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Module 1 > Immobility and Restraints > Flashcards

Immobility and Restraints Flashcards

1
Q

Mobility

A

A persons ability to move about freely

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2
Q

Mobility examples

A

Nonverbal gestures
ADLs
Satisfaction of basic needs
Express emotions

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3
Q

Paraplegia

A

May involve lower part of the body

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4
Q

Hemiplegia

A

May involve one side of body

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5
Q

Quadriplegia

A

May involve entire body from the neck down

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6
Q

Physical causes of immobility

A

Bone fracture
Surgical procedure
Major sprain or strain
Illness/disease
Cancer
Aging process

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7
Q

Psychosocial causes of immobility

A

Stress/depression
Decreased motivation
Hospitalizations
Long term care facility residents
Voluntary sedentary lifestyle

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8
Q

Prolonged immobility can

A

Reduce functional capacity
Alter metabolism

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9
Q

Immobility effects

A

Every body system

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10
Q

Osteoclasts

A

Break down bone

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11
Q

Osteoblasts

A

Grows bone
Deposits calcium into the bone

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12
Q

Osteoporosis risk factors

A

Sex (more common in women)
Insufficient or excessive exercise
Poor diet
Smoking

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13
Q

Joints not moved are at risk for

A

Contractures
-can begin forming within 8 hours

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14
Q

Range of motion exercises improves

A

Joint mobility

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15
Q

Active range of motion is done by

A

Patient

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16
Q

Active assist ROM is done by

A

Patient but with help

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17
Q

Passive ROM is done by

A

Nurse/caregiver

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18
Q

Respiratory assessment

A

Lung sounds
O2 sats
Respiratory rat
Activity tolerance (SOB)

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19
Q

Turn, cough, deep breath

A

Deep breath, hold three seconds, cough twice, tighten abdominal muscles

20
Q

Cardiac assessment

A

BP
Pulse rate
Heart sounds
Activity tolerance (BP, HR, chest pain)
Calf pain

21
Q

Deep vein thrombosis

A

Decreased muscle activity > pooling of blood > clot formation > DVTs (Ambulation, TED hose, SCDs)

22
Q

TED hose

A

Thrombo-embolic deterrent hose
-post surgical
-non-walking patients

23
Q

Sequential Compression Devices (SCDs)

A

Sleeves around the legs
Alternately inflate and deflate
Post surgical/circulatory disorders

24
Q

Metabolism assessment

A

Decreased appetite
Weight loss
Muscle loss
Weakness
Labs

25
Q

Integument assessment

A

Skin assessment (color changes, integrity)
Nutrition
Incontinence

26
Q

Gastrointestinal assessment

A

Bowel sounds
Abdominal palpation
Bowel habits
I & O

27
Q

Genitourinary assessment

A

I & O
Palpate abdomen
Incontinence
Urine (color, smell, clarity)

28
Q

Urinary stasis

A

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

29
Q

Urinary elimination changes

A

Immobility (decreased activity)
Decreased fluid intake
Dehydration
Concentrated urine
Increased risk for UTI and kidney stones

30
Q

Psychosocial assessment

A

Mood
Orientation
Speech
Affect
Sleep

31
Q

What is the best intervention to prevent immobility complications?

A

Ambulation

32
Q

Mobility level 1

A

Dependent

33
Q

Mobility level 2

A

Moderate assistance

34
Q

Mobility level 3

A

Minimum assistance

35
Q

Mobility level 4

A

Modified independent

36
Q

Restraint types

A

Extremity
Mitten
Posey
Belt

37
Q

Camouflage

A

Camouflage IV lines and tubes

38
Q

Encourage

A

Encourage family to stay with patient and bring familiar objects from home

39
Q

Orient

A

Orient patient to person, place, and time

40
Q

Involve

A

Involve patient in conversation

41
Q

Give

A

Give patient something to do

42
Q

Restraints must be

A

Ordered

43
Q

Risks of using restraints

A

Increase in injury or death
Loss in self esteem/humiliation
Fear/anger
Increased confusion and agitation

44
Q

Complications of restraints

A

Impaired skin integrity
Lower extremity edema
Altered nutrition
Physical exhaustion
Social isolation
Immobility complications
Death

45
Q

Assessment

A

Regularly assess the need for continued use of restraints
Inspect placement area
Assess behavior
Assess circulation, motion, sensation
VS

DOCUMENT

46
Q

The intervals for monitoring

A

No more than two hours

Module 1 (15 decks)

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