nursing interventions to prevent complications of immobility

Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered mood, and depression. Some nursing diagnoses related to immobility can include: At risk for pressure ulcers related to immobility Muscular weakness and muscular atrophy related to immobility The best way for nursing assistants to prevent DVT is to assist clients to ambulate or otherwise complete as much activity as they can tolerate. 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. You can gather or roll the sides of the hose down to the heel or choose to turn the stocking inside out to the heel marker. This process is referred to as autolysis. Patients in a coma, for example, should be given complete passive range of motion to all joints several times a day. Primary intention healing is facilitated with wounds without infection. 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. The externally placed skin traction must be applied firmly but without any potentially damaging pressure and in a smooth manner without any creases. Gait is a function of a number of different things including balance, coordination, muscular strength, and joint mobility. 13.3: Applying the Nursing Process - Medicine LibreTexts Determine the patients progress towards their specific SMART outcomes. See Figure 9.4[4] for an image of a client using an incentive spirometer. Monitor 24-hour trend of intake and output, as well as for symptoms of dysuria, urgency, or frequency. In terms of assessment, the nurse assesses and reassess the client for actual and potential complications of immobility as fully discussed above under the section entitled Identifying the Complications of Immobility" and the clients' needs in reference to mobility, gait, strength and motor skills as fully discussed in the section entitled "Assessing the Client for Mobility, Gait, Strength and Motor Skills". We use this action every day when we step to the side, get out of bed, and get out of the car. 7. Shearing can be prevented by elevating the head of the bed no more than 30 degrees unless contraindicated, using a lift or a lifting team, if you have one, by transferring clients carefully, getting help when turning and positioning a client, getting as much client cooperation as possible during turning, positioning and transfers, using a pressure relieving bed, and lubricating the skin with a lubricating moisturizer to prevent the damaging skin effects associated with pressure, friction and shearing. They should never touch the floor or any other surface such as a part of the bed because this will interfere with the traction's ordered weight. When applying stockings, proper placement on the heel is important. 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. Use any of these techniques to place the stocking on the heel, and then check for proper placement of the heel marker before applying the rest of the stocking. Hip Fracture Nursing Care Plan Active assist range of motion is joint movement by an individual with partial assistance from an outside force. Review a nursing care planning source for current NANDA-I approved nursing diagnoses and interventions. nursing fundamentals chapter 16 Flashcards | Quizlet 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. An example of segmenting ADLs would be assisting a person to bathe in bed as independently as possible, letting them rest after bathing, and then returning later to assist them with dressing and grooming to get them ready for the day. Some adverse respiratory system effects relating to immobility include the thickening of respiratory secretions, the pooling of respiratory secretions and an increased inability of the client to mobilize and expectorate these secretions, all of which can lead to atelectasis, hypostatic pneumonia, and respiratory tract infections. Unlike compression hose that exerts continuous pressure on the lower extremities, automatic sequential compression devices deliver intermittent pressure at the ordered pressure and as set on the pump. American Academy of Nursing's Expert Panel on Acute and Critical Care. The nurse should monitor these clients to insure that they are performing these active range of motion exercises in the correct manner and to the greatest possible extent of movement for all of the joints of the body. Regular socks or slippers can be placed over the TEDs for warmth if desired. 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. Both of these standardized screening tools are deemed valid and reliable for identifying those at risk. Alene Burke RN, MSN is a nationally recognized nursing educator. Casts can be made with plaster or fiberglass. At times, these devices are routinely ordered for post-operative clients to promote venous return. Nursing interventions promote a patients mobility and prevent effects of immobility. Health care team members play a vital role in preventing the physical and mental decline in functioning that can occur from immobility by proactively implementing interventions. Educate the patient about appropriately using assistive devices and other fall precautions. 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. 2023 Registered Nursing.org All Rights Reserved | About | Privacy | Terms | Contact Us. For example, hip abduction is the movement of the leg away from the midline of the body. The nurse determines whether or not the client's expected outcomes were accomplished after preventive measures were implemented to prevent the complications associated with immobility. Assess for potential signs of atelectasis and pneumonia. The margins around the wound are also assessed and described in terms of their color, their characteristics and their texture which can be classified and documented as macerated, edematous, swollen, indurated or normal. This method is the most rapid of all debridement methods but it can lead to client pain and discomfort. The length and width of all areas are measured and the depth of wounds is also measured. Immobility can adversely affect all physiological bodily systems. These devices are connected to traction. RYB stands for the colors of red, yellow and black. Promote excellence in nursing by enabling future and current nurses with the education and employment resources they need to succeed. It is an essential part of living. This type of fracture occurs with depressed skull fractures. This technique should be repeated by the client ten times every hour while they are awake. 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. The purpose of skin traction is to decrease pain and muscular spasms after a fracture has been surgically repaired with internal fixation. The resistance indicator on the right side should be monitored to ensure they are not breathing in too quickly. Apply and maintain the weights so that they hang freely. 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. Manual traction, which is applied with the hands, is done to properly align a bone after a fracture so that a cast can be applied to the bone while it is in correct anatomical alignment. 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 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 they are applied, they should be regularly checked to insure that they remain in place and without any wrinkling and they should also be removed at least one time a day so that the nurse can inspect the skin underneath it and also to check the skin for its color and warmth which can, at times, indicate a circulatory impairment. Herdman, T. H., & Kamitsuru, S. 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. The first type of hand device is a cone that slides into the palm of the hand and is kept in place with a soft elastic band. A joint should never be forced to achieve full ROM if there is resistance. Mobility is vital to independence; a fully immobilized person is as vulnerable and dependent as an infant" (Berman and Synder, 2012). Inline traction, also referred to as running traction and Buck's skin traction, exerts the traction force along the long axis of the bone and along one plane. 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. Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, percussion and vibration. 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. Nursing diagnoses for the hazards of immobility and the client's mobility were also discussed above in these same sections. Corn starch is NOT used. Chapter 8: Body Mechanics and Patient Mobility Flashcards WebDiscuss nursing interventions that prevent complications of immobility. At times a tilt table can be used to prevent this damage by placing the client in a position of weight bearing to avoid these complications. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Associations task force on competency and education for the nursing team members. A commonly used NANDA-I nursing diagnosis is Impaired Physical Mobility. Flexion is movement that decreases the angle between two bones and extension is movement that increases the angle between two bones. 9.4: Complications of Immobility - Medicine LibreTexts These techniques will be discussed below immediately after this section. After the heel of the stocking is placed properly on the clients heel, check that the hose is not twisted. 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. The depth of a wound is measured using a sterile cotton applicator which is then compared to the disposable rule for an accurate measurement. See Figure 9.5[6] for an image comparing both lengths. If constipation is suspected, palpate the patients left lower quadrant for signs of stool presence. WebActive and passive range of motion (ROM) exercises prevent complications of immobility in the musculoskeletal system. Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, Active range of motion is movement of a joint by the individual with no outside force aiding in the movement. 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. 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. Traction, when ordered, should be continuous and not interrupted. 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. People must be able to move to protect themselves from trauma and to meet their basic needs. Table 9.4 Potential Complications of Immobility and Preventative Measures. Odors can be described as malodorous, pungent, foul, or musty; and some pathogens like pseudomonas have a characteristic odor. 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. Risks of immobility are well-known, and complications are viewed as avoidable. Perform hourly rounding to check on the patients needs and prevent falls. 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. External pressure can cause creases and denting which can impair the skin below in terms of its neurological and circulatory status. Postural drainage, percussion and vibration are often referred to as pulmonary hygiene measures and pulmonary physiotherapy measures. Pressure ulcers are costly both in terms of health care costs and the human costs that the client suffers as the result of a pressure ulcer including, but not limited to, pain, sepsis, cellulitis, and osteomyelitis. The client should attempt to hold their breath for as long as possible (at least five seconds) and then exhale and rest for a few seconds. Interventions for Mobility & Immobility Issues | Study.com (Eds.). 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". The bones lose calcium as a result of the lack of weight bearing activity and this can lead to disuse osteoporosis, hypercalcemia, and fractures. 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. 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. Some of its disadvantages include local irritation, its relatively high cost, and the need for frequent dressing changes once or twice a day. WebPhysiologic changes including the release of inflammatory mediators, increased fatigue and reduction in body mass, and a decline in pulmonary function occurring after abdominal 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. 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. Braces are applied to various parts of the body to provide support and alignment of the part. We also acknowledge previous National Science Foundation support under grant numbers 1246120, 1525057, and 1413739. Pressure ulcers are staged from the least severe to the most severe from Stage 1 to Stage 5. Percussion is also performed by the nurse or the certified respiratory therapist. WebPreventing Complications From Immobility: Haematological - Medstrom Part 3: Haematological Part 3: How Can I Prevent Complications From Immobility? Movement, activity, and mobility positively affect ones overall health. Prior assessment of wound etiology is critical for the Monitor for signs of vertigo and orthostatic hypotension and assist the patient to a sitting or lying position if they occur. To avoid or minimize complications of immobility, mobilize the patient as soon as possible and to the fullest extent possible. An oblique fracture is one that occurs at an angle across the fractured bone. The circulatory system is jeopardized by immobility; some of these respiratory complications and risks include venous stasis, venous dilation, decreased blood pressure, edema, embolus formation, thrombophlebitis and orthostatic hypotension which is a risk factor that is often associated with client falls. Encourage their participation in the setting of realistic goals for mobility and modify these goals as needed for safety. Accessibility StatementFor more information contact us atinfo@libretexts.org. Some splints, like an inflatable arm splint, a Downey splint and a Sager splint, are temporarily placed on clients by paramedics in the field prior to their arrival at the emergency department of a hospital. Check that there are no wrinkles in the hose and that the client has no discomfort. The amount of pressure the hose applies to the legs is prescribed. An avulsion fracture occurs when a fragment of the fractured bone is pulled off the bone at its tendon or ligamentous attachment. 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. Skeletal fractures are classified and described in several ways, many of which are not mutually exclusive. Flexion occurs when the bicep muscle contracts and the elbow joint bends, lifting the weight. Pressure occludes the vessels that oxygenate the area and it also causes cellular damage because harmful substances, such as toxins, accumulate in the area where the pressure is exerted. Coughing is expected, and clients should be encouraged to expel any mucus (not swallow it). For example, a bicep curl during weight lifting demonstrates both flexion and extension. Nursing interventions promote a patients mobility and prevent effects of immobility. 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. Ways that the client can assist with position changes. For example, some compression stockings may seem like slightly tight socks, whereas other stockings for clients with severe edema are custom-made to fit very tightly and may have a zipper for ease of application. A staff member may provide verbal cues to complete the action, but the movement is done independently by the client. These stages are: The treatment of pressure ulcers is complex and it often includes a combination of treatments and therapies. There are three types of ROM exercises: passive, active, and active assist. The joints are affected with stiffness, pain, impaired range of motion and contractures including foot drop which is a plantar flexion contracture. Assess the respiratory system, including respiratory rate, oxygen saturation, lung sounds, chest wall movement and symmetry, and depth and effort of respirations. 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. 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. These devices are ordered by the doctor in terms of millimeters of mercury that they will apply to the lower extremities. The lateral position is a side lying position with the upper most knee bent and often maintained in that position with a pillow; the Fowler's position is a sitting position with the head of the bed up and elevated; the dorsal recumbent position and supine position are lying on the back with or without a pillow for the head; the prone position is lying on the stomach; and the Sim's position is a semi prone position. Parents are educated about these developmental milestones during well-child visits. 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. Home / NCLEX-RN Exam / Mobility and Immobility: NCLEX-RN. 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.
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