220-activity Flashcards
(30 cards)
Effects of immobility(increased)
Cardiac work load
Risk for venous thrombosis(pooling of blood risk for pulmonary embolism)
Urinary (uti/kindnet stones)
Risk for contractures(loss of function)
Risk for skin break down(pressure injury)
Sense of powerlessness
Bone loss
Work of breathing
Effects of immobility(decreased)
Death of respiration
Rate of respiration(risk of aspiration)
Bladder muscle tone(decreased retention/uti/kidney stone)
Muscle size, tone and strength
Endurance, stability, coordination
Sensory stimulation( prevents depression)
Para
Paralyzed below waist
Quad
Paralyzed arms and legs(spinal cord)
Hemi
Paralyzed on one side but
Patient activity assessment
Activity orders
Muscle mass, tone and strength (preexisting conditions)
Joint structure and function
Strength and endurance
Mobility problems
Physical health(pain/condition)
Mental health(depression/ disorder)
Fall risk
Medications(narcotics decrease mobility)
Nutrition
What is the AM PAC 6 clicks?
Mobility protocol that consist of 6 questions in EPIC, graded 1-4 and score is added up to give you a score that correlates with patients mobillity goal for that day.
what is the AM PAC W/ JH-HLM
Mobility protocol that rates the patient 1-8 and has the patients mobility goals.
Patients that should not be moved
unstable(HR<40/>140, Systolic<85/>200, R>35 per min, O2<90 on oxygen)
patients with INR>5/PTT>100 (risk for bleeding)
patients who do not respond to verbal stimuli
spinal trauma/unstable fracture
presence of femoral sheath
thrombolytic administration
Passive ROM
patient is unable to lift body parts themselves
Active ROM
Patient is able to lift body parts themselves
nursing intervention to promote activity
ambulation
ROM
position changes
Turn Q2
turn patient every two hours
Fowlers position
45-60 degree angle
Semi fowlers postion
30 degree angle
high fowlers position
90 degree angle
protective postion
the use of pillows, blankets, pressure reducing mattress, support boots, hand rolls, trochanter rolls to protect high pressure areas/ areas that are needed for functioning (knees, heels, elbows, scapula, hips, head, hands)
Nursing interventions to promote safety
trapeze bars/side rail
physical therapy
turning systems
log rolling
Specialty beds
avoid knee gatching(when the legs move up with the head it puts pressure on knees, poor circulation and risk for blood pooling)
Orthopneic postion
sitting up right with upper body hunched over the knees
used for patient that can not breath while laying down (COPD, emphysema)
Prone postion
Flat on back with pillow under tummy
lateral side laying position
laying onside, use for protective positioning
Sim’s position
side laying with one side of arms and legs on pillows and other side is positioned with flat hands and a rolled towel supporting the foot. (prevents foot drop)
Lithotomy position
legs in stir ups, flat on back
Primoboots
prevents foot drop