A. Alterations causing impaired mobility
1. congenital problems
2. neuromuscular deficits
3. musculoskeletal deficits
4. chronic health problems
5. trauma
6. affective disorders
7. therapeutic modalities
B. Impact of Immobility on Body Systems
1. musculoskeletal
2. cardiovascular
3. respiratory
4. metabolic
5. gastrointestinal
6. integumentary
7. urinary
8. psychoneurologic
C. The Nursing Process in Caring for Clients with
Impaired Mobility
1. assessment
a. objective signs
b. subjective symptoms
2. Nursing Diagnoses (examples)
a. activity intolerance
b. impaired peripheral tissue perfusion
c. impaired gas exchange
d. disuse syndrome
e. impaired skin integrity
f. constipation
g. alterations in thought processes
h. ineffective coping
3. Planning & Nursing Interventions
a. turning, ROM exercises
b. foot and leg exercises
c. anticoagulant therapy
d. deep breathing exercises
e. skin care
f. nutritional interventions
g. diversional activities
h. maintaining relationships, support
i. technology designed to prevent
complications of immobility
Readings:
Kozier: pp. 1068-1075, 857-859, 862-873
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Review:
1. Positioning & Transferring
2. Assisting client to walk
3. ROM exercises
New Skills:
1. 34-2 Transparent Dressing
2. 34-3 Hydrocolloid Dressing
3. 34-4 Irrigating a Wound
4. Applying a Wet to Damp Dressing (in SDLP)
Readings:
Kozier: Review pp. 1058-1066; 1077-1100
Read pp. 856-883
Videos
NUR 104 Skills Video
Nursing Management of Wounds
Wound Care for Nurses
Medcom: Wound Irrigation section of “Closed Suction,
Wound Drainage, Wound Irrigation and Specimen Collection”
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Clinical Assignment
1. Assess the level of mobility of your assigned
client.
2. Assess your assigned client for complications
related to immobility.
3. Implement a plan of care to prevent
complications of immobility.
4. Provide wound care.
In conference:
1. Review the policies and procedures of your
assigned agencies:
a. What screening tool is used to
assess risk for pressure sores?
b. What protocols exist for the care
of pressure sores?
c. What protocols exist for the use of
pressure relieving devices such as
an air fluidized bed?
d. Is the incidence of pressure sores
included in the quality assurance
program of your assigned unit?
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