Mobility

Question 1

What medications may make your patient a high fall risk?

Answer 1

PCA/Opiates, anticonvulsants, antihypertensives, diuretics, hypnotics, laxatives, sedatives, and psychotropics

Question 2

Why would diuretics and laxatives be included on the Fall Risk Assessment list?

Answer 2

Increase urgent trips to the bathroom and possible increased risk of “accidents”

Question 3

The Fall Risk Assessment includes the patient being “tethered.” What does that mean?

Answer 3

Tethered is attached to something that impedes free movement, such as IV poles/pumps, chest tubes, indwelling catheters, and SCD’s

Question 4

What is the Fall Risk Assessment Tool?

Answer 4

used to determine if your patient is a fall risk and to what degree they are a fall risk

Question 5

Is it better for your patient to have a high score or a low score on the Fall Risk Assessment Tool? What is the highest score?

Answer 5

Best score: lowest
Moderate: 6-13
High score: 13+; highest is 28

Question 6

What is the Braden Scale?

Answer 6

assesses patient’s risk of skin breakdown

Question 7

Is it better for your patient to have a high Braden score or low Braden score? What is the highest score?

Answer 7

Higher score: least risk of skin breakdown
Lower score: more risk of skin breakdown
Highest score: 20

Question 8

What is foot drop?

Answer 8

occurs when the muscles become weak or when there is nerve injury

Question 9

How is foot drop treated?

Answer 9

Braces or splints, PT, nerve stimulation, surgery

Question 10

One of your patients has a footboard and the other has foot splints to be places fours on and four hours off. What is the purpose of these devices?

Answer 10

prevent foot drop

Question 11

When do you log roll a patient?

Answer 11

when the patient has had spinal surgery or a possible neck injury

Question 12

When do you NOT log roll a patient?

Answer 12

when moving the patient from one surface to another, such as from bed to stretcher

Question 13

What is the turning schedule and why is it important?

Answer 13

Every 2hrs: Back –> Right –> Left –> repeat
The schedule is used to change the position of the patients using pillows to relieve pressure on pressure points and allow proper circulation

Question 14

BR stands for?

Answer 14

bed rest

Question 15

OOB stands for?

Answer 15

out of bed

Question 16

NWB stands for?

Answer 16

non-weight bearing

Question 17

Define Mobility.

Answer 17

A person’s ability to move about freely and perform functions of daily living

Question 18

Why is mobility important?

Answer 18

it affects not only physical health but psychological health

Question 19

What respiratory issues is an immobile patient at risk for? Why?

Answer 19

Atelectasis and pneumonia - due to stasis of secretions and decreased lung expansion

Question 20

What cardiovascular issues is an immobile patient at risk for?

Answer 20

Orthostatic hypotension, thrombus (blood clot)

Question 21

Why would an immobile patient be wearing TEDS and/or SCD’s?

Answer 21

TEDs and/or SCD’s decrease the chance for thrombus formation

Question 22

What musculoskeletal issues is an immobile patient at risk for?

Answer 22

osteoporosis, contractures, muscle atrophy, decubitus uclers/injury

Question 23

What nutrition and metabolic issues is an immobile patient at risk for?

Answer 23

calcium loss from bones and negative nitrogen balance

Question 24

What is a negative nitrogen balance?

Answer 24

with immobility there is more protein breakdown than protein synthesis secondary to muscle atrophy and decreased protein intake. Protein breakdown produces nitrogen which can be detected in urine

Question 25

What elimination issues is an immobile patient at risk for?

Answer 25

UTI, renal calculi, constipation

Question 26

What are restraints and what are the different types?

Answer 26

Physical or chemical restraints means of stopping a patient from moving freely

Question 27

Why would restraints need to be used?

Answer 27

patient is a safety threat to self and/or others

Question 28

A confused patient is on restraints for constantly pulling out their central line , how often do you check on their restraints?

Answer 28

1hr after application, then every 2hrs to release restraints, allow for range of motion and ADLs before reapplying

Question 29

Why can you NOT pull up all four siderails?

Answer 29

All 4 siderrails up is considered a restraints resulting in more injury from patients trying to climb over siderails. Rules may be different in psychiatric and pediatric units

Question 30

What is shear?

Answer 30

two layers of tissue rubbing against each other as patient is dragged up in bed

Question 31

You asked the patients to put their hands across their chest, put their chin to their chest and you have raised the bed to a comfortable height for you. What are you about to do?

Answer 31

move the patient up in bed

Question 32

When moving a patient up in bed, what devices could be used to reduce friction and shear?

Answer 32

use of hoyer lift and draw sheet

Question 33

What is the best plan for moving a patient?

Answer 33

ALWAYS use a lift device when available