Mobility Lecture Review PDF

120.502 FOUNDATIONS OF NURSING PRACTICE Kathryn Kushto- Reece, MSN, RN MOBILITY LECTURE Nicole Johnson, MSN, RN HIGHLIGHTED Shari Lynn, MSN, RN REVIEW  Who can define mobility? A person ability...

120.502 FOUNDATIONS OF NURSING PRACTICE Kathryn Kushto- Reece, MSN, RN MOBILITY LECTURE Nicole Johnson, MSN, RN HIGHLIGHTED Shari Lynn, MSN, RN REVIEW  Who can define mobility? A person ability to move about freely and perform functions of daily living. MOBILTY Why is mobility important? HIGHLIGHT It affects not only physical health but ED REVIEW psychological health. Is it the same for all? No, some people have alterations in mobility, either temporary or permanent. You received report on your patient, and they said the patient is on BR. What is this? The documentation says the patient can get OOB. What is this? Your patient is NWB. What is this?  You have three Purposeful patients. One is immobility to in a cast; one is keep limbs Why is it To maintain wearing a brace and joints important to proper and one is in aligned for properly alignment and traction. What proper healing position your decrease are these and to keep immobile pressure. examples of and further patient? what is their damage from purpose? occurring. MOBILITY HIGHLIGHTED REVIEW Your patient is on their ▪ Supine back facing the ceiling. What position is this? Your patient is face ▪ Prone down in the bed. What position is this? Your patient is moving their arm away from ▪ Abduction their body. What is this called? MOBILITY HIGHLIGHTED REVIEW Your patient is ▪ Adduction moving their arm toward their body. What is this called? ▪ Flexion Your patient is lifting a weight in their hand in a bicep curl motion. What is this called? MOBILITY HIGHLIGHTED REVIEW Your patient has straightened their ▪ Hyperextension arm backward beyond the point of regular movement. What is this called? Your patient is twisting their foot ▪ Eversion outward. What is this called? Your patient is twisting their foot inward. What is this called? ▪ Inversion ▪ Dorsiflexion Your patient is pulling their foot upward. What is this called? Your patient is pushing their foot downward as if to press on the ▪ Plantarflexion gas pedal. What is this called? MOBILITY HIGHLIGHTED REVIEW ▪ What is a turning schedule and why is it important? ▪ A schedule used to change a patient’s position every two hours or more, using pillows to relieve pressure on pressure points and allow proper circulation. MOBILITY HIGHLIGHTED REVIEW ▪ When would we log roll a patient? ▪ We log roll a patient when the patient has had spinal surgery or a possible neck injury. ▪ When would we not log roll a patient? ▪ When moving the patient from one surface to another, such as from bed to stretcher.  MOBILITY HIGHLIGHTED REVIEW ▪ One of your patients has a footboard and the other has foot splints to be placed four hours on and four hours off. What is the purpose of these devices? ▪ To prevent foot drop. ▪ What is foot drop? ▪ Foot drop occurs when the muscles become weak or when there is nerve injury. ▪ How is foot drop treated? ▪ Braces or splints, PT, nerve stimulation, surgery can fix foot drop. MOBILITY HIGHLIGHTED REVIEW ▪ What is the Braden Scale? ▪ The Braden Scale assesses patient’s risk of skin breakdown. ▪ Is it better for your patient to have a high Braden score or low Braden Score? What is the highest score? ▪ The higher the score the better as a high score means least risk of skin breakdown. The highest score is 20. Be sure to understand all parts of the Braden Scale for proper assessment.  MOBILITY HIGHLIGHTED REVIEW A Fall Risk Assessment Tool is used to What is the Fall Risk determine if your patient Assessment Tool? is a fall risk and to what degree they are a fall risk. On the Fall risk Assessment Scale, the Is it better for your lowest score is best. patient to have a high 6-13 points is moderate score or a low score on risk, and a high score the Fall Risk Assessment means a higher fall risk. Tool? The highest possible score is a 28 Non-skid Siderails & bed alarm Call bell socks MOBILITY HIGHLIGHTED REVIEW ▪ What medications may make your patient a high fall risk? ▪ PCA/Opiates, anticonvulsants, antihypertensives, diuretics, hypnotics, laxatives, sedatives and psychotropics. ▪ Why would diuretics and laxatives be included on the Fall Risk Assessment list? ▪ Increased urgent trips to the bathroom and possible increased risk of “accidents.” ▪ The Fall Risk Assessment includes the patient being “tethered.” What does that mean? ▪ Tethered is attached to something that impedes free movement such as IV poles/ pumps, chest tubes, indwelling catheters, and SCD’s. MOBILITY HIGHLIGHTED REVIEW Assistive devices Why is it important for include a cane, To keep all systems your patient to get up crutches and a walker. functioning as best as and moving as soon as How do you know these possible. possible? items are at the proper height for your patient? Atelectasis and pneumonia are With proper use the What respiratory issues complications of arms are bent at 160 is your immobile immobility due to stasis degrees. patient at risk for? of secretions and decreased lung expansion. ! What cardiovascular issues is your immobile patient at risk for? ! Orthostatic hypotension, thrombus, or blood clot. ! Why would an immobile patient be wearing TEDS and/or SCD’s? ! TEDs and/or SCDs decrease the chance for thrombus formation. ! What musculoskeletal issues is your immobile patient at risk for? ! The musculoskeletal issues your immobile patient is at risk for is osteoporosis, contractures, muscle atrophy, decubitus ulcers/injury. MOBILITY HIGHLIGHTED REVIEW ▪ What Nutrition and Metabolic Issues is your immobile patient at risk for? ▪ Nutrition and Metabolic Issues include: Calcium loss from bones and negative nitrogen balance. ▪ What is a negative nitrogen balance? ▪ 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. ▪ What Elimination issues is your immobile patient at risk for? ▪ Elimination issues include: UTI, renal calculi, constipation. ! What are restraints? ! Physical or chemical restraints means of stopping a patient from moving freely. ! Why would restraints need to be used? ! Patient is a safety threat to self and/or others. MOBILITY HIGHLIGHTED REVIEW ▪ You have placed wrist restraints on your patient who is confused and consistently attempts to pull out their central line. How often to you check on this restrained patient? ▪ One hour after application, then every two hours to release restraints, allow for range of motion and ADLs before reapplying. ▪ Why not just put all four siderails up? ▪ All 4 siderails up is considered a restraints resulting in more injury from patients trying to climb over siderails. Rules may be different in a psychiatric and pediatric units. MOBILITY HIGHLIGHTED REVIEW  MOBILITY HIGHLIGHTED REVIEW ▪ You just asked the patient 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? ▪ Move the patient up in bed. ▪ What is friction? ▪ Friction is two surfaces rubbing together like skin against bed sheets. ▪ What is shear? ▪ Shear is two layers of tissue rubbing against each other as patient is dragged up in bed. !When moving a patient up in bed what devices could reduce friction and shear? !Use of a Hoyer lift and draw sheet. !What is the best plan for moving a patient? !Always Use a lift device when available. THANK YOU!