Mobility Flashcards
What medications may make your patient a high fall risk?
PCA/Opiates, anticonvulsants, antihypertensives, diuretics, hypnotics, laxatives, sedatives, and psychotropics
Why would diuretics and laxatives be included on the Fall Risk Assessment list?
Increase urgent trips to the bathroom and possible increased risk of “accidents”
The Fall Risk Assessment includes the patient being “tethered.” What does that mean?
Tethered is attached to something that impedes free movement, such as IV poles/pumps, chest tubes, indwelling catheters, and SCD’s
What is the Fall Risk Assessment Tool?
used to determine if your patient is a fall risk and to what degree they are a fall risk
Is it better for your patient to have a high score or a low score on the Fall Risk Assessment Tool? What is the highest score?
Best score: lowest
Moderate: 6-13
High score: 13+; highest is 28
What is the Braden Scale?
assesses patient’s risk of skin breakdown
Is it better for your patient to have a high Braden score or low Braden score? What is the highest score?
Higher score: least risk of skin breakdown
Lower score: more risk of skin breakdown
Highest score: 20
What is foot drop?
occurs when the muscles become weak or when there is nerve injury
How is foot drop treated?
Braces or splints, PT, nerve stimulation, surgery
One of your patients has a footboard and the other has foot splints to be places fours on and four hours off. What is the purpose of these devices?
prevent foot drop
When do you log roll a patient?
when the patient has had spinal surgery or a possible neck injury
When do you NOT log roll a patient?
when moving the patient from one surface to another, such as from bed to stretcher
What is the turning schedule and why is it important?
Every 2hrs: Back –> Right –> Left –> repeat
The schedule is used to change the position of the patients using pillows to relieve pressure on pressure points and allow proper circulation
BR stands for?
bed rest
OOB stands for?
out of bed
NWB stands for?
non-weight bearing
Define Mobility.
A person’s ability to move about freely and perform functions of daily living
Why is mobility important?
it affects not only physical health but psychological health
What respiratory issues is an immobile patient at risk for? Why?
Atelectasis and pneumonia - due to stasis of secretions and decreased lung expansion
What cardiovascular issues is an immobile patient at risk for?
Orthostatic hypotension, thrombus (blood clot)
Why would an immobile patient be wearing TEDS and/or SCD’s?
TEDs and/or SCD’s decrease the chance for thrombus formation
What musculoskeletal issues is an immobile patient at risk for?
osteoporosis, contractures, muscle atrophy, decubitus uclers/injury
What nutrition and metabolic issues is an immobile patient at risk for?
calcium loss from bones and negative nitrogen balance
What is a negative nitrogen balance?
with immobility there is more protein breakdown than protein synthesis secondary to muscle atrophy and decreased protein intake. Protein breakdown produces nitrogen which can be detected in urine
What elimination issues is an immobile patient at risk for?
UTI, renal calculi, constipation
What are restraints and what are the different types?
Physical or chemical restraints means of stopping a patient from moving freely
Why would restraints need to be used?
patient is a safety threat to self and/or others
A confused patient is on restraints for constantly pulling out their central line , how often do you check on their restraints?
1hr after application, then every 2hrs to release restraints, allow for range of motion and ADLs before reapplying
Why can you NOT pull up all four siderails?
All 4 siderrails up is considered a restraints resulting in more injury from patients trying to climb over siderails. Rules may be different in psychiatric and pediatric units
What is shear?
two layers of tissue rubbing against each other as patient is dragged up in bed
You asked the patients to put their hands across their chest, put their chin to their chest and you have raised the bed to a comfortable height for you. What are you about to do?
move the patient up in bed
When moving a patient up in bed, what devices could be used to reduce friction and shear?
use of hoyer lift and draw sheet
What is the best plan for moving a patient?
ALWAYS use a lift device when available
