PCC-1 Module 7-8

Question 1

Fall Prevention

Answer 1

Older adults often fall due to either intrinsic or extrinsic factors.
Intrinsic-gender (females are at a greater risk to fall than males), age, impaired sensory, function impairment, medical conditions.
Extrinsic- environmental hazards (poor lighting, throw rugs, etc.), medications, alcohol.
Preventions: screen for falls, ask patient if they have fallen more than once, gotten injured from said fall, been afraid of falling.

Acute or long term care interventions: 
scheduled screenings
environmental assessment 
maintain client mobility
educate caregivers and staff
individualized safety measures

Community:
annual screening
medication review 
home hazard assessment (throw rugs, slippery areas etc.)
address visual deficits

Question 2

Restraints

Answer 2

look over powerpoint and read through

Two types of restraints: Physical and Chemical

Physical: vest, belt, mitt, limb, mummy, side rails,

Chemical: medications designed to control socially disruptive behavior

Question 3

Requirements for Restraints

Answer 3

WRITTEN MD ORDER:

1. Must include the reason for and use and length of use and type of restraint
2. Valid for 24 hours
3. Pt must be evaluated face to face by a qualified health care provider before the order can be renewed

CONSENT:
1.) If the client cannot give permission legal proxy must after full disclosure of risks and benefits
2.) If client is too confused or mentally incapacitated to give permission this must be documented and the proxy contacted
3.) Emergency restraint needed- DOCUMENT clients behavior- the restraint may be applied and then orders should be written to cover the situation
Licensed staff must supervise for use
Consider client and choose restraint accordingly

Question 4

Interventions for Agitation when using restraints

Answer 4

Warm, non-stimulating drink
Treat pain
Stable staff assignments
Soft lights
Reduced environmental stimuli
Back rub, foot massage, walk
Music

Question 5

Vest (Physical Restraint)

Answer 5

Apply as manufacturer directs- choking

Tie with quick release knot at 45 degree angle to a non-moving part of the bed

Question 6

Belt (P.R)

Answer 6

(bed) should allow patient to roll

Question 7

Mitt (P.R)

Answer 7

May have rigid backing to prevent bending of hand

Question 8

Limb (P.R)

Answer 8

(elbow) often used for KIDS to protect IV site

- the padded handcuff like restraints we practiced with in clinicals

Question 9

Mummy (P.R.)

Answer 9

Used for procedures for KIDS and to immobilize PSYCH patients out of control
-looks like someone wrapped in a sleeping bag

Question 10

Veil beds (P.R.)

Answer 10

no longer being used, off the market

Question 11

Side Rails (P.R.)

Answer 11

Make sure the head can’t fit between the mattress and the rail
Mattress should be stable and will not allow head entrapment

Question 12

Short Term Complications with the use of restraints

Answer 12

Hyperthermia
New onset of incontinence
Pressure ulcers
Increased risk for nosocomial infections
Decreased appetite
Constipation

Question 13

Severe or Permanent Complications

Answer 13

Brachial plexus nerve injuries
Joint contractures
Hypoxic encephalopathy
Deconditioning
Psychological effects
DEATH from strangulation
Social isolation
confusion
anger
poor self image

Question 14

Effects of Immobility

Bed Rest

Answer 14

Can be temporary, permanent, sudden or slow onset
Bedrest- restriction of the client to the bed for therapeutic reasons
Reduce physical activity therefore reducing oxygen demands
Reduce/minimize pain to reduce the need for large doses of analgesics
All the client to rest and regain strength
Allow for uninterrupted rest
Usually written in the chart as BR(complete bedrest) or BR with BRP(bedrest with bathroom privileges)

Question 15

Effects of Immobility

Answer 15

Hazards of immobility- the individual of average height and weight (without chronic illness) loses 3% of muscle strength per day

- disuse atrophy – describes the tendency of cells and tissue to reduce in size and function in response to prolonged inactivity
- physiological, psychological, and social effects – longer the immobility the greater the effect
- older adults- important to limit “bed rest” and provide physical activity more than just bed-to-chair. Loss of walking independence= increased hospital stays, nursing home placement, & risk for falls.
	* older adults with chronic illness develop pronounced effects of immobility more quickly than a younger patient without chronic disease

Question 16

Effects of Immobility

Musculoskeletal

Answer 16

Exercise: maintains muscle size, shape, tone, & strength, joint mobility, and weight bearing maintains bone density

Immobility: decrease muscle endurance, muscle mass, muscle atrophy, decrease in stability & balance, impaired calcium metabolism, increase risk of joint contracture and decrease joint mobility

Question 17

Effects of Immobility

Cardiovascular

Answer 17

Exercise: increases HR and systolic pressure, shunts blood to heart and muscles, cardiac output increases

Immobility: orthostasis, decrease cardiac reserve & increase cardiac workload, increase use of Valsalva(straining), increase vasodilation & stasis, increased risk of thrombus formation

Question 18

Diagnoses from immobility that are musculoskeletal related

Answer 18

Osteoporosis – immobility accelerates bone loss from primary osteoporosis- one of the leading causes for bone fracture in men and women over the age of 50.

Joint contracture – abnormal and possibly permanent condition caused by the shortening of the connective tissue and characterized by decreased range of motion and/or fixation of the joint. Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. Ex- foot drop = Ankle is fixed in plantar flexion.

Question 19

Diagnoses that could result from immobility related to cardiovascular

Answer 19

Orthostatic hypotension – a drop in blood pressure greater than 20 mmHg in systolic pressure or 10mm Hg in diastolic pressure and symptoms of dizziness, lightheadedness, nausea, tachycardia, pallor, or fainting when the patient changes from supine to standing position. (decreased circulating fluid volume and decreased autonomic response)

Thrombus formation – an accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel. (Virchow’s triad- damage to the vessel, altered blood flow, increased clotting)

Question 20

Effects of Immobility Respiratory

Answer 20

Exercise: increased ventilation, prevents pooling of secretions, decreases breathing effort, improves diaphragmatic excursion
Decrease in cough response

Immobility: decreased respiratory movement and vital capacity, increased pooling and stagnation of secretions, increase risk of atelectasis, increase risk of pneumonia

Question 21

Effects of Immobility

Metabolic

Answer 21

Exercise: increased basal metabolism rate, increases use of triglycerides and fatty acids

Immobility: decreased metabolic rate, negative nitrogen balance, increase percentage of body fat and a decrease in percentage of lean body mass, anorexia, negative calcium balance

Question 22

Effects of Immobility

Urinary

Answer 22

Exercise: increase in efficiency of blood flow and better waste disposal, decrease stasis of urine in the bladder

Immobility: increased urinary stasis & urinary calculi, decrease bladder muscle tone, urinary retention, increase risk of overflow incontinence, increase risk of UTI

Question 23

Diagnoses from Immobility related to Respiratory

Answer 23

Atelectasis (collapse of alveoli) – secretions block large and small airways (bronchus & bronchiole) causing the collapse of the distal lung tissue (alveoli) as existing air is absorbed = hypoventilation and decreased ability to cough. Hypoventilation and decreased cough then allow additional mucus accumulation. When a patient is supine, prone, or lateral mucus collects in the bronchi.

Hypostatic pneumonia = bacterial infection of the lungs caused by accumulation of mucus in the dependent airways.

Question 24

Diagnoses from immobility related to metabolic

Answer 24

Negative nitrogen balance – The body is constantly synthesizing proteins and breaking then down into amino acids to form other proteins. When the patient is immobile (protein intake is low) the body excretes more nitrogen [the end product of amino acid breakdown] than it injects in proteins. This results in weight loss, decreased muscle mass, and weakness resulting from tissue catabolism (tissue breakdown).

Negative calcium balance – Immobility leads to calcium resorption (loss) from bones. Immobility causes the release of calcium into the circulation. Pathological fractures occur if calcium resorption continues as a patient remains on bed rest or continues to be immobile.

Question 25

Diagnoses from immobility related to Urinary

Answer 25

Urinary stasis – When a patient is recumbent or flat, the kidneys and ureters are on a more even plane. Peristalsis in the ureters is not sufficient to overcome gravity. The renal pelvis fills before the urine enters the ureters. This increases the risk or UTI and renal calculi (plus hypercalcemia).

Question 26

Effects of Immobility

Gastrointestinal

Answer 26

Exercise: increase appetite and GI tract tone, improves digestion and elimination

Immobility: slowing of peristalsis, weakened defecation muscles, increase constipation, risk of impaction or bowel obstruction if constipation is severe

Question 27

Effects of Immobility

Integumentary

Answer 27

Exercise: increases blood flow which results in an increase in nutrients to tissues and removal of waste from tissues

Immobility: decrease in skin turgor, increased risk of skin breakdown, delayed wound healing

Question 28

Effects of Immobility

Psycho-neurologic

Answer 28

Exercise: improves stress tolerance, produces relaxation, less risk of depression, improves body image and sleep, increases energy and appetite

Immobility: changes to self-esteem, emotional changes, decrease perception of time, decrease in problem-solving and decision-making ability, changes in sleep/rest pattern

Question 29

Diagnoses from immobility commonly related to integumentary

Answer 29

Pressure ulcer – an impairment of the skin as a result of prolonged ischemia (decreased blood supply) in tissues. Ischemia develops when the pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin. The longer the pressure is applied, the longer the period of ischemia and therefore the greater the risk of skin breakdown

Question 30

Diagnoses from immobility related to psycho-neurologic

Answer 30

Depression – an affective disorder characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion to reality. Worrying quickly increases a patient’s depression, causing withdrawal. Withdrawn patients often do not want to participate in their own care.

Question 31

Assistive Devices

Walker

Answer 31

Elbows should be flexed 30 degrees
Never pull on the walker to stand up

Walkers – stability and security during walking. Used for weak patients of those patient who have balance problems. Line up the walker with the crease of the wrist. If a walker does not have wheels the walker is meant to be lifted in-between steps. Rolling walkers can cause falls.

Question 32

Assistive Devices

Cane

Answer 32

Hold can in opposite hand from the injured leg
In case of arm weakness place can in stronger hand regardless

Cane – Used when a patient has decreased unilateral leg strength. The cane is used on the strong side of the body. Two points of support are on the floor at all times.

C- Canes
O- Opposite
A- Affected
L- Leg

Question 33

Assistive Devices
Crutches

There is a lot sorry :)

Answer 33

Gait is ordered by MD and typically taught by PT
Nurses reinforce the training
Monitor for safety
Know how to measure
4-point gait is used for partial weight bearing of both extremities
3-point gait used for no weight bearing on the affected leg
2-point gait used for partial weight bearing on both extremities
Swing-through gait used for paralyzed lower extremities

Crutches – 2-3 finger widths from the axilla. Pressure on the axilla increases the risk to underlying nerves, which sometimes results in partial paralysis of the arm.
Determine correct position of the hand grips with the patient upright, supporting weight by the handgrips with the elbows slightly flexed at 20-25 degrees.
Crutch gait – alternately bearing weight on one or both legs and on the crutches.

2 point and 4 point require at least partial weight bearing on both legs
3 point allows for no weight bearing on the affected leg
Swing-through is used for paralyzed lower extermities

Question 34

Transferring Patients

Answer 34

Safety
Preparation
Types
Moving toward the head of bed
Bed-to-chair & chair-to-bed
Bed to stretcher
Logrolling

Things to assess before moving a patient?
Physiological capacity (muscle strength, joint mobility, paralysis or paresis, bone continuity)
Weakness, dizziness, orthostatic hypotension
Activity tolerance
Posture and equilibrium
Sensory limitations
Pain
Vital signs
Cognitive status
Motivation
Fall risk
Previous transfer techniques used
Accessibility and familiarity with equipment

Study pages listed on slide 14 of Immobility powerpoint, also slide 15 for pictures of transference of patients

Question 35

Patient Positioning

Answer 35

What are barriers to safe patient handling and encouraging early mobility?
Box 39-1 p.791 & Table 39-1 p.804 P&P
Mechanical lifts and lift teams are essential when a patient is unable to assist.
When a patient is able to lift …. Wide stance, low center of gravity, equilibrium, face the direction of the movement, use arms and legs, leverage, reduce friction
* Notice if the patient is unable to assist and >200 lbs= 3 or more care givers
Figure 39-4 p.793 P&P Repositioning patient in bed
Figure 39-5 p.794 P&P To and from chair to other device
Figure 39-6 p.795 P&P lateral transfer

Question 36

Hip Precautions

Answer 36

Post op Total Hip Arthroplasty
Abduction pillow
Do Not bend hip above 90 degrees
Do not cross legs 
Do not bend forward to pick up objects
Do not rotate leg when standing 
TEDs & SCDs
Promote venous return
Procedure 

Box 28-7 Applying SCDs sequential compression devices and elastic stockings
Nurse must measure to determine the correct size of elastic stockings and assess for impaired circulation or DVT.
Assess for risks of Virchow’s triad = hypercoagulability, venous wall abnormalities, blood stasis
DVT = redness, warmth, swelling, pain, & Homan’s sign – pain in the calf upon dorsiflexion of the foot