2. Nursing Management of Clients with Stressors that Affect Motor Function NUR101 Fall 2008 LECTURE # 4 K. Burger, MSEd, MSN, RN, CNE PPP By: Sharon Niggemeier RN MSN Revised KBurger806

3. Mobility  Related to the fulfillment of other basic needs  Requires an intact musculoskeletal and nervous system  Body Mechanics = efficient use of body; coordination of muscles/bones/nerves

4. Assessing Motor Functioning  Developmental considerations  Physical Health  Mental Health  Lifestyle/ Health habits  Nerve impairments  Skeletal abnormalities  Muscular impairments  Fatigue/Stress  External factors  Gait/Posture

5. Assessment of Impaired Mobility  Underlying conditions affecting mobility?  ROM; MAE? What is range (degrees)?  Gait steady? Standing erect?  Immobility effects on body systems?  Psychosocial effects?  Developmental effects?  Client expectations?

6. Nursing Diagnosis ACTUAL  Impaired physical mobility RISK  Risk for disuse syndrome  Risk for: Impaired skin integrity Ineffective airway clearance ETC. ETC. ETC.

7. Planning  “Client will walk 100 feet unassisted with steady gait by 9/22/06”  “Client will maintain intact skin throughout hospital stay”  “Client will increase abduction ROM of R shoulder to 180degrees within 2 months”

8. Effects of Immobility on the Body Cardiovascula r  Increased workload  Increased risk for venous thrombus  Increased risk for orthostatic hypotension

9. Nursing Interventions  Ambulate  ROM (Range of motion) exercises  Avoid prolonged knee/hip flexion  Never massage calf muscles  Apply antiembolitic stockings/ sequential TEDS  Sleep with HOB elevated

10. Effects of Immobility on the Body Respiratory  Decreased respiration rate and depth  Pooling of secretions  Impaired gas exchange

11. Nursing Interventions  Ambulate  T & P q2h (turn and position every 2 hours)  Encourage coughing and deep breathing  Keep hydrated

12. Effects of Immobility on the Body  Appetite changes  Constipation  Altered digestion of nutrients Gastrointestinal

13. Nursing Interventions  Ambulate  T&P q2h  Increase fluids and fiber  ROM exercises  Maintain regular exercise  Hi protein, Hi Kcal

14. Effects of Immobility on the Body Musculoskeletal  Decreased muscle tone & strength  Decreased flexibility, joint movement  Decreased endurance  Increased contracture formation  Bone demineralization

15. Nursing Interventions  Ambulate  ROM  Encourage ADLs  Apply assistive devices (braces/splints)  Encourage participation in physical therapy rx

16. Effects of Immobility on the Body Integumentary (skin)  Increased risk for skin breakdown !!!!!  Pressure sores/ decubitus ulcers

17. Nursing Interventions  Ambulate  ROM  T & P  Skin dry & clean  Bed linens wrinkle free  Apply assistive devices (heel pads/ specialty mattress)  Good nutrition  Reduce shearing forces

18. Effects of Immobility on the Body Psychological Well-Being  Increased risk for depression  Decreased self esteem  Decreased socialization  Altered sleep pattern

19. Nursing Interventions  Ambulate  Encourage independence  Increase socialization  Increase stimuli

20. Effects of Immobility on the Body Urinary  Increased urine stasis  Risk for renal calculi  Decreased bladder muscle tone  Increased risk for UTI (urinary tract infection)

21. Nursing Interventions  Ambulate  Encourage fluids  Maintain usual voiding pattern  Assist with bedpan/urinal  Position for full bladder emptying

22. Effects of Immobility on the Body Metabolic System  Increased risk for electrolyte imbalance  Altered exchange of nutrients and gases

23. Nursing Interventions  Provide appropriate diet- high calorie/high protein  Monitor intake and output  Monitor weight  Monitor lab values  Monitor skin turgor  Explore alternatives to oral feedings

24. Meeting Motor Needs Nursing Responsibilities Exercise: prevents illness and promotes wellness Isotonic Isometric Isokinetic Range of motion exercises

25. Range Of Motion  Goal: to exercise and keep body in best possible physical condition when bedrest is needed or immobility is present  PROM- passive ROM – patient is unable to move independently and the nurse moves each joint through full range of motion  AROM- active ROM – patient able to perform joint movement through full range of motion

26. ROM  Explain what each exercise is and how it is done  Move each joint through full range of motion  Move to point of resistance not pain  Perform each movement 5 times smoothly and evenly several times a day  Allow for rest periods prn

27. ROM  Return body part to normal anatomical position  Avoid friction LIFT body part don’t drag  Utilize cupping, cradling and supporting to prevent muscle/joint injury  Note drastic change in VS, extreme fatigue.

28. ROM Exercises  Adduction  Abduction  Flexion  Lateral Flexion  Extension  Hyperextension  Supination  Pronation  Rotation  Internal Rotation  External Rotation  Circumduction  Opposition  Dorsiflexion  Plantar flexion  Inversion  Eversion

29. Transferring  Safety is the MAJOR concern  Know Dx, ability to bear weight, medications  Confirm MD activity order  Plan for assistance  Position bed to proper height/Lock wheels  Skid-free shoes, sensible clothing  Clutter free environment

30. Transferring  Use proper body mechanics  Maintain body alignment  Use assistive devices  Hoyer Lift  Medicate for pain prn  Have patient assist as much as possible  Explain!  Use coordinated count and movement

31. Motor Needs  Log rolling  Dangling  Ambulating  Walker/Canes/Crutches

32. Principals of Body Mechanics  Efficient way to use your body as a machine while caring and transferring for patients. Also used to maintain personal health and well being.  Body Mechanics based on 4 components Balance Posture (body alignment) Coordinated body movement Postural reflexes

33. Principles of Body Mechanics  Ask for help !!!!!!!!!!!!!!!!  Maintain erect posture ( wide base of support & low center of gravity)  Bent at the knees NOT with your back  Use strong arm/leg muscles for power  Maintain internal girdle to support abdomen  Work close to an object

34. Principles of Body Mechanics  Better to Push objects then to pull (not patients)  Better to slide/push or pull objects than lift.  Use body weight as a force for motion  Use back supports

35. Meeting Motor Needs Nursing Responsibilities  Position pt. correctly to maintain alignment  Use devices to aid in positioning Pillows Mattresses Adjustable beds Trapeze Footboard Side rails Hand rolls/splints/braces Trochanter rolls / sandbags / wedge pillows Siderails

36. Meeting Motor Needs Nursing Responsibilities  Protective positioning Fowlers Supine Dorsal recumbent Lateral Sim’s Prone

37. Summary: Promoting Mobility  Nursing responsibility  Need to prevent complications related to immobility  Need to evaluate effectiveness of nursing interventions