Georgia Baptist College of Nursing of
Mercer University
Nursing Skills Laboratory
MODULE 5: ACTIVITIES OF DAILY LIVING/IMMOBILITY
Focus: Assisting the client with self care deficits
Objectives: Upon completion of this laboratory activity, the learner will be able
to:
1.
Assess a client for risk factors related to immobility.
2.
Identify a plan for teaching clients techniques to reduce the risk of
complications related to immobility.
3.
Assist clients with activities designed to prevent respiratory
complications.
4.
Assist clients with activities designed to prevent circulatory
complications.
5.
Assist clients with altered patterns of elimination.
6.
Provide a safe and comfortable environment for the dependent client.
Apply principles of body mechanics to clinical situations, thus providing
comfort and safety for the client and nurse.
7.
Perform passive range of motion exercises.
Required Readings:
Elkin, M., Perry, A., & Potter, P. (2004). Nursing Interventions and Clinical Skills.
(3rd Ed.). (pp. 110-146, 519-534). St. Louis: Mosby.
Learning Activities:
1.
2.
3.
4.
View and discuss videos (shown in lab). - "Basic Care: Positioning to
Prevent Complications " and "ROM".
Define module vocabulary.
Demonstrate evidence of preparation by participating in lab activities.
Complete "Problems of immobility" worksheet.
Validation:
1.
Demonstrate proficiency in selected lab activities (see module
checklist).
73
2.
3.
4.
Use correct body mechanics for nurse and client.
Maintain your client's comfort, safety, and privacy.
State scientific rationale for each action.
Clinical Application:
1.
2.
3.
Provide safe, thorough, and effective care for the pre- and postoperative
client, clients with mobility needs.
Initiate interventions designed to prevent complications related to the
surgical experience or immobility.
Consult with your clinical faculty for opportunities.
7/039SEB/FK; Rev. 04/04/FK; 02/05/FK
74
MODULE 5: ACTIVITIES OF DAILY LIVING, IMMOBILITY
Vocabulary: Activities of Daily Living
Directions: Define each word in the space provided.
1.
Aspiration pneumonia:
2.
Atelectasis:
3.
Decompression:
4.
Hypoventilaiton:
5.
Hypovolemia:
6.
Hypoxia:
7.
Paralytic ileus:
8.
Postoperative:
11/95/GH;6/98/GH
Revised 11/01/SEB; Rev. 11/03/SEB
75
MODULE 5
PROBLEMS OF IMMOBILITY
Body System
Problems
Assessment
Revised 11/01/SEB
76
Nursing Care
Positioning to Prevent Complications
Immoblilization can produce complications
1.
Respiratory System
A.
Decreased lung expansion
B.
Decreased gas exchange
C.
Secretions accumulate
D.
Pneumonia
2.
Musculoskeletal System
A.
Decreases muscle tone
B.
Atrophy
C.
Contractures
D.
Deformity
3.
Circulatory System
A.
Venous stasis
B.
Edema
C.
Phlebitis
D.
Clot formation (embolus)
4.
Nervous System
A.
Pain
B.
Neuritis
5.
Integumentary System
A.
Decubitus
6.
Gastrointestinal System
A.
Decreases appetite
B.
Poor nutrition
C.
Constipation
Prevent complications via
1.
Change position every two hours
2.
Ask client to assist
3.
Place on a ‘turn schedule’
4.
Keep client in good alignment
Supine positioning
1.
Neutral alignment
2.
Supportive aids
3.
Increase circulation
4.
Susceptible areas to pressureA.
Ear
B.
Scapula
C.
Elbow
D.
Hip
E.
Sacrum
F.
Knees
G.
Ankles
77
5.
6.
H.
Heels
Perform ROM
Provide dry, wrinkle-free bed
Before repositioning
1.
Consider sequence of position
2.
Consider related medical disease
3.
Get supportive aids
4.
Explain procedure to client
5.
Provide privacy
6.
Use proper body mechanics
7.
Assess skin integrity
8.
Provide skin care
9.
Align trunk
10.
Perform ROM
11.
Be sure bed is clean and dry
Four Positions :
1.
Supine
2.
Fowler’s
3.
Side-lying/Lateral
4.
Prone
SupineReposition up in bed
Use trochanter rolls at thigh and hip
Use supportive aids
Prevent footdrop, plantar flexion, contractures
Fowler’sReposition up in bed
Head of bed (HOB) up 45 degrees
Support weak extremities
Use supportive aids
Prevent foot drop
Check proper alignment
Low Fowler’s-approximately 30 degrees
Semi-Fowler’s-approximately 45 degrees
High Fowler’s-approximately 90 degrees
LateralSlide client over to one side with the draw sheet
Place support pillow at back and axillary area
Check proper alignment
Support upper arm
78
Alternate LateralUse if client has difficulty with lateral
Sim’s- (semi-prone)
Position between lateral and prone positions
PronePosition client over to side of bed and lower in bed
Place in side lying position
Roll to center of bed
Support with pillow
Be sure toes are off the end of mattress
Assess client tolerance
REMEMBER SAFETY
Position with draw sheet
Document tolerance, skin condition, skin care
Dev. 09/01/SEB
Rev. 02/05/FK
79
ASSISTIVE DEVICES
1.
Canes
A.
Standard
B.
T- handle
C.
Quad
2.
Crutches
A.
Axillary
B.
Lofstrand (handgrip and forearm band)
3.
Walker
A.
Standard
B.
Foldable
C.
Wheels
Terms
Weight bearing
Partial weight bearing
No weight bearing
REMEMBER SAFETY
Review health status
Assess V/S
Assess level of orientation
Assess ROM
Assess environment
Assess level of understanding
Cane Assisted Ambulation
1.
Used with partial weight bearing
2.
Assess balance, strength, and confidence
3.
Usually used unilaterally
4.
Instruct client to hold cane on uninvolved side.
The cane and weaker leg work together while ambulating
Allow 15-30 degrees elbow flexion with the cane
5.
Move cane forward 6-10 inches, while keeping weight on both legs
6.
Move affected leg forward so it is even with the cane
7.
Bring the unaffected leg past the cane
8.
Move affected leg even with the unaffected leg
9.
Repeat steps
Do not use words like good or bad; instead, use involved/uninvolved
affected/unaffected, right/left
80
Crutch Assisted Ambulation
What disorders necessitate the use of crutches?
REMEMBER SAFETY
Assess arm and shoulder strength
Assess balance
Assess endurance
Proper measurement is important
Standing measurements:
Two or three fingers should fit between the top of the crutch and the axilla and/or
Crutch pads should be 1 1/2- 2 inches below axilla
Rubber tips on crutch should reach 4 - 6 inches to side of client's feet
(Handgrip) Elbow should be flexed 15-30 degrees
AMBULATION
4 point gait
1.
Begin with feet comfortably apart and crutches 6 inches in front and 6
inches to side of each foot. (Be sure body is in alignment) [tripod position]
2.
Keeping feet together, move right crutch forward 4-6 inches
3.
(Crutch and foot move in opposition)
Move left foot forward to be equal level with left cane
4.
Move left crutch forward 4-6 inches
5.
(Crutch and foot move in opposition)
Move right foot forward to be equal level with right crutch
6.
Repeat
3 point gait
1.
Begin in tripod position (above)
2.
Bring both crutches and affected leg forward
3.
Move unaffected leg forward
4.
Repeat
2 point gait
1.
Begin in tripod position (above)
2.
(Crutch and foot move together in opposition)
Move left crutch and right foot forward (together)
3.
Move right crutch and left foot forward (together)
4.
Repeat
81
Swing-to gait
1.
Move both crutches forward
2.
Lift and swing legs to crutches
3.
Repeat
Swing-through gait
1.
Move both crutches forward
2.
Lift and swing legs through and past the crutches
3.
Repeat
Walker Assisted Ambulation
1.
Position- Upper bar of walker is slightly below client's waist.
Elbows are flexed 15-30 degrees (with hands on hand grips)
2.
Lift walker and move forward 6-8 inches. Step forward. Follow-through
with opposite foot. (If one side is affected, step forward with affected leg
first)
3.
Repeat
Outcomes:
1.
Client will correctly demonstrate use of the assistive device
2.
Client ambulates without injury
3.
No significant change(s) in V/S are noted
Documentation
A:ambdevices.901
Dev.9/01/SEB
Rev. 02/05/FK
82
Range of Motion
Objectives of Range of Motion
1.
Improve or maintain a) joint function and b) muscle tone and strength
2.
Promote circulation
3.
Counteract effects of prolonged bedrest or immobilization
4.
Prevent contracture formation
5.
Increase endurance
6
Develop coordination
7.
Prepare for ambulation and activity
Definition Range of Motion- Extent of movement of which a joint is normally
capable
Types of Range of Motion (ROM)
1.
Active Range of Motion (AROM)
2.
Active Assistive Range of Motion (AAROM)
3.
Passive Range of Motion (PROM)
Contracture-
Strength-
EnduranceTypes of movement of a synovial joint:
1.
Pivot joint
2.
Ball and socket joint
3.
Hinge
4.
Condyloid joint
5.
Saddle joint
6
Gliding joint
Joint Movement
1.
Flexion
2.
Extension
3.
Hyperextension
4.
Rotation- Internal and External
5.
Circumduction
6
Opposition
7.
Pronation
8.
Supination
9.
Adduction
83
10.
11.
12.
13.
14.
Abduction
Eversion
Inversion
Dorsiflexion
Plantar flexion
Guidelines for ROM
1.
Wash hands
2.
Explain/teach
3.
Use proper body mechanics
4.
Provide privacy
5.
ROM- Support joint and limb
6
Move smoothly, slowly, rhythmically
7.
Move to resistance (not pain)
8.
Return joint to neutral alignment
9.
Perform 2-3 times per day
10.
Assess client
11.
Document
Suggested order for performing ROM
1.
Wash hands
2.
Explain ROM
3.
Raise bed (body mechanics)
4.
Position client close to side of bed
5.
Neck- flexion, extension, rotation, hyperextension
6.
Shoulder- flexion, extension, hyperextension, abduction, adduction
external rotation, internal rotation, circumduction
7.
Elbow- flexion, extension
8.
Forearm- supination, pronation
9.
Wrist- flexion, extension, hyperextension, radial deviation, ulnar deviation
10.
Hands/fingers- flexion, extension, hyperextension, abduction, adduction
Thumb- flexion, extension, abduction, adduction, opposition
11.
Hip-flexion, -extension, abduction, adduction, external rotation,
internal rotation, circumduction, hyperextension
12.
Knee- flexion, extension
13.
Ankle- dorsiflexion, plantar flexion
14.
Foot- inversion, eversion
15.
Toes- flexion, extension, abduction, adduction
16.
Documentation
17.
Nursing diagnosis- Impaired Mobility
A: ROMvideo
Dev. 9/01/SEB
84
85
Georgia Baptist College of Nursing of
Mercer University
Nursing Skills Laboratory
MODULE 5: ACTIVITY OF DAILY LIVING/IMMOBILITY
ACTIVITY WORKSHEET
Directions: Participate in the following activities. Check or initial when
completed. Have faculty sign or initial in the space provided when you have
completed all activities.
1.
Practice and critique 2 or more crutch-walking gaits.
2.
Assist client with visual deficit to ambulate.
3.
Practice ambulation with a walker.
4.
Practice mobility using a wheelchair.
5.
Perform coughing and deep breathing exercises including
abdominal breathing and incentive spirometer.
6.
Perform leg exercises/ROM on partner.
7.
View and handle sequential compression device/plexipulse.
8.
Apply TED hose to lab partner.
9.
Change client's gown with "IV" in place.
10.
Apply "Depends" (brief) to manikin.
11.
View manikin display with various tubes & drains. Name & describe
management of each tube/drain.
12.
I feel I have mastered the content of this module and am able to
apply in the clinical setting.
13.
I need more practice/instruction.
Faculty
Date
Rev. 04/04/FK
86