Immobility and Restraints

Question 1

Mobility

Answer 1

A persons ability to move about freely

Question 2

Mobility examples

Answer 2

Nonverbal gestures
ADLs
Satisfaction of basic needs
Express emotions

Question 3

Paraplegia

Answer 3

May involve lower part of the body

Question 4

Hemiplegia

Answer 4

May involve one side of body

Question 5

Quadriplegia

Answer 5

May involve entire body from the neck down

Question 6

Physical causes of immobility

Answer 6

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

Question 7

Psychosocial causes of immobility

Answer 7

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

Question 8

Prolonged immobility can

Answer 8

Reduce functional capacity
Alter metabolism

Question 9

Immobility effects

Answer 9

Every body system

Question 10

Osteoclasts

Answer 10

Break down bone

Question 11

Osteoblasts

Answer 11

Grows bone
Deposits calcium into the bone

Question 12

Osteoporosis risk factors

Answer 12

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

Question 13

Joints not moved are at risk for

Answer 13

Contractures
-can begin forming within 8 hours

Question 14

Range of motion exercises improves

Answer 14

Joint mobility

Question 15

Active range of motion is done by

Answer 15

Patient

Question 16

Active assist ROM is done by

Answer 16

Patient but with help

Question 17

Passive ROM is done by

Answer 17

Nurse/caregiver

Question 18

Respiratory assessment

Answer 18

Lung sounds
O2 sats
Respiratory rat
Activity tolerance (SOB)

Question 19

Turn, cough, deep breath

Answer 19

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

Question 20

Cardiac assessment

Answer 20

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

Question 21

Deep vein thrombosis

Answer 21

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

Question 22

TED hose

Answer 22

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

Question 23

Sequential Compression Devices (SCDs)

Answer 23

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

Question 24

Metabolism assessment

Answer 24

Decreased appetite
Weight loss
Muscle loss
Weakness
Labs

Question 25

Integument assessment

Answer 25

Skin assessment (color changes, integrity) Nutrition Incontinence

Question 26

Gastrointestinal assessment

Answer 26

Bowel sounds Abdominal palpation Bowel habits I & O

Question 27

Genitourinary assessment

Answer 27

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

Question 28

Urinary stasis

Answer 28

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

Question 29

Urinary elimination changes

Answer 29

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

Question 30

Psychosocial assessment

Answer 30

Mood Orientation Speech Affect Sleep

Question 31

What is the best intervention to prevent immobility complications?

Answer 31

Ambulation

Question 32

Mobility level 1

Answer 32

Dependent

Question 33

Mobility level 2

Answer 33

Moderate assistance

Question 34

Mobility level 3

Answer 34

Minimum assistance

Question 35

Mobility level 4

Answer 35

Modified independent

Question 36

Restraint types

Answer 36

Extremity Mitten Posey Belt

Question 37

Camouflage

Answer 37

Camouflage IV lines and tubes

Question 38

Encourage

Answer 38

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

Question 39

Orient

Answer 39

Orient patient to person, place, and time

Question 40

Involve

Answer 40

Involve patient in conversation

Question 41

Give

Answer 41

Give patient something to do

Question 42

Restraints must be

Answer 42

Ordered

Question 43

Risks of using restraints

Answer 43

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

Question 44

Complications of restraints

Answer 44

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

Question 45

Assessment

Answer 45

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

Question 46

The intervals for monitoring

Answer 46

No more than two hours