mobility and immobility

Question 1

mobility
a persons ability to move freely

Answer 1

• nonverbal gestures
• self- defense
• ADLs
• recreational
• satisfaction og basic needs
• expression of emotion

Question 2

factors affecting mobility and activity

Answer 2

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

Question 3

diseases and abnormalities

Answer 3

• bones, muscles and nervous system
• pain
• trauma
• respiratory system
• circulatory
• psychological/social

Question 4

immobility
a person inability to move about freely

Answer 4

• may invoke a specific part of the body due to injury
•may involve lower part of body( paraplegia)
• may involve one side of body (hemiplegia)
•may involve entire body from the neck down (quadriplegia

Question 5

bedrest
restricts patients to bed for therapeutic reasons (6)

Answer 5

• sometimes prescribed for selected patients
• reduces physical activity and O2 demand of the body.
• reduces pain
• allow ill or debilitated patients to rest
• allows exhausted patients to rest
• duration depends on illness or injury and prior state of health

Question 6

physical causes of immobility (6)

Answer 6

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

Question 7

psychological causes of immobility

Answer 7

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

Question 8

prolonged immobility

Answer 8

• reduced functional capacity
• altered metabolism
• numerous physiological changes

Question 9

effects of immobility

Answer 9

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

Question 10

musculoskeletal assessment

Answer 10

•activity intolerance
• anthropometric measurements
• nutrition

Question 11

bone resorption

Answer 11

osteoclasts- move along surface of bone, dissolving grooves into bone with acid and enzymes. dissolved material, including calcium, is passed through osteoclasts and into bloodstream for reuse by the body
• osteoblasts- occurs when bone is injured, added bone strength is required and calcium is elevated in the bloodstream. deposits calcium into the bone.

Question 12

osteoporosis
risk factors

Answer 12

• sec (female more affected than males, especially after menopause)
• insufficient exercise or too much exercise
• poor diet (low in Ca and protein)
• smoking

Question 13

ROM
maximum amount of movement available at a joint

Answer 13

•joints not moved are at risk for contractures (can begin forming within 8 hours)
• range of motion exercises improves joint mobility
• ROM exercises is the easiest intervention to maintain or improve joint mobility
• ROM exercise can be coordinated with other activities

Question 14

ROM exercise

Answer 14

•active ROM
- done by patient
• active assist ROM
-done by patient but with help
• passive ROM
- done by nurse or other caregiver
-continuous passive motion (CPM)

Question 15

ROM

Answer 15

• three times a day
-after bath
-mild day
-bedtime
• start gradually and move slowly using smooth motions
•support the extremity
• stretch the muscles only to the point of resistance/ pain
• encourage active ROM if possible

Question 16

respiratory assessment

Answer 16

• lung sounds
• O2 sats
• respiratory rate
•activity tolerance (SOB)
• chest X-ray
• arterial blood gasses

Question 17

cardiac assessment

Answer 17

• blood pressure
•pulse rate
• heart sounds
• activity tolerance (BP, HR, chest pain)
• calf pain

Question 18

deep vein thrombosis

Answer 18

• decreased muscle activity
• pooling of blood
• clot formation
• DVTs
-ambulation
-TED hose
-SCDs

Question 19

TED hose

Answer 19

• thrombo-embolic deterrent hose
• post surgical
• nun-walking patient

Question 20

sequential compression devices (SCDs)

Answer 20

• sleeves around the legs
• alternately inflate and deflate
• post surgical/ circulatory disorders

Question 21

metabolism assessment

Answer 21

• decreased appetite
• weight loss
• muscle loss
• weakness
• labs

Question 22

integument assessment

Answer 22

• skin assessment
-color changes
-integrity
• nutrients
• incontinence

Question 23

pressure injury
impairment of the skin as a result of prolonged ischemia ( decreased blood supply) in tissues

Answer 23

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

Question 24

gastrointestinal assessment

Answer 24

• bowel sounds
• abdominal palpitations
• bowel habits (last bowel movement)
• I & O

Question 25

genitourinary assessment

Answer 25

• I & O • palpate abdomen • incontinence •urine (color, smell, clarity)

Question 26

urinary stasis

Answer 26

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

Question 27

urinary elimination changes

Answer 27

• immobility (decreased activity) • decreased fluid intake • dehydration • concentrated urine • increase risk for UTI and kidney stones

Question 28

psychological assessment

Answer 28

• mood • orientation • speech • affect • sleep

Question 29

psychological effects

Answer 29

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

Question 30

benefits of mobility

Answer 30

• strengthen muscles • joint flexibility • stimulates circulation • prevents constipation • prevents osteoporosis • stimulates the appetite • prevents urinary inconveniences and infection • relieves pressure-esteem • improves self esteem • decrease anxiety and depression

Question 31

wheel fail outside of room

Answer 31

• mobility level 1 dependent • mobility level 2 moderate assistance • mobility level 3 minimum assistance • mobility level 4 modified independent

Question 32

restraints

Answer 32

• 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

Question 33

non- violent restraints

Answer 33

• actions impede medical care • lack of awareness of potential harm to self and other • unable to follow commands and comply with safety instructions • attempts to pull out tubes, drains or other lines/ devices medically necessary for treatment • requires every 2 hours monitoring and documentation • new order required every calendar day • when discontinuing, date & time must be documented

Question 34

restraint types

Answer 34

• extremity • mitten • posey • belt

Question 35

alternative measures

Answer 35

• orient family and patient to environment • offer diversionary activities • use calm simple statements • promote relaxation techniques • attend to needs • use of glasses/ hearing aids

Question 36

alternative measure examples

Answer 36

• increase or decrease the light • place personal items within reach • place near nurse station • reduce environmental noise • keep call button accessible • use special furniture accordingly (bed alarm)

Question 37

alternative measures con’d

Answer 37

• camouflage • encourage • orient • involve • give

Question 38

restraint guidelines

Answer 38

• practitioner must order prior to applying • in emergencies- may apply but practitioner must be notified immediately • a new order must be obtained daily • must be discontinued at the earliest possible time • monitoring varies depending on patient needs and situational factors (could be continuous, every 15 mins or every 2-3 hours) • assessment includes vital signs, hydration and circulation, skin integrity and patients level of distress)

Question 39

risks of using restraints

Answer 39

• increase in injury or death • loss of self- esteem • humiliation • fear • anger • increase confusion and agitation MAKE SURE ALL OTHER MEASURES HAVE BEEN TAKEN TI AVOID RESTRAINTS

Question 40

complications of restraints

Answer 40

• impaired skin integrity • lower extremity edema • altered nutrition • physical exhaustion • social isolation • immobility communication •death

Question 41

intervention applications

Answer 41

• restrict movement as little as is necessary • make sure restraint fits properly • always tie (slip knot or new tie) to bed frame/ mattress spring • always explains the need for restraint • never leave patient unattended without the restraint • pas bony prominences • DOCUMENT!

Question 42

assessment

Answer 42

• regularly assess the need for continued use of restraints • inspect placement area of restraint • assess patient behavior • assess circulation, motion, sensation • make sure restraint fits properly • vital signs DOCUMENT ASSESSMENT

Question 43

assessment con’d

Answer 43

• inspect skin color and edema • palpate for skin temp • palpate pulse • check capillary refill • mental status • if they are able to respond- ask them to move the limb • if they are able to respond - ask if they have tingling

Question 44

interventions

Answer 44

• ROM • reposition • nutrition/ hydration/ toileting • release at the earliest possible time

Question 45

documentation

Answer 45

• any medical evaluation for restraint •description of the patient behavior and the intervention used • any alternatives or other less restrictive intervention attempted • patients condition or symptom that warranted the use of restraints • patient response to the intervention used and rationale for continued use of the intervention • individual patient assessment and reassessment • the intervals for monitoring • revisions to the plan of care

Question 46

documentation con’d

Answer 46

• patient behavior and staff concerns regarding safety risk to the patient, staff and others that necessitated the use of restraints • injuries to the patient • death associated with the use of restraint • the identity of the practitioner who ordered the restraint • orders for restraint • notification of the use of restraint to the attending physician • consultation • patient/ family teaching • response when restraint removed