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CSON IM1 > Mobility and restraints > Flashcards

Mobility and restraints Flashcards

1
Q

mobility definition

A

a person’s ability to move about freely

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2
Q

examples of mobility -6

A

~nonverbal gestures
~self-defense
~ADL’s
~recreational
~satisfaction of basic needs
~expression of emotion

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3
Q

factors affecting mobility and activity -6

A

~developmental
~nutrition
~lifestyle
~stress
~environment
~diseases and abnormalities

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4
Q

diseases and abnormalities affecting mobility -6

A

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

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5
Q

immobility definition

A

person’s inability to move about freely

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6
Q

paraplegia

A

may involve lower part of body

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7
Q

hemiplegia

A

may involve one side of body

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8
Q

quadriplegia

A

may involve entire body from neck down

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9
Q

bedrest definition

A

restricts patients to bed for therapeutic reasons

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10
Q

physical causes of immobility -6

A

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

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11
Q

psychosocial causes of immobility -5

A

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

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12
Q

prolonged immobility stages -3

A
  1. reduced functional capacity
  2. altered metabolism
  3. numerous physiological changes
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13
Q

effects of immobility -8

A

~musculoskeletal
~lungs
~heart and vessels
~metabolism
~integument
~gastrointestinal
~genitourinary
~psychological

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14
Q

Musculoskeletal assessments -3

A

~activity intolerance
~anthropometric measurements
~nutrition

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15
Q

bone resorption uses -2

A

~osteoclasts
~osteoblasts

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16
Q

osteoclasts

A

moves along surface of bone, dissolves grooves into bone with acid and enzymes, dissolved materials passed through osteoclasts and into bloodstream for reuse by the body

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17
Q

osteoblasts

A

occurs when bone is injured, added bone strength is required and calcium is elevated in the bloodstream, deposits calcium into the bone

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18
Q

osteoporosis risk factors -4

A

~sex, female more than male
~insufficient or too much exercise
~poor diet, low in calcium and protein
~smoking

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19
Q

range of motion definition

A

Maximum amount of movement available at a joint

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20
Q

active ROM

A

done by patient

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21
Q

active assist ROM

A

done by patient but with help

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22
Q

passive ROM

A

done by caregiver, continuous passive motion

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23
Q

how to do ROM -5

A

~x3 a day {after bath, mid-day, bedtime}
~start gradually and move slowly
~support the extremity
~stretch the muscle only to the point of resistance
~encourage active ROM if possible

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24
Q

respiratory assessment -6

A

~lung sounds
~O2 sats
~respiratory rate
~active tolerance {SOB}
~chest X-ray
~arterial blood gases

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25
Q

cardiac assessment -5

A

~blood pressure
~pulse rate
~heart sounds
~activity tolerance {BP, HR, chest pain}
~calf pain

26
Q

stages of deep vein thrombosis -4

A
  1. decreased muscle activity
  2. pooling of blood
  3. clot formation
  4. DVT {ambulation, TED hose, SCD’s}
27
Q

TED hose

A

thrombo-embolic deterrent hose, post-surgical, non walking patient

28
Q

SCD’s

A

sequential compression devices, sleeves around the legs, alternately inflate and deflate, post-surgical/circulatory disorders

29
Q

metabolism assessment -5

A

~decreased appetite
~weight loss
~muscle loss
~weakness
~labs

30
Q

integument assessment -3

A

~skin assessment {color changes, integrity}
~nutrition
~incontinence

31
Q

pressure injury definition

A

impairment of the skin as a result of prolonged ischemia {decreased blood supply} in tissues

32
Q

when would you get a pressure injury?

A

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

33
Q

gastrointestinal assessment -4

A

~bowel sounds
~abdominal palpation
~bowel habits
~I & O

34
Q

genitourinary assessment -4

A

~I & O
~palpate abdomen
~incontinence
~urine {color, smell, clarity}

35
Q

urinary stasis definition

A

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

36
Q

steps in urinary elimination changes -5

A
  1. immobility
  2. decreased fluid intake
  3. dehydration
  4. concentrated urine
  5. increased risk for UTI and kidney stones
37
Q

psychosocial assessment -5

A

~mood
~orientation
~speech
~affect
~sleep

38
Q

psychosocial effects -7

A

~social isolation
~loneliness
~decreased coping
~depression
~anxiety
~withdrawal
~delerium

39
Q

mobility strengthens muscles, especially…

A

those of the abdomen and legs

40
Q

mobility helps joint flexibility, especially that of…

A

the hips, knees, and ankles

41
Q

mobility stimulates circulation, which helps prevent…

A

phlebitis and the development of clots

42
Q

mobility prevents constipation, the movement of the…

A

abdominal muscles stimulates the intestinal tract

43
Q

mobility prevents osteoporosis due to the…

A

mineral loss from the bones when they do not bear weight

44
Q

mobility stimulates the…

A

appetite

45
Q

mobility prevents urinary incontinence and infection because when patients are able to…

A

go to the bathroom on their own, incontinence is reduced

46
Q

mobility relieves pressure on the…

A

body and skin, helping to prevent from pressure injurys

47
Q

mobility improves self-esteem and the…

A

patients feeling of independence

48
Q

mobility decreases anxiety and depression induced by…

A

hospitalization

49
Q

best intervention to prevent immobility complication

A

ambulation

50
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

51
Q

what is required for non-violent restraints -3

A

~every 2 hours monitoring and documentation
~new order required for every calender day
~when d/c, date and time must be documented

52
Q

when would non-violent restraints be used -4

A

~actions impede medical care
~lack of awareness of potential harm to self and others
~unable to follow commands and comply with safety instuctions
~attempts to pull out tubes, drains, or other lines/devices medically necessary for treatment

53
Q

covenants restraint policy

A

prior to restaining, alternatives must be attempted

54
Q

what do you do for an alternative measure

A

modify the environment

55
Q

five steps of alternative measures

A

~camouflage IV lines & tubes
~encourage family to stay with the patient
~orient patient to person, place, and time
~involve patient in conversation
~give patient something to do

56
Q

risks of using restraints -6

A

~increase in injury and death
~loss of self-esteem
~humiliation
~fear
~anger
~increased confusion and agitation

57
Q

complications of restraints -7

A

~impaired skin integrity
~lower extremity edema
~altered nutrition
~physical exhaustion
~social isolation
~immobility complications
~death

58
Q

intervention application -7

A

~restrict as little movement as necessary
~make sure restraints fit properly
~always tie to bed frame or mattress springs
~always explain the need for restraint
~never leave the patient unattended without the restraints
~pad bony prominences
~document

59
Q

restraint assessment -7

A

~regularly assess the need for continued use of restraints
~inspect placement area of restraint
~assess patients behavior
~assess circulation, motion, sensation
~make sure restraint fits properly
~vital signs
~document

60
Q

VS restraint assessment -7

A

~inspect skin color and edema
~palpate for skin temp
~palpate pulse
~check capillary refill
~menatal status
~ask to move the limb
~ask if having any tingling

61
Q

restraint interventions -4

A

~ROM
~reposition
~nutrition, hydration, toileting
~release at the earliest possible time

CSON IM1 (28 decks)

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