nursing interventions to prevent complications of immobilityst elizabeth family medicine residency utica, ny
Assess the cardiovascular system, including blood pressure, heart sounds, apical and peripheral pulses, and capillary refill time. The length and width of all areas are measured and the depth of wounds is also measured. The toe of the stocking is typically open to allow for easy assessment of the clients circulation. When applying TED hose, find the heel marker first. The stages of wound healing are the homeostasis phase, the inflammation phase which is also referred to as the exudate and lag phase, the proliferative and granulation phase, and the maturation phase. Prevention and management of limb contractures in neuromuscular diseases. For example, infants move their limbs, hold their head up, roll, sit, crawl, stand, and then eventually walk. The Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University. Insure that the counter traction force is less than the pulling traction force. Primary intention healing is facilitated with wounds without infection. Automatic sequential compression devices can have sleeves to accommodate for pressure on the legs as well as the foot. WebActive and passive range of motion (ROM) exercises prevent complications of immobility in the musculoskeletal system. Regular socks or slippers can be placed over the TEDs for warmth if desired. WebPreventing Complications From Immobility: Haematological - Medstrom Part 3: Haematological Part 3: How Can I Prevent Complications From Immobility? 1. When applying stockings, proper placement on the heel is important. 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. 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. Pressure can be eliminated and reduced with out of bed activity, pressure relieving surfaces, the provision of sitting and lying surfaces free of any objects and wrinkles, and by turning and repositioning clients frequently to prevent this damaging mechanic force. Both of these standardized screening tools are deemed valid and reliable for identifying those at risk. Autolytic debridement promotes the body's use of its own enzymes to debride the wound. Because immobility can negatively affect several body systems, perform a thorough assessment for patients with impaired mobility. To avoid or minimize complications of immobility, mobilize the patient as soon as Compression stockings require a physicians order and should be applied in the morning and taken off at night. Monitor oxygenation levels and provide supplemental oxygen as prescribed to maintain adequate oxygenation, especially during ambulation. Autolytic debridement is most often used to treat Stage 3 and Stage 4 pressure ulcers. The depth of a wound is measured using a sterile cotton applicator which is then compared to the disposable rule for an accurate measurement. The client should be coached and taught to: An incentive spirometer is used to coach the client in terms of deep breathing and coughing. Coughing, deep breathing and the use of an incentive spirometer are described as hyperinflation exercises because, when done properly, these respiratory techniques hyper inflate the lung to facilitate the loosening and mobilization of respiratory secretions. Demonstrate placement of patient in various positions, such as Fowler's, supine (dorsal), Gait is a function of a number of different things including balance, coordination, muscular strength, and joint mobility. Also, the skin around the surgical site for skeletal traction must also be inspected for any signs of infection. 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. WebActive and passive range of motion (ROM) exercises prevent complications of immobility in the musculoskeletal system. Muscles are adversely affected with weakness and atrophy as the result of immobility. If constipation is suspected, palpate the patients left lower quadrant for signs of stool presence. Lastly, skin traction applies the traction force to the skin overlying the affected bone. For example, the client is positioned prone and in a 45 degree Trendelenburg position to drain the posterior bronchus, a 45 degree Trendelenburg position to drain the posterior bronchus and on the left side to drain the lateral bronchus. [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. These hazards of immobility can be prevented with range of motion exercises and in bed exercises such as isotonic, isometric and isokinetic muscular exercises. Braces are applied to various parts of the body to provide support and alignment of the part. 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. When assisting with ROM exercises, the nursing assistant must support any joints below the joint being exercised to prevent injury. This process is referred to as autolysis. 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. Some of the elements of this teaching should include: The client positions that are used for maintaining good bodily alignment and optimal physiological functioning include the Sims or the semi prone position, the Fowler's position, the dorsal recumbent position, the prone position and the lateral position. See Figure 9.6[7] for an image of locating the heel marker. Conditions such as osteoarthritis, orthostatic hypotension, inner ear dysfunction, osteoporosis resulting in hip fractures, stroke, and Parkinsons disease are among the most common causes of immobility in old age. In addition to anti embolism stockings and sequential compression devices, as previously discussed, active or passive range of motion, positioning and mobilization are also measures that promote circulation. After the wound is assessed and measured, the wound dimension is calculated by multiplying the length by the width by the depth of the wound. A joint should never be forced to achieve full ROM if there is resistance. All trademarks are the property of their respective trademark holders. Therefore, nursing assistants must be diligent in their actions and observations to maintain their clients health and prevent complications. When implementing interventions to promote mobility, in addition to reviewing the current orders regarding assistance and weight-bearing, assess the patients current status. Some of the extrinsic factors that impact on the skin and its integrity are environmental humidity, chemical irritants, extremes in terms of hot and cold weather, radiation, and mechanical forces such as pressure, shearing and friction. We also acknowledge previous National Science Foundation support under grant numbers 1246120, 1525057, and 1413739. The three types of wound healing are primary intention healing, secondary intention healing and tertiary intention healing. All of these measures are used not only for immobilized clients but also for many post-operative clients. In addition to traction and splints, many fractures are also casted. Hamilton Russell traction is an example of balanced traction. ROM exercises facilitate movement of specific joints and Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). This technique entails the positioning of the client in different positions so that all areas of the lungs and airways are able to be drained of respiratory secretions using the force of gravity. Traction is used for the external fixation of a fracture, it is used to maintain anatomically correct alignment, it is used to reduce pain and it is used to decrease muscle spasms. These devices are connected to traction. Automatic sequential compression devices consist of a pump, a one time single patient use sleeve, and hosing that connects the sleeve to the pump. A spiral fracture occurs when the pattern twists around the fractured bone. Adduction refers to moving a limb towards the midline. Vibration is highly similar to percussion except vibration is done by placing the palm of the hand on the lung area and doing rapid vibrating movements on the area while the client is positioned for postural drainage. Note if urinary incontinence is occurring due to the inability of the patient to reach the restroom in time.[1]. The primary purposes of splinting for limb fractures are to protect soft tissue from further damage, to reduce the client's pain, to reduce the possibility of a fat embolism, and to minimize painful muscular spasms. The amount of pressure the hose applies to the legs is prescribed. Fractures can also be categorized and categorized according to it pattern. It can be difficult to see this square but stretching the fabric around the heel area should make it more visible. Monitor 24-hour trend of intake and output, as well as for symptoms of dysuria, urgency, or frequency. 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. For example, a client who has had limited mobility for several years may have a joint that can only be moved a few inches, but it is important to maintain that mobility, no matter how small. [7] See details about early mobilization protocols earlier in this chapter. For example, during the recovery period after shoulder surgery, a client attends physical therapy and receives 50% assistance in moving their arm with the help of a physical therapy assistant. 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 weights are gently applied, as ordered, and left to hang freely and without any interference. Some of these joint disorders can be prevented with frequent and proper positioning of the client in correct bodily alignment, the provision of range of motion exercises to all joints several times a day, and the use of devices like a hand roll and a bed board to prevent contractures of the hands and feet, respectively. Nursing diagnoses for the hazards of immobility and the client's mobility were also discussed above in these same sections. The treatment plan includes the removal of the cast and, at times, a fasciotomy or epimysiotomy are indicated. Immobility and complete bed rest can lead to life threatening physical and psychological complications and consequences. Some of these intrinsic factors include the client's urinary and/or fecal incontinence, poor nutritional and fluid intake, diabetes, hyperthermia, hypothermia, hypotension, a decreased cardiac output, obesity, an altered sensory perception, some medications, an alteration in terms of the client's perfusion and peripheral circulation, some of the normal changes of the aging process, cachexia and emaciation, an alteration in terms of the client's metabolic status, and the client's body build as well as the size of their boney prominences. Enzymatic chemical debridement can be used on wounds with at least moderate amounts of necrosis and eschar, including pressure ulcers and burns. The Applying Prosthetics and Orthotics section in Chapter 8 describes devices such as a foot split to prevent musculoskeletal contracture. See Figure 9.7[8] for a demonstration of these techniques. Hospitalization poses a risk for altered functional status of older adults due to acute illness, decreased mobility, and the negative effects of bedrest. When applying traction, the client should be placed in the supine position and boney prominences should be protected from friction and shearing. The skin area that has impaired skin integrity is also described according to its exact location and in reference to its anatomical location. Traction forces are classified and categorized as Inline or running traction and balanced traction. Postural drainage is done by the nurse or the certified respiratory therapist. While providing ROM, the nursing assistant must observe for objective and subjective signs of pain. Promote excellence in nursing by enabling future and current nurses with the education and employment resources they need to succeed. RegisteredNursing.org Staff Writers | Updated/Verified: Mar 10, 2023. External fixation devices, halo traction, skeletal traction, and Crutchfield or Vinke cervical tongs are immobilization techniques that are used for fractures and other serious disorders. 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. These bowel alterations are further confounded when the client is not getting adequate fluid intake. Legal. Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered mood, and depression. Prior assessment of wound etiology is critical for the WebOverview Complications of Immobility Psychologic Cardiovascular Pulmonary Gastrointestinal and renal Musculoskeletal and skin Nursing Points General Psychologic Planning is done according to the actual and potential health problems that were assessed and then expected client outcomes or goals and interventions are planned to meet these needs. Many of these costly complications of immobility can, and should be, prevented whenever possible. When passive range of motion is applied, the joint of an individual receiving the exercise is completely relaxed while the outside force moves the body part. These stages are: The treatment of pressure ulcers is complex and it often includes a combination of treatments and therapies. See Table 9.4 for potential complications of immobility by body system and additional preventative measures that will keep clients as healthy as possible. The resident should be asked if they are experiencing any pain during the movement, and the assistant should watch for nonverbal signs of pain like grimacing, clenching the teeth, groaning, or labored breathing. [2], View evidence-based strategies to reduce functional decline in hospitalized older adults provided by The Hartford Institute for Geriatric Nursing. See Figure 9.3[3] for an image of a passive motion machine. 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. WebNursing interventions While many interventions depend on the underlying cause of the patients immobility, the nursing interventions in this article will focus on aspects of The skin is described in terms of its color which can be yellow, ecchymosed, purple, green, blanched and reddened, for example. WebTo prevent the further complications of immobility, nurses would usually perform the following interventions:. 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. Mobility can be assessed by using direct observation of the client's movements and mobility and using some standardized tests such as the Timed Get Up and Go Test with which the nurse assesses the client's ability to rise from a chair, walk, and then return to the chair and sit, the Assessment Tool for Safe Patient Handling and Movement, the Egress test which the nurse uses to assess the client's ability to sit and then stand, march in place and advance forward with each foot and return to the same position. Tertiary intention healing begins with several days of open wound irrigations and packing, which is secondary healing, followed by the closure of the wound edges with approximation and suturing which is primary healing. Inspiratory muscle training techniques entail instructing the client to lie in a comfortable supine position, torelax, and then to take deep breaths with a mouth piece with an increasingly smaller lumen so that the clienthas to progressively take deeper and deeper breaths using their diaphragm while overcoming the resistance of the obstructive mouth piece. Secondary intention healing, also referred to as healing by second intention, is done for contaminated wounds in order to prevent infections, to prevent the formation of abscesses and to promote healing from the bottom up to the outer surface of the skin so that any potential infection is not closed in at the bottom of the wound. Determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer ). If there is writing on the stocking, it should be on the outside and facing away from the skin when worn. Monitor vital signs before, during, and after physical activity and institute appropriate fall prevention strategies as indicated. When removed at night, the compression stockings should be washed by hand in the sink with soap and water and then hung to air dry. For example, if a person has their fingers spread wide apart, bringing them back together is adduction. 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. People must be able to move to protect themselves from trauma and to meet their basic needs. 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. Percussion is also performed by the nurse or the certified respiratory therapist. The risk factors associated with immobility are client deconditioning, a cognitive impairment, spasticity, poor cardiac functioning and poor tolerance for activity, inadequate muscular strength, impaired balance, improper bodily posture and alignment, an impaired gait, pain, the use of sedating medications, joint pain and stiffness in addition to other skeletal problems, obesity, and neurological impairments in addition to a physiological health problem that mandates that the client be on complete bed rest. Encourage or perform active or passive range of motion exercises as prescribed by the physical therapist. Pressure ulcers are also referred to as stasis ulcers, trophic ulcers, and ischemic ulcers; they can result from the mechanic forces of pressure, friction and shearing, all of which can, and should, be prevented. Skin traction is the most commonly used type of traction. Traction, when ordered, should be continuous and not interrupted. The distribution of impaired skin integrity can be described as generalized and across many areas of the body, localized to one area of the body, asymmetrical and on only one side of the body and also symmetrical which affects both sides of the body bilaterally. A second type of device is a palm protector that is softer than the cone and separates the fingers from one another. Segmenting ADLs refers to breaking up tasks to accommodate the clients activity intolerance.