Week 12: Safe Client Handling and Mobility (Falls) Flashcards
Definition: Cane measurement
Measure the patient so that the elbow is 15-30 degrees flexed, and that the wrist is level with the cane handle, will typically be about ½ of the patient’s height
Definition: Center of gravity
A point where the entire body’s mass is considered to be concentrated, typically located slightly in front of the sacrum, around the second vertebra level, when standing upright
Definition: Crutch measurement
Standing = crutch pad 4-5cm below the axilla (2-3 fingers)
supine = crutch pad 3-4 finger widths under the axilla
handgrips = elbows should be flexed at 15-30 degrees
Definition: Crutch palsy
A condition caused by compression of the radial nerve, often due to improper or prolonged use of axillary crutches, leading to symptoms like wrist drop and weakness in hand and finger extension
Definition: Fowler’s
Position where patient/patient’s head of bed is inclined to about 45-60o, promotes oxygenation and helps with breathing
Definition: Gait belt
A device used by caregivers to assist patients with mobility, providing a secure grasp for guiding and supporting them during transfers, walking, or standing
Definition: Hemi-paresis
Weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing
Definition: High Fowler’s
Position where the patient is seated upright with their spine straight, upper body is resting at a 60-90o angle to the lower body
Definition: Lateral
Meaning the patient is resting on their side
Definition: Lateral recumbent
A position where the person lies on their left or right side with the operative side up
Definition: Partial weight bear
Placing a portion, but not full, weight on an injured or affected limb
Definition: Prone
A position where the patient is laying flat on their stomach, opposite to supine, often used for drainage of the mouth after oral/neck surgery
Definition: Sim’s
A position where the patient is laying laterally (on their side), good for sleeping and resting, weight is place on the anterior ilium, humerus, and the clavicle
Definition: Supine
A position where patient is lying flat on their back, common for resting/surgery, opposite to prone position
Definition: Swing to/through gait
Crutch walking technique where the user advances the crutches, and then either swings both feet to the level of the crutches (swing-to) or swings both feet past the crutches (swing-through)
Definition: Three-point gait
Used with crutches, involves moving both crutches and the affected leg forward together, followed by the unaffected leg, ensuring three points of contact (both crutches and the unaffected foot) at all times
Definition: Tripod position
A physical stance where someone sits or stands leaning forward, supporting their upper body with their hands on their knees or another surface, often used by individuals experiencing respiratory distress to facilitate breathing
Definition: Two-point gait
The left crutch and right leg move forward followed by the right crutch and left leg
Definition: Walker measurement
Upper bar should be slightly below patient’s wrist, elbows should be flexed at 15-30 degrees when patient is standing with walker and hands on hand grips
What is Shearing?
The skin sticks to the surface of the bed but the internal structures (bones and muscles) slide in the direction the body is moving
What is Disease atrophy?
Bed rest, casting, nerve damage, trauma can cause the tissues and cells to decrease in
size and function
What factors do you have to assess that may predispose a client to falls?
History of falls, problems with gait or balance, impaired cognition or communication, drugs, age, postural hypotension, attached
equipment
What steps do you have to take if you have a client with a high risk of falling?
Non-skid shoes, call bell, bed low and locked
What sort of things do we assess before moving a patient?
- Their physical status, cognitive status, sensory status, and the environment they are in
What sort of things are looked at to assess physical status?
Dizziness, fatigue, BP, body alignment and posture, need for assistive devices, muscle weakness, weight bearing, urinary agency, pain and comfort
What sort of things are looked at to assess cognitive status?
Risk of falls, level of cooperation, confusion, how much assistance do they need, language abilities, motivation
What sort of things are looked at to assess sensory status?
Communication deficits, do they wear glasses, hearing aids, non-slip footwear, numbness in feet
What sort of things do we do to ensure our body mechanics and alignment are safe as a nurse?
Leverage, rolling, turning, or pivoting requires less work than lifting, transfer sheets, reducing force of work, maintain good body mechanics and positioning to reduce fatigue and injury, periods or rest
When might you log roll a patient?
- Making a bed while a patient is in it
- Assessment of the skin on the back of the body
- Bed bathing
- Spinal injuries
- Position changes
When might you need to assist a patient from lying to sitting on the side of the bed?
When transferring to a chair or if a patient will need assistance
(nurse or assistive device) to mobilize (ex. to the bathroom)
What are some Metabolic complications of immobility?
Endocrine, calcium absorption, and gastrointestinal
function
What are some Respiratory complications of immobility?
Atelectasis (collapsing of alveoli) and pneumonia
What are some Cardiovascular complications of immobility?
Orthostatic hypotension, Thrombus (blood clots)
What are some Musculoskeletal complications of immobility?
Loss of endurance and muscle mass, and decreased stability and balance
What are some Muscle effects of immobility?
Loss of muscle mass, Muscle atrophy (wasting)
What are some Skeletal effects of immobility?
mpaired calcium absorption, Joint abnormalities
What are some Urinary elimination complications of immobility?
Urinary stasis, Renal calculi (stones)
What are some Integumentary complications of immobility?
Pressure ulcer, Ischemia (lack of oxygen to tissue)
Who are some individuals who are greater fall risks?
- Older adults
- Those with disabilities
- Women 65 and older (osteoporosis)
- Vision loss and sensory and auditory impairment
- Orthostatic hypotension
- Adolescents- risk takers
