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Nursing Management of Clients with Stressors that Affect Motor Function

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. Mobility . Related to the fulfillment of other basic needs

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Nursing Management of Clients with Stressors that Affect Motor Function

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  1. 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

  2. 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

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

  4. 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?

  5. Nursing Diagnosis ACTUAL • Impaired physical mobility RISK • Risk for disuse syndrome • Risk for:Impaired skin integrityIneffective airway clearanceETC. ETC. ETC.

  6. 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”

  7. Increased workload Increased risk for venous thrombus Increased risk for orthostatic hypotension Effects of Immobility on the Body Cardiovascular

  8. 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

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

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

  11. Effects of Immobility on the Body Gastrointestinal • Appetite changes • Constipation • Altered digestion of nutrients

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

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

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

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

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

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

  18. Nursing Interventions • Ambulate • Encourage independence • Increase socialization • Increase stimuli

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

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

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

  22. 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

  23. Meeting Motor NeedsNursing Responsibilities Exercise: prevents illness and promotes wellness • Isotonic • Isometric • Isokinetic • Range of motionexercises

  24. 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

  25. 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

  26. 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.

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

  28. 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

  29. 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

  30. Motor Needs • Log rolling • Dangling • Ambulating • Walker/Canes/Crutches

  31. 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

  32. 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

  33. 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

  34. 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

  35. Meeting Motor NeedsNursing Responsibilities • Protective positioning • Fowlers • Supine • Dorsal recumbent • Lateral • Sim’s • Prone

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

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