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
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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
Assessing Motor Functioning
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Developmental
considerations
Physical Health
Mental Health
Lifestyle/ Health
habits
Nerve impairments
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Skeletal
abnormalities
Muscular
impairments
Fatigue/Stress
External factors
Gait/Posture
Assessment of Impaired Mobility
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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?
Nursing Diagnosis
ACTUAL
 Impaired physical mobility
RISK
 Risk for disuse syndrome
 Risk for:
Impaired skin integrity
Ineffective airway clearance
ETC. ETC. ETC.
Planning
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“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”
Effects of Immobility on the Body
Cardiovascular
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Increased workload
Increased risk for
venous thrombus
Increased risk for
orthostatic
hypotension
Nursing Interventions
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Ambulate
ROM (Range of motion)
exercises
Avoid prolonged knee/hip
flexion
Never massage calf muscles
Apply antiembolitic
stockings/ sequential TEDS
Sleep with HOB elevated
Effects of Immobility on the Body
Respiratory
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Decreased
respiration rate and
depth
Pooling of
secretions
Impaired gas
exchange
Nursing Interventions
 Ambulate
T
& P q2h (turn and position
every 2 hours)
 Encourage coughing and deep
breathing
 Keep hydrated
Effects of Immobility on the Body
Gastrointestinal
 Appetite
changes
 Constipation
 Altered
digestion of
nutrients
Nursing Interventions
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Ambulate
T&P q2h
Increase fluids
and fiber
ROM exercises
Maintain regular
exercise
Hi protein, Hi
Kcal
Effects of Immobility on the Body
Musculoskeletal
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Decreased muscle
tone & strength
Decreased flexibility,
joint movement
Decreased
endurance
Increased
contracture
formation
Bone
demineralization
Nursing Interventions
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Ambulate
ROM
Encourage ADLs
Apply assistive
devices
(braces/splints)
Encourage
participation in
physical therapy rx
Effects of Immobility on the Body
Integumentary
(skin)
 Increased
risk
for skin
breakdown !!!!!
 Pressure
sores/
decubitus ulcers
Nursing Interventions
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Ambulate
ROM
T&P
Skin dry & clean
Bed linens wrinkle free
Apply assistive devices
(heel pads/ specialty
mattress)
Good nutrition
Reduce shearing forces
Effects of Immobility on the Body
Psychological
Well-Being
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Increased risk for
depression
Decreased self
esteem
Decreased
socialization
Altered sleep
pattern
Nursing Interventions
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Ambulate
Encourage
independence
Increase
socialization
Increase stimuli
Effects of Immobility on the Body
Urinary
 Increased
urine stasis
 Risk for renal calculi
 Decreased bladder
muscle tone
 Increased risk for UTI
(urinary tract
infection)
Nursing Interventions
 Ambulate
 Encourage
fluids
 Maintain usual voiding pattern
 Assist with bedpan/urinal
 Position for full bladder
emptying
Effects of Immobility on the Body
Metabolic
System
 Increased
risk
for electrolyte
imbalance
 Altered
exchange
of nutrients and
gases
Nursing Interventions
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Provide appropriate diet- high
calorie/high protein
Monitor intake and output
Monitor weight
Monitor lab values
Monitor skin turgor
Explore alternatives to oral feedings
Meeting Motor Needs
Nursing Responsibilities
Exercise: prevents
illness and
promotes wellness
 Isotonic
 Isometric
 Isokinetic
 Range
of motion
exercises
Range Of Motion
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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
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
ROM
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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.
ROM Exercises
 Adduction
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 Abduction
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 Flexion
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 Lateral
Flexion
 Extension
 Hyperextension
 Supination
 Pronation
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Rotation
Internal Rotation
External Rotation
Circumduction
Opposition
Dorsiflexion
Plantar flexion
Inversion
Eversion
Transferring
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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
Transferring
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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
Motor Needs
 Log
rolling
 Dangling
 Ambulating
 Walker/Canes/Crutches
Principals of Body Mechanics
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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
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Balance
Posture (body alignment)
Coordinated body movement
Postural reflexes
Principles of Body Mechanics
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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
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
Meeting Motor Needs
Nursing Responsibilities
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Position pt. correctly to maintain alignment
Use devices to aid in positioning
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Pillows
Mattresses
Adjustable beds
Trapeze
Footboard
Side rails
Hand rolls/splints/braces
Trochanter rolls / sandbags / wedge pillows
Siderails
Meeting Motor Needs
Nursing Responsibilities
 Protective
positioning
 Fowlers
 Supine
 Dorsal
 Lateral
 Sim’s
 Prone
recumbent
Summary: Promoting Mobility
 Nursing
responsibility
 Need to prevent
complications related to
immobility
 Need to evaluate
effectiveness of nursing
interventions