Nursing Management of Clients with Stressors that Affect Motor Function

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Nursing Management of Clients with Stressors that
Affect Motor Function

• NUR101
• Fall 2010
• LECTURE 4
• K. Burger, MSEd, MSN, RN, CNE
• PPP By Sharon Niggemeier RN MSN
• Revised KBurger806

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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

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Assessing Motor Functioning

• Developmental considerations
• Physical Health
• Mental Health
• Lifestyle/ Health habits
• Nerve impairments

• Skeletal abnormalities
• Muscular impairments
• Fatigue/Stress
• External factors
• Gait/Posture

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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?

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Nursing Diagnosis

• ACTUAL
• Impaired physical mobility
• RISK
• Risk for disuse syndrome
• Risk forImpaired skin integrityIneffective
  airway clearanceETC. ETC. ETC.

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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

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Effects of Immobility on the Body

• Increased workload
• Increased risk for venous thrombus
• Increased risk for orthostatic hypotension

• Cardiovascular

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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

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Effects of Immobility on the Body

• Decreased respiration rate and depth
• Pooling of secretions
• Impaired gas exchange

• Respiratory

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Nursing Interventions

• Ambulate
• T P q2h (turn and position every 2 hours)
• Encourage coughing and deep breathing
• Keep hydrated

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Effects of Immobility on the Body

• Appetite changes
• Constipation
• Altered digestion of nutrients

• Gastrointestinal

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Nursing Interventions

• Ambulate
• TP q2h
• Increase fluids and fiber
• ROM exercises
• Maintain regular exercise
• Hi protein, Hi Kcal

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Effects of Immobility on the Body

• Decreased muscle tone strength
• Decreased flexibility, joint movement
• Decreased endurance
• Increased contracture formation
• Bone demineralization

• Musculoskeletal

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Nursing Interventions

• Ambulate
• ROM
• Encourage ADLs
• Apply assistive devices (braces/splints)
• Encourage participation in physical therapy rx

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Effects of Immobility on the Body

• Increased risk for skin breakdown !!!!!
• Pressure sores/ decubitus ulcers

• Integumentary (skin)

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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

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Effects of Immobility on the Body

• Increased risk for depression
• Decreased self esteem
• Decreased socialization
• Altered sleep pattern

• Psychological
• Well-Being

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Nursing Interventions

• Ambulate
• Encourage independence
• Increase socialization
• Increase stimuli

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Effects of Immobility on the Body

• Increased urine stasis
• Risk for renal calculi
• Decreased bladder muscle tone
• Increased risk for UTI (urinary tract infection)

• Urinary

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Nursing Interventions

• Ambulate
• Encourage fluids
• Maintain usual voiding pattern
• Assist with bedpan/urinal
• Position for full bladder emptying

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Effects of Immobility on the Body

• Metabolic System

• Increased risk for electrolyte imbalance
• Altered exchange of nutrients and gases

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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

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Meeting Motor NeedsNursing Responsibilities

• Exercise prevents illness and promotes
  wellness
• Isotonic
• Isometric
• Isokinetic
• Range of motion exercises

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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

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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

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ROM

• Return body part to normal anatomical position
• Avoid friction LIFT body part dont drag
• Utilize cupping, cradling and supporting to
  prevent muscle/joint injury
• Note drastic change in VS, extreme fatigue.

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ROM Exercises

• Rotation
• Internal Rotation
• External Rotation
• Circumduction
• Opposition
• Dorsiflexion
• Plantar flexion
• Inversion
• Eversion

• Adduction
• Abduction
• Flexion
• Lateral Flexion
• Extension
• Hyperextension
• Supination
• Pronation

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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

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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

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Motor Needs

• Log rolling
• Dangling
• Ambulating
• Walker/Canes/Crutches

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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

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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

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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

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Meeting Motor NeedsNursing 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

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Meeting Motor NeedsNursing Responsibilities

• Protective positioning
• Fowlers
• Supine
• Dorsal recumbent
• Lateral
• Sims
• Prone

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Summary Promoting Mobility

• Nursing responsibility
• Need to prevent complications related to
  immobility
• Need to evaluate effectiveness of nursing
  interventions