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Module 1 (Intro To Basics) > Mobility/Immobility > Flashcards

Mobility/Immobility Flashcards

1
Q

Mobility def

A

person’s ability to move about freely

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2
Q

Mobility examples

A

nonverbal gestures
self-defense
ADLs
recreational
satisfaction of basic needs
expression of emotion

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3
Q

Factors affecting Mobility and Activity

A

developmental
nutrition
lifestyle
stress
environment
diseases and abnormalities

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4
Q

Diseases and Abnormalities associated with Mobility

A

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

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5
Q

Immobility

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

may involve lower part of body

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7
Q

Hemiplegia

A

paralysis on one side of the body
- common in strokes-

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8
Q

Tetraplegia/Quadriplegia

A

paralysis involving the entire body from the neck down

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9
Q

Bedrest

A

restricts pts to bed for therapeutic reasons

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10
Q

Bedrest reasons

A

sometimes prescribed for selected pts
reduces physical activity and O2 demand of the body
reduces pain
allow ill or debilitated pts to rest
allows exhausted pts to rest
duration depends on illness or injury and the prior state of health

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11
Q

Physical causes of immobility

A

bone fx
surgical procedure
major sprain or strain
illness/disease
cancer
aging process

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12
Q

Psychosocial causes on immobility

A

stress/depression
decreased motivation
hospitalization
long term care facility residents
voluntary sedentary lifestyles

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13
Q

Prolonged Immobility in order

A

-Reduced functional capacity
-Altered metabolism (slows down)
-Numerous physiological changes

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14
Q

Effects of Immobility in what systems?

A

musculoskeletal
lungs
heart and vessels
metabolism
integument
GI
GU
psychological

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15
Q

Immobility - Common effects on body systems
Musculoskeletal

A

brittle bones
contractures
muscle weakness and atrophy
foot drop

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16
Q

Immobility - Common effects on body systems
Nervous System

A

lack of stimulation
feelings of anxiety and isolation
confusion
depression

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17
Q

Immobility - Common effects on body systems
Digestive System

A

decreased appetite and low fluid intake
constipation and/or bowel obstruction
Incontinence
Electrolyte imbalances

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18
Q

Immobility - Common effects on body systems
Integumentary

A

decreased blood flow
pressure ulcer
infections
skin breakdown and pressure ulcers

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19
Q

Immobility - Common effects on body systems
Cardiovascular

A

blood clots
reduced blood flow

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20
Q

Immobility - Common effects on body systems
Respiratory

A

pneumonia
decreased respiratory effort
decreased O2 of blood

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21
Q

Immobility - Common effects on body systems
Urinary

A

reduced kidney function
incontinence
UTI
Urinary retention

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22
Q

Musculoskeletal Assessments

A

-activity intolerance (prolonged bedrest)
-anthropometric measurements (weak bones, muscle loss, stiffness)
-nutrition (need high proteins)

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23
Q

For every week on bed rest, the person loses ___% of their muscle mass

A

10

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24
Q

Bone Reabsorption: Osteoclasts

A

dissolve bone and pass all Ca into the blood stream

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25
Q

Bone Reabsorption: Osteoblasts

A

grow bone and deposit Ca back into the bone

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26
Q

Osteoporosis risk factors
Which gender? Especially after?

A

sex (females are more affected especially after menopause)
insufficient exercise or too much exercise
poor diet ( low in Ca and protein)
smoking
pt on bedrest

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27
Q

Osteoporosis def

A

porous bone with dead space and easily broken

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28
Q

How to prevent osteoporosis?

A

Calcium and Vitamin D (sunlight, dairy, green leafy veggies, eggs, and fish
Protein diet
ROM and exercise

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29
Q

Bone density is strongly related to

A

estrogen

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30
Q

ROM def

A

maximum amount of movement available at a joint
-exercise improves joint mobility
-easiest intervention to maintain or improve joint mobility
coordinated with other activities
- no moving is at risk for contractures (can be formed within 8 hours

31
Q

Active ROM

A

Done by pt completely and instructed by the nurse

32
Q

Active assist ROM

A

Done by pt but with help by nurse

33
Q

Passive ROM

A

done by nurse
continuous passive motion

34
Q

If a patient reports pain or muscle spasms during ROM, _____________ exercises immediately to prevent injury

A

discontinue

35
Q

ROM essentials and criticals to remember

A

3 times daily (after bath, midday, bedtime)
support extremity
start gradually and move slowly using smooth motions
stretch the muscle only to the point of resistance/pain
encourage active ROM if possible

36
Q

Contractures

A

joints flex into an angle and stay there
- shortening of the muscles (hands, arms, and foot drop

37
Q

What is the natural angle for hands to be?

A

fingers angled and prone

38
Q

Respiratory Assessment

A

lung sounds
O2 Sats
Respiratory rate
Activity tolerance (SOB)
CXR (black is good, white clouds bad)
ABG

39
Q

When should you do respiratory assessments of immobile pts?
At risk of developing fluid in lungs

A

general every 8 hours
critical care every 4 hours

40
Q

Cardiac Assessment

A

B/P
Pulse rate
Heart sounds
Activity tolerance (BP, HR, chest pain)
Calf pain

41
Q

When the patient is laying down and has calf pain, the person is at risk of

A

DVT

42
Q

DVT is caused by

A

decreased muscle activity
pooling of blood
clot formation
DVTs

43
Q

How do prevent DVTs?

A

ambulation
TED Hose
SCDs

44
Q

TED Hose

A

Thrombo-embolic deterrent hose
-post surgical
-nonwalking patients

45
Q

SCDs

A

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

46
Q

Metabolism Assessment

A

Decreased appetite
Weight loss
Muscle loss
Weakness
Labs
GI slows down: constipation, bowel obstruction, or perfusion

47
Q

Integument Assessment

A

Skin assessment
-color changes
-integrity
Nutrition
Incontinence

48
Q

Pressure Injury

A

Impairment of the skin as a result of prolonged ischemia (decreased blood supply) in tissues

49
Q

Develops when pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin

A

inflammation
forms over bony prominences
longer pressure applied the greater risk of injury

50
Q

GI Assessment

A

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

51
Q

GU Assessment

A

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

52
Q

Kidney stones are formed by

A

Calcium

53
Q

Urinary Stasis

A

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

54
Q

Development of kidney stones and UTIs

A

When a person is lying, urine can settle in the renal pelvis and bladder, urine is concentrated and thick with calcium

55
Q

Urinary Elimination Changes

A

immobility (decreased activity)
decreased fluid intake
dehydration
concentrated urine
increased risk for UTI and kidney stones

56
Q

Psychological Assessment

A

Mood
Orientation
Speech
Affect
Sleep

57
Q

Psychosocial Effects

A

social isolation
loneliness
decreased coping
depression
anxiety
withdrawal
delerium

58
Q

Benefits of Mobility

A

strengthen muscles (abdomen and legs)
joint flexibility (hips, knees and ankles)
stimulates circulation (helps prevent phlebitis and clot development)
prevents constipation (stimulates intestinal tract)
prevents osteoporosis (mineral loss and when they do not bear weight)
stimulates appetite
prevents urinary incontinence and infection
relieves pressure (prevent pressure injuries)
improves self-esteem
decreases anxiety and depression (induced by hospitalization)

59
Q

Best intervention to prevent immobility complications

A

ambulation

60
Q

Mobility Levels

A

1-dependent
2-moderate assistance
3-minimum assistance
4-modified independent

61
Q

Restraints

A

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

62
Q

Non-Violent Restraints are used when the patient

A

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 hours monitoring and documentation
New orders required every calendar day
When discontinuing, the date & time must be documented.

63
Q

Covenant’s Restraint Policies

A

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

64
Q

Alternative Measures - Nurses

A

Orient family and patient to the environment
Offer diversionary activities
Use calm simple statements
Promote relaxation techniques
Attend to needs (bathroom)
Use of glasses/hearing aids

65
Q

Alternative Measures by modifying measures

A

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

66
Q

Alternative Measures - Nursing Interventions

A

Camouflage lines and tubes
encourage family to stay with pt and bring familiar objects from home
orient pt to person, place and time
involve pt in conversation
give pt something to do

67
Q

Restraint Guidelines

A

Practioner must order prior to applying.
In emergencies – may apply but practioner must be notified immediately.
A new order must be obtained daily.
Must be discontinued at the earliest possible time.
Monitoring varies depending on patient needs and situational factors (could be continuous, every 15 min or every 2-3 hours)
Assessment includes vital signs, hydration and circulation, skin integrity and patient’s level of distress)

68
Q

Risks of Using Restraints

A

Increase in injury or death
Loss of self-esteem
Humiliation
Fear
Anger
Increased confusion and agitation

Make sure all other measures have been taken to avoid restraints

69
Q

Complications of Restraints

A

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

70
Q

Intervention application

A

Restrict movement as little as is necessary
Make sure restraint fits properly
Always tie (slip knot or bow tie) to bed frame/mattress springs
Always explain the need for restraint
Never leave patient unattended without the restraint
Pad bony prominences

DOCUMENT, DOCUMENT, DOCUMENT

71
Q

Documentation

A

any medical evaulation for restraint
Description of the patient’s behavior and the intervention used
Any alternatives or other less restrictive interventions attempted.
Patient’s condition or symptom that warranted the use of restraints
Patient’s response to the intervention used and rationale for continued use of the intervention.
individual pt assessments and reassessments
intervals for monitoring
revisions to the plan of care
orders, consultations, teaching, reponse

72
Q

easiest intervention to maintain or improve joint mobility

A

ROM

73
Q

Requires every ___ hours monitoring and documentation
New orders required every ________

A

2 hours;
Calendar day

Module 1 (Intro To Basics) (32 decks)

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