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IMMOBILITY Stacie Pigues, MSN, RN NWCC NUR 1117 Foundations of Nursing MOBILITY • • • • • • 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 • • • • 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 • • • • 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! • o o o o 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 • • • • • • 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 • • • • 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 • • • • • 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 • • • • • • 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 • • • • • • • Loss of strength and endurance Muscle atrophy Joint contractures Osteoporosis (disuse) Foot drop Bone resorption Decreased Joint stability INTERVENTIONS • • • • 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 • • • • Nutrition Condition of the Epidermis Allergy Infections CHANGES ASSOCIATED WIITH IMMOBILITY Integumentary • • • • • Abnormal growth rate Systemic diseases Trauma Burns Mechanical forces (friction, shear, pressure) CHANGES ASSOCIATED WIITH IMMOBILITY Gastrointestinal • • • • Constipation Loss of defecation reflex Decreased gastric motility Impaction Interventions • • • • • • • 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 • • • • • Decreased lung expansion Generalized muscle weakness Stasis of secretions Atelectasis- collapse of alveoli Hypostatic Pneumonia Interventions • • • • • • • 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 • • • • 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 • • • • Renal calculi- increased Ca excretion in the urine Urinary retention Urinary Tract Infection Urinary Stasis Interventions • • • • • • 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 • • • • • Depression Behavioral Changes in sleep-wake cycle Decreased Coping Developmental changes NURSING INTERVENTIONS • • • • • 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 • • • • • 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 • • • • 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 • • • • • • 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 • • • • • • • 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 • • • • • 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 • • • • 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 • Risk assessment tool available to assist in the predication of patients at increased risk for pressure ulcer development/skin breakdown. • Provide a numeric score to rate the individual patient’s level of risk. • Score of 18 or < indicates the patient is at risk • 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 • • • • • • • 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 • • • • • • 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 • • • • 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.