220-activity

Question 1

Effects of immobility(increased)

Answer 1

Cardiac work load
Risk for venous thrombosis(pooling of blood risk for pulmonary embolism)
Urinary (uti/kindnet stones)
Risk for contractures(loss of function)
Risk for skin break down(pressure injury)
Sense of powerlessness
Bone loss
Work of breathing

Question 2

Effects of immobility(decreased)

Answer 2

Death of respiration
Rate of respiration(risk of aspiration)
Bladder muscle tone(decreased retention/uti/kidney stone)
Muscle size, tone and strength
Endurance, stability, coordination
Sensory stimulation( prevents depression)

Question 3

Para

Answer 3

Paralyzed below waist

Question 4

Quad

Answer 4

Paralyzed arms and legs(spinal cord)

Question 5

Hemi

Answer 5

Paralyzed on one side but

Question 6

Patient activity assessment

Answer 6

Activity orders
Muscle mass, tone and strength (preexisting conditions)
Joint structure and function
Strength and endurance
Mobility problems
Physical health(pain/condition)
Mental health(depression/ disorder)
Fall risk
Medications(narcotics decrease mobility)
Nutrition

Question 7

What is the AM PAC 6 clicks?

Answer 7

Mobility protocol that consist of 6 questions in EPIC, graded 1-4 and score is added up to give you a score that correlates with patients mobillity goal for that day.

Question 8

what is the AM PAC W/ JH-HLM

Answer 8

Mobility protocol that rates the patient 1-8 and has the patients mobility goals.

Question 9

Patients that should not be moved

Answer 9

unstable(HR<40/>140, Systolic<85/>200, R>35 per min, O2<90 on oxygen)
patients with INR>5/PTT>100 (risk for bleeding)
patients who do not respond to verbal stimuli
spinal trauma/unstable fracture
presence of femoral sheath
thrombolytic administration

Question 10

Passive ROM

Answer 10

patient is unable to lift body parts themselves

Question 11

Active ROM

Answer 11

Patient is able to lift body parts themselves

Question 12

nursing intervention to promote activity

Answer 12

ambulation
ROM
position changes

Question 13

Turn Q2

Answer 13

turn patient every two hours

Question 14

Fowlers position

Answer 14

45-60 degree angle

Question 15

Semi fowlers postion

Answer 15

30 degree angle

Question 16

high fowlers position

Answer 16

90 degree angle

Question 17

protective postion

Answer 17

the use of pillows, blankets, pressure reducing mattress, support boots, hand rolls, trochanter rolls to protect high pressure areas/ areas that are needed for functioning (knees, heels, elbows, scapula, hips, head, hands)

Question 18

Nursing interventions to promote safety

Answer 18

trapeze bars/side rail
physical therapy
turning systems
log rolling
Specialty beds
avoid knee gatching(when the legs move up with the head it puts pressure on knees, poor circulation and risk for blood pooling)

Question 19

Orthopneic postion

Answer 19

sitting up right with upper body hunched over the knees
used for patient that can not breath while laying down (COPD, emphysema)

Question 20

Prone postion

Answer 20

Flat on back with pillow under tummy

Question 21

lateral side laying position

Answer 21

laying onside, use for protective positioning

Question 22

Sim’s position

Answer 22

side laying with one side of arms and legs on pillows and other side is positioned with flat hands and a rolled towel supporting the foot. (prevents foot drop)

Question 23

Lithotomy position

Answer 23

legs in stir ups, flat on back

Question 24

Primoboots

Answer 24

prevents foot drop

Question 25

hand rolls

Answer 25

prevents the hand from closing into a fist

Question 26

trochanter rolls

Answer 26

prevents the hips from turning outwards

Question 27

why is protective positioning used?

Answer 27

it protects the body from pressure injury, and keep the body in a natural functioning position vs a flaccid relaxed position.

Question 28

walkers

Answer 28

adjusted to the height of patients hips

Question 29

canes

Answer 29

hold cane on strong side
advance can
advance weak leg
advance strong leg

Question 30

crutches

Answer 30

axillary and forearm
do not place in armpits