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27 Cards in this Set

  • Front
  • Back
what are the two types of restraints?
physical and chemical
NEVER RESTRAIN A CLIENT WITHOUT AN ORDER
this type of restraint is any manual method of physical or mechanical device, material or equipment attached to the clients body. they can not be removed easily and they restrict the clients movement
physical
this type of restraint uses medications that control socially disruptive behavior
chemical
what are some reasons to use restraints?
prevent falling out of bed
pulling out IVs
breaking open sutures
unsafe ambulation
wandering
infringing on the rights of others
what are the two categories of when to use restraints due to a behavior?
violent/non
ALWAYS USE LEAST RESTRICTED TYPE
this category due to a behavior is used in emergency situations when a pts behavior becomes aggressive or violent presenting an immediate serious danger to his/her saftety or that of others
violent
this category due to a behavior is used in therapeutic measure to prevent pt from displacing medical devices or dressings to temporarily immobilize a patient related to medical or surgical procedures
non-violent
time limits on restraints:
violent is only good for ?
non is only good for ?
4hrs
24hrs
the MD must have a face to fact assessment within an ____ on either type of restraint
hour
for violent restraint if the RN thinks pt can come out of restraints and they become violent again do they need a new order?
YES
for nonviolent restrain if a RN lets pt out of restraints do they need a new order to be placed back on?
NO
pt with restraints must be checked every ___ minutes and each restraint must be released one at a time for skin assessment
15
for documentating purposes a pt must be offered nourishment and toileting every ___ hrs
2 must be documentated
chemical restraints are only used during ________ situations
violent
what are some alterations to restraints?
keep pt closely supervised
stay with confused pt using a bedsie commode
keep bed in lowest position
use side rails (top)
talk softly to agitated pts
this definition is the ability to move in ones enviornment with ease and without restriction
mobility
this definition is the lack of movement, the state of not being mobile
immobility
what are some factors related to potential for altered mobility?
congential, neuromuscular, chronic hlth problems, trauma, affective disorders, theraputic disorders
what are some manifestations of being immobile?
edema,thrombus formation, embolus
what are some signs and the treatment of a VTE: venous thromboembolism?
redness, tenderness, warmth
measure legs every shift elivate leg dont massage
dec. muscle strength/tone is another immobility which consist of?
atrophy, spasticity, flaccidity, altered gait, falls
decreased joint flex. is another immobility which consist of?
contracture-flexor muscle stronger than extensor
foot drop-plantar position
bone loss-mainly long bones
with immobility activity intolerance dec. which causes ?
shortness of breath
fast heart
discomfort/weak
valsalva maneuver-increases abdominal pressure
with immobility nutrition and metabolism dec. which causes?
decrease metabolic rate of drugs, negative nitrogen balance, anorexia, bone reabsorption, disuse osteoporosis, pressure ulcers
with immobility elimination is dec. which causes?
constipation
urinary statis(fluid not going anywhere)
what are some assessments for a immobile pt?
ADLs
Activity
Alignment-balance, muscles
Risk for falls
weakness-orthostatic
what are 3 nursing interventions for immobility?
passive ROM
injury prevention
positioning