Safety & Mobility Flashcards
(21 cards)
Decreased mobility leads to increased risk of what?
pressure ulcers, constipation, DVT, atelectasis, edema, joint pain and stiffness, decreased endurance
What puts patient at increased risk of decreased mobility?
meds, treatment, lack of sleep, change in environment
What is a contracture and what can you do to prevent them?
When flexor muscles are stronger than extensor muscles. Lay patient on their side to stretch.
What is AROM?
active range of motion, patient can move their own extremities, they should be taught to do their own exercises in bed to move joint fluid
What is PROM?
passive range of motion, the RN moves the extremities for the patient.
What are factors that affect mobility?
- Injury
- Cognitive function (dementia, brain cancer)
- Comorbidities: chronic pain, COPD, obesity, heart failure
- Age
- Pt’s own experiences with activity
- Home environment
What is the number 1 quality care indicator of a nursing environment?
Falls
What are changes to fall rate related to?
Staff turnover, staff changes, population, nursing culture, rate to get to call light
What is the widely used fall assessment tool?
John’s Hopkins Fall Assessment
What is the number 1 contributor to fall risk?
Recent history of a fall
What fall risk test has the patient stand, walk, turn, and sit back down?
Timed up and Go Test
What does the fall prevention bundle include?
- Proactive rounding
- 4 Ps: position, potty, pain, possessions
- Rounding every 2h
- Gripper socks
- Patient education
Most common type of restraint, for wrists and legs, medical/surgical restraint.
Extremity restraint
You use this restraint when there is a risk for decreased healing.
Medical/surgical
You use this restraint when a patient is homicidal or suicidal.
Behavioral
Type of restraint used on hands so the patient can’t grab or scratch.
Mittens
Type of restraint that is helpful if the patient is trying to get out of bed, the patient can still use their arms.
Vest
Type of restraint that zips and locks around the patient.
Posey (veil) bed
- need to let patient out every 2h
Type of violent restraint.
Seclusion room
Legal Considerations: Med/surg restraints
- RN-initiated but need Rx within 1h
- Provider needs to see pt in 24h
- Order lasts 24h, no PRN
- Charting: what RN tried, visit pt q30 min, chart visits q2h, offer fluid/food, hygiene, toilet q2h
Legal Considerations: Behavioral
- Need Rx within 1h
- Provider needs to see pt in 4h
- Order lasts 4h
- Chart q15 min
- Continue restraints until behavior subsides
