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IMMOBILITY
Stacie Pigues, MSN, RN
NWCC NUR 1117
Foundations of Nursing
MOBILITY
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Ability to move freely within the environment
Occurs when a person has no physical or psychological factors that limit movement
Regular Exercise and nutrition are essential
Use or lose it!
The function of the bones and joints depends on the bones mineral content!
Adequate calcium, phosphorus and vitamin B are essential for maintaining bone
resilience.
IMMOBILITY
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Occurs when a person cannot move his or her entire body of a specific part
Affects every body system
Joints become less flexible and elastic
Immobility can affect a person’s ability to complete activities of daily living
(ADL’s).
IMMOBILITY
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After age 40 you will start to see changes that will affect mobility
Age 40 to 60- Muscle tone and bone density decrease
Women have an increased incidence of fractures
Aging causes postural changes and chronic joint disorders
IMMOBILITY
Common Causes
• Therapeutic treatments
• Conditions that lead to progressive disability
• Permanent changes
IMMOBILITY
• Many things contribute to immobility!
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They are:
Length of Illness
Severity of Illness
Emotional State
Physical Condition
TERMS
• Atrophy- muscles decrease in size and strength because of disuse.
• Gait- style and character of persons walk.
TERMS
• Ataxia- Impaired muscle coordination
• Contracture- Shortening of the muscle and loss of joint mobility resulting from
fibrotic changes in the tissues.
• Paraplegia- Decreased motor and sensory function to the legs.
• Tetraplegia- Previously called quadriplegia. Describes paralysis of arms and legs
TERMS
• Range of Motion (ROM)- The ability to move all joints through the full extent
of intended function. Table 24-1(Craven)
• Flaccidity- Decreased muscle tone (also called hypotonicity).
• Spasticity- Neurologic impairment that results in increased muscle tone.
BEDREST
BENEFITS
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Promote healing and tissue repair by decreasing metabolic needs
Relieve edema (swelling)
Reduce the body’s oxygen requirements
Decrease pain
Support a weak, exhausted, or febrile patient
Avoid dislodging a deep vein thrombosis
BEDREST
Hazards
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Muscle atrophy
Muscle weakness
Joint contractures
Thromboembolic disease
CHANGES ASSOCIATED WIITH
IMMOBILITY
Metabolic
• Decreased BMR this is caused by reduced cellular energy and oxygen
demands.
• Decreased ability to produce insulin and metabolize glucose.
• This decreased ability to metabolize glucose will result in the breaking
down protein stores for energy.
Interventions
• High Protein-High Calorie diet for tissue repair and to prevent further
breakdown
• Ambulate and dangle feet to increase energy requirements and BMR
• Nutritional assessment
CHANGES ASSOCIATED WIITH
IMMOBILITY
Fluid and Electrolytes
• Are altered due to increased perspiration and diuresis.
• Increased urine production can cause the body to lose potassium and
sodium.
• Hypercalcemia can occur due to increased calcium resorption. (Increased
Calcium in the blood)
INTERVENTIONS
• Lab tests for electrolytes imbalances
• Strict intake and output
CHANGES ASSOCIATED WIITH
IMMOBILITY
Cardiovascular
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Major shifts in blood volume
Blood shifts from the lower extremities
Increased cardiac workload
Increased need for more oxygen
Orthostatic hypotension
THROMBUS FORMATION
• Thrombus formation is caused from slow blood flow due to bed rest
Signs and Symptoms:
• Pain
• Edema
• Warmth
• Fever
• Redness
• Call the doctor!!!! Very important
PULMONARY EMBOLI
What are pulmonary emboli?
• These clots block the pulmonary artery and disrupts blood flow to one or
more of the lobes of the lungs
• Patient with DVT are at an increased risk of developing a pulmonary
embolism
• Why is that true??
PULMONARY EMBLOUS
INTERVENTIONS
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Have patient get up or do range of motion exercise
Ankle circles
Avoid crossing legs or wearing tight clothing
Use TED hose or elastic stockings
Ask MD about SCD boots
Watch for s/s of bleeding if patient on an anticoagulant
CHANGES ASSOCIATED WIITH
IMMOBILITY
Musculoskeletal
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Loss of strength and endurance
Muscle atrophy
Joint contractures
Osteoporosis (disuse)
Foot drop
Bone resorption
Decreased Joint stability
INTERVENTIONS
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ROM – maintains joint mobility
Splints to help with contractures
Ambulation
High top tennis shoes for foot drop
CHANGES ASSOCIATED WIITH
IMMOBILITY
Integumentary
• Circulation- adequate skin perfusion requires four factors:
1. Heart must be able to pump adequately
2. Volume of circulating blood must be sufficient
3. Arteries and veins must be patent and functioning well
4. Local capillary pressure must be higher than external pressure
CHANGES ASSOCIATED WIITH
IMMOBILITY
Integumentary
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Nutrition
Condition of the Epidermis
Allergy
Infections
CHANGES ASSOCIATED WIITH
IMMOBILITY
Integumentary
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Abnormal growth rate
Systemic diseases
Trauma
Burns
Mechanical forces (friction, shear, pressure)
CHANGES ASSOCIATED WIITH
IMMOBILITY
Gastrointestinal
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Constipation
Loss of defecation reflex
Decreased gastric motility
Impaction
Interventions
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Encourage fluids, fruits, and veggies
Promote a natural position
Allow privacy
Assess frequency and consistency of BM
Weigh daily
Assess for impaction
Encourage client to respond when they feel the need to go
CHANGES ASSOCIATED WIITH
IMMOBILITY
Respiratory
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Decreased lung expansion
Generalized muscle weakness
Stasis of secretions
Atelectasis- collapse of alveoli
Hypostatic Pneumonia
Interventions
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Assess respiratory status at least q 2 hour
Assess for oxygen deprivation
Turn cough and deep breath q2hr
Increase fluid intake to at least 2000 cc
Change position every 2 hours
Incentive spirometry
Chest PT
CHANGES ASSOCIATED WIITH
IMMOBILITY
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Developmental
Newborn and Infant: neuromuscular assessment important to detect deformities
Toddler and Preschool: master walking, running, jumping, climbing stairs
Child and Adolescent: appear gangly and awkward, uneven motor function
affects body image
• Adult and Older Adult: chronic health problems, falling, or fear of falling affects
mobility
CHANGES ASSOCIATED WIITH
IMMOBILITY
Elimination
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Renal calculi- increased Ca excretion in the urine
Urinary retention
Urinary Tract Infection
Urinary Stasis
Interventions
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Encourage patient to drink fluids
Strict I/O
Watch for bladder distention
Watch the color of urine
Promote upright position
Encourage voiding every 3 hour
IMPACT ON PSYCHOSOCIAL FUNCTION
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Depression
Behavioral
Changes in sleep-wake cycle
Decreased Coping
Developmental changes
NURSING INTERVENTIONS
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Watch for emotional or behavioral changes
Provide stimuli for orientation
Offer books, t.v., newspaper
Encourage family to visit
Place a clock or calendar in room
FUNCTION OF SKIN
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Protection
Thermoregulation
Sensation
Metabolism
Communication
SKIN
What to look for:
• The first sign is a red mark that won’t go away
• Aggressive treatment is needed at this point!
• Complications:
 Systemic Infection
 Osteomyelitis
 Death
WOUND CLASSIFICATION
• Acute: heals within 6 months (knife, gunshot, burn, surgical incision)
• Chronic: healing time greater than 6 months (wound persists beyond normal
healing time)
• Open: break present in the skin: tissue damage present
• Closed: no break seen in skin, soft tissue damage evident
WOUND CLASSIFICATION
• Abrasion: involves friction of skin; superficial
• Puncture: intentional or unintentional penetrating trauma by sharp object;
penetrates skin and underlying tissue
• Laceration: cut in the skin
• Contusion: closed wound; bleeding in underlying tissues from blunt blow; bruising
WOUND CLASSIFICATION
Surgical
• Clean: closed wound; did not enter GI, respiratory, or genitourinary systems; low
infection risk
• Clean/contaminated: wound entering GI, respiratory, or genitourinary systems;
infection risk
• Contaminated: open, traumatic wound; surgical wound with break in asepsis;
high infection risk
• Infected: wound site with pathogens present; signs of infection
CHANGES ASSOCIATED WIITH
IMMOBILITY
• Pressure Ulcer is the best name to describe the cause.
• Pressure causes decreased tissue circulation.
• The longer the pressure, the longer the period of ischemia. This will
increase risk of skin breakdown.
• These are an ongoing healthcare issue!
PRESSURE ULCERS
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Localized injury to skin and/or underlying tissue
Usually over a bony prominence
Result of pressure or pressure in combination with shear and/or friction
Pressure decreases blood flow, impairing the supply of nutrients and
oxygen to skin and underlying tissues
• Cells die, decompose, and an ulcer is formed
• Classified based on depth of tissue destruction using a staging system
PRESSURE ULCER-STAGES
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Stage I
Stage II
Stage III
Stage IV
Unstageable
Suspected Deep Tissue Injury
STAGE I PRESSURE ULCER
• Intact skin with nonblanchable
redness of localized area
• Usually over bony prominence
• Darker toned skin may have no
visible blanching (may be difficult
to detect in darker skin tones)
STAGE I INTERVENTIONS
• Keep pressure off ulcer
• Daily skin care
• Float heels off pillows
• Moisture barrier cream
Stage II Pressure Ulcer
• Partial-thickness loss of dermis
• May involve epidermis and/or
dermis
• Presents as a shallow open ulcer
• Red-pink wound bed
• May present as an intact or
open/ruptured blister
DuoDERM® CGF® Extra Thin is a hydrocolloid
moisture-retentive wound dressing for superficial
wounds with little or no exudate and for early
intervention on those at-risk for skin breakdown.
Stage III Pressure Ulcer
• Full-thickness tissue loss
• Subcutaneous fat may be visible
• May include undermining and
tunneling
Undermining
• Tissue destruction underlying intact
skin along wound margins
Stage IV Pressure Ulcer
• Full-thickness tissue loss
• Exposed bone, tendon, or muscle
• Often includes undermining and
tunneling
UNSTAGEABLE PRESSURE ULCER
• Full-thickness tissue loss
• Base of ulcer is covered with
slough (yellow, tan, gray, green, or
brown) and/or eschar (tan, brown,
or black)
NURSING INTERVENTIONS
Identify clients at risk and the specific factors placing them at risk
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Inspect pressure points daily
Clean skin regularly; treat dry skin with moisturizers
Do not message bony prominences
Minimize exposure of skin to incontinence, perspiration, or wound drainage
Protect skin from friction and shear
Provide adequate calories and nutrients
Keep the client mobile, active, or perform ROM
NURSING INTERVENTIONS
Identify clients at risk and the specific factors placing them at risk
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Reposition q2hr
Use pillows to keep bony prominences from rubbing against each other
Float client heels
Lift, do not drag the client when moving
Provide education about pressure ulcer prevention
DRESSINGS
• Transparent films- adhesive semipermeable (Tegaderm)
• Foams- provide absorption and protection for partial and full-thickness
wounds
• Hydrocolloids- absorb excess exudate
• Hydrogels- encourage granulation with full-thickness wounds
• Alginate- used for absorption (draining wounds)
DRESSINGS
• Collagens- contain collagen (major protein in the body). Used for partialand full-thickness wounds
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Composites- contain two or more products
Contact layers- nonadhernt dressings, will not stick to wound surface
Silver dressings- antimicrobial dressings used for infected wounds
Gauzes- highly absorbent, woven cotton material
BRADEN SCALE
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Risk assessment tool available to assist in the predication of patients at
increased risk for pressure ulcer development/skin breakdown.
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Provide a numeric score to rate the individual patient’s level of risk.
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Score of 18 or < indicates the patient is at risk
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Score of 16 – you should be initiating preventative measures
NURSING INTERVENTION
• Goal is preventing or minimizing the hazards of immobility.
• Progressively restoring mobility as the patient’s condition allows.
• Therapeutic positioning is used to prevent complications when mobility is
limited.
• Important have patient on a turning schedule
NUTRITIONAL ASSESSMENT
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Aggressive nutritional support is needed
Consult dietician
Keep strict weight logs
Watch for decreased albumin
Provide adequate protein, calorie and fluid intake
Assess personal preferences or any special needs of the patient
Provide vitamins and liquids supplements as ordered
EDUCATION: CRUTCH WALKING
• The top of your crutches should reach between 1 and 1.5
inches below your armpits while you stand up straight
• The handgrips of the crutches should be even with the
top of your hip line.
• Your elbows should bend a bit when you use the handgrips.
• Hold the top of the crutches tightly to your sides, and use
your hands to absorb the weight. Don't let the tops of the
crutches press into your armpits.
EDUCATION: CRUTCH WALKING
• Begin your step as if you were going to use the injured foot
or leg, but shift your weight to the crutches instead of the
injured foot.
• Your body swings forward between the crutches.
• Finish the step normally with your non-injured leg. When
the non-injured leg is on the ground, move your crutches
ahead in preparation for the next step.
• Keep focused on where you are walking, not on your feet.
EDUCATION: MOVING PATIENTS
NURSING DIAGNOSIS
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Impaired Physical Mobility
Activity Intolerance
Impaired Walking
Risk for Disuse Syndrome
Impaired Skin Integrity
Impaired Tissue Integrity
CHARTING
• Document any current or chronic health problems that may limit mobility or
decrease activity intolerance
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Document client positioning q2hr
Document any changes in skin condition (redness, tears, breakdown, etc.)
Document diet (what percentage of diet did the client consume, fluid intake, etc.)
Document client activity level
REFERENCES
• Craven, R, Hirnle, C. & Jensen, S.(2013). Fundamentals of Nursing (7th
ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
Chapters 24 and 29.