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National American University

Student Interactive Notes



MODULE TITLE:


Module

5
: Mobility/Hygiene



MODULE CONTENT:


Mobility


A.

Body Mechanics

1.

Definitions

2.

Foundations of body mechanics

3.

Principles of body mechanics

B.

Effects of Exercise

1.

Cardiovascular

2.

Respira
tory

3.

Metabolic

4.

Musculoskeletal

5.

Activity tolerance

6.

Neurosensory

7.

Psychosocial

C.

Effects of Immobility

1.

Metabolic

2.

Respiratory

3.

Cardiovascular

4.

Musculoskeletal

5.

Integument

6.

Urinary

7.

Psychosocial

8.

Developmental

D.

Assessment of Mobility

1.

Range of Motion

2.

Gait

3.

Exercise/Activi
ty tolerance

4.

Physiologic Conditions

E.

Planning Care and Nursing Interventions

1.

Planning

2.

Moving patients in bed

3.

Patient positioning

4.

Positioning devices

5.

Transfers

6.

Range of motion

7.

Orthopedic applications


2

8.

Elastic stockings

9.

Sequential Compression Stockings

F.

Evaluat
ion


Hygiene


A.

Skin Integrity

1.

Integumentary system

2.

Functions of skin

3.

Factors affecting skin integrity

4.

Assessment of skin

5.

Pathophysiology of pressure ulcer formation

6.

Nursing interventions

B.

Bathing

1.

Types

2.

Purposes of daily hygiene

C.

Perineal Care

D.

Care of the Feet

and Nails

E.

Oral Hygiene

F.

Hair Care

G.

Eyes, Ears and Nose

H.

Bedmaking



MODULE OUTCOMES: Upon completion of this module the student will be able to:


1.

List and define key concepts of body mechanics.

2.

Identify and describe the physiological and psychological effec
ts of exercise.

3.

Identify and describe the physiological and psychological effects of immobility.

4.

Discuss the assessment of mobility.

5.

Describe proper lifting techniques and proper patient positioning.

6.

Discuss the use of assistive devices in proper positioni
ng.

7.

Identify and explain the rationale for nursing interventions to reduce the risk of injury due
to immobility.

8.

Discuss evaluation of nursing interventions for the patient with impaired mobility.

9.

Demonstrate minimum competency for the proper positioning o
f the patient who is
immobile.

10.

Demonstrate minimum competency for moving a patient up in bed.

11.

Demonstrate minimum competency for transferring a client.

12.

Identify and discuss the purposes of ROM exercises.

13.

Identify and explain how the joints of the body are
placed th
rough range of motion
exercises.

14.

Identify and describe the use of orthopedic applications in regards to mobility.

15.

Explain the use of assistive devices for ambulating.


16.

Demonstrate minimum competency in assisting patients with impaired mobility.


3

17.

De
scribe and explain the rationale for the application of elastic stockings and sequential
compression stockings.

18.

Identify and describe risk factors and pathogenesis for pressure ulcer development.

19.

List and describe the classifications of pressure ulcers.

20.

Li
st and explain nursing interventions for a client with impaired skin integrity.

21.

Discuss the evaluation of nursing care for the patient with impaired skin integrity.

22.

Discuss factors that influence hygiene practices.

23.

Describe the types of bathing techniques
utilized for clients through the life span.

24.

Demonstrate minimum competency for hygiene cares.

25.

Describe and explain the purpose of perineal care.

26.

Explain the importance of foot care.

27.

Describe measures to provide oral hygiene.

28.

Describe hair
-
washing technique
s.

29.

Discuss hygiene measures for the eyes, ears and nose.

30.

Make an occupied, unoccupied and surgical bed.




Mobility


A.

Body Mechanics


1.

Definitions

a.

body mechanics
-

coordinated efforts of the musculoskeletal and nervous system to
maintain balance, posture and

body alignment during lifting, bending, moving and
performing activities of daily living


b.

center of gravity
-

point at which the mass of a body is centered

c.

line of gravity

d.

base of support
-

foundation that provides for an objects stability

e.

friction
-

for
ce that occurs in a direction opposite to movement

f.

body alignment


2.

Foundation of body mechanics

a.

balance (stability)



low center of gravity



line of gravity passes through the base of support




b.

friction



greater the surface area the greater the amount of fr
iction exerted when trying to
move that body



passive or immobile clients produce more friction with movement




reduce friction by lifting rather than pushing or sliding
-

use a lift sheet, Hoyer
lift, sliding board, slide mats

c.

alignment
-

whether sitting,
standing or lying



elongate spinal column
-

curves within normal


4



body parts
-

normal anatomical position in relation to midline



prevent disuse complications
-

ROM


3.

Principles of body mechanics

a.


b.

use internal girdle and long midriff to stabilize pelvis and pr
otect abdominal organs


pelvic tilt


do not hold your breath

c.

work close to the object to be lifted
-

brings center of gravity closer

d.

increase pulling and pushing forces with rocking

e.


f.

flex knees
-

especially when bending

g.

work at a comfortable height
-


h.

pi
vot motion of feet
-

i.

move smoothly



j.

count so everyone is moving at the same time

k.

pay attention to what you are doing
-



l.

use appropriate equipment



beds
-

move high and low, brakes on, use trapeze if able, have patient hold onto
side rails when turning, us
e slide mats and lift sheets to reduce friction and
shearing forces



chair
-

straight backs
-

try not to lean over high back of chair




wheelchair



m.

get help, usually no more than two other people, more may just get in the way

n.

face the direction of your mo
vement
-

o.

be prepared for lifting and moving patients by



good shoes



good posture



strong muscles of abdomen, thighs



lose weight



plan before you move especially if more than one involved



count


B. Effects of Exercise

1.

Cardiovascular



increased cardiac output



s
trengthens cardiac musculature decreasing workload as work more efficiently



decreased resting heart rate



improved venous return



maintains normal blood pressure in response to position change



5

2.

Respiratory



increased respiratory rate and depth
-

patient with
decreased lung expansion intolerant
of exercise



improved alveolar ventilation
-

due to improved expansion



decreased work of breathing
-

due to improved muscular activity/expansion



improved diaphragmatic excursion
-

due to improved muscular activity



improve
s removal of respiratory secretions


3.

Metabolic



increased basal metabolic rate
-

BMR



improved utilization of glucose and fatty acids
-

also triglyceride breakdown



increased gastric mobility
-

aids elimination of wastes



increased production of body heat



prom
otes the formation of urine and emptying of the bladder


4.

Musculoskeletal



maintains muscle tone and strength



maintains and improves joint mobility



improves muscle tolerance to exercise



reduces bone loss
-

needs to be weight bearing not isometrics



increases
muscle mass


5.

Activity tolerance
-

endurance



improves activity tolerance



decreases fatigue


6.

Neurosensory



maintains coordination and position sense



maintains orientation



aids with sleep


7.

Psychosocial



improved tolerance to stress



improves depression


feel be
tter



decreased illness
-

due to overall effects on body and effects on immune system


C. Effects of Immobility

1.

Metabolic

a.

decrease in BMR
-

b.

altered metabolism of carbohydrates, fats and protein



pancreatic activity decreases


decreased insulin



protein intak
e decreased





negative nitrogen balance


more nitrogen excreted than ingested


c.

fluid and electrolyte imbalance



increased excretion of calcium, chloride and sodium


6



fluid excretion increased due to sodium excretion



diuretic response



d.

gastrointestinal ch
anges



gastric motility decreased



appetite decreased



urinary fluid output increased





interferes with absorption of fluid and nutrients

e.

bone metabolism



excretion of calcium increased


source is bone calcium



calcium in blood increased
-

hypercalcemia


2.

Resp
iratory

a.

lung volume/expansion decreased

b.

work of respiration increased
-


c.

static secretions


increased viscosity
-

pneumonia

d.

atelectasis



3.

Cardiovascular

a.

orthostatic hypotension


b.

cardiac workload increased
-

decreased circulating volume and venous pooling



c.

thrombus formation
-

increase of Ca in blood,


viscosity of blood, venous pooling


4.

Musculoskeletal changes

a.

muscle atrophy
-

decreased muscle tone, size and strength

b.

joint contractures



c.

disuse osteoporosis
-

impaired calcium metabolism


5.

Integument

a.

ti
ssue ischemia
-



b.

pressure ulcer development



impaired cellular metabolism



loss of lean body mass



negative nitrogen balance


6.

Urinary

a.

urinary stasis


no gravitational help

b.

renal calculi
-

increase in excretion of calcium and urinary stasis



7.

Psychosocial

a.

sen
sory input altered
-

either more or less


7

b.

self image altered
-

dependence and inability to care for self

c.

impaired coping


8.

Developmental

a.

regression to previous level of development

b.

failure to progress to next stage of development


D.

Assessment of Mobility

1.

Rang
e of motion



a.

definition
-

maximal amount of movement available at a joint in one of the three
planes of the body
-



sagittal


passes through the body front to back


right and left



frontal


passes through the body from side to side


front and back



tran
sverse


horizontal line


upper and lower portions

b.

key terms


please fill in



extension


joint movement that increases angle between 2 adjoining bones



flexion


bending of a joint



hyperextension
-






abduction


movement of limb away from body



adduction


movement of a limb toward the body



inversion


turning inward or medially



eversion


turning outward or laterally



pronation


turning to the posterior
-



supination


turning to the anterior
-



internal rotation


movement toward the body



external rotation


movement away from the body



dorsiflexion


turning upward of the foot or toes or of hand or fingers



plantar flexion


toe
-
down motion of the foot


2.

Gait


manne
r or style of walking



balance



posture



level of independence



safety


3.

Exercise/activity tolerance



physiologic effects of exercise and activity



monitor for symptoms of
:




recovery time after activity
-


4.

Physiologic conditions



assess body systems likely to be affected by immobility


8



anthropometric measurements
-



E.

Planning Care and Nursing Interventions

1.

Planning

a.

assist patient in achieving his/her maximum level of independence

b.

prevent the complications associated with immobility

c.

set realistic goals

d.

set goals that are measurable

e.

start interventions early in your day

f.

plan ahead
-



g.

precede activity with




2.

Moving patients in bed



raise level of the bed to comfortable working height



remove all pillows,




flex the patients knees and place their feet on the bed if possible
-



friction



cross their arms across their chest
-




nurse to face the direction of movem
ent
-



3.

Patient positioning

a.

supine
-

resting on the back with head of the bed flat



small towel under lumbar spine



pillow under upper shoulders, head and neck,




support feet in dorsiflexion




b.

Fowler’s


on back with head of bed elevated 45 to 60




rest he
ad on bed or small pillow






small pillow or roll under the thighs and ankles



puts pressure on sacrum and ischial tuberosities

c.

Sim’s


semi prone position


lateral position lying partially on abdomen



pillow under head, upper flexed arm, upper flexed leg



mai
ntain feet in dorsiflexion

d.

lateral


side lying



lower head of bed completely or as low as patient tolerates



pillows under head/neck, upper flexed arm, upper flexed leg, behind back



bring lower shoulder blade forward

e.

prone


lying on abdomen





9



turn head to

the side and support with small pillow



small pillow under abdomen and lower legs
-





hang feet off end of bed
-


Responsible for knowing
Moving and

Positioning Clients in Bed


Skill
47
-
1

(pp. 1254
-
1259).


4.

Positioning devices



foot boots
-




trochanter rolls
-




sandbags


provide support, immobilization



hand
-
wrist splints
-




trapeze


assists with bed mobility and transfers



wedge pillow


used to maintain abduction


5.

Transfers

a. think and plan the transfer first



b. know your abilities and the ability of t
he patient and anyone helping you

c.

use assisti
ve devices


d.


e.

move toward the patient’s “good” side
-

don’t try to bear weight on paralyzed or
broken limbs

f.

lock the brakes on bed and wheelchair

g.

raise the head of the bed first
-


h.

assess for comfort, proper body
alignment and undue pressure on body parts after
transfer
-

especially ischial tuberosities


Responsible for knowing
Using Safe
/
Effective Transfer Techniques


Skill
47
-
2

(pp.

1266
-
1274).


6.

Range of motion

a.

definitions



taking a joint through the complete ext
ent of movement which the joint is
normally capable of



range of motion


ROM
-





passive range of motion
-

PROM
-

manual or mechanical means


CPM



b.

purposes







maintain muscle strength and tone





10

c.


principles guiding range of motion exercises



move body part t
o stretch muscles and keep joints flexible
-





start slowly
-




perform at least 2 times a day for immobile patients



support the extremity above and below the joint






perform each movement at least 3
-
5 times



involve patient in planning exercise program and the
ir participation


Responsible for knowing
Range
-
of
-
Motion Exercises


Table
47
-
2

(p. 1236).


7.

Orthopedic applications

a.

casts



check if dry



never cover with plastic
-

increases heat, delays drying, promotes growth of
microorganisms

b.

traction



maintain weights an
d counter balance
-




weights must be free of impedance to do the job
-

if weights are against anything
will decrease their effectiveness

c.

walkers



have patient push up from arms of chair
-




move walker forward and then bring feet up

d.

canes



straight cane and qua
d cane






place cane forward while keeping body weight on both legs



weaker leg moves forward to the cane





stronger leg is then advance past the cane and cycle repeats

e.

crutches



measure for fit




assess for excess pressure on axilla by placing two to three f
ingers between crutch
pad and axilla



use one of four gaits



4 point
-

for those who may weight bear on both limbs
-

move right crutch,
left leg, left crutch, right leg



3 point
-
for those who may bear weight only one leg
-

move weight bearing
limb, then both

crutches with non weight bearing leg



2 point
-

for those who may bear weight at least partially on both limbs, move
crutch and opposite leg, then other crutch and other opposite leg


11



swing through
-
for those who have limited weight bearing abilities both l
ower
limbs, i.e. paraplegics
-

move both crutches forward and then swing legs
through



going up stairs



modified 3 point gait



unaffected leg advanced


crutches and affected leg follow






going down stairs



modified 3 point gait



crutches placed on the stair bel
ow



affected leg moves forward


then unaffected leg follows





8.

Elastic stockings
-

used to improve venous return



measure according to manufacturer’s instructions



thigh high are better than knee high


follow MD order



keep sock smooth
-





Responsible for kno
wing
Appl
ication of TED Hose


Box
47
-
9

(p. 1249).



9.

Sequential compression devices



do not use stockinette


patient usually wearing TED’s



also known as PAS (pneumonic antithrombic stockings), IPC (Intermittent
Pneumonic Compression), etc.


Responsible for

knowing
Application of Sequential Compression

Device

Stockings


Box

47
-
8

(p. 1248).


F. Evaluation



evaluation is summative and continuous



if goals are measurable


evaluation easy



goals unmet


reassess and revise plan of care



Hygiene


A.

Skin Integrity

1.

I
ntegumentary system

a. largest system in the body

b. includes skin, hair, nails, sweat and sebaceous glands


2.

Functions of the skin

a.

protection


12



first of line of defense for the body



prevents bacterial invasion and protects underlying tissues



sebum
-

se
cretion of the skin has antibacterial and antifungal properties

b.

regulates body temperature
-

perspiration and vasoconstriction/vasodilation

c.

sense organ
-

nerve receptors for touch, temperature, pain and pressure

d.

excretory organ
-

excrete water, salts and
nitrogenous wastes

e.

helps maintain water and electrolyte balance

f.

synthesizes and absorbs vitamin D


3.

Factors affecting skin integrity

a.

age



infants and elderly more sensitive



aging skin becomes thinner and loses elasticity

b.

immobilization


risk for pressure u
lcers

c.

impaired sensation


stroke, paralysis, diabetes, local nerve damage

d.

limited caloric, protein or fluid intake

e.

excessive secretions/excretion
-

moisture


bacterial growth and maceration

f.

external devices


casts, restraints, dressings


pressure or fr
iction

g.

vascular insufficiency


impaired venous and arterial circulation

h.

environmental factors
-

sun and wind exposure

i.

hygiene and lifestyle practices


bathing practices, use of lotions, make
-
up



4.

Assessment of skin int
egrity


Braden Scale


Table
48
-
4

(
pp. 1288
-
89).

a.

Braden Scale and Norton Scale tools to rate risk for pressure ulcer development

b.

examine color texture, thickness, turgor, temperature, and hydration

c.

presence and condition of any skin lesions

d.


e.

special note


5.

Pathophysiology of pressure ulcer
formation

a.

predisposing factors

1) pressure



primary cause of pressure ulcers



tissue ischemia
-





nourishment to the cells is decreased



cellular wastes accumulate



if pressure is not relieved
-








2) shearing force


13



pressure exerted against the skin whe
n a patient is moved or repositioned by
being pulled or allowed to slide down in bed



skin and subcutaneous layers adhere to the bed while the muscles and bones
slide in the direction of body movement



minute layers



3) friction



mechanical force exert
ed when skin is dragged across a coarse surface



skin dragged across bed linens






shallow abrasion injuries


4) moisture




5) malnutrition, edema, dehydration


6)


7) age


older adult


8) infection


9) obesity


10) cachexia
-



b.

S
igns and symptoms
(Figure 48
-
3 (p.1280)






reactive blanching hyperemia
-




localized vasodilation to compensate for decrease in perfusion to the
area can prevent injury
-

appears red and warm



area will blanche (turn lighter in color) with fingertip pressure



w
ith dark skin


harder to assess






nonblanching reactive hyperemia
-

progression if pressure not relieved



deep tissue damage has occurred
-

excessive vasodilation



induration
-

localized area of edema as body pulls fluids to the area of
inflammation



area

is much darker than surrounding skin





c.

Stages



Figure
48
-
6

(p.1283)

I.

nonblanchable erythema of intact skin

II.

partial thickness skin loss (epidermis or dermis), superficial
-

abrasion, blister or
shallow crater

III.

full thickness skin loss involving subcutaneous

tissue, does not extend through
underlying fascia

IV.

full thickness skin loss with extensive destruction may involve bone and
muscles, often see undermining of adjacent tissue




14


6.

Nursing interventions

a.

turn all patients who are unable to move themselv
es a minimum of every 2 hours
-



b.

skin cares



various types of devices and products on the market



reduce pressure by turning at least every two hours



pressure reducing mattresses and beds may also be used



keep the skin clean and dry



watch bony prominences
against bony prominences



assess the skin frequently for evidence breakdown




enhance nutrition and fluid balance


B.

Bathing

1.

Types

a.

complete bed bath
-



b.

partial bed bath


bathing only body parts that would cause odor or discomfort


body
parts the patient can
not reach

c.

assisted bath
-

most common



patient sits up at sink or in chair at bedside or in bed when on bedrest



nurse does back, feet, and legs
-



d.

shower
-

fairly common



for cardiac patients should have doctor’s order
-




use shower chair or seat if availabl
e

e.

tub bath


rare in hospital



usually only with independent patients

f.

towel bath
-

post delivery



use beach towel with special soap that doesn’t need to be washed off



lay towel over entire patient and give a mini massage as you wash


2.

Purposes of daily hygie
ne

a.

cleanliness

b.

promotes circulation

c.

exercise (ROM/PROM)

d.

assessment

e.

communication

f.

teaching

g.

stimulate respirations

h.

increase self image and self esteem

i.

increase independence
-

even most debilitated patient can usually wash their own face

j.

refreshes/relaxation

k.

impression to patient and visitors
-

appearance


15

l.

increased perspiration due to fever, meds, and condition

m.

medication use, especially those which are eliminated through the skin

Responsible for knowing
Bathing a Client


Skill
39
-
1

(pp. 869
-
76).



Key points

to remember:



provide privacy, safety, and warmth



promote patient independence



test water temperature to prevent burns






wash eyes with plain water


separate corners of wash cloth






bath distal to proximal


improves circulation



use long firm strokes
-




back

rub should follow a bed bath


C.

Perineal Care

1.

Wear gloves

2.

Frequency of perineal care



a minimum of once every shift






after each voiding post delivery

3.

Female care






urethral meatus 1
st


4.

Male care



wash male genitalia 1
st

penis, 2
nd

scrotum, 3
rd

rectum
-





if unc
ircumcised
-



5.

Urinary catheter care



can use plain soap and water and pat dry



hold onto catheter to reduce tugging at bladder sphincter





Responsible for knowing
Providing Perineal Care


Skill
39
-
2

(pp. 877
-
80).


D.

Care of the Feet and Nails

1.

Foot care



put th
e feet in pan of water while doing bath and let soak


check temperature



do not soak the feet of patients with diabetes, peripheral vascular disease, foot
wounds, rashes







apply lotion
-



16



good fitting shoes



white, cotton socks



never barefoot especially if D
M or PVD


2.

Toenails



do not cut



let podiatrist cut especially with DM or PVD


3.

Fingernails



do not cut if DM or PVD



filing fingernails safest


Responsible for knowing
Performing Nail and Foot Care


Skill
39
-
3

(pp. 880
-
83).


E.

Oral Hygiene

1.

Unconscious patient






p
erform every two hours at a minimum



position patient on their side
-







may bite down with oral stimulation

2.

Dentures



do not use too hot or too cold water to clean
-




line the sink with a washcloth or towel
-

to break the impact should you drop the
dentures



p
rovide the patient with a labeled denture cup



remove at night to give gums a rest and minimize bacterial build up


Responsible for knowing
Providing Oral Hygiene



Skill
39
-
4

(pp. 886
-
88)


Responsible for knowing
Performing Mouth Care for an Unconscious or

Debilitated
Client


Skill
39
-
5

(pp. 888
-
90).





Responsible for knowing
Cleaning Dentures


Box
39
-
13

(p. 891).



F.

Hair Care

1.

Comb or brush at least twice a day

2.


3.

Washing



hair washing tray to use with shampoo and water



disposable shower type cap with shamp
oo that you wet and do not have to rinse

4.

Shaving


special care with razors with blades


anticoagulant and ASA use



17

Responsible for knowing
Shampooing Hair of Bed
-
Bound Client



Box
39
-
14

(p. 892).


G.

Eyes, Ears and Nose

1.

Eyes



clean wash cloth with warm w
ater


no soap



clean inner to outer canthus



use separate corners of wash cloth for each eye

2.

Ears



clean with end of moistened washcloth



do not put anything into an ear to clean it unless specifically ordered


no cotton
swabs, bobby pins, paper clips



store
hearing aids in designated container in drawer of bedside stand

3.

Nose



gently clean nose and internal nares



if on O
2

it is questionable regarding the use of petroleum products near nose



use non petroleum product on lips and around nose if available


H.

Bedmakin
g
-


Responsible for knowing
Making an Unoccupied Bed


Box
39
-
17

(p. 899).


Responsible for knowing
Making an Occupied Bed


Skill
39
-
6

(
pp. 900
-
904)


Key points:



follow basic principles of asepsis



keep soiled linen away from uniform



do not place linen on
the floor



do not fan linen



do not use linen that drops on the floor


put in laundry



use proper body mechanics






lock the bed



linen



put linens in order of use for organization






make one side of the bed completely then make the other side






keep linen smooth


pull out wrinkles



patient



provide warmth and privacy when making an occupied bed