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Exam 7 > Mobility and Immobility > Flashcards

Mobility and Immobility Flashcards

1
Q

Mobility

A

A person’s ability to move about freely
- nonverbal gestures
- self-defense
- ADLs
- recreational
- satisfaction of basic needs
- expression of emotion

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2
Q

Factors affecting mobility and activity includes

  • developmental
  • nutrition
  • lifestyle
  • stress
  • environment
  • disease and abnormalities
A

Developmental (very old -> comorbidities)
Nutrition
Lifestyle (sitting down all day)
Stress
Environment
Disease and abnormalities

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3
Q

Factors affecting mobility and activity includes

  • developmental
  • nutrition
  • lifestyle
  • stress
  • environment
  • disease and abnormalities
A

Developmental (very old)
Nutrition
Lifestyle
Stress
Environment
Disease and abnormalities

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4
Q

Disease & Abnormalities includes

  • bones, muscles and nervous system
  • pain
  • trauma
  • respiratory system
  • circulatory
  • psychological/ social
A

Bones, muscles and nervous system
Pain
Trauma
Respiratory system
Circulatory
Psychological/ social

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5
Q

Immobility

A

A person’s inability to move about freely
May involve a specific part of the body due to injury

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6
Q

Paraplegia

A

Lower part of the body paralysis

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7
Q

Hemiplegia

A

One side of the body paralysis

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8
Q

Quadriplegia

A

Entire body from the neck down paralysis

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9
Q

Bedrest

A

Restricts patients to bed for therapeutic reasons

  • sometimes prescribed for selected pt
  • reduces physical activity and O2 demand of the body
  • reduces pains
  • allow ill or debilitated pt to rest
  • allows exhausted pt to rest
  • duration depends on illness or injury & prior state of health
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10
Q

Physical causes of immobility

  • bone fracture
  • surgical procedure
  • major sprain or strain
  • illness/ disease
  • cancer
  • aging process
A

Bone fracture
Surgical procedure
Major spring or strain
Illness/ disease
Cancer
Aging process

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11
Q

Psychosocial causes of immobility includes

  • stress/ depression
  • decreased motivation
  • hospitalization
  • long term care facility residents
  • voluntary sedentary lifestyle
A

Stress/ depression
Decreased motivation
Hospitalization
Long term care facility residents
Voluntary sedentary lifestyle

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12
Q

Prolonged immobility

A
  • Reduced functional capacity
  • Altered metabolism
  • Numerous physiological changes
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13
Q

Effects of immobility includes

  • musculoskeletal
  • lungs
  • heart and vessels
  • metabolism
  • integumentary
  • gastrointestinal
  • genitourinary
  • psychological
A

Musculoskeletal
Lungs
Heart and vessels
Metabolism
Integumentary
Gastrointestinal
Genitourinary
Psychological

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14
Q

Musculoskeletal Assessments

A

Activity intolerance
Anthropometric measurements (mass muscle decrease)
Nutrition

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15
Q

Bone Resorption

A

Osteoclasts - move along surface of bone, dissolving grooves into bone with acid and enzymes. Dissolved material, including calcium, is passed through osteoclasts and into bloodstream for reuse by the body

Osteoblasts - occurs when bone is injured, added bone strength is required and calcium is elevated in the bloodstream. Deposits calcium into the bone.

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16
Q

Osteoporosis risk factors include

  • sex (females more affected than males, especially after menopause)
  • insufficient exercise or too much exercise
  • poor diet (low Ca and protein)
  • smoking
  • normal bone
A

Sex ( females more affected than males, especially after menopause )
Insufficient exercise or too much exercise
Poor diet (low in Ca and protein)
Smoking

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17
Q

Range of Motion

Maximum amount of movement available at a joint

A

Joints not moved are at risk for contractures (can begin forming within 8hrs)
ROM exercises improves joint mobility
ROM exercise is the easiest intervention to maintain or improve joint mobility
ROM exercises can be coordinated with other activities

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18
Q

ROM Exercises

  • active ROM
  • Active assist ROM
  • Passive ROM
A

Active ROM
- done by pt

Active assist ROM
- done by pt but w/ help

Passive ROM
- done by nurse or other caregiver
- continuous passive motion, CPM (device)

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19
Q

ROM includes

  • TID
  • start gradually and move slowly using smooth motions
  • support the extrimity
  • stretch the muscle only to the point of resistance/ pain
  • encourage active ROM if possible
A

TID ( after bath, mid-day, bedtime)
start gradually and move slowly using smooth motions
support the extremity
stretch the muscle only to the point of resistance/ pain
Encourage active ROM if possible

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20
Q

Respiratory Assessment Includes

  • lung sounds
  • O2 sats
  • respiratory rate
  • activity tolerance (SOB)
  • chest X-ray
  • arterial blood gases
A

Lung sounds
O2 sats
Respiratory Rate
Activity Tolerance (SOB)
Chest X-ray
Arterial Blood Gases

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21
Q

Cardiac Assessment Includes

  • BP
  • pulse rate
  • heart sounds
  • activity tolerance (BP, HR, chest pain)
  • CALF PAIN
A

Blood pressure
Pulse rate
Heart sounds
Activity tolerance (BP, HR, chest pain)
CALF PAIN

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22
Q

Deep Vein Thrombosis (DVT)

A

decreased muscle activity > pooling of blood > clot formation >DVT’s (ambulation, TED hose, SCD’s)

23
Q

TED Hose

A

thrombo-embolic deterrent Hose
- post surgical
- non-walking pts

24
Q

SCD

A

Sequential Compression Devices
- sleeves around the legs
- alternately inflate and deflate
- post-surgical/ circulatory disorders

25
Q

Metabolism Assessment Includes

  • Decreased appetite
  • Weight Loss
  • Muscle Loss
  • Weakness
  • Labs
A

Decreased appetite
Weight loss
Muscle loss
Weakness
Labs

26
Q

Integument Assessment Includes

  • skin assessment
  • nutrition
  • incontinence
A

Skin assessment
- color changes
- integrity
nutrition
incontinence

27
Q

Pressure Injury

  • Impairment of the skin as a result of prolonged ischemia in tissues
A

develops when pressure on the skin is greater than the pressure inside the small peripheral BV supplying blood to the skin

  • inflammation
  • forms over bony prominence
  • the longer pressure is applied, the greater the risk of injury
28
Q

Gastrointestinal Assessment Includes

  • bowel sounds
  • abd palpation
  • bowel habits (last bowel movement?)
  • I&O
A

Bowel sounds
Abdominal palpation
Bowel habits (last bowel movement?)
I & O

29
Q

Genitourinary Assessment Includes

  • I & O
  • palpate abd
  • incontinence
  • urine (color, smell, clarity?)
A

I & O
Palpate abdomen
Incontinence
Urine (color, smell, clarity?)

30
Q

Urinary Stasis

A

when the renal pelvis fills before urine enters the ureters bc peristaltic contractions of the ureters are insufficient to overcome gravity

31
Q

Urinary Elimination Changes

Immobility (decreased activity) > Decreased fluid intake > Dehydration > Concentrated Urine > Increased risk for UTI & kidney stones

A

Immobility (decreased activity) > Decreased fluid intake > Dehydration > Concentrated Urine > Increased risk for UTI & kidney stones

32
Q

Psychosocial Assessment Includes

  • mood
  • orientation
  • speech
  • affect
  • sleep
A

Mood
Orientation
Speech
Affect
Sleep

33
Q

Psychosocial Effects

  • social isolation
  • loneliness
  • decreased coping
  • depression
  • anxiety
  • withdrawal
  • delerium
A

Social isolation
Loneliness
Decreased coping
Depression
Anxiety
Withdrawal
Delerium

34
Q

Benefits of Mobility Includes

  • strengthen muscles
  • joint flexibility
  • stimulates circulation
  • prevents constipation
  • prevents osteoporosis
  • stimulates the appetite
  • prevents urinary incontinence and infection
  • relieves pressure
  • improves self-esteem
  • decreases anxiety and depression
A

Strengthen muscles (esp those of the abd & legs)
Joint flexibility (esp that of the hips, knees, & ankles)
Stimulates circulation (helps prevent phlebitis & devp of clots)
Prevents constipation (mvmnt of the abd msucles stimulates the intestinal tract)
Prevents osteoporosis ( due to mineral loss from bones when they don’t wear weight)
Stimulates the appetite
Prevents urinary incontinence & infection (when pt are able to go to the CR on their own)
Relieves pressure
Improves self-esteem
Decreased anxiety & depression

35
Q

Ambulation

A

best intervention to prevent immobility complications

36
Q

Restraints

A

any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a pt to move arms, legs, body, or head freely

37
Q

Non-violent restrains

  • actions impede medical care
  • lack of awareness of potential harm to self and others
  • unable to follow commands and comply with safety instructions
  • attempts to pull out tubes, drains, or other lines/ devices medically necessary for treatment
  • requires every 2 hrs monitoring and documentation
  • new order required EVERY CALENDAR DAY
  • when discontinuing, date & time MUST BE DOCUMENTED
A

Actions impeded medical care
Lack of awareness of potential harm to self & others
Unable to follow commands and comply with safety instructions
Attempts to pull out tubes, drains, or other lines/ devices medically necessary for treatment
Requires every 2 hrs monitoring and documentation
New order required every calendar day
When discontinuing, date & time must be documented

38
Q

Restraint Types Include

  • extremity
  • mitten
  • posey
  • belt
A

Extremity
Mitten
Posey
Belt

39
Q

Papoose or Mummy Restraint

A

used on children

40
Q

Covenant’s Restraint Policies Include

Prior to restraining, alternatives must be attempted:
- Reorientation
- Limit setting
- Use of sitter
- Increased observation and monitoring
- Change the pt’s physical environment
- Review & modification of medication regimens

A

Reorientation
Limit setting
Use of sitter
Increased observation & monitoring
Change the pt’s physical environment
Review & modification of medication regimens

41
Q

Alternative Measures

A

Orient family & pt to environment
Offer diversionary activities
Use calm simple statements
Promote relaxation techniques
Attend to needs
Use of glasses/ hearing aids

42
Q

Alternative Measures

Modify the environment
- increase or decrease the light
- place personal items within reach
- place near nurses station
- reduce environmental noise
- keep call button accessible
- use special furniture accordingly (bed alarms)

A

Increase or decrease the light
Place personal items within reach
Place near nurses station
Reduce environmental noise
Keep call button accessible
Use special furniture accordingly (bed alarms)

43
Q

Alternative Measures Include

  • Camouflage
  • Encourage
  • Orient
  • Involve
  • Give
A

Camouflage - IV lines & tubes
Encourage - family to stay with pt & bring familiar objects from home
Orient - pt to person, place & time
Involve - pt in conversation
Give - pt something to do

44
Q

Restraint Guidelines Includes

  • practitioner must order prior to applying
  • in emergencies - may help apply but practitioner must be notified immediately
  • a new order must be obtained daily
  • must be discontinued at the earliest possible time
  • monitoring varies depending on pt needs and situational factors (could be continuous, every 15 min or every 2-3 hrs)
  • assessment includes vital signs, hydration & circulation, skin integrity & pts lvl of distress
A

Practitioner must order to prior to applying
In emergencies - may help apply but practitioner must be notified immediately
A new order must be obtained daily
Must be discontinued at the earliest possible time
Monitoring varies depending on pt needs & situational factors (could be continuous, every 15 min or every 2-3 hrs)
Assessment includes vital signs, hydration & circulation, skin integrity & pts lvls of distress

45
Q

Risks of using restraints includes

  • increase in injury or death
  • loss of self-esteem
  • humiliation
  • fear
  • anger
  • increased confusion & agitation
A

Increase in injury or death
Loss of self-esteem
Humiliation
Fead
Anger
Increased confusion & agitation

MAKE SURE ALL OTHER MEASURES HAVE BEEN TAKEN TO AVOID RESTRAINTS

46
Q

Complications of Restraints Includes

  • impaired skin integrity
  • lower extremity edema
  • altered nutrition
  • physical exhaustion
  • social isolation
  • immobility complications
  • death
A

Impaired skin integrity
Lower extremity edema
Altered nutrition
Physical exhaustion
Social isolation
Immobility complications
Death

47
Q

Intervention Application Includes

  • restrict mvmnt as little as necessary
  • make sure restraint fits properly
  • always tie (slip knot or bow tie) to bed frame/ mattresss springs
  • always explain the need for restraint
  • never leave pt unattended w/ out the restraint
  • pad bony prominences
  • DOCUMENT, DOCUMENT, DOCUMENT
A

Restrict movement as little as necessary
Make sure restraints fit properly
Always tie (slip knot/ bow tie) to bed frame/ mattress springs
Always explain the need for restraint
Never leave pt unattended w/out the restraint
Pad bony prominences
DOCUMENT, DOCUMENT, DOCUMENT

48
Q

Assessment Includes

  • regularly assess the need for continued use of restraints
  • inspect placement area of restraint
  • assess pt’s behavior
  • assess circulation, motion, sensation
  • make sure restraint fits properly
  • vital signs
  • DOCUMENT ASSESSMENT!!!
A

Regularly assess the need for continued use of restraints
Inspect placement area of restraint
Assess pt’s behavior
Assess circulation, motion, sensation
Make sure restraint fits properly
Vital Signs
DOCUMENT ASSESSMENT!!!!!

49
Q

Assessment Includes pt2

  • inspect skin color and edema
  • palpate for skin temp
  • palpate pulse
  • check capillary refill
  • mental status
  • if they are able to respond: ask them to move the limb
  • if they’re able to respond: ask if they have tingling sensation
A

Inspect skin color and edema
Palpate for skin temp
Palpate pulse
Check capillary refill
Mental status
If they’re able to respond: ask them to move the limb
If they’re able to respond: ask if they have tingling sensation

50
Q

Interventions Include

  • ROM
  • reposition
  • nutrition/ hydration/ toileting*
  • release at the earliest possible time
A

ROM
Reposition
Nutrition/ Hydration/ Toileting*
Release at the earliest possible time

51
Q

Documentation Includes

  • any medical evaluation for restraint
  • description of the pt behavior & the intervention used
  • any alternatives/ other less restrictive interventions attempted
  • pt’s condition or symptom that warranted the use of restraints
  • pt’s response to the intervention used & rationale for continued use of the intervention
  • individual pt assessments & reassessments
  • intervals for monitoring
  • revisions to the plan of care
A

Any medical evaluation for restraint
Description of the pt’s behavior & the intervention used
Any alternatives/ other less restrictive interventions attempted
Pt’s condition/ symptom that warranted the use of restraints
Pt’s response to the intervention used & rationale for continued use of the intervention
Individual pt assessments & reassessments
The intervals for monitoring
Revisions to the plan of care

52
Q

Documentations Includes pt2

  • pt’s behavior and staff concerns regarding safety risks to the pt, staff and others that necessitated the use of restraint
  • injuries to the pt
  • death associated with the use of restraint
  • the identity of the practitioner who ordered the restraint
  • orders for restraint
  • notification of the use of restraint to the attending physician
  • consultations
  • pt/ family teaching
  • response when restraint removed
A

Pt’s behavior & staff concerns regarding safety risks to the pt, staff, & others that necessitated the use of restraint
Injuries to the pt
Death associated with the use of restraint
The identity of the practitioner who ordered the restraint
Orders for restraint
Notification of the use of restraint to the attending physician
Consultations
Pt/ family teaching
Response when restraint removed

53
Q

Wheel Dial outside of room includes

  • mobility lvl 1: dependent
  • mobility lvl 2: moderate assistance
  • mobility lvl 3: minimum assistance
  • mobility lvl 4: modified independent
A

Mobilitu lvl 1: dependent
Mobility lvl 2: moderate assistance
Mobility lvl 3: minimum assistance
Mobility lvl 4: modified independent

Exam 7 (2 decks)

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