Copy of Unit 1 Fundamentals PDF

Safety The Joint Commission (TJC) creates National Patient Safety Goals (NPSGs) and standards each year. It accredits healthcare facilities on safety, policy, procedures, practice, and outcomes. -​ Now more than 250 standards of compliance National Patient Safety Goals -​ Identify Clients Cor...

Safety The Joint Commission (TJC) creates National Patient Safety Goals (NPSGs) and standards each year. It accredits healthcare facilities on safety, policy, procedures, practice, and outcomes. -​ Now more than 250 standards of compliance National Patient Safety Goals -​ Identify Clients Correctly, Improve Staff Communication, Use Medications Safely, Use Alarms Safely, Prevent Hospital-Acquired Infections, Reduce the risk of suicide, Prevention of Adverse Events in Surgery, Improve Health Care Equity NPSG: Identify Clients Correctly -​ Use two client identifiers- name, date of birth, or hospital number NPSG: Improve Staff Communication -​ Reporting critical results promptly- results that are outside the expected range & can be life-threatening NPSG: Use Medications Safely -​ Label all medications -​ Establish an accurate and current medications list for the client and have the provider reconcile the list with the new drugs ordered- identifies discrepancies or interactions. Must be completed on client admission, transfer, or discharge NPSG: Use Alarms Safely (Clinical alarm systems) NPSG: Prevent Hospital-Acquired Infections -​ Hand hygiene! -​ Central line-associated bloodstream infection (CLABSI): Pathogens enter the bloodstream via a central line, which accesses a large vein in the body and can remain for long periods of time. -​ Catheter-associated urinary tract infection (CAUTI): Pathogens enter the urinary system via a catheter. -​ Surgical-site infection (SSI): Infection that occurs in the part of the body where surgery occurred -​ Ventilator-associated pneumonia (VAP): Pneumonia that develops while on a ventilator. NPSG: Identify Client Safety Risks: Reduce the Risk of Suicide -​ Ensure that suicide prevention methods are maintained while a client with a risk for suicide is present NPSG: Universal Protocol: Prevention of Adverse Events in Surgery -​ TJC mandates that a time-out (pause in activities within the procedure room) occurs before each surgery- Allows for the confirmation of the correct client, site, and procedure. -​ The NPSG states that hospitals perform a series of safety checks before beginning any procedure 1.​ Use two client identifiers 2.​ Mark the surgical site if possible. 3.​ Perform a time-out in the procedure room. NPSG: Improve Health Care Equity TJC’s Standards of Compliance= Former National Safety Goals that have been adopted and are now retired. ​ Medical error prevention ​ Verification of qualifications and competency of health care staff ​ Rights and education of clients ​ Infection control ​ Management of medications ​ Emergency preparedness Patient Safety  -​ Near Miss= Potential error or event that could have caused harm to the patient but was avoided -​ Patient Safety Event= Event that occurred without injury to the patient -​ Sentinel Event= Adverse event that caused severe physical or psychological harm to the patient All client safety events or concerns must immediately be presented to the nurse leader. Once the leadership and the provider are notified and the client is safe, then an incident report should be made. Incident reports should be used for process improvement through Root-Cause-Analysis (determines why errors occurred) Age-Related Considerations Infants and Preschoolers (0–4 Years) -​ Burns related to hot liquids or steam. -​ Accidental poisonings and choking due to their curious nature and tendency to put objects in mouths. -​ Drowning -​ Car safety- Improper use of age-specific child car seats, boosters, and seat belts. School-Age Children (5–12 Years) -​ Sports -​ Water safety -​ Car safety -​ Firearm safety Adolescents (13–19 Years) -​ Risks involving water, fire, sports, firearms, and vehicles. -​ Bullying and intimate-partner violence-> increases the risk of suicide. -​ Risk-taking behaviors such as speeding, alcohol or drugs, and unprotected sex. Adults (19 Years and Older) -​ Lifestyle choices such as alcohol consumption or smoking. -​ Workplace accidents, as well as leisure activities -​ Middle-aged adults are at the highest risk of alcohol abuse, mental disorders, and obesity. Older adults = chronic illnesses, less physical activity, impaired mobility, and cognitive or sensory deficits. The main safety risk for older adults is falling Hospital-Acquired Conditions (HAC) ​ SSIs - surgical site infections ​ CAUTIs - catheter-associated urinary tract infection ​ CLABSIs - Central Line-associated Bloodstream Infection ​ Burn, Blood transfusion incompatibility, Fall injury, Deep vein thrombosis (DVT), Pressure injury Falls= Greatest risk are children & older adults ; Identify high risk, Document evidence, Implement prevention interventions Seizures ​ Time the seizure ​ Do not restrain ​ Protect from harm ​ Maintain airway, suction as needed ​ Administer medication Restraints -​ Purpose = Protect patient, medical devices, or staff -​ Physical restraints or Chemical restraints -​ Legal Considerations  -​ Written MD order required q24h -​ Medicare reimbursement -​ Prevent complications -​ Policy and Procedure -​ Rounding & documentation -​ Proper application, quick release -​ Ongoing assessment -​ Skin integrity, nourishment, hygiene and elimination, Vital signs, Range of Motion Fire Safety -​ Fire response: R.A.C.E. -​ Rescue anyone in danger -​ Activate alarm -​ Contain the fire by closing all doors in the fire area -​ Extinguish small fires if possible -​ Use of fire extinguisher: P.A.S.S. -​ Pull the pin, release lock latch, or press a puncture level -​ Aim the extinguisher at base of fire -​ Squeeze the handle of the extinguisher -​ Sweep from side to side at the base of the flame Infant and Toddler Safety Risks -​ Aspiration= Small objects out of reach, No small round foods, Don’t lay flat to feed or prop their bottle -​ Suffocation= Safe sleep recommendations, Never alone in bathtub, Toilet lids down -​ Poisoning = Cleaning products out of reach, Medications locked up, Know poison control number -​ Falls= Crib rails up, Stair safety, gates, Never leave unattended on high surfaces Emergency Preparedness -​ Disaster= A mass casualty or interfacility event that overwhelms the normal flow of a hospital ISBARR= a handoff report to convey relevant client information to other medical professionals. Using Hand-Off Communication: I-SBAR-R Technique (I) Identification: Identify self, unit, patient, room number, where you are calling from (S) Situation: The problem or reason for contact, diagnosis, or changing conditions (B) Background: Pertinent background information related to the situation could include the following: -​ The admitting diagnosis and date of admission -​ List of current medications, allergies, IV fluids, and labs -​ Most recent vital signs -​ Lab results: provide the date and time test was done and results of previous tests for comparison -​ Other clinical information -​ Code status (A) Assessment: General client impression and significant findings (R) Recommendation: What is the nurse’s recommendation / treatments provided Examples: -​ Notification that patient has been admitted -​ Patient needs to be seen now -​ Order change (R) Readback: Restate the orders/instructions  -​ Document the change in the patient’s condition, provider notification and instructions, and interventions/evaluation. You are the nurse working in the CCU. Mr. Holloway, in room 217, is a 55-year old man admitted for a GI bleed who received 2 units of PRBC. He has a history of HTN. During your assessment, you observed that he looked pale, sweaty, confused, and weak. He was also complaining of chest pressure. ​ Identify = Identify self and patient to the provider ​ Situation = he is pale, sweaty, confused, and weak. He has chest pressure ​ Background = Just received 2 units of blood, was admitted for a GI bleed, has hypertension ​ Assessment = Experiencing a complication, potentially concerning blood loss ​ Recommendation = He needs a further assessment, vital signs checked, an X-Ray, more blood, an IVan EKG. Needs to be immediately seen. ​ Readback = Dr//Nurse/PA I am going to do … so they can recommend anything else. The Transforming Care at the Bedside plan includes the following components: ​ Have nurses spend 70% of their time at the bedside performing direct client care ​ Strengthen management through leadership development programs ​ Implement a rapid response team for the facility’s medical–surgical units - an ICU nurse, a respiratory therapy provider, and a critical care provider. ​ Create frameworks for standardized communication- Ex. ISBARR Pre Seizure Nursing Care ​ Ensure that suction equipment is set up at the bedside. ​ Ensure that oxygen is set up at the bedside. ​ Check baseline vital signs, including oxygen saturation. ​ Establish two IV sites. ​ Ensure that the side rails are padded ​ Remove potentially constrictive clothing and jewelry ​ Ask if the client feels an aura before having a seizure. If so, ask the client to notify you as soon as they feel it. If they have dentures, they need to remove them during the aura, if possible. Nursing Care During a Seizure ​ Call for immediate assistance (a rapid response team or 911 if not in the hospital). If the seizure lasts longer than 3 minutes or the client develops difficulty breathing, a medical support team is necessary. ​ Assist the client in assuming a side-lying position. Suction as needed ​ Protect the client’s head from injury. Place padding under the client’s head if on the ground. ​ Remove objects that may pose a danger ​ Do not restrain ​ Loosen any tight clothing around the neck ​ Do not leave the client. ​ Monitor the seizure for the time ​ Identify which body parts are involved. ​ Determine whether the seizure activity is the same on each side or is occurring unilaterally. ​ Determine what the eyes are doing (e.g., twitching, open or closed, pupil size). ​ Administer, per the provider’s prescription, a benzodiazepine IV (or IM if IV is not yet established) ​ Monitor the client’s airway, breathing status, and circulation status. ​ Provide oxygen if the saturation levels are low. ​ Assess vital signs.  ​ Assess skin color and temperature. Does the client look pale or cyanotic or feel clammy? ​ Provide verbal assurance that help is on the way. ​ Assess if the client has had any bowel or bladder incontinence. ​ Obtain a blood glucose level at the bedside, and if needed, plan to replace glucose per the provider’s prescription. Post Seizure Nursing Care ​ Obtain a laboratory toxicology screen if prescribed by the provider. ​ Obtain the blood drug level of the client's anticonvulsant medication if prescribed by the provider. ​ Assess the gag reflex and determine if the client can follow directions before giving the client anything to eat or drink ​ Explain to the client what occurred and provide reassurance that the client is safe. ​ Imaging studies and an electroencephalogram (EEG) are often done to determine the client’s baseline and the risk of recurrence. Communication How is information shared? -​ Verbal connection = words -​ Body language = nonverbal communication -​ Emotions -​ Technology = interpreter, devices if patient has deficits, hearing aids Levels of Communication -​ Intrapersonal = communication within yourself -​ Interpersonal = communication between 2+ people -​ Public = between you and a public group ; ex. ted talks -​ Small Group = between you and a small group of people ; ex. a committee or your study group Communication Models In order for communication to occur, there must be Sender -> Message -> Receiver -​ The sender (AKA impactor) is the one who starts the message. -​ The encoder is the means by which the message is transmitted  -​ The channel is how the encoder transmits the message, such as a phone line. -​ The decoder changes the signal back to the message. -​ The receiver is the one who receives the message. -​ Interpersonal variables impact communication -​ Environment = AKA “noise”; any environmental distractor that can interfere with the message; ex. other people talking, patient feeling high stress -​ Referent = whatever initiates the communication process (Example teacher is the referent in class) ; Teacher trying to encode info so it makes sense and sends it to us through teaching. We are the receiver; we must decode this message and make meaning out of it. Feedback = We tell the teacher if it makes sense and she can also look at our nonverbal communication to see if we understand. Factors that influence communication -​ Developmental level, gender, literacy, values, environment, Sociocultural differences -​ Physical, cognitive, and intellectual deficits/disabilities - patient in pain, disabled, tube in throat -​ Roles, competence, and responsibilities - Ex. education, job, spouse -​ Physical, mental, and emotional state -​ How message was delivered - changes interpretation of how information is understood Communication Styles -​ Passive - avoidance ; makes it seem like one doesn’t care; anxious or powerless -​ Assertive - confident ; honest and clear ; uses “I” statements -​ Aggressive - “you” statements ; can be tone of voice, abusive language, physical violence, swearing -​ Passive Aggressive - indirect ways of expressing dissatisfaction Modes of Communication= Verbal (language), Nonverbal (body language), Electronic, Written Communication and the Nursing Process -​ Planning = communicate with the patient Caring Practices= Maintain meaningful relationships, Be a good listener, Be caring, Be open minded and respectful, Treating oneself and others with kindness, Be in the moment and respect the world and those around you, Strengthen your spiritual beliefs Phases of the Therapeutic Relationship -​ Orientation phase = initial phase in which the client reaches out to the health care provider for help -​ Identification phase = establishing your position and theirs; establishing a mutually respectful relationship  -​ Working phase : Exploitation = care plan, goals of patient, helping patient achieve these goals ; active phase of the relationship where the nurse educates the client to change the situation or behavior -​ Termination phase : Resolution = your relationship with the patient ends. Feedback occurs Goals of the Therapeutic Relationship -​ Agreement on goals, frequency, and duration of the relationship. -​ Client will actively engage, cooperate, and communicate. -​ Client will evaluate goal progress and express feelings. Therapeutic Communication -​ Open ended questions : How would you describe your pain? -​ Restating/summarizing/paraphrasing : You started to feel this way yesterday. Is that correct? -​ Reflection : What are your thoughts on your diagnosis? Motivational interviewing (MI)= therapeutic communication that allows the nurse and client to develop plans to promote the client’s health by using several techniques, known by the mnemonic OARS\ -​ Open-ended questions -​ Affirmations -​ Reflection -​ Summarizing Interprofessional Education Collaborative (IPEC) competencies= Communication is one of the four top competencies Barriers to communication = False reassurance, Passing judgment, Giving advice, Close-ended questions, Why questions, Leading questions, Changing the subject, Language differences, Speech/hearing/visual impairments, Developmental or cognitive disorders, Level of consciousness Barriers to Communication= Need an interpreter no matter what, even if nurse speaks fluent Spanish, because it’s not her NATIVE language Recommendations for Communicating with Clients with Vision Loss ​ Identify and introduce yourself when you approach the client. ​ Tell the client when you are leaving the room. ​ Allow the person to take your arm. ​ Place the person's hand on the back or arm of the seat. ​ Be specific when offering directions or use clock cues if the client is accustomed to this approach. ○​ Examples: “Left about 10 feet” or “The door is at 10 o'clock.” ​ Provide medical information in large print, Braille, audio recording, printed information, etc. ​ Provide a reader who can effectively, accurately, and impartially read medical information to the client. Recommendations for Communicating with Clients with Hearing Loss ​ Ask the client how they prefer to communicate and minimize any background noise and distractions. ​ Ensure the assistive hearing device is working and the client is using it. ​ Before you speak, visually wave or lightly touch the client to get the client’s attention. ​ Do not exaggerate your words or raise your voice (unless requested to do so). ​ If the client lip reads, face them and keep your hands and objects away from your mouth. ​ Make appropriate eye contact  ○​ Only 30% of lip reading is understood; Be prepared to repeat information or questions. ​ Provide a sign language interpreter if necessary. ○​ If an interpreter is present, speak directly to the client, not the interpreter, even if the client does not make eye contact with you. Pause occasionally to allow the interpreter time to translate accurately and completely. During the phone call while talking with the oncoming nurse, the charge nurse was pleasant and accepting that the nurse would be late. However, once the phone call ended, the charge nurse then complained about the nurse always being late to the other staff. The charge nurse exhibited a passive-aggressive style of communication. -​ Psychosocial factors= the client's financial situation. -​ Cognitive factors= client is thinking and verbalizing clearly. -​ Situational factors= the new prescription for dialysis. Situational factors that can affect communication cause emotions including fatigue, anxiety, grief, and fear. -​ Environmental factors= no extreme temperatures, excessive noise, etc. -​ Physiological factors= hearing or vision loss -​ Verbal is correct. The nurse planned on teaching in a face-to-face presentation of the information. It can also occur during a telephone call. -​ Written is correct. The written mode of communication is any form of communication in which the receiver reads the message from the sender. -​ Electronic is incorrect. The nurse does not plan to include any electronic communication modes in the teaching session. This includes email, texting, and posts on social media. -​ Nonverbal is correct. Actions such as eye contact, facial gestures, posture, and overall appearance all send messages to the receiver in addition to what the sender is saying. The nurse will be sending and receiving messages with the AP as they deliver the verbal information in a face-to-face environment. -​ Assertive is incorrect. Assertiveness is a style of communication. It is not a mode of communication. -​ "I'm glad you decided to continue your fitness routine." -​ This statement by the nurse builds the client's confidence and acknowledges the client's efforts to make positive changes. It is an example of the use of affirmations -​ "You are adjusting very well for your age." -​ This statement by the nurse does not build the client's confidence or acknowledge their accomplishment. This statement is condescending. -​ "Reducing your caffeine intake is good, but you really need to stop completely." -​ This statement by the nurse does not build the client's confidence or acknowledge their accomplishment. It focuses more on what the client has not achieved than what they have achieved. Documentation ​ Comprehensive health record = How healthcare team members communicate & plan client care ​ Health Care Analysis & audits = Basis for determining quality of care ​ Documentation= Provides data necessary for reimbursement & Main source of data for clinical research Standards Set by The Joint Commission (TJC) ​ Assessment components= physical, psychosocial, environmental, self-care, patient education, discharge planning needs ​ Specific intervention details ​ Evaluation of patient response and outcomes for treatments, teaching, and preventative care Components of Health Record = Demographics, Vital signs, Medical history, Medications, Allergies, Immunizations, Data and description for each event Electronic Documentation Guidelines ​ Don't use anyone else’s login information ​ Use a strong, unique password and change it frequently. ​ Log off when done with documentation and before leaving a computer station. ​ Protect your computer screen from being seen by others. ​ If using an electronic signature, ensure your name and professional credentials are correct. Documentation Formats 1.​ Source-Oriented Medical Records -​ Documenting within a medical record that is divided into specific sections, such as history, physical examination, progress notes, nurses’ notes, laboratory reports, and diagnostic testing. It can limit sharing of information among the members of the medical team= fragmented care. 2.​ Problem-Oriented Medical Records (POMR) -​ Used to create a comprehensive and organized approach among all members of the interdisciplinary team. Contains four components: ​ A database in which assessment data are documented ​ A problem list that lists the client’s problem chronologically ​ An initial plan ​ Progress notes using the SOAP (subjective, objective, assessment, plan) format ​ SOAP documentation= component of POMR that includes clinician observations. -​ Subjective = contains information from the client. -​ Objective = what the nurse observes or measures -​ Assessment= analysis of the combined subjective and objective data -​ Plan = interventions the nurse plans to implement ​ PIE Model -​ The PIE model focuses on the client’s: ​ Problems ​ Interventions ​ Evaluations ​ A simplified approach to documentation. The PIE model focuses on the nursing process and is useful in situations where only specific issues and interventions need to be documented. ​ Focus Charting (AKA DAR) ○​ Documents a client’s specific health care problem by focusing on the diagnosis as well as changes in the client’s condition.  ○​ Documents Data, Action, and Response (DAR). Focus charting also includes immediate and future nursing actions. 3.​ Charting by Exception -​ Documents only unexpected or unusual findings based on standardized protocols. 4.​ Computerized Records ​ Real-time access to EHR 5.​ Narrative Charting ​ Written notes ​ Often chronologic FACT Charting Acronym = provides a guide for accurate and complete documentation ​ Factual: subjective and objective data ​ Accurate: facts ONLY-concise; without interpretations of situation ​ Complete: what, where, why and how ​ Timely: date and time of client care in chronological order What if you make a written documentation error? -​ Keep the original document. -​ Draw a single line through the entry and write “error” along with your initials. -​ Record the date and time of when the correction was entered. -​ Document the correct information. Guidelines for Making a Late Charting Entry ​ Make sure to identify the entry as a “late entry.” ​ Identify which event the late entry is for. ​ Make sure all new entries are signed and dated. ​ Identify which event or previous note the new note is referencing. ​ Make sure there are no blank lines. Change of Shift Report  -​ Includes significant objective information about the client’s health problems. -​ Relate recent medication changes, treatments, and the discharge plan. Transfer/Hand-Off Report = includes everything ​ Demographic Information ​ Providers & medical diagnosis ​ Health status overview (physical, psychosocial, alterations) ​ Plan of care & recent progress ​ Immediate assessments and care ​ Medications, last doses, allergies ​ Diet & activity ​ Equipment, adaptive devices ​ Advanced directive, resuscitation status ​ Discharge plan, teaching ​ Family involvement & health care proxy Telephone Reports -​ Have all the data ready before contacting any team member. -​ Use exact, relevant, and accurate information. -​ Document the details of the call, including names, time, content, and instructions received. Telephone or Verbal Prescriptions 1.​ Confirm the correct client and any allergies. 2.​ Make sure all prescriptions are complete (medication, dose, strength, route, time/frequency, indication, special instructions, prescriber’s name.) 3.​ Clarify similar-sounding words. 4.​ Document prescription immediately. 5.​ Validate accuracy through read-back and sign chart. 6.​ Resolve discrepancies or concerns before implementing the prescription. 7.​ Ensure prescriber cosigns. Receiving and Transcribing Verbal Prescriptions -​ Verbal prescriptions are reserved for emergency situations. -​ When taking a verbal prescription, write it down in the client’s record as it is heard so that it can be read back. The only time a prescription does not need to be written down immediately is when there is an emergency or in a sterile environment. In these situations, the nurse should repeat back the prescription prior to its implementation. Note that you should not accept verbal prescriptions for chemotherapeutic medications, unless the directive is to withhold or stop the medication. Safeguards to prevent client harm when using verbal prescriptions ​ Establish facility-specific regulations for verbal prescriptions. ​ Confirm the correct client, and the presence of any allergies. ​ Ensure verbal prescriptions include duration, indication, specific instructions, and prescriber’s name. ​ Clarify words that sound alike. ​ Document the prescription in the client’s record immediately. ​ Read-back all prescriptions with the prescriber. ​ Resolve any discrepancies or concerns with the provider prior to implementing Health Care Record= must adhere to ANA’s standards, HIPAA, State & federal regulations, Institution policies HIPAA ​ Secure sign-on process and automatic log-off ​ Encrypted messaging OR alternative and equivalent security measure ​ Delivery and read receipts ​ Date and time stamp ​ Customized message retention time frames ​ PHI sent as attachments must be indecipherable if intercepted. ​ Patient permission and possible consent ​ Communication becomes part of the client’s medical records. What Is Confidential? -​ All information about patients written on paper, spoken, on computer -​ Name, address, phone, fax, social security number -​ Reason the person is sick -​ Treatments patient receives -​ Information about past health conditions Potential Breaches in Patient Confidentiality ​ Displaying information on a public screen ​ Sending confidential email messages via public networks ​ Sharing printers among units with differing functions ​ Discarding copies of patient information in trash cans ​ Holding conversations that can be overheard ​ Faxing confidential information to unauthorized persons ​ Sending confidential messages overheard on pagers Social Media Precautions ​ Do not use social networking media in clinical settings. ​ Do not post information about your facility, clinicals, clients, and other health care staff ​ Do not take pictures that show clients or their family members. Electronic health records (EHRs) = A computerized, real-time form of a client's chart that can be shared between members of the medical team; includes info such as medical history, diagnosis, and testing results. Electronic documentation advantages ​ Real-time access to client records by all members of the interdisciplinary team ​ Built-in clinical alerts that reduce medical errors and duplicate tests ​ Increased coordination of care ​ Elimination of illegible records ​ Client portals that allow the client to interact with providers Commonly Used Medical Abbreviations ABBREVIATION MEANING ABD Abdomen a.c. or ac Before meals Ad lib At liberty (client can move around freely) BID or b.i.d. Twice a day BK Below the knee BP Blood pressure cath Catheter CBC Complete blood count c/o complains of CPR Cardiopulmonary resuscitation C&S Culture and sensitivity CXR Chest x-ray DNR Do not resuscitate DX Diagnosis FBS Fasting blood sugar GI Gastrointestinal gtt Drop H&H Hemoglobin and hematocrit HOB Head of bed hr Hour Hx History ICU Intensive care unit I&O Input and output IV Intravenous LLE Left lower extremity LMP Last menstrual period LOC Level of consciousness LUE Left upper extremity MI Myocardial infarction (heart attack) MRSA Methicillin-resistant Staphylococcus aureus NG Nasogastric NKA No known allergies NKDA No known drug allergies NPO Nothing by mouth N&V, N/V Nausea and vomiting  O2 Oxygen OOB Out of bed per Through or by PO By mouth PRN As needed q Every r/o Rule out Rx Prescription Stat At once, immediately TID Three times a day Tx Treatment UA Urinalysis Wt Weight Mobility ​ Mobility= Independence in purposeful movement with the ability to adapt to and have self-awareness of the environment. ​ Dependent upon Musculoskeletal function, Nervous system function, Metabolic function, Age Body Mechanics= The combined effort of the musculoskeletal and nervous systems to maintain posture, alignment, and balance. -​ Proper body mechanics is good posture in motion. Immobility= Inability to move freely and independently at will -> Risk of complications increases with degree of immobility and the length of time. -​ Disuse osteoporosis= bones have become weaker and thinner due to prolonged bed rest. -​ Atrophy= When muscles are not used they become smaller and weaken. A well-developed muscle tends to atrophy faster than a smaller, less developed muscle when not being used -​ Sarcopenia= the loss of muscle mass due to age or immobility. The muscles in the lower extremities usually experience this loss first because they are constantly working to hold the body upright.​​ -​ Joint contractures= a condition where a joint loses its normal range of motion due to structural changes in the surrounding muscles and connective tissues. Atrophy leads to an imbalance between the flexor and extensor muscles. The stronger flexor muscles pull a joint in a bent, nonfunctional position. After several weeks, the collagen in connective tissue becomes denser & less flexible, restricting movement. -​ Foot drop is a type of joint contracture that results in the inability to pull the toes up (dorsiflexion). It results from nerve entrapment and shortening of the calf muscles and Achilles tendon in the lower leg​​. Detriments of Prolonged Immobility  -​ Immobility might be prescribed post operation -​ Detectable muscle loss occurs Clot (embolism) flows to lungs position. -​ Orthostatic Hypotension Guidelines= A decrease in systolic BP of 20 mm Hg or more OR A decrease in diastolic BP of 10 mm Hg or more within 3 minutes of changing to a sitting or standing position. Partial or complete collapse Pneumonia is an of the lungs due to shallow infection that often breathing. This results in occurs in clients due to the decrease of alveoli. shallow breathing, decreased ability to Patients at risk should use cough, and thickened an incentive spirometer. mucus. Patient should be placed in a Fowler's position Pressure injury= localized damage or necrosis of the skin and underlying tissue due to pressure or friction trauma. The skin at the back of the head, shoulder blades, elbow, sacrum, Ischium, and heels have thinner skin and are more susceptible to pressure injuries Types of Postural Misalignments Lordosis = Lower back significantly curves inward with the pelvis tilting anteriorly Kyphosis= Hunchback - Upper back is abnormally rounded with a forward tilt in the pelvis. Most common in older adult females due to weakening and breakage of the vertebra. Scoliosis = C- or S-shaping of the spine. ​ History ○​ Activity tolerance vs. intolerance ○​ Activities of Daily Living (ADLs) - bathing, feeding, dressing, toileting ​ Assessment ○​ Gait, Ambulation, ROM (Active/Passive), Balance, Coordination, Muscle strength/tone, Use of assistive devices Utilizing Assistive Devices -​ Gait Belt= fastened snugly, but with enough space for the nurse to slip fingers under the belt -​ Cane= Held on strong side of body. When the client is standing with the arms relaxed at their side, the top of the cane should be level with the inside of the wrist. When the client is gripping the cane, the elbow should be bent at approximately a 20º to 30º angle. -​ Walker -​ No wheels= most support, but requires more strength and coordination. -​ Two-wheeled walker= wheels in place of the front legs. Best used by clients who require only minor support when ambulating. -​ Walkers with three or four wheels mainly assist with balance. -​ Gait while using a walker = client should move the walker and then step with the weaker leg first -​ Observe the client while standing within the walker with the arms at the side. The top of the walker should be at the level of the wrist. When the client grips the walker, the elbows should be bent at approximately a 15-degree angle. ​ Crutches are typically used by younger clients. ○​ Axilla crutches should be adjusted so that the crutch pads rest 1 to 2 inches below the axilla. The hand grips should be at the level of the client’s hips. The elbows should have a 20 degree bend when holding the hand grips. ○​ Multiple gaits= two-, three-, or four-point gait; swing-through gait; and swing-to gait. -​ Did the patient meet the goal? Patient Positioning ​ Maintain proper body alignment ​ Eliminate pressure points ​ Goals for client positioning and alignment consist of the two Ps: promotion and prevention. ​ Promotion: comfort, safety, dignity, privacy, participation, frequent position changes ​ Prevention: strain, injury, and skin breakdown Position Characteristics Advantages Prone Lying on abdomen with the head turned to one Allows for full extension of hip & side; hips are unflexed knee joints to prevent contractures Promotes drainage of secretions  Supine or Lying flat on the back, possibly with knees bent Enables visualization of the client dorsal for examination recumbent Lateral Side-lying; the hips and knees are flexed with a Promotes spinal alignment pillow separating the knees/legs Reduces pressure on sacrum & heels Fowler Semi-seated or reclined position; head of the bed Promotes lung expansion elevated 45 degrees; knees may be flexed Semi-Fowler: Head of bed elevated 15-30 degrees High-Fowler: Head of bed elevated 60-90 degrees Lateral Placed between the prone and lateral positions, Reduces pressure on the sacrum semi-prone with the top leg flexed up toward the chest and and hips recumbent supported with a pillow; the bottom arm is placed to Promotes drainage of secretions the side of the torso, not underneath Trendelenburg Lying flat on the back, with the foot of the bed Promotes venous return above the head of the bed Promotes drainage of the lower Reverse Trendelenburg: The foot of the bed is lobes of the lungs lower than the head of the bed Ergonomic Principles ​ Factors in object’s design or use that contribute to comfort, safety, efficiency, and ease of use ​ Using good body mechanics when positioning and moving promotes safety for patient and caregivers Using Transfer Devices -​ Gait Belt -​ Hoyer Lift -​ Sera Steady; Sit-to-Stand -​ Transfer Sheet CARDIOVASCULAR SYSTEM -​ Body fluids normally present in the lower extremities will be redistributed to the head and torso. This change temporarily increases the blood volume returning to the heart, and the body releases hormones to regulate fluid balance. This lowered demand results in atrophy of the heart muscle, known as cardiac deconditioning. -​ Deep vein thrombosis (DVT) occurs when a blood clot develops in a deep vein. Clients who are immobile are at a greater risk due to their increased blood viscosity and the atrophy of muscles that normally assist the body in pumping the blood. The most serious complication of DVT is a pulmonary embolism, which occurs when part of the thrombus breaks off and travels into the lungs. -​ Muscle atrophy inhibits venous pumping that can lead to blood clot formation. RESPIRATORY SYSTEM -​ Immobility reduces the amount of air exchanged and increases the risk of infection. -​ Clients who are immobile also frequently experience dehydration, which thickens the mucus secretions in the lungs, making it difficult for the client to expel the mucus when coughing. -​ Atelectasis is the partial or complete collapse of the lung. It occurs as a result of shallow breathing. This collapse decreases the number of alveoli that are available to exchange oxygen and carbon dioxide.  -​ Pneumonia often occurs in clients with limited mobility as a result of shallow breathing, thickened mucus, and decreased ability to cough. As the thick secretions collect in the lower airways, the client experiences a reduced ability to remove pathogens and irritants, which can result in an infection. GI SYSTEM -​ The gastrointestinal tract uses gravity to optimize the movement of food. -​ Clients on bed rest tend to have a decreased appetite= vitamin and mineral deficiency and malnutrition -​ Having less food in the gastrointestinal tract slows peristalsis and reduces the thickness of the mucosal lining. The use of opioids further slows this motility. Prolonged transit time in the intestinal tract increases the absorption of water from the feces and results in a drier, harder stool. -​ Gastroesophageal reflux may also occur due to supine positioning. -​ Supine positioning increases the risk of incomplete emptying of the bladder, known as urinary retention. Incomplete drainage of the kidneys and urinary retention can lead to the formation of renal calculi. These stones and urinary retention increase the risk of bacterial growth, which can promote the development of a urinary tract infection. Integumentary System Effects -​ Prolonged pressure compresses the tissues, restricting the flow of blood and lymph to those areas, especially bony prominences. Skin that is exposed to moisture is at an even greater risk for breakdown. -​ A pressure injury is localized damage or necrosis of the skin and/or underlying tissue from extended pressure, shear (sliding), or friction (rubbing) trauma. Psychological Effects -​ Decreased mobility can lead to an increased dependence on others, a loss of privacy, and an inability to participate in things previously enjoyed. These changes can negatively impact the client’s self-concept and self-esteem and can lead to feelings of frustration, anxiety, and depression. Interventions for Musculoskeletal Reduced Mobility ​Musculoskeletal Assessment Interventions Complication ​Disuse ​Monitor client for increased ​Notify provider if a fragility fracture is suspected. osteoporosis pain levels, especially in the ​Ambulate client with assistance to protect from falls. vertebral areas; such pain can ​Monitor for increased pain as weight-bearing activities indicate a fracture. increase. ​Perform hourly rounding to ensure the client’s needs are met and to decrease the risk of falls. ​Sarcopenia ​Observe client for diminishing ​Encourage the client to participate in self-care strength and coordination. activities and use the muscles. ​Monitor the client for ​Gradually increase activities to include dangling, weakness and unsteadiness. sitting, and then standing to build strength. ​Assess the client for fatigue ​Assist with ambulation to decrease the risk of falls. during activity, which could indicate a loss of muscle mass ​Joint ​Assess the client for increased ​Encourage the client to perform ADLs as able to contractures muscle tone or rigidity of the promote flexion and extension. extremities and joints. ​Ensure each joint is moved at least once every 8 hrs ​Assess the client’s ROM ​Use splints as prescribed to support and stretch ​Monitor the client for reports of contracted joints. increased stiffness  ​Inspect the client’s position and posture for proper body alignment every 2 hours. ​Foot drop ​Observe the client’s foot ​Notify the provider of foot drop if present. position while at rest and the ​Apply splints as prescribed to support and stretch the ability to flex the foot upward limb. ​Monitor the client’s gait for the ​Assist with ambulation to decrease the risk of falls. presence of toe dragging during ambulation. Interventions for Cardiovascular Complications of Immobility Cardiovascular Assessment Interventions Complication ​Orthostatic ​Monitor vital signs while the ​Elevate the head of the bed to promote blood flow hypotension client is lying, sitting, and to the lower extremities. standing, and compare. ​Assist the client with position changes ​Monitor the client for reports ​Teach the client to change positions slowly of dizziness or ​Apply antiembolism stockings to decrease venous lightheadedness during pooling in lower extremities. position changes. ​Implement fall precautions to decrease risk of falls. ​Deep vein ​Assess the client’s pulses ​Instruct the client to perform lower leg exercises to thrombosis and capillary refill for promote contraction of muscles and venous return (DVT) presence and equality. ​Apply antiembolism stockings for venous return. ​Observe the client for the ​Use sequential compression devices as prescribed presence of unilateral edema, to promote venous return. especially in lower ​Encourage fluid intake to prevent dehydration and extremities. decrease the risk of developing a clot. ​Ambulate the client frequently, if appropriate, to stimulate muscles moving the venous blood along. ​Administer anticoagulant medications as prescribed to decrease the formation of blood clots. Interventions for Respiratory Complications of Immobility Respiratory Assessment Interventions Complication ​Atelectasis ​Auscultate the lung fields to confirm ​Encourage the use of an incentive spirometer to air movement throughout all lobes. promote lung expansion. ​Observe chest wall movement for ​Instruct the client to perform deep breathing and symmetry and depth during cough exercises respirations. ​Monitor oxygen saturation levels. ​Provide supplemental oxygen as prescribed. ​Elevate the head of the bed at least 30 to 45 degrees to encourage deep breathing. ​Turn and reposition the client every 2 hours to promote lung expansion.  ​Pneumonia ​Auscultate lung fields for the ​Use prone positioning to promote drainage of presence of adventitious sounds secretions, if appropriate. ​Observe respiratory rate, depth, and ​Elevate the head of the bed at least 30 to 45 effort degrees to encourage deep breathing. ​Assess oxygen saturation levels. ​Encourage fluid intake to thin secretions. ​Monitor the client for swallowing ​Provide supplemental oxygen as prescribed. difficulties, which can increase the ​Encourage deep breathing and coughing risk of aspiration pneumonia. exercises to promote lung expansion and ​Monitor labs for manifestations of expectoration of secretions. infection like elevated WBC count ​Turn and reposition the client every 2 hours to ​Assess vital signs for indications of promote lung expansion. an infection, such as an elevated temp, heart rate, and RR Interventions for Gastrointestinal Complications of Immobility Gastrointestinal Assessment Interventions Complication ​Constipation ​Auscultate bowel sounds for peristalsis. ​Encourage fluid intake to soften ​Palpate abdomen for distention or stools. discomfort. ​Encourage the consumption of ​Monitor bowel movements for consistency high-fiber foods, which increases and regularity. water absorption in stool. ​Assess client for nausea, vomiting, or ​Increase the client’s mobility as abdominal pain, which can indicate tolerated to promote peristalsis and constipation or a blockage in intestines. move stool to the rectum. ​Gastroesophageal ​Assess the client for reports of heartburn ​Elevate the head of the bed after reflux or regurgitation. meals to promote the collection of gastric secretions in lower stomach. ​Malnutrition ​Monitor the client’s appetite and intake. ​Instruct client about consumption of ​Assess the client’s weight for changes. nutrient-dense foods ​Monitor laboratory values related to ​Help the client select foods based nutrition: serum albumin, serum protein, on preferences and nutrients glucose, and electrolytes. ​Assist client during meals if needed to promote adequate intake. ​Consult a dietitian to provide dietary guidance for nutritional deficiencies. Interventions for Genitourinary Complications of Immobility Genitourinary Assessment Interventions Complication ​Urinary retention ​Assess the client for the presence ​Encourage fluid intake of suprapubic pain or incontinence, ​Remind the client to remain in an which can indicate retention. upright position during urination to use ​Monitor output to determine if the gravity to promote bladder emptying. client is passing adequate volumes ​Assist the client to use the toilet or of urine. bedside commode to promote complete emptying of the bladder.  ​Urinary tract infection ​Monitor the client for the ​Encourage frequent voiding to (UTI) development of urinary urgency, decrease the pooling of urine, which frequency, and burning, which increases the risk of renal calculi and could indicate an infection. infection. ​Encourage the client to increase activity in bed to decrease the risk of developing renal calculi, which can lead to a UTI. ​Maintain perineal cleanliness to decrease bacteria in the urethra. Interventions for Integumentary Complications of Immobility Complication ​Assessment ​Interventions ​Pressure ​Assess the ​Ensure the client is repositioned at least every 2 hours to promote injury client’s skin for adequate blood flow to bony prominences. manifestations of ​Use pillows and cushions to support the client in different positions. damage daily. ​Use assistive devices and proper technique when repositioning to ​Inspect identified minimize additional skin trauma. areas of ​Use pressure redistribution devices to decrease prolonged pressure breakdown daily on areas susceptible to breakdown. for changes. ​Moisturize dry skin to decrease the risk of skin breakdown. ​Ensure intake of adequate calories, protein, and micronutrients to promote healing of damaged areas. ​Keep skin free from moisture due to incontinence, wound drainage, or perspiration. -​ Deconditioning may have occurred if the client experiences weakness, lightheadedness, chest pain, diaphoresis, or significant changes in vital signs with an increased activity level. The nurse should monitor for these manifestations as the client increases movement and performs ADLs. -​ Borg Rating of Perceived Exertion (RPE) scale= a subjective scale enabling clients to gauge their level of exertion during activity. The lowest level is 6 (effortless). The highest level is 20 (maximal effort). The target zone is for the client to rate activities between 12 and 14. -​ Activity Intolerance = Physical inactivity that leads to a loss of the ability to perform tasks. Ex. prolonged bed rest, decrease in mobility, balance difficulties, or weakness due to an illness Mobility Assessment= evaluates how well a client can move, including which equipment or aids are needed. The following items should be included in a mobility assessment. ​ Normal mobility status ​ Ability to sit, stand, and walk ​ Need for assistance ​ Condition of the skin ​ Presence of any manifestations during activity Bedside mobility assessment tool (BMAT)= determines a client’s mobility level. Level Assessment Tasks Results and Action Equipment Recomme Needed nded Assistance  1 ​Client extends arm and shakes ​Client can perform: Move to ​Mechanical lift 2 or more Maximum hands with nurse next level ​Slide boards personnel Assist ​Client moves self from ​Client unable to perform semi-reclining position to sitting both activities: Assign Level on edge of bed and maintains 1 Mobility for at least 2 mins 2 ​While seated at edge of bed, ​Client can perform: Move to ​Mechanical 2 or more Moderate client places feet on floor next level sit-to-stand lifts personnel Assist ​Client extends one leg out, ​Client unable to perform all ​Ambulation flexes ankle and points toes; activities: Assign Level 2 assistive repeat with other leg Mobility devices 3​ ​Client can raise self from a ​Client can perform: Move to ​Gait belt 1 to 2 ​Minimal seated position using assistive next level ​Ambulation personnel Assist device (cane or bed rail) ​Client unable to perform all assistive ​Client can maintain standing activities: Assign Level 3 devices position for at least 5 seconds Mobility 4​ ​Client can march in place ​Client unable to perform all ​None 0 to 1 ​No Assist ​Client can step forward and activities OR requires the personnel backward use of assistive devices: Assign Level 3 Mobility Transferring a Client Before attempting any type of transfer, the nurse must determine the amount of assistance a client will require. The BMAT is a beneficial tool for evaluating the level of assistance necessary. ​ Maximum assistance: The client cannot bear weight, assist, or maintain a seated position. Use a total mechanical lift or sling. ​ Moderate assistance: The client can maintain a seated position and has some upper extremity strength but lacks enough lower extremity strength to transfer safely. Use sit-to-stand powered lifts and assistive devices. ​ Minimum assistance: The client can rise from a seated position and sustain a steady stand. Use a gait belt and ambulation assistive devices as indicated. ​ No assistance: The client can stand, march or step in place, and walk without any help. Assistive Devices for Transferring a Client -​ Slide or Transfer Board= allows the lateral transfer of a client. A minimum of three to four staff members should be used when performing this type of transfer. -​ Pivot Disc= used for sitting or standing transfers for clients who have weight-bearing capabilities but have difficulty moving their feet. The disc enables the health care personnel to easily rotate the client to the desired position. -​ Mechanical Sit-to-Stand Lift= assists client in rising from a seated to a standing position. -​ Mechanical Lift= for clients who cannot support their weight. These devices lift and move a client Timed Up & Go (TUG) assessment= client is instructed to stand up from a seated position, ambulate 10 feet, turn and ambulate back to the chair, and become seated. Health care member monitors how long it takes. The nurse observes the client’s balance, stride, posture, and gait. A mobility assessment should be performed prior to initially mobilizing a client, repeated every 24 hours, and conducted following procedures that may alter a client’s mobility and need for assistance. Clients who have been immobile may experience orthostatic hypotension, so they should be instructed to sit for a few minutes on the side of the bed prior to standing. Age and Developmental-Related Considerations -​ Infancy= A bedside mobility assessment tool (BMAT) can be used to determine mobility level. -​ Childhood= Continued development of gross motor skills lead to changes in gait & stance. Fine-tuning of gait is achieved between ages 5 and 7. Strength and endurance peaks during late adolescence. -​ Adulthood=muscle mass and strength reach their maximum, but there is a slight decline in mobility when performing challenging tasks. -​ Older Adulthood= changes to body systems can result in a significant decline in the ability to ambulate Age-Related Changes Affecting Mobility in the Older Client Factor Age-Related Change Reason Effect on Mobility Posture ​Increased thoracic spinal ​Bone loss ​Forward leaning or curvature with head protrusion ​Degeneration of vertebral discs stooped posture ​Increased flexion in knees and ​Unsteady hips ambulation Reflexes ​Poor balance ​Dysfunction of nervous system ​Unsteadiness and decreased ability to right oneself Joint ​Slow movement ​Changes to brain and ​Slower steps of mobility ​Joint stiffness peripheral nervous system varied length with a ​Ankle and foot weakness ​Loss of cartilage in joints wider stance ​Changes in bones in joint areas Muscle ​Less endurance ​Loss of muscle mass ​Increased fatigue mass ​Decreased strength with ambulation Vision ​Lower vision acuity ​Reduced tone of eye muscles ​Slower ambulation ​Reduced depth perception ​Thickening of lens in the eye ​Increased risk of tripping and falling Range of Motion= the movement of a joint in any direction. -​ Passive range of motion is the movement of a joint by another individual without the client’s assistance. Passive ROM preserves joint flexibility, but it doesn’t prevent loss of muscle or bone demineralization -​ Active range of motion is the voluntary movement of a joint by the client without any type of assistance. Types of Movement ​ Flexion: bend; reduce the angle between the bones ​ Extension: straighten the limb ​ Abduction: move away from baseline ​ Adduction: bring closer to baseline ​ Pronation: turning to face backward ​ Supination: turning to face forward ​ Circumduction: circular motion ​ Rotation: side-to-side ​ Inversion: turn inward ​ Eversion: turn outward