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.. > Module 5 - Mobility and the Older Person > Flashcards

Module 5 - Mobility and the Older Person Flashcards

1
Q

What is the nurses role in relation to mobility and the older person?

A

The nurse’s role to assess, maintain and promote the mobility and functionality for an older person.

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2
Q

What is the medical term for a decrease in skeletal muscle mass?

A

Sarcopenia

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3
Q

How can sarcopenia be avoided?

A

This can be avoided by regular exercise.

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4
Q

What happens to the Neuromuscular System when we age?

A
  • Muscle strength and endurance is reduced resulting in impaired balance.
  • Gradual reduction of speed and power.
  • Reaction time is also slowed.
  • Height decreases.
  • Decrease in bone density.
  • Joints, tendons and ligaments decrease in elasticity, strength and hydration causing stiffness and pain.
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5
Q

How can a nurse promote the health and maintain function of the Neuromuscular System? List 4 interventions.

A
  • Encouraging regular physical activity
  • Assessment of mobility and ability to perform activities of daily living
  • Education about osteoporosis and ensuring adequate intake of Vitamin D and calcium
  • Education regarding falls and falls prevention
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6
Q

What assessment is used to identify falls risk?

A

Ontario Modified Stratify (Sydney Scoring) Falls Risk Screen Falls Prevention in Hospital

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7
Q

What are some fall prevention strategies? List 5.

A
  1. Regular falls risk assessments.
  2. Ensure glasses, hearing and other sensory aids are on or within reach.
  3. Advocate for a review of all medications (with particular attention to sedatives, antidepressants, antipsychotics and opioids)
  4. Consider need for Vitamin D or calcium supplements
  5. Measure postural BP to identify any postural hypotension
  6. UTI screening.
  7. Refer to physiotherapy >assess mobility, recommend mobility aids and exercise plan.
  8. Documentation and handover.
  9. Appropriate footwear (non-slip socks, etc)
  10. Promote physical activity
  11. Education regarding falls risk.
  12. Promote usual bowel and urinary function for the person
  13. Surrounding environment (height of the bed, brakes functioning, surroundings is free from clutter, appropriate lighting, ensure water, personal belongings and food is within reach)
  14. Consider placing a person who is deemed a high risk of falls close to staff,
  15. ensure call bell is also within reach and consider if hip protectors are appropriate for the person.
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8
Q

How does the WHO describe a fall?

A

‘an event which results in a person coming to rest inadvertently on the ground or floor or other lower level’

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9
Q

What are the functions of the skin?

A
  • protecting underlying tissues from injury
  • regulating body temperature,
  • secretion of sebum (an oily substance),
  • nerve receptors that respond to stimuli - including pain, temperature, touch and pressure producing
  • absorbing vitamin D
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10
Q

What happens to the skin when we age?

A
  • Epidermis thins as cells contain less moisture and cell regeneration declines.
  • Melanocytes decrease reducing UV protection. Age spots appear.
  • Vitamin D production decreases.
  • Dermis: dermal epidermal layer also thins. Collagen decreases and elastin fibres thicken.
  • Greater fragility of blood vessels and decrease in numbers.
  • Sebaceous glands produce less oil (sebum).
  • Sweat glands decrease in number reducing perspiration, and can lead to hyperthermia.
  • Hypodermis: fat cell layer thins, reducing protection from trauma and insulation.
  • Loss of fat on feet predisposes to calluses.
  • Nerve changes so response to pressure, pain and light touch are altered.
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11
Q

What happens to hair when we age?

A
  • Gradual decrease in pigment from the hair bulb.
  • Hair become thinner.
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12
Q

What happens to our nails when we age?

A

The nails the fingers and toes become thicker, form ridges in the nails and slow in rate of growth, as a result of the increase in calcium deposition.

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13
Q

How can we promote the health of the Integumentary System?

A
  • Ensure appropriate nutritional intake (including water)
  • Encourage use of moisturisers and creams (not sorbolene) immediately after showering or bathing.
  • Avoiding sun exposure/damage, and promoting use of sunscreen with a high SPF and other sun protection measures (hats, sunglasses)
  • Promote regular checking of skin and getting lesions checked by a medical professional.
  • Avoiding harsh materials on the skin (towels, sheets, clothing)
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14
Q

What are two assessments used to measure skin integrity?

A

Braden Scale and Waterlow Scale.

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15
Q

What are some measures to prevent pressure injuries? List 5.

A
  1. Good nutrition
  2. Hydration
  3. Regular and careful mobilisation
  4. Good skin hygiene
  5. Good moisturising regime.
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16
Q

What could be indications of skin integrity issues?

A
  • Dry skin,
  • oedema,
  • variations in skin colour,
  • bruising,
  • inflammation,
  • scratch marks,
  • jaundice,
  • swelling,
  • breaks, ulcers, lesions or rashes.
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17
Q

When touching to assess skin, you need to assess:

A
  1. Texture Moisture (wet or dry?)
  2. Swelling
  3. Temperature
  4. Reddened areas
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18
Q

What is the name of the classification system used for skin tears?

A

Skin Tear Audit Research (STAR) classification system

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19
Q

Describe Category 1a of STAR

A

Edges can be realigned to the normal anatomical positions without stretching. Skin flap is NOT pale, dusky or darkened.

20
Q

Describe Category 1b of STAR

A

Edges can be realigned to the normal anatomical positions without stretching. Skin flap IS pale, dusky or darkened.

21
Q

Describe Category 2a of STAR

A

The edges cannot be realigned to normal anatomical position. Skin flap is NOT pale, dusky or darkened.

22
Q

Describe Category 2b of STAR

A

The edges cannot be realigned to normal anatomical position. Skin flap IS pale, dusky or darkened.

23
Q

Describe Category 3 or STAR

A

The skin flap is completely absent.

24
Q

Pressure injuries are the ______________ most commonly occurring preventable conditions.

A

5th

25
Q

Where are pressure injuries more likely to occur?

A

Boney prominences, such as the sacrum, elbow or heels

26
Q

What is standard 8 of the National Safety and Quality Health Service Standards (NSQHSS)?

A

Standard 8 - Preventing and Managing Pressure Injuries.

27
Q

What are some strategies to promote and maintain skin integrity?

A
  • Review and assess nutritional status, refer to dietician
  • Use a high specification reactive (constant low pressure) support foam mattress on beds, or active (alternating pressure) support mattresses.
  • Reposition persons regularly (if skin intergrity and medical condition allows)
  • When repositioning a person in any position always check the positioning of heels and other bony prominences.
  • Use a support cushion for patients at risk of pressure injury when seated in a chair or wheelchair and limit the time spent in seated positions without pressure relief
  • Educate older people and their families about pressure injuries.
28
Q

If a patient is laying on their back what areas would be more susceptible to pressure injury?

A
  • Back of Head
  • Shoulder
  • Elbow
  • Tailbone
  • Heel
29
Q

If a patient is laying on their side what areas would be more susceptible to pressure injury?

A
  • Ear
  • Shoulder
  • Hip
  • Knee
  • Ankle
30
Q

If a patient is in a wheelchair what areas would be more susceptible to pressure injury?

A
  • Ball of foot
  • Heel
  • Shoulder Blades
  • Buttocks.
31
Q

Define restrictive practices.

A

Restrictive Practices are defined as the use of chemical or physical restraint; practices in which activities or interventions have an effect of limiting a person’s movement or ability to make decisions.

32
Q

When considering restraining a patient, what should happen?

A

Close and thoughtful consultation with the older person (and/or their families) and appropriate consent MUST be obtained.

33
Q

What are the two types of restraint?

A

Physical and Chemical

34
Q

What are common types of chemical restraint?

A

Medications that can cause sedation, limits mobility, affects ability to make decisions or something affecting the mind, emotions and behaviours of a person. These include stimulants, antidepressants, antipsychotics, mood stablisers, psychotropics, anti-anxiety agents and opioids.

35
Q

What are common types of physical restraint?

A
  • Sitting persons in chairs with deep seats or reclining a chair far back so the person cannot stand up easily.
  • Using both bed rails
  • Holding a person’s limbs to limit their movement
  • Locking over bed tables in front of a person so they cannot move it
  • Using a lap belt, leg, arm or vest restraints
  • Securing a person in a locked ward or unit
  • Removing mobility aids
36
Q

Define Dignity of Risk.

A

The right to self determination and choice to take risks in their life.

37
Q

What bioethical principle underpins the concept of dignity of risk?

A

Autonomy

38
Q

What is gait apraxia?

A

Inability to initiate the process of walking.

39
Q

What is the Berg Balance Scale?

A

An assessment designed to measure a patients ability to safely balance during a series of predetermined tasks.

40
Q

How many assessments items are in the Berg Balance Scale?

A

14

41
Q

What to the scores for the Berg Balance Scale mean?

A

0 indicates lowest level of function 4 indicates the highest level of function

42
Q

What are the 7 key principles for the use of restraint issued by NSW health?

A
  • Principle 1 Protection of fundamental human rights
  • Principle 2 Protection against inhumane or degrading treatment
  • Principle 3 Right to highest attainable standards of care
  • Principle 4 Right to medical examination
  • Principle 5 Documentation and notification
  • Principle 6 Right to appropriate review mechanism
  • Principle 7 Compliance with legislation and regulation
43
Q

What are the specific considerations for manual/ mechanical restraint issued by NSW Health?

A
  • Restraint devices must be professionally manufactured, not hand-made
  • Restraint devices must meet the requirements set out in Section 1.2 Key definition
  • A person cannot be confined in a mechanical restraint device inside a locked room at any time
  • A person held in a four limb restraint device should be cared for in a designated clinical space / area to protect the patient’s privacy
  • Care must be undertaken to protect the privacy and dignity of any person in any kind of mechanical restraint device.
  • Allow the patient / individual to safely regain control of their behaviour
  • Allow the application of mechanical restraint
  • Administer medication, and / or remove the patient / individual to a safer environment
44
Q

Who can apply a manual/mechanical restraint to a patient with disturbed and/or aggressive behaviour?

A

An appropriate team leader is someone who:

  • Has completed training in the safe use of restraint
  • Is confident and competent to lead a restraint procedure, or has the best rapport with the patient
  • Assigns roles for each staff member (one to support or hold each limb) participating in the restraint procedure
  • Positions close to the head of the patient and continues to engage with the patient during the restraint in an effort to reassure and calm the patient
  • Monitors the patient’s airway and physical condition during the restraint procedure.
45
Q

What are the mandatory on-going nursing assessments while a patient is physically restrained?

A
  • Immediately after the patient/ individual is being restrained, a clinical assessment must be undertaken by a medical officer to identify and treat any underlying clinical condition that may have caused the aggressive behaviour.
46
Q

What needs to be considered when choosing appropriate footwear to prevent falls?

A
  • Non-slip sole
  • Supportive Room at the toes
47
Q

When a patient is admitted to hospital, a falls risk assessment should be done:

A

When clinical conditions change.

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