nursing interventions to prevent complications of immobility

These risk factors are assessed by the nurse to determine the etiology of an identified deficit and to recognize that, because of one or more risk factors, a client is at risk for impairments in terms of their mobility, gait, strength and motor skills. The later signs of compartment syndrome include burning pain secondary to ischemia, paresthesia secondary to neurological impairment, hypoesthesia secondary to sensory nerve damage, pulselessness, and cool and pale skin. The best way to maintain skin integrity and to prevent skin breakdown is to prevent them from occurring in the first place. The wound edges are approximated and closed with a closure technique such as suturing, Steri Strips, and surgical glues. Joint mobility and range of motion are assessed for the client. Coordination can be adversely affected with a neurological disorder of the cerebellum, cerebral cortex and basal ganglia; muscular strength can be impaired with things like muscular atrophy, spasticity, nutritional deficits, paresis, flaccidity and other causes; and joint mobility can be impaired disuse, arthritis and other disorders of the bone. A spiral fracture occurs when the pattern twists around the fractured bone. Some of the elements of this teaching should include: The client positions that are used for maintaining good bodily alignment and optimal physiological functioning include the Sims or the semi prone position, the Fowler's position, the dorsal recumbent position, the prone position and the lateral position. A commonly used NANDA-I nursing diagnosis is Impaired Physical Mobility. This page titled 9.4: Complications of Immobility is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request. Mobility abilities and impairments can be also assessed by observing the client while they: Simply defined, gait is the way the person walks, or ambulates. Hamilton Russell traction is an example of balanced traction. If the clot breaks free, it can travel to the lungs and become fatal. WebPreventing Complications From Immobility: Haematological - Medstrom Part 3: Haematological Part 3: How Can I Prevent Complications From Immobility? Preventive measures and the treatments of these skin integrity disorders will be discussed below in the section entitled "Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown". Assess muscle strength and coordination, and then assess mobility skills in the following order: mobility in bed, dangling on the bed with supported and unsupported sitting, weight-bearing while transferring from sitting to standing or to a chair, standing and walking with assistance, and walking independently. The complications and hazards associated with immobility and according to bodily system are described below: As the result of immobility, the urinary system can be adversely affected with urinary retention, urinary stasis, renal calculi, urinary incontinence and urinary tract infections. Enzymatic chemical debridement can be used on wounds with at least moderate amounts of necrosis and eschar, including pressure ulcers and burns. In addition to traction and splints, many fractures are also casted. Compression stockings may be knee length or hip length. We also acknowledge previous National Science Foundation support under grant numbers 1246120, 1525057, and 1413739. Risks of immobility are well-known, and complications are viewed as avoidable. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mmHg or more or in diastolic blood pressure of 10 mm Hg or more within three minutes of standing. Encourage their participation in the setting of realistic goals for mobility and modify these goals as needed for safety. These hazards of immobility can be prevented with range of motion exercises and in bed exercises such as isotonic, isometric and isokinetic muscular exercises. The toe of the stocking is typically open to allow for easy assessment of the clients circulation. It can be difficult to see this square but stretching the fabric around the heel area should make it more visible. Gait is a function of a number of different things including balance, coordination, muscular strength, and joint mobility. Immobility and complete bed rest can lead to life threatening physical and psychological complications and consequences. The American Academy of Nursing issued a recommendation in 2014 stating, Dont let older adults lie in bed or only get up to a chair during their hospital stay. This recommendation highlights the importance of implementing evidence-based measures to promote activity during hospitalization to prevent functional decline in older adults. Promote excellence in nursing by enabling future and current nurses with the education and employment resources they need to succeed. For instance, if the shoulder is being exercised, the nursing assistant places their hands underneath the elbow and wrist to support them. Like automatic sequential compression, compression stockings are fitted for the specific client after measuring the client's legs and checking the doctor's order for the amount of pressure that these stockings should exert on the client's leg. ROM exercises facilitate movement of specific joints and promote mobility of the extremities. Skalsky, A. J., & McDonald, C. M. (2012). Compression fractures occur when the fractured bone collapses as occurs with vertebral spinal fractures. When pressure ulcers are not prevented, the nurse must assess and care for it. Topical antibiotics that are often used to treat wounds, as based on the identified offending microorganism, include, among others: Nursing care consists of all of the phases of the nursing process including assessment, nursing diagnosis, planning implementation and evaluation. Passive range of motion is movement applied to an individuals joint by another person or by a passive motion machine. See Figure 9.9[10] for images of both types of applications of the toe opening of the stocking. Prevention and management of limb contractures in neuromuscular diseases. Encouraging activity as tolerated means involving the resident in movement while also adhering to mobility restrictions noted in the care plan and observing for respiratory changes that indicate the resident may be lacking endurance to maintain the activity. WebThere are many ways that nurses can assist with procedures and psychomotor skills to help immobile clients. See Table 9.4 for potential complications of immobility by body system and additional preventative measures that will keep clients as healthy as possible. The pressure from compression stockings helps return fluid into the cardiovascular system and may reduce the risk for DVT. Permanent care can prevent some of the potential complications of being bedridden and largely immobile but, unfortunately, these patients' immobility at some point results in at least one or even multiple complications. Wound discharge, which is also referred to as wound exudate, is assessed and described as the lack of any drainage or the presence of some drainage which be described in terms of color, amount and characteristics. For example, a bicep curl during weight lifting demonstrates both flexion and extension. Coughing is expected, and clients should be encouraged to expel any mucus (not swallow it). Some of the expected client outcomes relating to immobility and mobility can include specific goals such as: The interventions for immobility according to system that can be adversely affected with immobility, in addition to the constant monitoring of the client, assessments and reassessments for these hazards, include: Clients are encouraged to cough, deep breathe, use an incentive spirometer, and perform inspiratory respiratory exercises, and the nurse, or the certified respiratory therapist, will also perform postural drainage, percussion, and vibration to correct and prevent the collection of respiratory secretions in the client's airway which can result from immobility and some respiratory diseases and disorders. Assess the respiratory system, including respiratory rate, oxygen saturation, lung sounds, chest wall movement and symmetry, and depth and effort of respirations. Do not send them to the laundry or put them on a heater to dry because this can cause shrinking and ruin the hose. Administer medications if warranted and consider nonpharmacologic measures such as repositioning, splinting, and heat/cold application to reduce musculoskeletal discomfort. Insure that the counter traction force is less than the pulling traction force. Skin traction is the most commonly used type of traction. See Figure 9.4[4] for an image of a client using an incentive spirometer. Fiberglass casts are lighter in terms of weight than plaster casts; and bivalve casts, unlike solid casts, permit some swelling after the traumatic fracture and, as such, prevent compartment syndrome, a complication associated with casting. Some of its disadvantages include local irritation, its relatively high cost, and the need for frequent dressing changes once or twice a day. Promoting clients independence in completing their ADLs and encouraging activity as tolerated can help prevent all these complications of immobility. A joint should never be forced to achieve full ROM if there is resistance. See Figure 9.5[6] for an image comparing both lengths. The resident should be asked if they are experiencing any pain during the movement, and the assistant should watch for nonverbal signs of pain like grimacing, clenching the teeth, groaning, or labored breathing. Automatic sequential compression devices consist of a pump, a one time single patient use sleeve, and hosing that connects the sleeve to the pump. The three types of wound healing are primary intention healing, secondary intention healing and tertiary intention healing. The joint should be moved gently and only to the point to where there is slight resistance. Some of these preventive techniques include: The Braden Scale for Predicting Pressure Ulcers and the Norton Pressure Ulcer Scale are two of the most popular standardized screening tools that are used to screen and assess clients in order to determine if they are at risk for skin breakdown. This technique should be repeated by the client ten times every hour while they are awake. Movement of bone fragments Anxiety and stress The use of immobility devices or traction Evidenced by Verbalizations of pain Facial mask of pain Distracted behaviors Narrowed focus Guarding, protective behavior Autonomic responses Altered muscle tone Desired Outcomes After implementation of nursing interventions, the The client should be reminded and encourage to take at least 10 breaths using the incentive spirometer at least every 2 hours while they are awake. The stages of wound healing are the homeostasis phase, the inflammation phase which is also referred to as the exudate and lag phase, the proliferative and granulation phase, and the maturation phase. Accessibility StatementFor more information contact us atinfo@libretexts.org. Some of these joint disorders can be prevented with frequent and proper positioning of the client in correct bodily alignment, the provision of range of motion exercises to all joints several times a day, and the use of devices like a hand roll and a bed board to prevent contractures of the hands and feet, respectively. People must be able to move to protect themselves from trauma and to meet their basic needs. If neither of these devices is available, a washcloth can be rolled and placed underneath the fingers. While the client is in an upright semi-Fowler's position or sitting in the chair, the client is instructed to put the mouth piece tightly into their mouth and to take the deepest possible diaphragmatic breath while observing the ball rise to the level of their goal. Educate the patient about appropriately using assistive devices and other fall precautions. WebOverview Complications of Immobility Psychologic Cardiovascular Pulmonary Gastrointestinal and renal Musculoskeletal and skin Nursing Points General Psychologic Postural drainage, percussion and vibration are often referred to as pulmonary hygiene measures and pulmonary physiotherapy measures. Corn starch is NOT used. 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https://med.libretexts.org/@app/auth/3/login?returnto=https%3A%2F%2Fmed.libretexts.org%2FBookshelves%2FNursing%2FNursing_Fundamentals_(OpenRN)%2F13%253A_Mobility%2F13.03%253A_Applying_the_Nursing_Process, \( \newcommand{\vecs}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}}}\) \( \newcommand{\vecd}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash{#1}}} \)\(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\) \(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( 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Tertiary intention healing, also referred to as healing by tertiary intention, is a combination of secondary and primary healing. The nurse or respiratory therapist initially teaches the client how to use the incentive spirometer but encouraging and observing clients complete this action every hour is commonly delegated to a nursing assistant. The bones lose calcium as a result of the lack of weight bearing activity and this can lead to disuse osteoporosis, hypercalcemia, and fractures. The enzymes introduced for this type of debridement are maintained within a moist environment so that they can destroy cellular debris, slough and eschar. Primary intention healing is facilitated with wounds without infection. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. Tertiary intention healing begins with several days of open wound irrigations and packing, which is secondary healing, followed by the closure of the wound edges with approximation and suturing which is primary healing. Skeletal traction is applied directly to an affected bone with a continuous traction force and with the use of a surgically inserted Steinman pin that is placed into the distal end of the affected bone. An oblique fracture is one that occurs at an angle across the fractured bone. When passive range of motion is applied, the joint of an individual receiving the exercise is completely relaxed while the outside force moves the body part. It is an essential part of living. This technique entails the placing a cupped hand over the lung areas and doing gentle tapping on the area for about one minute while the client is hyper inflating their lungs and holding the breath as long as possible. The procedure for autolytic debridement entails the use of a semi-occlusive, occlusive, hydrocolloid, alginate, or hydrogel treatment and a transparent dressing to keep the area moist while the body uses its own enzymes like its fibrinolytic, proteolytic, and collagenolytic enzymes, as well as its on white blood cells to debride a wound and remove its eschar and slough. An incentive spirometer consists of a plastic chamber with a ball, a mouthpiece and tubing. Some of the disadvantages of mechanical debridement include the fact that it nonselective and, as such can damage healthy tissue, it can cause pain, it is more subject to an infection than other forms of debridement, and it is more time consuming on the part of the person performing this procedure, when compared to other methods of debridement. This page titled 13.3: Applying the Nursing Process is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Ernstmeyer & Christman (Eds.) The LibreTexts libraries arePowered by NICE CXone Expertand are supported by the Department of Education Open Textbook Pilot Project, the UC Davis Office of the Provost, the UC Davis Library, the California State University Affordable Learning Solutions Program, and Merlot. The RYB Color Code of Wounds is sometimes used by nurses to guide the treatment options. (OpenRN) via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request. Autolytic debridement promotes the body's use of its own enzymes to debride the wound. At each stage of growth and development, the nurse assesses a patients mobility and provides appropriate education. Monitor and document the patients response to activity, such as heart rate, blood pressure, dyspnea, and skin color.[13],[14]. The weights are gently applied, as ordered, and left to hang freely and without any interference. Lastly, skin traction applies the traction force to the skin overlying the affected bone. Because mobility issues are directly related to musculoskeletal disorders, perform a thorough assessment of the musculoskeletal system and its effect on the patients mobility status. They should be applied upon awakening because edema is usually at its lowest point after lying in bed overnight. One of its disadvantages, when compared to some other method of debridement, is the need to anesthetize the client which, in itself, has some risks. See Figure 9.1[1] for an image of a cone and palm protector, and Figure 9.2[2] for images showing application of these devices. When mobilization and ambulation are impaired as the result of muscular weakness and/or impairments of their gait, balance and coordination, the client should be provided with rehabilitation and restorative care to facilitate this mobilization and ambulation. Range of motion exercises can be active, active assisted and passive. Some nursing diagnoses related to immobility can include: Mobility is defined as the "ability to move freely, easily, rhythmically, and purposefully in the environment. Clients should be educated about the proper methods that will be used to position and reposition them in bed while they are immobilized. For example, a client who has had limited mobility for several years may have a joint that can only be moved a few inches, but it is important to maintain that mobility, no matter how small. Perform hourly rounding to check on the patients needs and prevent falls. Deep-vein thrombosis (DVT) is a common complication for clients experiencing immobility. Encourage or perform active or passive range of motion exercises as prescribed by the physical therapist. An impacted fracture is one that occurs when a bone fragment of the fractured bone is pushed and wedged into another bone fragment of the fractured bone. The fabric should be completely over the toes, or completely at the base of the toes, to prevent skin breakdown or blockage of circulation to the toes. Some of these intrinsic factors include the client's urinary and/or fecal incontinence, poor nutritional and fluid intake, diabetes, hyperthermia, hypothermia, hypotension, a decreased cardiac output, obesity, an altered sensory perception, some medications, an alteration in terms of the client's perfusion and peripheral circulation, some of the normal changes of the aging process, cachexia and emaciation, an alteration in terms of the client's metabolic status, and the client's body build as well as the size of their boney prominences. WebThe nurse teaches the importance ofNursing measures to prevent integumentary complications include providing adequate nutrition because tissue cannot repair itself Postural drainage is done by the nurse or the certified respiratory therapist. The incentive spirometer encourages a client to complete slow, deep breathing to keep their bronchioles open. The risk factors associated with immobility are client deconditioning, a cognitive impairment, spasticity, poor cardiac functioning and poor tolerance for activity, inadequate muscular strength, impaired balance, improper bodily posture and alignment, an impaired gait, pain, the use of sedating medications, joint pain and stiffness in addition to other skeletal problems, obesity, and neurological impairments in addition to a physiological health problem that mandates that the client be on complete bed rest. Segmenting ADLs refers to breaking up tasks to accommodate the clients activity intolerance. Traction is used for the external fixation of a fracture, it is used to maintain anatomically correct alignment, it is used to reduce pain and it is used to decrease muscle spasms. Because changes in joints can occur after just three days of immobility, ROM exercises should be started by the nursing assistant as soon as they are directed by the nurse as safe to do so. The area of an abnormality is measured with a disposable rule in terms of centimeters. For example, the nurse will determine whether or the client is able to: SEE Basic Care & Comfort Practice Test Questions. The procedure for setting up traction is as follows: The neurological condition of the areas of traction must be frequently assessed and inspected, the skin should be assessed and cared for, and the client should be repositioned as much as possible in a frequent manner, typically every 2 to 4 hours. These devices are connected to traction. Braces are applied to various parts of the body to provide support and alignment of the part. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. Assess the gastrointestinal system by inspecting for distension, auscultating bowel sounds, and palpating the abdomen for tenderness. The rationale for maintaining an angle of no more than 30 degrees to prevent skin breakdown, Signs and symptoms like a burning or sore feeling on a bodily part that must be reported to the nurse, The purpose of and the procedure for a mechanical lift if the client will be using one, The purpose of the lifting team if the facility has one, Lubricate the pulleys with a silicone spray, Add the precise weight that was ordered by the doctor. The advantages of this kind of wound debridement include its effectiveness, its ease in terms of performing it, its relative safety, and lack of pain for the client. Traction forces are classified and categorized as Inline or running traction and balanced traction. ROM exercises facilitate movement of specific joints and The rationale for the need for frequent position changes, The different positions that they will be used, The devices, such as pillows and bolsters, that will be used to maintain the position and proper bodily alignment. After the client is assessed, the mobility of the client, in addition to other functional activities, can be graded and classified as follows in terms of this level of functional ability: The skin, which is the first line of defense against infection, should be intact and not broken, it should be warm and without any excessive moisture, and the skin should also have good elasticity, which is referred to as good skin turgor. For example, hip abduction is the movement of the leg away from the midline of the body. [5], A sample nursing diagnosis in PES format is, Impaired Physical Mobility related to decrease in muscle strength as evidenced by slow movement and alteration in gait., A sample overall goal for a patient with Impaired Physical Mobility is, The patient will participate in activities of daily living to the fullest extent possible for their condition., A sample SMART outcome is, The patient will demonstrate appropriate use of adaptive equipment (e.g., a walker) for safe ambulation by the end of the shift..
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nursing interventions to prevent complications of immobility 2023