Mobility and restraints Flashcards
mobility definition
a person’s ability to move about freely
examples of mobility -6
~nonverbal gestures
~self-defense
~ADL’s
~recreational
~satisfaction of basic needs
~expression of emotion
factors affecting mobility and activity -6
~developmental
~nutrition
~lifestyle
~stress
~environment
~diseases and abnormalities
diseases and abnormalities affecting mobility -6
~bones, muscles, and nervous system
~pain
~trauma
~respiratory system
~circulatory
~phychological/social
immobility definition
person’s inability to move about freely
paraplegia
may involve lower part of body
hemiplegia
may involve one side of body
quadriplegia
may involve entire body from neck down
bedrest definition
restricts patients to bed for therapeutic reasons
physical causes of immobility -6
~bone fracture
~surgical procedure
~major sprain or strain
~illness/disease
~cancer
~aging process
psychosocial causes of immobility -5
~stress/depression
~decreased motivation
~hospitalization
~long term care facility residents
~voluntary sedentary lifestyle
prolonged immobility stages -3
- reduced functional capacity
- altered metabolism
- numerous physiological changes
effects of immobility -8
~musculoskeletal
~lungs
~heart and vessels
~metabolism
~integument
~gastrointestinal
~genitourinary
~psychological
Musculoskeletal assessments -3
~activity intolerance
~anthropometric measurements
~nutrition
bone resorption uses -2
~osteoclasts
~osteoblasts
osteoclasts
moves along surface of bone, dissolves grooves into bone with acid and enzymes, dissolved materials 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
osteoporosis risk factors -4
~sex, female more than male
~insufficient or too much exercise
~poor diet, low in calcium and protein
~smoking
range of motion definition
Maximum amount of movement available at a joint
active ROM
done by patient
active assist ROM
done by patient but with help
passive ROM
done by caregiver, continuous passive motion
how to do ROM -5
~x3 a day {after bath, mid-day, bedtime}
~start gradually and move slowly
~support the extremity
~stretch the muscle only to the point of resistance
~encourage active ROM if possible
respiratory assessment -6
~lung sounds
~O2 sats
~respiratory rate
~active tolerance {SOB}
~chest X-ray
~arterial blood gases
cardiac assessment -5
~blood pressure
~pulse rate
~heart sounds
~activity tolerance {BP, HR, chest pain}
~calf pain
stages of deep vein thrombosis -4
- decreased muscle activity
- pooling of blood
- clot formation
- DVT {ambulation, TED hose, SCD’s}
TED hose
thrombo-embolic deterrent hose, post-surgical, non walking patient
SCD’s
sequential compression devices, sleeves around the legs, alternately inflate and deflate, post-surgical/circulatory disorders
metabolism assessment -5
~decreased appetite
~weight loss
~muscle loss
~weakness
~labs
integument assessment -3
~skin assessment {color changes, integrity}
~nutrition
~incontinence
pressure injury definition
impairment of the skin as a result of prolonged ischemia {decreased blood supply} in tissues
when would you get a pressure injury?
when pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin
gastrointestinal assessment -4
~bowel sounds
~abdominal palpation
~bowel habits
~I & O
genitourinary assessment -4
~I & O
~palpate abdomen
~incontinence
~urine {color, smell, clarity}
urinary stasis definition
when the renal pelvis fills before urine enters the ureters because peristaltic contractions of the ureters are insufficient to overcome gravity
steps in urinary elimination changes -5
- immobility
- decreased fluid intake
- dehydration
- concentrated urine
- increased risk for UTI and kidney stones
psychosocial assessment -5
~mood
~orientation
~speech
~affect
~sleep
psychosocial effects -7
~social isolation
~loneliness
~decreased coping
~depression
~anxiety
~withdrawal
~delerium
mobility strengthens muscles, especially…
those of the abdomen and legs
mobility helps joint flexibility, especially that of…
the hips, knees, and ankles
mobility stimulates circulation, which helps prevent…
phlebitis and the development of clots
mobility prevents constipation, the movement of the…
abdominal muscles stimulates the intestinal tract
mobility prevents osteoporosis due to the…
mineral loss from the bones when they do not bear weight
mobility stimulates the…
appetite
mobility prevents urinary incontinence and infection because when patients are able to…
go to the bathroom on their own, incontinence is reduced
mobility relieves pressure on the…
body and skin, helping to prevent from pressure injurys
mobility improves self-esteem and the…
patients feeling of independence
mobility decreases anxiety and depression induced by…
hospitalization
best intervention to prevent immobility complication
ambulation
restraints
any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body, or head freely
what is required for non-violent restraints -3
~every 2 hours monitoring and documentation
~new order required for every calender day
~when d/c, date and time must be documented
when would non-violent restraints be used -4
~actions impede medical care
~lack of awareness of potential harm to self and others
~unable to follow commands and comply with safety instuctions
~attempts to pull out tubes, drains, or other lines/devices medically necessary for treatment
covenants restraint policy
prior to restaining, alternatives must be attempted
what do you do for an alternative measure
modify the environment
five steps of alternative measures
~camouflage IV lines & tubes
~encourage family to stay with the patient
~orient patient to person, place, and time
~involve patient in conversation
~give patient something to do
risks of using restraints -6
~increase in injury and death
~loss of self-esteem
~humiliation
~fear
~anger
~increased confusion and agitation
complications of restraints -7
~impaired skin integrity
~lower extremity edema
~altered nutrition
~physical exhaustion
~social isolation
~immobility complications
~death
intervention application -7
~restrict as little movement as necessary
~make sure restraints fit properly
~always tie to bed frame or mattress springs
~always explain the need for restraint
~never leave the patient unattended without the restraints
~pad bony prominences
~document
restraint assessment -7
~regularly assess the need for continued use of restraints
~inspect placement area of restraint
~assess patients behavior
~assess circulation, motion, sensation
~make sure restraint fits properly
~vital signs
~document
VS restraint assessment -7
~inspect skin color and edema
~palpate for skin temp
~palpate pulse
~check capillary refill
~menatal status
~ask to move the limb
~ask if having any tingling
restraint interventions -4
~ROM
~reposition
~nutrition, hydration, toileting
~release at the earliest possible time
