Regents College Nursing

Study Guide Expanded Notes

Commonalities in Nursing Care: Area A

Study Guide

III. Activity/Mobility

A. Theoretical framework: basis for care

1. Principles related to mobility (e.g., normal body alignment, body mechanics, range of motion, positioning, transfer)

2. Common disturbances related to immobility

a. Physiological responses (e.g., decreased lung expansion, orthostatic hypotension , pressure ulcer , constipation , contractures , renal calculi , thrombophlebitis )

b. Psychological responses (e.g., hopelessness, sensory deprivation, changes in sleep patterns, attention-seeking behaviors, feelings of powerlessness)

c. Developmental responses (e.g., regression in children, increased dependence in the older adult)

3. Factors affecting activity/mobility

a. Developmental level: infancy through senescence

b. Individual preferences and patterns ( e.g., sedentary lifestyle, smoking, energy levels, leisure activities)

c. Physical condition (e.g., nutritional status, muscle atrophy , presence of other illness or disability)

d. Ethnic and cultural considerations (e.g., value of physical activity, compliance with treatment)

e. Socioeconomic factors (e.g., occupation)

f. Environmental factors (e.g., climate)

g. Psychological factors (e.g., hopelessness, helplessness)

4. Theoretical basis for interventions related to activity/mobility

a. Interventions to promote activity/mobility

1) Exercise (e.g., quadriceps setting, active and passive range-of-motion)
2) Positioning
3) Use of mechanical aids (e.g., walkers, canes, crutches)

b. Interventions to prevent complications of immobility

1) Maintain fluid balance
2) Prevent stasis of pulmonary secretions
3) Maintain nutrition
4) Maintain skin integrity
5) Promote venous return
6) Maintain normal elimination patterns
7) Provide psychosocial stimulation
8) Maintain autonomy

B. Nursing care related to theoretical framework

1. Assessment: gather and synthesize data about the patient's activity/mobility needs in relation to the patient's functional health patterns

a. Obtain information about the patient's activity/mobility patterns (e.g., activity tolerance, exercise patterns, ability to perform activities of daily living [ADLs], endurance)

b. Assess factors affecting activity/mobility (see IIIA3)

c. Obtain objective data (e.g., range of motion, gait, body alignment, muscle strength and symmetry, ambulation)

d. Review laboratory and other diagnostic data (e.g., serum calcium levels , blood urea nitrogen [BUN] , hematocrit )

2. Analysis: identify the nursing diagnosis (patient problem) and determine the expected outcomes (goals) of patient care

a. Identify nursing diagnosis (e.g., impaired physical mobility related to bed rest, activity intolerance related to sedentary lifestyle, impaired skin integrity related to increased pressure over bony prominences, high risk for injury related to unsteady gait)

b. Set priorities and establish expected outcomes (patient-centered goals) for care (e.g., patient will demonstrate active range of motion in all body joints; patient will verbalize the need to incorporate exercise into daily activities; patient's skin will be clean, intact, and well-hydrated; patient will not experience injury)

3. Planning: formulate specific strategies to achieve the expected outcomes

a. Plan nursing measures to help the patient achieve the expected outcomes (e.g., instruct the patient to perform range-of-motion exercises, explore the patient's activity preferences, turn and position the patient q2h , provide a safe environment for the patient)

b. Incorporate factors affecting activity/mobility in planning the patient's care (e.g., establish an age-specific exercise program, plan activities based on the patient's age and physical findings, administer prn pain medication prior to exercise)

4. Implementation: carry out nursing plans designed to move the patient towards the expected outcomes

a. Use nursing measures to maintain the patient's activity/mobility (e.g., turning, positioning, active and passive range-of-motion exercises)

b. Promote the use of assistive devices (e.g., walkers, canes, crutches)

c. Provide information and instruction regarding activity/mobility (e.g., instruct the patient in crutch walking, instruct the patient regarding transfer activities, instruct the patient about body mechanics)

5. Evaluation: appraise the effectiveness of the nursing intervention relative to the nursing diagnosis and expected outcomes

a. Record and report the patient's response to nursing actions (e.g., colour and condition of the skin, development of pressure areas, ROM exercises performed, ambulates independently, skin intact no areas of redness, intake and output are normal)

b. Reassess and revise the patient's plan of care as necessary (e.g., turn and reposition the patient more frequently, select a device to minimize pressure for a patient who cannot keep weight off pressure areas)