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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
Metabolism Assessment Includes - Decreased appetite - Weight Loss - Muscle Loss - Weakness - Labs
Decreased appetite Weight loss Muscle loss Weakness Labs
26
Integument Assessment Includes - skin assessment - nutrition - incontinence
Skin assessment - color changes - integrity nutrition incontinence
27
Pressure Injury - Impairment of the skin as a result of prolonged ischemia in tissues
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
Gastrointestinal Assessment Includes - bowel sounds - abd palpation - bowel habits (last bowel movement?) - I&O
Bowel sounds Abdominal palpation Bowel habits (last bowel movement?) I & O
29
Genitourinary Assessment Includes - I & O - palpate abd - incontinence - urine (color, smell, clarity?)
I & O Palpate abdomen Incontinence Urine (color, smell, clarity?)
30
Urinary Stasis
when the renal pelvis fills before urine enters the ureters bc peristaltic contractions of the ureters are insufficient to overcome gravity
31
Urinary Elimination Changes Immobility (decreased activity) > Decreased fluid intake > Dehydration > Concentrated Urine > Increased risk for UTI & kidney stones
Immobility (decreased activity) > Decreased fluid intake > Dehydration > Concentrated Urine > Increased risk for UTI & kidney stones
32
Psychosocial Assessment Includes - mood - orientation - speech - affect - sleep
Mood Orientation Speech Affect Sleep
33
Psychosocial Effects - social isolation - loneliness - decreased coping - depression - anxiety - withdrawal - delerium
Social isolation Loneliness Decreased coping Depression Anxiety Withdrawal Delerium
34
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
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
Ambulation
best intervention to prevent immobility complications
36
Restraints
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
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
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
Restraint Types Include - extremity - mitten - posey - belt
Extremity Mitten Posey Belt
39
Papoose or Mummy Restraint
used on children
40
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
Reorientation Limit setting Use of sitter Increased observation & monitoring Change the pt's physical environment Review & modification of medication regimens
41
Alternative Measures
Orient family & pt to environment Offer diversionary activities Use calm simple statements Promote relaxation techniques Attend to needs Use of glasses/ hearing aids
42
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)
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
Alternative Measures Include - Camouflage - Encourage - Orient - Involve - Give
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
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
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
Risks of using restraints includes - increase in injury or death - loss of self-esteem - humiliation - fear - anger - increased confusion & agitation
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
Complications of Restraints Includes - impaired skin integrity - lower extremity edema - altered nutrition - physical exhaustion - social isolation - immobility complications - death
Impaired skin integrity Lower extremity edema Altered nutrition Physical exhaustion Social isolation Immobility complications Death
47
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
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
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!!!
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
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
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
Interventions Include - ROM - reposition - nutrition/ hydration/ toileting* - release at the earliest possible time
ROM Reposition Nutrition/ Hydration/ Toileting* Release at the earliest possible time
51
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
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
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
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
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
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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