Immobility and Restraints Flashcards
Mobility
A persons ability to move about freely
Mobility examples
Nonverbal gestures
ADLs
Satisfaction of basic needs
Express emotions
Paraplegia
May involve lower part of the body
Hemiplegia
May involve one side of body
Quadriplegia
May involve entire body from the neck down
Physical causes of immobility
Bone fracture
Surgical procedure
Major sprain or strain
Illness/disease
Cancer
Aging process
Psychosocial causes of immobility
Stress/depression
Decreased motivation
Hospitalizations
Long term care facility residents
Voluntary sedentary lifestyle
Prolonged immobility can
Reduce functional capacity
Alter metabolism
Immobility effects
Every body system
Osteoclasts
Break down bone
Osteoblasts
Grows bone
Deposits calcium into the bone
Osteoporosis risk factors
Sex (more common in women)
Insufficient or excessive exercise
Poor diet
Smoking
Joints not moved are at risk for
Contractures
-can begin forming within 8 hours
Range of motion exercises improves
Joint mobility
Active range of motion is done by
Patient
Active assist ROM is done by
Patient but with help
Passive ROM is done by
Nurse/caregiver
Respiratory assessment
Lung sounds
O2 sats
Respiratory rat
Activity tolerance (SOB)
Turn, cough, deep breath
Deep breath, hold three seconds, cough twice, tighten abdominal muscles
Cardiac assessment
BP
Pulse rate
Heart sounds
Activity tolerance (BP, HR, chest pain)
Calf pain
Deep vein thrombosis
Decreased muscle activity > pooling of blood > clot formation > DVTs (Ambulation, TED hose, SCDs)
TED hose
Thrombo-embolic deterrent hose
-post surgical
-non-walking patients
Sequential Compression Devices (SCDs)
Sleeves around the legs
Alternately inflate and deflate
Post surgical/circulatory disorders
Metabolism assessment
Decreased appetite
Weight loss
Muscle loss
Weakness
Labs
Integument assessment
Skin assessment (color changes, integrity)
Nutrition
Incontinence
Gastrointestinal assessment
Bowel sounds
Abdominal palpation
Bowel habits
I & O
Genitourinary assessment
I & O
Palpate abdomen
Incontinence
Urine (color, smell, clarity)
Urinary stasis
When the renal pelvis fills before the urine enters the ureters because peristaltic contractions of the ureters are insufficient to overcome gravity
Urinary elimination changes
Immobility (decreased activity)
Decreased fluid intake
Dehydration
Concentrated urine
Increased risk for UTI and kidney stones
Psychosocial assessment
Mood
Orientation
Speech
Affect
Sleep
What is the best intervention to prevent immobility complications?
Ambulation
Mobility level 1
Dependent
Mobility level 2
Moderate assistance
Mobility level 3
Minimum assistance
Mobility level 4
Modified independent
Restraint types
Extremity
Mitten
Posey
Belt
Camouflage
Camouflage IV lines and tubes
Encourage
Encourage family to stay with patient and bring familiar objects from home
Orient
Orient patient to person, place, and time
Involve
Involve patient in conversation
Give
Give patient something to do
Restraints must be
Ordered
Risks of using restraints
Increase in injury or death
Loss in self esteem/humiliation
Fear/anger
Increased confusion and agitation
Complications of restraints
Impaired skin integrity
Lower extremity edema
Altered nutrition
Physical exhaustion
Social isolation
Immobility complications
Death
Assessment
Regularly assess the need for continued use of restraints
Inspect placement area
Assess behavior
Assess circulation, motion, sensation
VS
DOCUMENT
The intervals for monitoring
No more than two hours
