nursing interventions to prevent complications of immobility

nursing interventions to prevent complications of immobility

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. 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. Compression stockings require a physicians order and should be applied in the morning and taken off at night. Extension occurs when the arm is straightened back to starting position, increasing the angle between the elbow joint. Mobility is vital to independence; a fully immobilized person is as vulnerable and dependent as an infant" (Berman and Synder, 2012). Fiberglass casts are lighter in terms of weight than plaster casts; and bivalve casts, unlike solid casts, permit some swelling after the traumatic fracture and, as such, prevent compartment syndrome, a complication associated with casting. This process is referred to as autolysis. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the lower leg, but can occur anywhere within the cardiovascular system. This method is the most rapid of all debridement methods but it can lead to client pain and discomfort. Some of the factors that impact on the skin and its integrity include intrinsic and extrinsic factors and forces. When a client experiences immobility, normally healthy alveoli can collapse and cause decreased lung function. The procedure for setting up traction is as follows: The neurological condition of the areas of traction must be frequently assessed and inspected, the skin should be assessed and cared for, and the client should be repositioned as much as possible in a frequent manner, typically every 2 to 4 hours. They are commonly used for clients with swelling of their extremities (edema) caused by cardiac conditions that cause fluid retention. See Figure 9.4[4] for an image of a client using an incentive spirometer. Some of the disadvantages of mechanical debridement include the fact that it nonselective and, as such can damage healthy tissue, it can cause pain, it is more subject to an infection than other forms of debridement, and it is more time consuming on the part of the person performing this procedure, when compared to other methods of debridement. The rationale for maintaining an angle of no more than 30 degrees to prevent skin breakdown, Signs and symptoms like a burning or sore feeling on a bodily part that must be reported to the nurse, The purpose of and the procedure for a mechanical lift if the client will be using one, The purpose of the lifting team if the facility has one, Lubricate the pulleys with a silicone spray, Add the precise weight that was ordered by the doctor. Traction, when ordered, should be continuous and not interrupted. Sometimes a clients lack of endurance in completing activities requires the nursing assistant to segment their ADLs. See Figure 9.7[8] for a demonstration of these techniques. 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. [5], A sample nursing diagnosis in PES format is, Impaired Physical Mobility related to decrease in muscle strength as evidenced by slow movement and alteration in gait., A sample overall goal for a patient with Impaired Physical Mobility is, The patient will participate in activities of daily living to the fullest extent possible for their condition., A sample SMART outcome is, The patient will demonstrate appropriate use of adaptive equipment (e.g., a walker) for safe ambulation by the end of the shift.. Encourage their participation in the setting of realistic goals for mobility and modify these goals as needed for safety. 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". [10], For bed-bound patients, elevate the head of the bed to 30 to 45 degrees, unless medically contraindicated, and turn and reposition the patient every two hours. See Figure 9.8[9] for heel placement. If the clot breaks free, it can travel to the lungs and become fatal. Postural drainage is done by the nurse or the certified respiratory therapist. Encouraging activity as tolerated means involving the resident in movement while also adhering to mobility restrictions noted in the care plan and observing for respiratory changes that indicate the resident may be lacking endurance to maintain the activity. Identifying the Complications of Immobility, Assessing the Client for Mobility, Gait, Strength and Motor Skills, Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown, Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown, Applying a Knowledge of Nursing Procedures and Psychomotor Skills When Providing Care to Clients with Immobility, Coughing, Deep Breathing, Incentive Spirometry, Postural Drainage, Percussion, Vibration and Inspiratory Respiratory Exercises, Applying, Maintaining and Removing Orthopedic Devices, Applying and Maintaining Devices That are Used to Promote Venous Return, Educating the Client Regarding the Proper Methods Used When Repositioning an Immobilized Client, Maintaining the Client's Correct Body Alignment, Maintaining and Correcting the Adjustment of the Client's Traction Device, Implementing Measures to Promote Circulation, Evaluating the Client's Responses to Interventions to Prevent the Complications From Immobility, Adult Gerontology Nurse Practitioner Programs (AGNP), Womens Health Nurse Practitioner Programs, Advanced Practice Registered Nurse (APRN), Non Pharmacological Comfort Interventions, Basic Care & Comfort Practice Test Questions, Identify complications of immobility (e.g., skin breakdown, contractures), Assess the client for mobility, gait, strength and motor skills, Perform skin assessment and implement measures to maintain skin integrity and prevent skin breakdown (e.g., turning, repositioning, pressure-relieving support surfaces), Apply knowledge of nursing procedures and psychomotor skills when providing care to clients with immobility, Apply, maintain or remove orthopedic devices (e.g., traction, splints, braces, casts), Apply and maintain devices used to promote venous return (e.g., anti-embolic stockings, sequential compression devices), Educate the client regarding proper methods used when repositioning an immobilized client, Maintain the client's correct body alignment, Maintain/correct the adjustment of client's traction device (e.g., external fixation device, halo traction, skeletal traction), Implement measures to promote circulation (e.g., active or passive range of motion, positioning and mobilization), Evaluate the client's response to interventions to prevent complications from immobility, At risk for pressure ulcers related to immobility, Muscular weakness and muscular atrophy related to immobility, At risk for venous stasis and emboli related to immobility, At risk for altered and impaired respiratory functioning related to immobility, At risk for falls related to orthostatic hypotension secondary to immobility, At risk for osteoporosis and fractures related to the loss of calcium from the bones secondary to the lack of weight bearing activity, Plantar flexion contracture related to immobility, Loss of complete range of motion related to immobility, Are sitting to determine whether or not they need support while sitting, Change from a sitting position to standing, transferring from the bed to the chair, and sitting down on a chair or bed, At risk for impaired skin integrity related to immobility, At risk for impaired skin integrity related to poor skin turgor, Impaired skin integrity related to impaired tissue perfusion, At risk for impaired skin integrity related to boney prominences, Impaired skin integrity related to pressure, shearing and friction, Impaired skin integrity related to poor nutritional status, The screening of all clients for their potential for skin breakdown and then initiating special preventive measures, Performing skin assessments and reassessments on a regular basis, Keeping the client clean and dry at all times to prevent moisture and skin maceration as well as debris, Turning and positioning clients at least every two hours when the client is unable to move about in bed to turn and position on their own, Maintaining the client's nutritional and fluid needs, The utilization of supportive and assistive devices such as a wedge, pillow, and a pressure relieving mattress, The elimination of pressure, friction, shearing and moisture on the client's body and bodily parts, The client will perform active range of motion to all joints two times a day, The client will safely transfer from the bed to the chair with assistance, The client will demonstrate proper deep breathing and coughing, The client will ambulate 30 feet three times a day with a walker and the assistance of another, The client will increase their level of exercise and physical activity, The client will demonstrate the proper use of their assistive device, The client will maintain adequate respiratory functioning, Splint any painful or tender abdominal areas with a pillow or the client's hand, Take the deepest possible diaphragmatic breath through the nose, Repeat this coughing and deep breathing as often as necessary to clear the airways. Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered mood, and depression. 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. Assess for the presence of urinary tract abnormalities related to immobility, such as suprapubic distention or tenderness that can result from urinary retention. 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. These sleeves, like compression hose, require that the nurse regularly check them to insure that they remain in place and they, too, 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. Because mobility issues are directly related to musculoskeletal disorders, perform a thorough assessment of the musculoskeletal system and its effect on the patients mobility status. Legal. The American Academy of Nursing issued a recommendation in 2014 stating, Dont let older adults lie in bed or only get up to a chair during their hospital stay. This recommendation highlights the importance of implementing evidence-based measures to promote activity during hospitalization to prevent functional decline in older adults. Nurses maintain skin integrity and prevent skin breakdown in a number of different ways. Nursing diagnoses for the hazards of immobility and the client's mobility were also discussed above in these same sections. The purpose of skin traction is to decrease pain and muscular spasms after a fracture has been surgically repaired with internal fixation. 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". Older adults are at increased risk for immobility. RegisteredNursing.org Staff Writers | Updated/Verified: Mar 10, 2023. Automatic sequential compression devices can have sleeves to accommodate for pressure on the legs as well as the foot. The homeostasis phase is marked with vasoconstriction, platelet formation, thrombin formation and the formation of a fibrin mesh for healing; the inflammation phase is characterized with the signs and symptoms of inflammation including edema, swelling, pain, in addition to the beginning of debris removal to prevent infection through the process of phagocytosis; the proliferative and granulation phase is marked with the fibroblastic production of collagen and granulation tissue; and, lastly, the maturation phase of wound healing is characterized with the still fragile skin after the wound healing process that can last up to two years after a wound. A commonly used NANDA-I nursing diagnosis is Impaired Physical Mobility. A complete fracture involves the entire cross section of the fractured bone; an incomplete fracture affects only part of the bone and not the entire cross section; stable fractures are defined as fractures that are not likely to be displaced, therefore, reduction is not indicated; an unstable fracture, unlike a stable fracture, necessitates reduction because it is likely that this fracture is displaced; a closed fracture is defined as one that does not break through the surface of the skin and this type of fracture and this type of fracture is also referred to as a simple fracture; an opened fracture, on the other hand, breaks through the skin surface to the exterior of the body and, as such, an opened fracture is prone to infection because the skin lacks integrity; and a pathological fracture is one that results from a disease process rather than undue stress or trauma as other fractures do. 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. People must be able to move to protect themselves from trauma and to meet their basic needs. This method is not used as much today as it was previously used. 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. Risks of immobility are well-known, and complications are viewed as avoidable. The three basic traction techniques can also be classified as manual traction, skeletal traction and skin traction. Immobility can Complicate Life Hospitalization poses a risk for altered functional status of older adults due to acute illness, decreased mobility, and the negative effects of bedrest. Decreased lung function can reduce a persons stamina and their ability to perform activities, referred to as activity intolerance. Encourage rest between activities. Affected skin areas can be assessed and described as macerated, edematous, swollen, indurated or normal. Monitor for signs of vertigo and orthostatic hypotension and assist the patient to a sitting or lying position if they occur. The Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University. Planning Interventions. 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. Patients in a coma, for example, should be given complete passive range of motion to all joints several times a day. The cone should not be forced into the fingers but placed gently. They should be applied upon awakening because edema is usually at its lowest point after lying in bed overnight. 1. 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. External pressure can cause creases and denting which can impair the skin below in terms of its neurological and circulatory status. The incentive spirometer encourages a client to complete slow, deep breathing to keep their bronchioles open. Underlying bed tissue reflects the extent to which the wound is healing, regenerating and renewing. Some casts are solid and others are what are referred to as a bivalve cast which has two pieces. Casts must be applied in a smooth manner and they should also be allowed to dry without any external pressure applied to them. Skeletal fractures are classified and described in several ways, many of which are not mutually exclusive. WebActive and passive range of motion (ROM) exercises prevent complications of immobility in the musculoskeletal system. Report completion of the activity to the nurse who documents frequency and effectiveness of this intervention.[5]. For example, infants move their limbs, hold their head up, roll, sit, crawl, stand, and then eventually walk. [2], View evidence-based strategies to reduce functional decline in hospitalized older adults provided by The Hartford Institute for Geriatric Nursing. Nursing Interventions for Impaired Physical Mobility. Intervention of this condition includes prevention of dependent disabilities, restoring mobility when possible, as well as maintaining or preserving the existing mobility. Special patient care includes changing position, exercises, nutrition and giving a safe environment, etc. Some of its disadvantages include local irritation, its relatively high cost, and the need for frequent dressing changes once or twice a day. When applying TED hose, find the heel marker first. At times, these devices are routinely ordered for post-operative clients to promote venous return. The RYB Color Code of Wounds is sometimes used by nurses to guide the treatment options. Joint mobility and range of motion are assessed for the client. 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. If turned inside out, put your hand inside the hose, hold at the top of the heel marker with your thumb and forefinger, and then pull the top of the stocking down to the heel marker. An oblique fracture is one that occurs at an angle across the fractured bone. All trademarks are the property of their respective trademark holders. Some of the nursing diagnoses related to skin and skin integrity can include: All skin areas that are not within normal limits and indicate any signs of skin breakdown are assessed and described according to its color, size, location, odor, drainage, margins, texture, distribution and underlying bed tissue. The skin area that has impaired skin integrity is also described according to its exact location and in reference to its anatomical location. At each stage of growth and development, the nurse assesses a patients mobility and provides appropriate education. Nursing assistants are often expected to encourage clients to use their incentive spirometer hourly. Because immobility can negatively affect several body systems, perform a thorough assessment for patients with impaired mobility. 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. (n.d.). Make any adjustments before proceeding because the hose will be very difficult to adjust after it is pulled up the leg. Promoting clients independence in completing their ADLs and encouraging activity as tolerated can help prevent all these complications of immobility. The best way to maintain skin integrity and to prevent skin breakdown is to prevent them from occurring in the first place. See Figure 9.6[7] for an image of locating the heel marker. The bones lose calcium as a result of the lack of weight bearing activity and this can lead to disuse osteoporosis, hypercalcemia, and fractures. 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. Monitor and document the patients response to activity, such as heart rate, blood pressure, dyspnea, and skin color.[13],[14]. Movement, activity, and mobility positively affect ones overall health. Pressure ulcers are staged from the least severe to the most severe from Stage 1 to Stage 5. Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, A staff member may provide verbal cues to complete the action, but the movement is done independently by the client. 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. The depth of a wound is measured using a sterile cotton applicator which is then compared to the disposable rule for an accurate measurement. Traction forces are classified and categorized as Inline or running traction and balanced traction. 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. A greenstick fracture occurs when only one side of the bone is fractured. See Table 9.4 for potential complications of immobility by body system and additional preventative measures that will keep clients as healthy as possible. These bowel alterations are further confounded when the client is not getting adequate fluid intake. Assess the respiratory system, including respiratory rate, oxygen saturation, lung sounds, chest wall movement and symmetry, and depth and effort of respirations.

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