NURS 1730 Lecture Notes - Lecture 3: Ethnocentrism, Ageism, Overactive Bladder
11-63-173
Week Three: January 22-27, 2018
Introduction to Nursing II
Promoting Mobility and Protecting Against Immobility-Related Outcomes
Objectives:
-Identify factors that influence mobility
-Apply the nursing process to promote healthy mobility
-Define evidence-based practice (EBP), identify the steps of EBP and describe the hierarchy of evidence
-Describe interventions to promote mobility and skin integrity in the older adult
Mobility
- Influenced by physiology and principles of body mechanics.
- Alignment and balance
- Gravity and friction
- Movement and posture regulated by..
- Musculoskeletal system
- Skeletal muscle
- Nervous System
Immobility Syndrome
- A state in which an individual is at risk for deterioration of body systems owing to
prescribed or unavoidable musculoskeletal inactivity.
Systemic Effects
Metabolic
- Endocrine, calcium absorption and
gastrointestinal function.
Respiratory
- Atelectasis and hypostatic pneumonia
Cardiovascular
- Orthostatic hypotension, thrombus
Musculoskeletal
- Loss of endurance and muscle mass, and
decreased stability and balance
Muscle Effects
- Loss of muscle mass, muscle atrophy
Skeletal Effects
- Impaired calcium absorption, joint
abnormalities
Urinary Eliminatory
- Urinary stasis, renal calculi
Integumentary
- Pressure ulcer, ischemia.
Frailty Syndrome
→ Incidence and prevalence increases with age.
→ Frail older adults are at high risk for disability, falls, institutionalization, hospitalization, and
death.
→ Various criteria, measures.
- Fried et al. (2011) – Any three of the following:
- Unintentional weight loss
- Exhaustion
- Muscle weakness
- Slowness while walking
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11-63-173
Week Three: January 22-27, 2018
- Low levels of activity
Scarpenic: Loss of skeletal muscle mass. ⇒
Other Effects of Immobility
- Decline in mood-elevating substances
- Perception of time intervals deteriorates
- Problem-solving and decision-making abilities may deteriorate
- Loss of control over events can cause anxiety
- Vulnerability, fear, despair
Multi-System Assessment
-Mobility
- Range of motion (ROM)
- Body alignment - standing, sitting, lying
- Gait
- Exercise and activity tolerance
-Musculoskeletal
- Muscle strength
- Tone
- Mass
-Metabolic
- Anthropometric measurements
- Wound healing
-Cardiovascular
- Blood pressure (BP)
find more resources at oneclass.com
find more resources at oneclass.com
11-63-173
Week Three: January 22-27, 2018
- Pulse
- Peripheral circulation
- Signs of deep-vein thrombosis (DVT)
-Respiratory
- Ventilatory status
- Breath sounds
- Lung expansion
-Elimination
- Habits
- Intake
-Integument
- Colour
- Integrity
- Tugot
Psychological Assessment
- Reactions to immobility
- Developmental stages
- Patient needs, expectations and goals
Nursing Diagnosis
- Activity intolerance
- Risk for frailty syndrome
- Impaired physical mobility
- Impaired skin integrity
- Social isolation
For activity and exercise problems
- Activity intolerance
- Risk for activity intolerance
- Impaired physical mobility
- Sedentary lifestyle
Etiology is where we direct our nursing interventions⇒
The mobility problem becomes the etiology:
- Fear (of falling)
- Ineffective coping
- Social isolation
- Powerlessness
- Risk for falls
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Apply the nursing process to promote healthy mobility. Define evidence-based practice (ebp), identify the steps of ebp and describe the hierarchy of evidence. Describe interventions to promote mobility and skin integrity in the older adult. Influenced by physiology and principles of body mechanics. A state in which an individual is at risk for deterioration of body systems owing to prescribed or unavoidable musculoskeletal inactivity. Loss of endurance and muscle mass, and decreased stability and balance. Frail older adults are at high risk for disability, falls, institutionalization, hospitalization, and death. Fried et al. (2011) any three of the following: Loss of control over events can cause anxiety. Etiology is where we direct our nursing interventions. Etiology lack of blood flow to skin which is under constant pressure. Signs red patches that proceed to blisters, open sores, holes & necrosis. Restored or improved capability to ambulate or participate in adls. Absence of injury from falling or improper use of body mechanics.
