as
needed.
Always remind the client to splint the abdomen while completing breathing
exercises. Range of motion (ROM) can be completed but it should be
encouraged twice daily.
Inadequate fluid intake along with immobility can cause decreased skin
turgor and constipation.
Depression and pain medication may contribute to constipation but not
decreased skin turgor. A negative nitrogen balance leads to muscle wasting.
2
, Clients with impaired mobility can be at risk for decreased lung expansion,
increased oxygen demand, decreased metabolism, and increased cardiac
workload.
Compression stockings and sequential compression devices (SCDs) maintain
external pressure on the legs and promote venous return to the heart. By
reducing the stasis of blood, they reduce the risk for deep vein thrombosis
(DVT) formation in the lower extremities.
Compression stockings do not prevent muscle weakness, improve joint
mobility, or prevent varicose veins.
Clients immobilized or on bed rest for an extended amount of time are at risk
for activity intolerance when mobility increases. This increases the risk for
falls.
The data from the scenario does not support other diagnoses, including
impaired circulation, chronic pain, or risk for impaired skin integrity.
For clients with gastrointestinal complaints, encourage fluids, a high-fiber
diet, and administer medications such as stool softeners or laxatives.
For respiratory complaints, have the client cough, deep breathe, and
complete inspiratory respiratory exercises.
For musculoskeletal complaints, have the client complete active or passive
range of motion. Ambulate if possible.
For urinary complaints, review intake and output as well as hydration.
Catheterization is needed.
By age 4, a child should be able to say their name and speak clearly.
Small children with immobility may have delays in gross motor skills, as well
as in musculoskeletal and intellectual development. Marissa may have
psychological complications by realizing they are different from other
children. Being dependent on parents and enjoying stories is to be expected.
3
