Mobility Chapter42 AllisonSutphin

4Basicelementsfornormalmovement Bodyalignment(posture) Jointmobility Balance Coordination Alignment&Posture Balance Lungexpansion,circulation,organfunction generalhealth,physicalfitness&attractiveness Reflectsmood,selfesteem&personality JointMobility movementoncontraction Flexorsarestrongerthanextensorsinactivitycausesflexion(musclesare permanentlyshortened) I:counteractw/exercise&positionchanges/ROM

Balance Equilibrium labyrinth(innerear) vision(vestibuloocularinput) stretchreceptorsofmuscles&tendons(vestibulospinalinput)

CoordinatedMovement Cerebralcortexvoluntarymotoractivitymovement Cerebellum coordinatedmotoractivitiesofmovementtranslates instructionsintodetailedactions Basalgangliamaintainposture

Table421&422Typeofjointmovements Flexion Extension Hyperextension Abduction Adduction Rotation circumduction Eversion Inversion Pronation Supination Protraction Retraction TypesofExercise Typeofmusclecontraction Isotonic Isometric Isokinetic Sourceofenergy Aerobic anaerobic Isokinetic(resistive) Contraction(isotonic)ortension(isometric)againstresistance Move:machineordevice Physicalconditioning Buildsupmuscles(chest,calves,quads)

Isotonic(dynamic): muscleshortenscontraction&activemovement Run,walk,swim,cycle,ADL,ROM Push&pullagainststationaryobject Increasesmuscletone,mass&strength Maintainjointflexibility&circulation IncreasesHR&COlittletonochangeinBP

Isometric(staticorsetting) changeinmuscletension,nochangeinlength,nomuscleorjoint movement Exertpressureagainstsolidobjecttensing(holdforseveralseconds) Strengthenabdominal,gluteal&quads ModerateincreaseinHR&COnoincreaseinBF

Aerobic activitywhichamtofO2takeninisgreaterthantheamtbodyrequires Largemusclegroups,performedcontinuously&rhythmic Walk,jog,run,cycle,dance,crosscountryskiing,jumprope,row,swim& skate ImproveCVconditioning&physicalfitness

Measuringintensityofexercise TargetHRsustainbasedonage MaximumHR:220age TargetHR:6085%ofmaxHR Talktestabletohaveconversationw/somelaboredbreathing Increaseintensityifunlimitedunlaboreddiscussion Borgscaleofperceivedexertion howdifficultexercisefeelstotheperson

Anaerobic musclescannotdrawoutenoughO2frombloodstream anaerobicpathwaysareusedtoprovideadditionalenergyforashorttime endurancetraining(athletes)

Benefitsofexercisebysystems Musculoskeletal Mildexercisemaintainssize,shape,tone&strength Strenuousexercisemuscleshypertrophy,increasesefficiencyofcontraction Increasesjointflexibility&ROMWtbearingmaintainsbonedensity

Cardiovascular IncreasesHR,strengthofheartcontraction&bloodsupplyIncreasesCO

Respiratory Respiratory Increasesventilation,preventspoolingofsecretions(inbronchi& bronchioles),decreasesbreathingeffort,improvesdiaphragmaticexcursion

GI Improvesappetite&increasesGItracttone>digestion&elimination

Metabolic ElevatesMRwhichincreasesbodyheat,wasteproducts,andcalorieuse Increasesuseoftriglycerides&fattyacidswhichleadstodecreasedserum levelsoftriglyceridesandcholesterol

Urinary IncreasesBladderFunction>excreteswastesmoreeffectivelyprevents stasisofurineinbladder Psychoneurologic Senseofwellbeingimprovesstresstolerance,selfconcept,bodyimage Reducedepression,increasesenergylevel&qualityofsleep Factorsaffectingbodyalignment&activity:Growth&development st Newborn:movementsarereflexive&randomcontrolprogressesduring1 yrGrossmotor(headtotoe)precedesfinemotor Toddler=widestance&unsteadygait 15:gross&finemotorarerefined 612:refinemotor&exercisepatternsforlaterlife Adolescence:growthspurtspostureawkwardnesscanpersistintoadulthood

Factorsaffectingbodyalignment&activity Adult 2040:fewphysicalchangesex.pregnancy(alterscenterofgravity,balance &reducesexercisetolerance) Elderly:decreasedmuscletone,bonedensity,loseofjointflexibility,slow reactiontime,bonemass& osteoporosis=brittle&fragilebonesd/tCadepletion Affectposture,gait&balancepronetohip&vertebraefx

Factorsaffectingbodyalignment&activity:Physicalhealth Congenitalproblems Disordersofnervoussystem:(weak,paralyzed,spasticorflaccid) Musculoskeletaldisorders: Innerearinfections&dizziness(balance) Acute&chronicillness:limitsO2supply&nutrientsformusclecontraction (activitytolerance)

Factorsaffectingbodyalignment&activity:Mentalhealth Depression:affectdesiretomove/activity,lackenergyforhygiene Chronicstress:depleteenergyreserves>fatiguediscouragingexercise Exercisecanenergize&facilitatecoping

Factorsaffectingbodyalignment&activity:Nutrition Undernutrition:muscleweakness&fatigue Vitddeficiency>bonedeformityduringgrowth Cadeficiency>riskofosteoporosis Overnutrition/obesity:distortmovementaffectsposture&balance

Factorsaffectingbodyalignment&activity:PersonalValues&attitudes Familyinfluencesthevalueofregularexercise Lifestyletransmitstochildren Sedentaryfamiliesarespectators Valuesinappearanceinfluenceparticipationinregularexercise

Factorsaffectingbodyalignment&activity:ExternalFactors Temperature&humidity:maydiscourageactivity Availabilityofrecreationalfacilitieslackof$ Neighborhoodsafetypromotesoutdooractivity

Factorsaffectingbodyalignment&activity:Prescribedlimitations Casts,bracessplintsortractionpromotehealing IfSOBmaynotwalkupstairs BRforedema,reducemetabolic&O2needsorpain,tissuerepair

Effectsofimmobilityon:Musculoskeletalsystem Disuseosteoporosis Nowtbearing>bonesdemineralize/osteoporosis, Ca>spongydeform&fx Disuseatrophy: insize>losingstrength&function Contractures:permanentshorteningofmuscleirreversibleexceptbysurgery Stiffness&jointpain Ankylosed Cadeposit Effectsofimmobilityon:Cardiovascularsystem Diminishedcardiacreserve IncreasesrestingHRforeachdayofimmobilization IncreaseduseofValsalvamaneuver tachycardia&cardiacarrhythmias Orthostatic(postural)hypotension Compromisedcerebralperfusion>dizzy/lightheaded,faintaSuddenincrease inHRtoprotectbrain Cardiovascularsystem Venousvasodilatation&stasis musclesdontcontractsufficiently&atrophy Bloodpools>vasodilatation&engorgementincreasesvenousBP Dependentedema serousbloodgoesintointerstitialspaces Impedesvenousreturn>pooling&edema Tissuessusceptibletoinjury Thrombusformation Virchowstriad embolus

Effectsofimmobilityon:Respiratorysystem Decreasedrespiratorymovement decreaseschestexpansion shallowresp&reducevitalcapacity Poolingofrespiratorysecretions interferesw/diffusion Nocough Respiratoryacidosis Respiratory Atelectasis collapseofalobeorentirelungd/tdecreasedsurfactant+secretions blockingbronchioles Hypostaticpneumonia MediaforbacterialgrowthminorURI>severeLRTI>impairsexchange Commoncauseofdeathin:weakened,immobile Effectsofimmobilityon:Metabolicsystem Decreasedmetabolicrate D/tdecreasedenergyrequirements DecreaseinGImotility&digestiveglands Negativenitrogenbalance Catabolic(proteinbkdnofmusclemass)>anabolic(proteinsynthesis)= decreaseinnitrogen Proteinisneededforbuildingmuscletissue&woundhealing Metabolic Anorexia D/tdecreasedMR&increasedcatabolism Decreaseincaloriesd/tdecreaseenergyrequirements Decreaseinprotein>decreaseinnitrogen>malnutrition Negativecalciumbalance Decreaseofbonecalcium

Effectsofimmobilityon:Urinarysystem Urinarystasis Horizontalpositionimpedesemptyingofurinefromkidneys&bladder urinarystasisOccursafterafewdaysofBR Renalcalculi Imbalanceofurinecalciumandcitricacid(alkaline)&formstones Stonespassthroughureters>pain&bleedingorobstruction Urinary Urinaryretention D/tdecreasedbladdermuscletone&inabilitytorelaxperinealmuscles sufficiently Bladderstretches>inhibitsurgetovoid>dribbling Urinary Urinaryinfection staticurine&urinarydistention>minutetears Increasedalkalinityd/tdecreaseCa>^bacteria E.coli(residesincolon)causesUTIs Improperperinealcare,indwellingurinarycatheter, urinaryrefluxbacksuptorenalpelvis>infection

Effectsofimmobilityon:Gastrointestinalsystem Constipation D/tdecreasedperistalsis&colonmotility Weakabdominal&perinealmuscles Unnatural&uncomfortablepositionofbedpan GI Embarrassment,lackofprivacy&dependency&disruptionofnormalhabits Postponement>suppressesurge&weakensdefecationreflex AvoidValsalvamaneuver(increasesintrabdominal&intrathoracicpressures >stressonheart

Effectsofimmobilityon:Integumentarysystem Reducedskinturgor D/tskinatrophy Skinbreakdown D/tdecreasedcirculation&supplyofnutrienttoareas

Effectsofimmobilityon:Psychoneurologicsystem Frustration Decreaseselfesteem Apathetic&withdrawn Angry&aggressive Anxiety D/talteredroles&dependenceonothers Decreasedproblemsolving&decisionmakingd/tlackofintellectual stimulation&stress Impairedsocial&motordevelopmentofyoungchildren Assessing:Nursinghx Activity&exercise(p.1072) Dailyactivitylevel activitytolerance type&frequencyofexercise Recentpatternchangeordifficulties:moredetailedhx Specificnature:whenbegan&frequency Cause&howaffectsdailyliving coping&effectiveness (Table423Assessingimmobilityproblems) Physicalexam Bodyalignment Gait Appearance&movementofjoints Capabilities&limitationsformovement Musclemass&strength Activitytolerance Physicalfitness Bodyalignment Viewlateral,anterior&posterior:shoulder&hips,toes,spine Slumpedcommonproblem(fig4236) Poorposture>lowerbackpain&fatigue

Gait 2phases:stance&swing Assesswhenwalkintoroomorwalk10feet Head,gaze,vertebralcolumn,heeltoe,feet,armswing,gait Assesswithandwithoutdevicetocomparegaits Pace(70100steps/min),needforprosthesisorassistivedevice

Appearance&movementofjoints Inspect(activeorpassiveROM)&palpatebilaterally Joints Deformity muscledevelopment Tenderness Crepitation Temp Degreeofjointmovement(goniometer) Capabilities&limitationsformovement

Clientsillness,encumbrancestomovement: (IVs,cast),mentalalertness&abilitytofollowdirections,balance&coord, orthostatichypotension,comfort/pain,vision

Assessamountofassistancerequired movinginbed,transferring Musclemass&strength st 1 Assesstolowerriskofmusclestrain&injury Obtainappropriateassistance Activitytolerance Determinetoencourageindependence HR,strength,&rhythm RR,depth&rhythm BP Before(atrest),during,immediatelyafteractivity,&3minafter Activitytolerance Stopimmediatelyiftoostrenuous/prolonged Pallor,dizzinessorweakness,increasedHRorRR,changeinheartorresp rhythm,weakpulse,dyspnea,SOB,CP,changeDBPof10mmHgormore Safe:ifHrtobaselinewithin5minafteractivity

Problemsr/timmobility(Table423) Inspect,palpate&auscultate,labs,measure,bodywt,I&O Comparetobaseline Preventcomplications Identifyatrisk:poorlynourished,decreasedsensitivitytopain,tempor pressure,haveCV,pulmonaryornmproblems&unconscious

Diagnosing Activityintolerance Riskforactivityintolerance Impairedphysicalmobility Riskfordisusesyndrome

Diagnosing:mobilityasetiology Fear(offalling) Riskforinjury Powerlessness Selfcaredeficit Selfesteemdisturbance Ineffectiveindividualcoping Planning Determinewhoneedsassistance&degreeofassistanceneeded Makegoalsmeasurable Teachfamily/caregivers Safemoving,lifting,&transferring Planforhomecare Teachingguide Homecareassessment(p.1076)

Implementing Positioning Moving&turning Transferring ROM Ambulating(withorwithoutaids) Preventingcomplicationsofimmobility

Bodymechanics(Table424) closerthelineofgravityistothecenterofthebaseofsupport,thegreaterthe stability broaderthebaseofsupport&lowerthecenterofgravity,thegreaterthe stability&balance Avoid: twisting(rotation)ofthoracolumbarspine acuteflexionofbackw/hips&kneesstraight(stooping)

Lifting Holdobjectclosetobodyscenterofgravitytoavoiddisplacementofcenter ofgravity Synchronize&usemajormusclegroupstopreventbackstrain Maintain12inchesbetweenfeet

Pulling&pushing Enlargebaseofsupportindirectionofmovement Easier&safertopullobjecttowardowncenterorgravity Pivoting Avoidstwistingofspinebyturningbody SEE:Principles&guidelinesr/tbodymechanics(Table424)

Preventingbackinjury Riskfactors: poorstanding&sittingposture Overweight Pregnancy Wearinghighheels Sedentary Wellnessteachingbox:preventingbackinjuries(P.1080)

Supportdevices(BOX421) Pillow Mattress Bedboard Chairbeds Footboot Footboard

Positioningclients weak,frail,inpain,paralyzedorunconscious assessskin&carebefore&pchanges prolongedposition>Detrimental preventsmusclediscomfort,pressureulcers,damagetosuperficialnerves& bloodvessels&contractures Positioning maintains:muscletone&stimulatesposturalreflexes Firm&levelmattress/bedboard Bedclean&dry,wrinklefreesheets,allowformovement Supportdevices Avoidplacingbodypartontopofanothercandamageveins>thrombus (popliteal) Havea24hrsystematicschedule Fowlers/semisitting High:head&trunk90degrees Low/semi:head&trunk1545degrees For:difficultybreathingorheartproblems(diaphragmdropsforexpansion& lungventilation) Avoidneckflexionw/largepillowsbehindhead Orthopneic liesoverbedtableacrosslap Allowsformaximumchestexpansion presslowerpartofchestagainstedgeoftable Dorsalrecumbent(backlying) Head&shouldersslightlyelevatedonsmallpillow comfort&healingpsurgeryoranesthetic Dorsal/supine:head&shouldersarenotelevated

Prone onabdomenheadtooneside,hipsnotflexed Adv:preventsflexioncontractureofhip&knee promotesdrainageofmouth(unconsciousormouthorthroatsurgery recovery) Disadv: Lordosis&plantarflexion notusedif: cervicalorlumbarspineproblems(causeslordosis&rotatesneck) cardiacorrespiratoryproblems(decreaseschestexpansion) Lateral/sidelying lieononeside,flexingtophip&knee Reduceslordosisandpromotesbackalignment Relievespressureonsacrum&heels Ifsensory/motordeficiton1side:placeonunaffectedside Sims/semiprone b/tlateral&prone Facilitatesdrainage/preventaspiration Usedfor: Unconscious:drainagepreventsaspiration Paralyzed:reducespressureonsacrum&greatertrochanterofhip Enemas,examinationortxofperineum Pregnantforsleepingcomfort Sensoryormotordeficit:placeonunaffectedside Moving&turninginbed Procedures: 421movingupinbed 422turningtoalateralorpronepositioninbed 423logrolling 424movingtosittingpositiononedgeofbed

Moving&lifting Assessclientsphysical&mentalability,weight,orthostatichypotension,& ownstrength Relievepain Preparesupportiveequipment(pillows) Explainprocedure,privacy,washhands Raisebed&lockwheels Moving&liftingcont. Facedirectionofmovement Broadstance:trunkforward,flexhips&knees Tightengluteal,abdominal,leg&armmuscles Aftermoving,assessclientscomfort,bodyalignment,tolerance&safety Transferringclients Procedures:425(bed&chair)&426(bed&stretcher) Assessphysical&mentalcapabilitiesofclient Planwhat&how(#assistants,skill&strengthof) Equipmentneeded&checkfxn Removeobstacles Explaintopt&helpstepbystep Support/holdclient Documentplan&clienttolerance Usingahydrauliclift I.e.Hoyerlift Ifptcannothelpthemselvesorwhoaretooheavyforotherstoliftsafely Transfersbetweenbed,WC,bathtuborstretcher Checkinworkingorder Knowyourpolicymayneed2nurses ROMexercises:Active isotonicexercises,moveseachjointthroughcompleteROM,maximally stretchingallmusclegroups maintainsorincreasesmusclestrength&endurance&Cardiorespfunction Preventsdeterioration&contractures FormostWC&ambulatoryclientsuntilregainnormalactivitylevels ROM:Passive AnotherpersonmoveseachjointthroughcompleteROM Onlydoneifclientunabletoachieveactively NotformusclestrengthMaintainsjointflexibility toslightresistance,systematic,3repetitions,seriesBID Candoduringbathlyingsupineismosteffective

ROM:Activeassistive Ctusesstronger,oppositearmorlegtomoveeachofthejointsofalimb incapabletoactivemotion nursecontinuespassivelytomaximaldegree For:strokevictims/hemiplegic ROM:ADLsforjointflexibility Eat,shave,groom,bathe: Write,eat Walking Reaching Dressing Ambulating Longerinbed,moredifficultywalking(weak,unsteady,shaky) D/t:surgery,BR,elderly Preambulatoryexercises Quadricepdrillsorsets Assistingclientstowalk 1or2nurses Assistivedevices Preventpostural(orthostatic)hypotension(boxP.1098) Symptoms: Pallor Diaphoresis Nausea Tachycardia Dizziness NursingIntervention:assisttosupine Usingmechanicalaidsforwalking:Canes elbowshouldbeslightlyflexed Straightlegged Tripodorcrab Quad Walkers Moresupportthancane Standardrequirespartialstrengthtopickup 4&2wheeledrollerwalkersdonotneedtopickup,lessstable,somehave seatonback Makesurebarisbelowwaistw/elbowsslightlyflexed

Crutches Underarmoraxillary Lofstrandorforearm:substitutesacane,metalcuffaroundforearmto stabilizewrists&abilitytoreleasethehandbarforusewithoutfalling Platform,Canadianorelbowextensorhascuffforupperarmtosupport weakextensormusclesofarm(triceps) Readthefollowing Measuringclientsforcrutches Fivestandardcrutchgaits Crutchstance&gaits Gettingin&outofachair Goingup&downstairs