Quiz 5 Flashcards
- Osteoporosis
- limited joint mobility
- cerebrovascular accident
- spinal cord injury
- brain injury
- Balance/equilibrium problems
Risk factors for immobility
Supine- flat on back High fowlers 90 & semi-fowlers 45 Side lying Sims- side lying with hip and knee flexion Prone- face down
Patient positions
- Over age of 65
- history of falls
- balance problems
- muscle weakness
- visual impairment
- neurological impairment
- cognitive impairment
- bowel/bladder incontinence
- cardiovascular issues
- multiple medications
Fall Risk factors
What should you do when trying to get a patient out of bed
Dangle the patient first, raise head of bed, turn patient and lower legs to floor, sit patient at the side of the bed and have them move their legs before standing
Risk factors for Activity intolerance
- heart failure
- peripheral vascular disease
- chronic obstructive pulmonary disease
Cardiovascular system- DVT, orthostatic hypotension
Pulmonary system- Pulmonary edema, pneumonia
Integumentary system- tissue ischemia, pressure ulcers
Musculoskeletal system- foot drop, bone loss
Gastrointestinal system- constipation, bowel obstruction
Urinary system- UTI, kidney stones
Nervous system- altered proprioception, altered balance
Psychosocial impact- depression, loneliness
Effects of immobility on body systems
- assess every patient for fall risk
- frequently observe patient
- bed safety
- answer call light quickly
- good lighting in room, nightlight at night
- keep patients belongings within reach
- use non-skid shoes & socks
- keep walkways clear, clean, and dry
- use proper fitting clothing
- familiarize patient with environment
- show patient how to use call light
- patient to use handrails in bathroom/hallways
- keep wheelchair wheels locked
- communicate and document fall risk to health team
Fall precautions
In pressure ulcers, damage to the skin & underlying structures depends on which 3 things
- Intensity of the pressure
- Length of time that the tissue us subjected to pressure
- Intrinsic & extrinsic factors
What is thought to significantly contribute to the development of pressure ulcers?
What kind of lift can be used in immobile patients to reduce the injuries resulting from it?
Shear.
Mechanical lift.
All bony prominences such as:
- Greater trochanter
- Sacrum
- Ischia
- Heels
High risk areas to asses for pressure ulcers
- Immobility
- Impaired sensation
- Malnourishment
- Aging
- Fever
Intrinsic risk factors for pressure ulcer development
- Friction
- Pressure
- Shearing
- Exposure to moisture
Extrinsic factors for pressure ulcer development
What does a stage 1 pressure ulcer look like?
Intact, non-blistered, red, non-blanching
What type of test should you use to test if a spot is a pressure ulcer?
Use the PUSH test- if it does not blanch, it is a pressure ulcer
- Turn every 2 hours or more frequently
- Float heels
- If side lying, elevate the head of the bed no more than 30 degrees to reduce the effects of shear
- Position pillow or other devices between bony prominences to prevent direct pressure
- Use floatation devices
- Eliminate/prevent moisture on skin
- Adequate nutrition
- Adequate oxygenation
- Maintain fluid balance
Pressure ulcer prevention
