NUR-215 Exam 2
Discuss the three components of mobility - answer-ROM
-gait
-exercise
Write nursing interventions and rationale for the following nursing diagnoses: Impaired
physical mobility, and activity intolerance r/t excess weight - answer
Describe "helping a pt to walk" in the acute care setting - answer- asses patient risk to
determine how much assistance is needed
- explain procedure to pt
- begin by sitting pt on side of bed for a few minutes w/ leg dangling (ensure proper
footwear)
- (apply gait belt if required) walk behind pt in case of falling risk
Describe positioning pt's and what the nurse might do before doing so - answer- assess
pt strength, vital signs, coordination, and balance
- carefully lay pt on side and assist to sitting position
- allow pt to sit on bed for 1-2 mins with feet dangling (prevent injury and maintain
safety)
Discuss the use of canes and walkers in the healthcare setting and teaching pts -
answer- assistive devices are used when pt cannot bear full weight
- can reduce the risk of falling, decrease pain with mobility, improve balance
- Walkers: can be used by pt who has lower extremity weakness or has problems with
balance, walkers w/ wheels are useful for pts who have difficulty lifting/advancing the
walker b/c of limited balance or endurance
Disadvantage: walker can roll forwards when eight is applied, teach pt ow to use
walkers safely and avoid risk of falling
- Canes: canes provide less support than a walker and are less stable, most common is
straight legged cane, have pt keep cane on stronger side of body, cane should be
placed forward keeping body weight on both legs
Define passive and active ROM: How does an RN provide passive ROM? When would
they provide it? Purpose of ROM? - answer- active ROM: exercise to the joint by pt
while doing ADLs or during joint assessment
- passive ROM: range of movement through which a joint is moved with ASSISTANCE
- RN provides passive rom by assisting pt with joint movement, it is provided when pt
cannot perform active ROM
- Purpose of ROM is to assess for max amount of movement available at joint in one of
three planes of body (sagittal, frontal, transverse)
, Concerning mobility (turning pts) what can you delegate to NAP? - answerNAP can use
effective transfer techniques ie: bed to chair, sitting, log rolling, bed to bed/stretcher
Can also move/position pts in bed (lateral, semi fowler, supine)
Discuss how pts in acute care are affected by immobility by system (respiratory,
cardiac, etc.) and the nursing interventions to combat each. What assessment types
might you use for each system? - answer- METABOLIC CHANGES: decreased
metabolic rate (altering the metabolism of nutrients, fluid, electrolyte and calcium
imbalance, decreased appetite, slowing peristalsis)
INTERVENTIONS: assess, monitor lab work, encourage intake, provide high protein,
high salorie diet w/ vitamin B and C supplements
- RESPIRATORY CHANGES: atelectasis (partial/complete collapse of lung), hypostatic
pneumonia
INTERVENTIONS: assess, encourage pts to cough and deep breath ever 1-2 hrs,
assist in mobilizing secretions
- CARDIOVASCULAR CHANGES: orthostatic hypotension, increased cardiac workload,
thrombus (clot) formation
INTERVENTIONS: assess for VTE (venous throboembolism), progress from bed to
chair to ambulation, SCD (sequential compression devices that improve blood flow to
legs such as sleeves, imitates walking and promotes blood flow to prevent clots such as
TED ((Thrombo-embolic detterent)) hose) and leg exercises
- MUSCULOSKELETAL CHANGES: muscle effects: lean body mass loss, muscle
atrophy/weakness, skeletel effects: disuse osteoporosis, joitn contracture
(tightening/shortening of joints causing deformity)
INTERVENTIONS: assess mobility, provide PASSIVE ROM, encourage ACTIVE ROM
- INTEGUMENTARY CHANGES: pressure injuries: inflammation, ischemia (reduced
blood flow)
INTERVENTIONS: assess skin/pressure points, reposition every 2 hrs, provide skin
care
- ELIMINATION & BLADDER CHANGES: urinary stasis (stopping of fluid), renal calculi,
infection, constipation/impaction (stuck stool)
INTERVENTIONS: assess for UTI and dehydration, provide adequate hydration,
encourage high fiber diet
Discuss each position, how to move pt into the position, where the pressure points are
in each position (supine, lateral, Sims, prone, etc) - answer- pt is positioned based of of
disease process
- supported (semi) fowlers (HOB elevated): 45-60 degrees, knees slightly elevated
without pressure to restrict circulation in lower legs
- supine: on back
- prone: laying face down, head turned to side, used recently w covid pt, increases
oxygen levels
- side lying (lateral): pt on side, weight on dependent hip and shoulder
- sims: pt places weight on front of body
Discuss the three components of mobility - answer-ROM
-gait
-exercise
Write nursing interventions and rationale for the following nursing diagnoses: Impaired
physical mobility, and activity intolerance r/t excess weight - answer
Describe "helping a pt to walk" in the acute care setting - answer- asses patient risk to
determine how much assistance is needed
- explain procedure to pt
- begin by sitting pt on side of bed for a few minutes w/ leg dangling (ensure proper
footwear)
- (apply gait belt if required) walk behind pt in case of falling risk
Describe positioning pt's and what the nurse might do before doing so - answer- assess
pt strength, vital signs, coordination, and balance
- carefully lay pt on side and assist to sitting position
- allow pt to sit on bed for 1-2 mins with feet dangling (prevent injury and maintain
safety)
Discuss the use of canes and walkers in the healthcare setting and teaching pts -
answer- assistive devices are used when pt cannot bear full weight
- can reduce the risk of falling, decrease pain with mobility, improve balance
- Walkers: can be used by pt who has lower extremity weakness or has problems with
balance, walkers w/ wheels are useful for pts who have difficulty lifting/advancing the
walker b/c of limited balance or endurance
Disadvantage: walker can roll forwards when eight is applied, teach pt ow to use
walkers safely and avoid risk of falling
- Canes: canes provide less support than a walker and are less stable, most common is
straight legged cane, have pt keep cane on stronger side of body, cane should be
placed forward keeping body weight on both legs
Define passive and active ROM: How does an RN provide passive ROM? When would
they provide it? Purpose of ROM? - answer- active ROM: exercise to the joint by pt
while doing ADLs or during joint assessment
- passive ROM: range of movement through which a joint is moved with ASSISTANCE
- RN provides passive rom by assisting pt with joint movement, it is provided when pt
cannot perform active ROM
- Purpose of ROM is to assess for max amount of movement available at joint in one of
three planes of body (sagittal, frontal, transverse)
, Concerning mobility (turning pts) what can you delegate to NAP? - answerNAP can use
effective transfer techniques ie: bed to chair, sitting, log rolling, bed to bed/stretcher
Can also move/position pts in bed (lateral, semi fowler, supine)
Discuss how pts in acute care are affected by immobility by system (respiratory,
cardiac, etc.) and the nursing interventions to combat each. What assessment types
might you use for each system? - answer- METABOLIC CHANGES: decreased
metabolic rate (altering the metabolism of nutrients, fluid, electrolyte and calcium
imbalance, decreased appetite, slowing peristalsis)
INTERVENTIONS: assess, monitor lab work, encourage intake, provide high protein,
high salorie diet w/ vitamin B and C supplements
- RESPIRATORY CHANGES: atelectasis (partial/complete collapse of lung), hypostatic
pneumonia
INTERVENTIONS: assess, encourage pts to cough and deep breath ever 1-2 hrs,
assist in mobilizing secretions
- CARDIOVASCULAR CHANGES: orthostatic hypotension, increased cardiac workload,
thrombus (clot) formation
INTERVENTIONS: assess for VTE (venous throboembolism), progress from bed to
chair to ambulation, SCD (sequential compression devices that improve blood flow to
legs such as sleeves, imitates walking and promotes blood flow to prevent clots such as
TED ((Thrombo-embolic detterent)) hose) and leg exercises
- MUSCULOSKELETAL CHANGES: muscle effects: lean body mass loss, muscle
atrophy/weakness, skeletel effects: disuse osteoporosis, joitn contracture
(tightening/shortening of joints causing deformity)
INTERVENTIONS: assess mobility, provide PASSIVE ROM, encourage ACTIVE ROM
- INTEGUMENTARY CHANGES: pressure injuries: inflammation, ischemia (reduced
blood flow)
INTERVENTIONS: assess skin/pressure points, reposition every 2 hrs, provide skin
care
- ELIMINATION & BLADDER CHANGES: urinary stasis (stopping of fluid), renal calculi,
infection, constipation/impaction (stuck stool)
INTERVENTIONS: assess for UTI and dehydration, provide adequate hydration,
encourage high fiber diet
Discuss each position, how to move pt into the position, where the pressure points are
in each position (supine, lateral, Sims, prone, etc) - answer- pt is positioned based of of
disease process
- supported (semi) fowlers (HOB elevated): 45-60 degrees, knees slightly elevated
without pressure to restrict circulation in lower legs
- supine: on back
- prone: laying face down, head turned to side, used recently w covid pt, increases
oxygen levels
- side lying (lateral): pt on side, weight on dependent hip and shoulder
- sims: pt places weight on front of body
