Immobility Fall 2006 By: Lee Resurreccion

1. Causes, Effects, Complications, Technologies, and Prevention ImmobilityFall 2006By: Lee Resurreccion

2. Definition: Immobility • Immobility refers to a reduction in the amount and control of movement a person has. By: Kozier, et. al. p. 847

3. Nursing interventions to prevent deep vein thrombosis (DVT) include all the following EXCEPT: • wearing sequential compression devices (SCD’s) • encouraging early ambulation • avoiding keeping TED hose stocking from rolling down the leg • restricting fluids

4. Nursing interventions to prevent deep vein thrombosis (DVT) include all the following EXCEPT: • wearing sequential compression devices (SCD’s) • encouraging early ambulation • avoiding keeping TED hose stocking from rolling down the leg • restricting fluids

5. Which of the following clients is MOST at risk for developing complications of immobility? • a 30 year old with a fractured ankle • an 80 year old with a fractured leg • a three year old with a burned hand • a 42 year old who is one day post abdominal surgery

6. Which of the following clients is most at risk for developing complications of immobility? • a 30 year old with a fractured ankle • an 80 year old with a fractured leg • a three year old with a burned hand • a 42 year old who is one day post abdominal surgery

7. Which of the following clients is MOST at risk for developing complications of immobility? • a 30 year old with a fractured ankle • an 80 year old with a fractured leg • a three year old with a burned hand • a 42 year old who is one day post abdominal surgery

8. The Body’s Response to Immobility • “It is always assumed that the first thing in any illness is to get the patient to bed…yet we should think twice before ordering our patients to bed and realize that beneath the comfort of the blanket there lurks a host of formidable dangers.” British Medical Journal, 1947.

9. Causes of Immobility • Congenital Problems: Spinal bifida • Neuromuscular Deficits: MS • Musculoskeletal Deficits: Arthritis • Chronic Health Problems: low back pain • Trauma: Fractures, Head Injury • Affective Disorders: Uncontrolled Depression • Therapeutic Modalities: DVT’s, Chemo

10. Complications of Immobility Dependent on: • duration of inactivity • baseline health status • sensory awareness

11. Patients on Bed Rest • Difficulty in defining bed rest • Benefits • Relieves pain • Initially promotes healing and repair • Decreases oxygen needs by body’s cells • Restful both physiologically and psychologically

12. Impact of Immobility on Body Systems • Complications of bed rest or immobilization are sometimes referred to as immobilization disabilities, a.k.a. - iatrogenic consequences of immobility • Immobilization effects every system and every major organ in the body • Skin, heart, brain, kidney, bones, lungs, muscle.

13. Musculoskeletal System • Musculoskeletal iatrogenic consequences of immobility include: • Disuse Osteoporosis: demineralization of the bones resulting to bones become spongy, deformed, & fracture easily. • Disuse Atrophy: muscles decrease and loose strength and normal function • Contractures: muscle fibers no longer shorten and lengthen and eventually permanently shortens limiting joint mobility. • Stiffness and Pain in Joints: without movement collagen (connective tissue) becomes stiffened and permanently immobile.

14. Cardiovascular System • Tachycardia • Increased use of Valsalva maneuver • Orthostatic hypotension: • Venous stasis • Dependent edema • Thrombosis generation : --- Causes of Thrombus formation in immobile patients: Impaired venous return Hypercoagulability

15. Respiratory System • Decreased respiratory movement • Pooling of respiratory secretions • Hypostatic pneumonia • Atelectasis

16. Metabolic System • Decreased metabolic rate • Negative Nitrogen Balance: • anabolism : Protein synthesis • Catabolism: protein breakdown *the anabolic process decreases and the catabolic process increases which then depletes the protein stores essential for muscle tissue and wound healing.

17. Urinary System • Urinary stasis: Stoppage or slowing of flow • Renal calculi: If urine becomes more alkaline, calcium salts precipitate out and become “stones” • Urinary retention: Decreased muscle tone of bladder inhibits its ability to empty completely. • Urinary incontinence: Involuntary urination because of poor bladder muscle tone. • Urinary infection: Eschericia coli • urinary reflux: Contaminated urine back flow

18. Constipation: Decreased peristalsis and colon motility decreased perineal muscle tone bedpan use causes a disruption of normal bowel habits. Gastrointestinal System

19. Integumentary System • Reduced skin turgor • Skin Breakdown (Decubiti) = pressure ulcers • Other complicating factors • inadequate nutrition • incontinence • decreased mental status • diminished sensation • increased body heat • elderly • other chronic conditions (diabetes, heart disease)

20. Staging Pressure Ulcers • Stage 1 • Stage 2 • Stage 3 • Stage 4

21. Wound Debridement Types of debridement: • Sharp: scapel is used • Mechanical: scrubbing method • Chemical: agents are applied • Autolitic: body fluids are trapped over the escar and the body’s own enzymes remove the escar

22. Factors affecting wound healing • Developmental: Elderly • Nutrition: decreased protein, carbohydrates, vitamin C. • Lifestyle: smoking • Medications: steroids

23. Assessment of Pressure Ulcers • Risk assessment tools • Braden Scale • Norton’s Pressure Area Risk Assessment Scale • RAPS: (Risk Assessment Pressure Score) * • Descriptive tool • RYB color code *Lindgren, et al (2004). Immobility - a major risk factor of pressure ulcers among adult hospitalized patients: A prospective study. Scand J. Caring Sci, 18, 57-64.

24. Six subscales: 1. sensory perception moisture activity mobility nutrition friction/shear risk Points given on a Likert-like scale. The higher the points, the less risk for pressure ulcers. Maximum score is 23: 19 – 23 no risk < 18 at risk < 12 high risk Braden Scale: for Predicting Pressure Sore Risk

25. Norton’s Pressure Area Risk Assessment Scale Subscales include: a. general physical condition b. mental status c. activity d. mobility e. incontinence

26. RAPS: Risk Assessment Pressure Score Modified Norton Scale. It measures instead of incontinence it measures moisture. Instead of mental status it measures sensory perception. And includes friction and shear and serum albumin level.

27. RYB color code:(often used as a documentation tool) Red – transparent type dressing Yellow– Clean to remove non-viable tissue (wet to damp, hydrogel, or other exudate absorbers) Black– necrotic tissue (escar) present, debridement necessary.

28. Documenting Pressure Ulcers • Location • Size (length, width, depth) • Sinus tract involvement • Stage • Color • Condition of margins • Integrity of surrounding skin • S/S of infection (odor/purulent drainage…)

29. Promoting Skin Healing • Nutrition • Preventing infection • Positioning

30. Self esteem: Role change and dependence Frustration: Exaggerated emotional reactions Emotions vary: Apathy, anger, regress, withdraw Decreased intellectual stimulation: Life view narrows, decision making and problem solving abilities deteriorate Social development : particularly for peds patients Motor development: particularly for peds patient Psychoneurologic System

31. The Nursing Process:Assessments of Immobility • Objective Assessments: Body alignment, joint movement, capabilities and limitations, muscle mass and strength, activity tolerance, need for assistance, baseline data. • Subjective Assessments: Includes clients sensations, feelings, values, beliefs, attitudes, and perception of personal health, and life situations.

32. Planning (Nursing Interventions) • Turning and ROM exercises • Foot and leg exercises • Anticoagulant Therapy • Deep breathing exercises • Skin care • Nutritional Interventions • Diversional Activities

33. Planning ( Interventions cont’d) • Maintaining relationships; support people for patient’s psychosocial needs • Technologies designed to prevent complications of immobility

34. Nursing Actions for Immobility • Identify among patients assigned to you those who are most susceptible to the complications of immobility • Assess patients who are on bed rest in order to prevent the possible complications of immobilization. • Draw up a specific plan of care for patients on bed rest and put the plan into action.