Pressure, particularly over boney prominences, areas of poor tissue perfusion, and areas affected with poor circulation, is a physical force associated with the development of pressure ulcers and skin breakdown. To prevent a decrease in lung function, reduce the build-up of fluids in the airways, and prevent pneumonia, clients are often prescribed incentive spirometry to keep their bronchioles open. The metabolic system alterations associated with immobility are a decreased rate of metabolism which can lead to unintended weight gain, a negative calcium balance secondary to the loss of calcium from the bones during immobilization, a negative nitrogen balance secondary to an increase in terms of catabolic protein breakdown, and anorexia. Vibration is highly similar to percussion except vibration is done by placing the palm of the hand on the lung area and doing rapid vibrating movements on the area while the client is positioned for postural drainage. (n.d.). WebDiscuss nursing interventions that prevent complications of immobility. We also acknowledge previous National Science Foundation support under grant numbers 1246120, 1525057, and 1413739. 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. Abduction refers to the movement of a limb away from the bodys midline. Pressure can be eliminated and reduced with out of bed activity, pressure relieving surfaces, the provision of sitting and lying surfaces free of any objects and wrinkles, and by turning and repositioning clients frequently to prevent this damaging mechanic force. A joint should never be forced to achieve full ROM if there is resistance. The prevention of the complications associated with immobility include early out of bed activity as soon as possible after surgery and complication related Some of the extrinsic factors that impact on the skin and its integrity are environmental humidity, chemical irritants, extremes in terms of hot and cold weather, radiation, and mechanical forces such as pressure, shearing and friction. 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. The wound edges are approximated and closed with a closure technique such as suturing, Steri Strips, and surgical glues. Some of these complications can be prevented with leg exercises, the use of sequential compression devices or antiembolism stockings, and the initiation of falls risk prevention measures when an immobilized client is adversely affected with orthostatic hypotension. Some commonly used braces are neck braces, back braces, and elbow braces. Some wounds, like surgical incisions, are planned wounds and others such as those occurring secondary to a trauma or a pressure ulcer are considered unplanned wounds. The Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University. Shearing is a combination of both pressure and friction that can cause some distortion of the client's skin and its underlying tissues. (n.d.). The muscles, joints and bones are adversely affected by immobility. Coughing, deep breathing and the use of an incentive spirometer are described as hyperinflation exercises because, when done properly, these respiratory techniques hyper inflate the lung to facilitate the loosening and mobilization of respiratory secretions. Demonstrate placement of patient in various positions, such as Fowler's, supine (dorsal), Some clients are prescribed compression stockings, also referred to as thrombo-embolic-deterrent hose (TED hose). Report completion of the activity to the nurse who documents frequency and effectiveness of this intervention.[5]. Some of the factors that impact on the skin and its integrity include intrinsic and extrinsic factors and forces. Casts can be made with plaster or fiberglass. For example, a patient undergoing a cardiac catheterization may be mobilized within a few hours following the procedure, whereas a patient undergoing total knee arthroplasty may begin mobilizing 24 hours following the surgery. The purpose of skin traction is to decrease pain and muscular spasms after a fracture has been surgically repaired with internal fixation. The client is placed in the same positions that are used for postural drainage, as discussed immediately above. Encourage the patient to perform activities of daily living (ADLs) as independently as possible and participate in prescribed physical therapy. 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. Prior assessment of wound etiology is critical for the For example, clients who undergo knee replacement surgery may be prescribed a passive range of motion machine that continuously flexes and extends the patients knee while they are lying in bed. Simply defined, full range of motion is defined as the maximum movement of a joint specific to that joint. Instructing the patient to perform simple exercises around their ROM exercises facilitate movement of specific joints and When removed at night, the compression stockings should be washed by hand in the sink with soap and water and then hung to air dry. We also acknowledge previous National Science Foundation support under grant numbers 1246120, 1525057, and 1413739. These open wounds are irrigated with a sterile solution and then packed to keep them open and, over time, they will heal on their own. She got her bachelors of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. ROM exercises facilitate movement of specific joints and They are commonly used for clients with swelling of their extremities (edema) caused by cardiac conditions that cause fluid retention. Note if urinary incontinence is occurring due to the inability of the patient to reach the restroom in time.[1]. 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"source@https://wtcs.pressbooks.pub/nursingfundamentals" ], 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, \( \newcommand{\vecs}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}}}\) \( \newcommand{\vecd}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash{#1}}} \)\(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\) \(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( 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For example, serous drainage is clear or a slight yellowish color because it consists of serum which is the clear portion of the blood; sanguineous drainage is bloody and red because it consists of red blood cells; serosanguinous drainage is pinkish in color because it is a combination of serum and red blood cells; and purulent drainage can be yellow, green, rust color or brown and this drainage indicates the presence of infection and thick pus. For example when the length of the sound is 4 cm and the width of the wound is 3 cm and the depth of the wound is 1 cm, the wound dimension is 12 cm because 4 x 3 x 1 = 12 cm. Gait is a function of a number of different things including balance, coordination, muscular strength, and joint mobility. This method of debridement entails the removal of necrotic tissue using a scalpel, forceps and scissors by the doctor. Clients often have two or more pairs of compression stockings to ensure they dry completely before wearing them again in the morning. These bowel alterations are further confounded when the client is not getting adequate fluid intake. Some of its disadvantages, however, include the fact that autolytic debridement is not as rapid as a surgical debridement in terms of its effectiveness and the fact that anerobic microbes may thrive under the dressing that is used for this type of debridement. Constipation, impaction and difficult to evacuate feces can occur as the result of immobility and the lack of exercise that is needed to promote normal bowel functioning. Legal. Administer medications if warranted and consider nonpharmacologic measures such as repositioning, splinting, and heat/cold application to reduce musculoskeletal discomfort. The skin is described in terms of its color which can be yellow, ecchymosed, purple, green, blanched and reddened, for example. Prevention Complications of Immobility Promote adequate elimination Hydration Toilet/Bedside Mobilization efforts, ranging from dangling on the edge of the bed, sitting up in a chair, and assisting with early ambulation, depend on the patients unique circumstances, such as their medical condition and surgery performed. Table 9.4 Potential Complications of Immobility and Preventative Measures. An oblique fracture is one that occurs at an angle across the fractured bone. 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. These stages are: The treatment of pressure ulcers is complex and it often includes a combination of treatments and therapies. 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. See the steps for providing ROM for the shoulder and hip joints in the ROM Exercises for the Shoulder and ROM Exercises for the Hip and Knee Skills Checklists later in this chapter. WebOverview Complications of Immobility Psychologic Cardiovascular Pulmonary Gastrointestinal and renal Musculoskeletal and skin Nursing Points General Psychologic At the current time, automatic sequential compression devices are used in health care facilities and they have virtually replaced the use of compression hose; however, compression stockings continue to be used in other areas including the client's home, for example. The wound remains vulnerable to injury until full healing is completed with good tensile strength. Therefore, nursing assistants must be diligent in their actions and observations to maintain their clients health and prevent complications. Fractures are treated to prevent deformity. Make any adjustments before proceeding because the hose will be very difficult to adjust after it is pulled up the leg. Decreased lung function can reduce a persons stamina and their ability to perform activities, referred to as activity intolerance. Active range of motion is movement of a joint by the individual with no outside force aiding in the movement. Compression stockings may be knee length or hip length. There are additional devices that can prevent a clients hand contracture, as well as prevent their fingernails from creating open skin areas in their palm. This type of fracture occurs with depressed skull fractures. Parents are educated about these developmental milestones during well-child visits. Some assessment forms allow the nurse to draw the area of concern on it to graphically show both the location and the relative size of the skin area that is affected with impaired skin integrity. Monitor for signs of vertigo and orthostatic hypotension and assist the patient to a sitting or lying position if they occur. 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. Some nursing diagnoses related to immobility can include: Mobility is defined as the "ability to move freely, easily, rhythmically, and purposefully in the environment. This relatively inexpensive type of debridement can be done with a damp dressing, hydrotherapy, and manually scrubbing the affected area to remove the debris. Traction is often set up by the nurse and, at times, a traction team may be used for the setup of the doctor's ordered traction. We use this action every day when we step to the side, get out of bed, and get out of the car. See Figure 9.6[7] for an image of locating the heel marker. Some of the orthopedic devices that nurses apply, maintain and remove include traction devices, splints, braces and casts: Traction, simply defined, is a physical pulling force that exerts pulling on the bodily part. 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. Encourage or perform active or passive range of motion exercises as prescribed by the physical therapist. PLEASE NOTE: The contents of this website are for informational purposes only. As teenagers become adults, the nurse provides education about the effects of alcohol and other drugs on balance and safety while driving. 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. When implementing interventions to promote mobility, in addition to reviewing the current orders regarding assistance and weight-bearing, assess the patients current status. Monitor 24-hour trend of intake and output, as well as for symptoms of dysuria, urgency, or frequency. Similar to compression hose, sequential compression sleeves are also fitted according to the client's measurements and they come in both thigh high and knee high sleeves. Assess for the presence of lower extremity edema and for signs of a potential deep vein thrombosis (DVT).
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