ATI Module Mobility (Fundamentals)| 63 questions and answers.

What are bedridden patients at risk for? DVT (Deep Vein Thrombosis) What is another name for elastic stockings? Antiembolic or Thromboembolic Device (TED) What do TED's prevent? These stockings prevent clots by continuous pressure to lower extremities What are common compression strengths for elastic stockings? 12-20mmhg Sequential Compression Devices or Intermittent Pneumatic Devices are used for? Intermittent compression to promote venous return and prevent DVT Why do compression devices need to fit properly? They can either not promote proper compression or cut of circulation if too tight. How do we measure compression stockings? The circumference and the length of leg. How do we check the fit of compression stockings? Place two fingers between skin and stocking they must fit. How often should stockings be removed? Every 8hrs for skin assessment etc. What do we educate patients on when discussing elastic stockings Do not roll stockings down, do not pull toe openings back, do not place tubes under leg. What must we assess when preparing to move a client? Muscle strength, ability to move, activity tolerance, need for assistive devices Where should a nurse bend using proper body mechanics? Bend at knees Where should the client be when transferring? Close to nurses body When a nurse is working with a client in bed, where should the bed be postioned? Working height, hip level, so the back is not bending When using proper body mechanics how should the base of support be? Wide base feet approx.1 foot apart. What are the most common assistive devices? Gait belt, transfer board, draw sheet. When would we use a gait belt? Transferring from bed to chair When would we use a draw sheet? When repositioning a client. When would we use a transfer board? When transferring from a bed to a stretcher. Why do we reposition a client? (3) Prevent pressure ulcers, prevent contractures, and foot drop. How often should we reposition a client? Every 2 hours. What are some support devices used in positioning? Footboard, trochanter rolls, hand rolls, pillows. How can we prevent hand contractures? Using a hand roll and placing in clients hand. Supine Position Laying on back: pillow under head, lower back, knees Prone position Laying on stomach head to the side: pillow under head, abdomen, knees What can the prone position cause? Hyperextension of lower back and difficulty breathing Lateral Position Laying on side: pillow under head and shoulder, between legs, behind back Why do we use the lateral position? To relieve pressure on sacrum Sims position Halfway between prone and lateral with one hand behind back What position would we use for clients with breathing problems? Orthopneic position: Placing head down on surface when sitting up High Fowlers >80 degrees ; used for eating, drinking, adls Semi Fowlers 30 degrees Fowlers Position 45 degrees Trendelenburg Position Laying flat head is lowered and feet are elevated ; promotes venous return Reverse Trendelenburg Laying flat head is raised above lower body ; used for gi issues or acid reflex Why do we perform ROM exercises? To keep the mobility and strength of a clients muscles and joints Active ROM? Client independently performs ROM. Passive ROM? Nurse will put clients joints and muscles through ROM. Do muscles contract during PASSIVE rom? No : passive ROM does not maintain muscle strength. Where do we support when providing passive or assisted ROM? Above and below joint. What does a continuous passive motion device do? A device that puts a clients joints through ROM ; will extend and flex the legs; usually used after surgery Who prescribes a CPM The provider will prescribe which leg and frequency of machine use. What is flexing? Extremities toward body What is extension? Extremities away from body Supination of forearm Palm up Pronation of forearm Palm down Adducting Towards body Abducting Away from body What should we always do before transferring a client? Assess ability of client When preparing to transfer a client from bed to __ , after assessing what must be done next? Lower bed, Lock bed, Lock assistive devices. (Gait Belt Assist) Once client is standing and preparing to ambulate, where should the nurse place herself? To the side, slightly behind client, holding onto gait belt When using a cane, what side should it be placed? On the stronger side When assisting a client with a cane, where should the nurse stand? On the affected side How far should the client advance the cane? 6-10 inches How would a client walk when using a cane? Affected leg and cane move together, strong leg then follows Where should the nurse stand when a client is using a walker? Slightly behind client on one side. How far should a client move walker forward? 6-8 inches How does a client ambulate with a walker properly? Affected leg and walker moves together, strong leg the follows. When using crutches, how far ahead should they be placed? 12 inches out and slightly to sides Four Point Gait Tell the client to move the right crutch forward 12 inches, followed by the left foot moving to the level of the right crutch. The client will then move the left crutch 12 inches forward, followed by the right foot moving to the level of the right crutch. Three Point Gait Instruct the client to move the affected leg and both crutches forward 12 inches, then move the stronger leg forward to the level of crutches. Two Point Gait Instruct the client to move the left crutch and the right foot forward 12 inches, following by moving the right crutch and left foot forward. What would a nurse do if a client begins to fall? Place one leg out so client can slide down.