Ch.28 Immobility

Cardiovascular Assessment Hazards

*Auscultation: Orthostatic hypotension *Auscultation, palpation: increased HR, third heart sounds, weak peripheral pulses, peripheral edema

Nurse is teaching how to minimize risk of developing osteoporosis. What reflects understanding of what was taught?

*I go swimming at the YMCA 3 times a week. *ask doctor about a bone mineral density check *if i don't drink milk i will eat broccoli or cabbage to get calcium

Nursing Diagnosis related to Immobility

*Ineffective airway clearance *Ineffective coping *impaired physical mobility *Impaired urinary elimination *Risk for impaired skin integrity *Risk for disuse syndrome *Social isolation

Skin Assessment Hazards

*Inspection, palpation: Break in skin integrity

Musculoskeletal Assessment Hazards

*Inspection. palpation: decreased ROM, erythema, increased diameter in calf or thigh *Palpation: joint contracture *Inspection: activity intolerance, muscle atrophy, joint contracture

Respiratory Assessment Hazards

*Inspection: asymmetrical chest wall movement, dyspnea, increased respiratory rate *Auscultation: Crackles, wheezes

Elimination Assessment Hazards

*Inspection: decreased urine output, cloudy or concentrated urine, decreased frequency of bowel movements *Palpation:distended bladder and abdomen *Auscultation: decreased bowel sounds

Metabolic Assessment Hazards

*Inspection: slow wound healing, abnormal leg data, muscle atrophy * Anthropometirc measures: decreased amount of subcutaneous fat *Palpation: generalized edema

Complications of immobility on Urinary System

*Urinary stasis- renal pelvis fills before urine enters the ureters. When standing, gravity is the force to send urine to the ureters. Risk for uti and renal calculi * Renal calculi- calcium stones that lodge in the renal pelvis. immobile patients often have hypercalcemia, dehydrated causes decreased urine output concentrating urine increases risk for calculi and infection

Psychosocial Intervention to reduce impact of immobility

1) Anticipate changes in patient's status and provide routine and informal socialization 2) Stimuli to maintain patient's orientation

Measures used to assess for deep vein thrombosis

1) Ask patient about the presence of calf pain 3) Observing the dorsal aspect of lower extremities for redness, warmth, and tenderness 3) Measure the circumference of the leg each day, placing the tape measure at the midpoint of the knee NOT a measure: homan signs

Metabolic Intervention to reduce impact of immobility

1) High protein, high-caloric diet: helps repair tissue and rebuild protein stores 2) Vitamin B ad C supplements: b for energy metabolism and C for skin integrity and wound healing

Complications of immobility in relation to Musculoskeletal System

1) Loss of endurance, strength, and muscle mass and decreased stability and balance 2) Impaired calcium metabolism 3) Impaired joint mobility 4) Osteoporosis 5) Joint contractures 6) Footdrop

Musculoskeletal Intervention to reduce impact of immobility

1) Perform passive and active range of motion exercises- prevent muscle atrophy and joint contractures 2) CPM Machines- performs frequent ROM exercises to restore function of injured joint after surgery

Health Promotion Activities for Mobility and Immobility

1) Prevent work related injury 2) Fall prevention measures 3) Exercise 4) Early detection of scoliosis

Areas of Assessment of Mobility

1) Range of motion 2) Gait 3) Exercise and activity tolerance 4) Body alignment

Cardiovascular Intervention to reduce impact of immobility

1) Reduce orthostatic hypotension and early mobilization- mobilize as early as allowed (even if just sitting dangling off bed) to maintain muscle tone and increase venous return. *isometric exercise is ineffective for hypotension but improves activity intolerance 2) Reduce Cardiac workload and avoid Valsalva movements- holding breath and strains causes intrathoracic pressure and decreases venous return and cardiac output. releasing strain increases systolic BP and pulse pressure. Produces a reflex bradycardia and decreased BP that could result in death for heard disease patient. Teach to breathe out instead of holding breath in strain. 3) Prevent thrombus formation and prophylaxis- identify risk and continues throughout immobilization to reduce risk of thrombus formation and decreases risk for resulting pulmonary embolism- leg foot ankle exercises, provide fluids, frequent position changes, patient teaching. use anticoagulant, compression stocking.

Elimination Intervention to reduce impact of immobility

1) Well Hydrated- helps prevent renal calculi and UTI 2) Prevent urinary stasis and calculi and infection 3)Diet rich in fluids, fruits, veggies, and fiber to facilitate normal peristalsis of GI

Place the following options in the order in which elastic stockings should be applied

1) identify patient using 2 identifiers 2) assess condition of skin and circulation in legs 3) use tape measure to measure legs and determine proper stocking size 4) Turn the stocking inside out until heel is reached 5) Place toes into foot of stocking 6) Slide remainder of sock over patients heel and up to leg 7) smooth any creases or wrinkles

Complications of Immobility in relation to Metabolic Functioning

1)Decreased metabolic rate- increases if fever or wound 2) Altered metabolism of Carbs, Fats, Proteins- excrete more nitrogen from protein breakdown than ingested 3) Fluid and electrolyte and calcium imbalances - absorb calcium from bones, which may not be able to be escreted by kidneys causing hypercalcemia. 4) GI disturbances - constipation and pseudodiarrhea

Which is a physiological effect of prolonged bed rest?

A decrease in lung expansion- decreased lung elastic recoiling and secretions accumulating in portions of the lungs

Thrombus

Accumulation of platelets, fibrin, clotting factors, and cellular elements of blood attach to interior wall of vein or artery and can occlude lumen. Factors that contribute to formation- Virchow;s triad: damage to vessel wall, alteration of blood flow, alteration of blood constituents.

Instrumental Activities of Daily Living (IADL)

Activities such as shopping, preparing meals, driving, taking medications that are necessary to be independent in society beyond the necessary eating, grooming, transferring and toileting.

Postural Abnormalities

Affect efficiency of musculoskeletal system and body alignment, balance, and appearance. Can cause pain, impair alignment or mobility.

Ligaments

Aid in joint flexibility and support- bind joints together, connect bones to cartilage.

Trapeze Bar

Allows patient to pull with the upper extremities to raise trunk off of the bed, assist in transfer, or perform exercises. Increases independence, maintains upper body strength, and decreases shearing from sliding around in bed.

Assisting patient with hemiplegia (one side paralysis) or hemiparesis (one side weakness)

Always stand on the patient's affected (weak) side and support them using a gait belt

To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery?

Ambulate patient to chair in the hall

A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding:

Bruising, bleeding gums, coffee ground-like vomitus

Atrophy

Cells and tissues reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting, or local nerve damage

Atelectasis

Collapse of alveoli: secretions block a bronchiole or bronchus causing distal lung alveoli to collapse when existing air is absorbed, producing hypoventilation.

Tendons

Connect muscle to bone

Skeletal Muscles

Contract and relax are the working elements of movement.

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend?

Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert

What is a physiological outcome of immobility?

Decreased lung expansion

Patient is on day 4 of bedrest. Nurse identifies the following as sign associated with immobility

Decreased peristalsis

Outcome of immobility to infants, toddlers, and preschoolers

Delays on child's gross motor skills, intellectual development, or musculoskeletal development

Body Mechanics

Describes the coordinated efforts of the musculoskeletal and nervous system.

Body Alignment

Determines normal physiological changes. identifies deviations from incorrect posture, learning needs, trauma muscle damage or nerve dysfunction, and risk factors.

Orthostatic Hypotension

Drop of blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic when you go from supine to standing position. Caused by decreased circulating fluid volume, pooling of blood in lower extremities, and decreased autonomic response. Feel dizziness, light headed, nausea, tachycardia, pallor or fainting.

Integumentary Intervention to reduce impact of immobility

Early identification of high risk for pressure ulcers helps prevent 1) Positioning and skin care- helps to maintain the condition of the skin. position every 1-2 hr to disrupt pressure 2) Use of therapeutic devices to relieve pressure- air loss mattress, heel boots

Psychosocial effects of Immobility

Emotional and behavior responses, sensory alterations, and changes in coping. Social isolation, loneliness, depression, withdrawal

Appropriate intervention to maintain the respiratory system of immobilized patient

Encourage the patient to deep breathe and cough every 1 o 2 hours

Exercise

Enhance feelings of well-being and improve endurance, strength, and health. Reduces risk of many health problems such as cardiovascular disease, diabetes, and osteoporosis. Encourage patient to find exercise that meets lifestyle and health related needs. Ex- aquatic therapy if patient has arthritis. Exercise is a key prescription for health promotion of all patients regardless of age.

Nurses risk for injury

Especially at risk for injury to lumbar muscles when lifting, transferring, or positioning immobilized patients. Be aware of policies and protocols that protect staff and patients. *When lifting: assess weight and determine assistance. Use mechanical or other ergonomic assistive devices to reposition and lift patients. Be aware of an agency lift team or no-lift policy.

Shear

Force exerted against the skin while the skin remains stationary and the bony structures move

Friction

Force that occurs in a direction in a direction to oppose motion

Osteoporosis

Have special health promotion needs: asess diets for calcium and vitamin D intake. if lactose intolerant, need dietary teaching about alternative sources of calcium. Early evaluation, consultation and referral to health care providers, dietitians, and physical therapists are important interventions. Goal is to maintain independence with activities of daily living. Use ambulatory devices, adaptive clothing, and safety bars. Patient teaching- limit severity of disease through diet and activity.

Fowler Position

Head of bed 45-60 degrees and knees slightly elevated without pressure to restrict circulation in lower legs.

Disuse Osteoporosis

Immobilization causes calcium bone resorption, bone tissue is less dense (lost) and patient is at risk for fractures.

Damage to the Nervous System

Impaired body alignment, balance, and mobility. Damage to cerebellum causes balance issues and Damage to motor strip causes motor impairment directly related to degree of damage. Damage to spinal cord also impairs mobility.

Immobility

Inability to move about freely . Associated with systemic effects- risk associated with immobility depends on patients overall health, degree and length of immobility, and age.

Hydrostatic Peumonia

Inflammation of the lungs from stasis or pooling of secretion. With complications of immobility, there is a decline in a productive cough, which causes mucus to increase. this is an excellent site for bacterial growth.

An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility?

Left ankle joint soreness

Prone Position

Lies face or chest down

Hand Rolls

Maintains the thumb in slight adduction and opposition to the fingers

Goal of Restorative Care

Maximize functional mobility and independence and reduce residual functional deficits such as impaired gait and decreased endurance. Focus on activities of daily living and instrumental activities of daily living.

Range of Motion

Maximum amount of movement available at a joint in one of the three planes of the body: Sagittal, frontal, or transverse. Exercises are active and passive. Want to get a baseline for later evaluation.

Cartilages

Nonvascular and supports connective tissues. Located in joints, thorax, trachea, larynx, nose, ear.

Gait

Particular manner of walking. Mechanics involves coordination of skeletal, neurological, and muscular systems. Can draw conclusion about balance, posture, and ability to walk without assistance to assess fall risk.

Sims Position

Patient places the weight on the anterior ileum, humerus and clavicle.

Side-lying Position

Patient rests on the side with body weight on the dependent hip and shoulder

Positioning a Patient

Patients with impaired nervous, skeletal, or muscular system functioning and weakness or fatigue need nurses help to position and maintain proper alignment. Use positioning devices.

Mobility

Person's ability to move about freely

Exercise

Physical activity for conditioning the body, improving health, and maintaining fitness. Used as therapy to maximal state of health- has beneficial psychological changes to numerous body systems.

Outcome of immobility on Adults

Physiological systems are at risk, loss of job

What is a potential hazard to assess when the patient is in the prone position?

Plantar flexion aka footdrop. Allow foot to be dorsiflexed at ankle to prevent this.

Complications of immobility on Integumentary Changes

Pressure ulcers- impairment of skin results from prolonged ischemia in tissues caused from pressure on skin greater than pressure in small peripheral blood vessels.

Trochanter Roll

Prevents external rotation of hips when patient is supine. Extends from femur to lower border of popliteal space. Also could use a sandbag

The nurse puts elastic stockings on patient following stockings. They are used to

Promote venous return to the heart

Nervous System

Regulates movement and posture. Motor fibers from the precentral of the cortex cross at the medulla to control opposite side of the body.

Outcomes for the goal "patient skin remains intact""

Remember goals should be individualized, realistic, and measureable. Focus on preventing problems or risks to impaired body alignment and mobility. 1) Patient's skin color and temperature return to normal baseline within 20 minutes of position change 2) Patient changes position at least every 2 hours

An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility?

Respirations 26/minute, HR 114, Crackles over lower lobes heard on auscultation Not: BP 128/84 or pain level 3

Supine Position

Resting on back; all body parts in relation to each other: laying flat on back

Outcome of immobility on adolescents

Social isolation

Body Alignment

The individual's center of gravity is stable. Reduces strain on musculoskeletal structures, aids in maintaining adequate muscle tone, promotes comfort, contributes to balance and conservation of energy.

The effects of immobility on the cardiac system include which of the following?

Thrombus formation, increased cardiac workload, orthostatic hypotension

Activity Tolerance

Type and amount of exercise that a person is able to perform without undue exertion or possible injury.

Thick Pillow

Under bony prominences to protect skin and tissue from pressure damage

Thin Pillow

Under patients head to prevent cervical flexion that a thick pillow causes

Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?

Use of incentive spirometer every 2 hours while awake

Respiratory Intervention to reduce impact of immobility

Want to promote lung expansion and remove pulmonary secretions 1) Deep breathe and cough every 1 or 2 hours, use incentive spirometry , controlled coughing 2) Chest physiotherapy (CPT)- percussion and postural drainage gets secretions into trachea so it can be coughed up 3) Ensure intake of 1400 mL/day of fluid- helps mucociliary clearance normal by preventing thick tenacious secretions

Outcomes of immobility on Older Adults

Weaker bones, increased risk of falls, increased physical dependence on others

Muscle Abnormalities

Weakness and wasting of muscles, which increase disability and deformity. Direct trauma to system causes bruises, contusions, fractures and sprains.

Joint Contracture

abnormal and possibly permanent fixation of a joint caused by immobility. Flexor muscles are stronger than extensors so disuse, atrophy, and shortening causes contracture and cannot achieve full ROM.

Joints

connections between bones- cartilaginous fibrous, and synovial

A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient?

encourage use of overhead trapeze for positioning and ransfer

Footdrop

foot is permanently fixed in plantar flexion. Causes difficulty ambulating because foot cannot dorsiflex.

The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed?

inflation pressure averages 40 mm Hg, patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve

Disuse Atrophy

loss of endurance, decreased muscle mass and strength, and joint instability place patients at risk for falls.

A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken:

pressure ulcers

Bed Rest

restricts patients to bed for therapeutic reasons. Muscular deconditioning hazards of immobility occurs within a few days- losing 3% of muscle strength per day.