Mobility and restraints Flashcards

Question

cardiac assessment -5

Answer 1

~blood pressure ~pulse rate ~heart sounds ~activity tolerance {BP, HR, chest pain} ~calf pain

Answer 2

1. decreased muscle activity 2. pooling of blood 3. clot formation 4. DVT {ambulation, TED hose, SCD's}

Answer 3

thrombo-embolic deterrent hose, post-surgical, non walking patient

Answer 4

sequential compression devices, sleeves around the legs, alternately inflate and deflate, post-surgical/circulatory disorders

Answer 5

~decreased appetite ~weight loss ~muscle loss ~weakness ~labs

Answer 6

~skin assessment {color changes, integrity} ~nutrition ~incontinence

Answer 7

impairment of the skin as a result of prolonged ischemia {decreased blood supply} in tissues

Answer 8

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

Answer 9

~bowel sounds ~abdominal palpation ~bowel habits ~I & O

Answer 10

~I & O ~palpate abdomen ~incontinence ~urine {color, smell, clarity}

Answer 11

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

Answer 12

1. immobility 2. decreased fluid intake 3. dehydration 4. concentrated urine 5. increased risk for UTI and kidney stones

Answer 13

~mood ~orientation ~speech ~affect ~sleep

Answer 14

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

Answer 15

those of the abdomen and legs

Answer 16

the hips, knees, and ankles

Answer 17

phlebitis and the development of clots

Answer 18

abdominal muscles stimulates the intestinal tract

Answer 19

mineral loss from the bones when they do not bear weight

Answer 20

go to the bathroom on their own, incontinence is reduced

Answer 21

body and skin, helping to prevent from pressure injurys

Answer 22

patients feeling of independence

Answer 23

hospitalization

Answer 24

ambulation

Answer 25

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

Answer 26

~every 2 hours monitoring and documentation ~new order required for every calender day ~when d/c, date and time must be documented

Answer 27

~actions impede medical care ~lack of awareness of potential harm to self and others ~unable to follow commands and comply with safety instuctions ~attempts to pull out tubes, drains, or other lines/devices medically necessary for treatment

Answer 28

prior to restaining, alternatives must be attempted

Answer 29

modify the environment

Answer 30

~camouflage IV lines & tubes ~encourage family to stay with the patient ~orient patient to person, place, and time ~involve patient in conversation ~give patient something to do

Answer 31

~increase in injury and death ~loss of self-esteem ~humiliation ~fear ~anger ~increased confusion and agitation

Answer 32

~impaired skin integrity ~lower extremity edema ~altered nutrition ~physical exhaustion ~social isolation ~immobility complications ~death

Answer 33

~restrict as little movement as necessary ~make sure restraints fit properly ~always tie to bed frame or mattress springs ~always explain the need for restraint ~never leave the patient unattended without the restraints ~pad bony prominences ~document

Answer 34

~regularly assess the need for continued use of restraints ~inspect placement area of restraint ~assess patients behavior ~assess circulation, motion, sensation ~make sure restraint fits properly ~vital signs ~document

Answer 35

~inspect skin color and edema ~palpate for skin temp ~palpate pulse ~check capillary refill ~menatal status ~ask to move the limb ~ask if having any tingling

Answer 36

~ROM ~reposition ~nutrition, hydration, toileting ~release at the earliest possible time

Mobility and restraints Flashcards

(61 cards)