The amount of pressure the hose applies to the legs is prescribed. 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. The client should be coached and taught to: An incentive spirometer is used to coach the client in terms of deep breathing and coughing. 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. 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. 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. When working with school-age children, nurses provide education to prevent injury that can occur with activity, such as using helmets and knee pads to prevent injury while bicycling and skateboarding. 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. WebOverview Complications of Immobility Psychologic Cardiovascular Pulmonary Gastrointestinal and renal Musculoskeletal and skin Nursing Points General Psychologic Alene Burke RN, MSN is a nationally recognized nursing educator. See Figure 9.4[4] for an image of a client using an incentive spirometer. A greenstick fracture occurs when only one side of the bone is fractured. Some wounds and wound drainage have odors and others do not. (Eds.). Active assist range of motion is joint movement by an individual with partial assistance from an outside force. Some nursing diagnoses related to immobility can include: Mobility is defined as the "ability to move freely, easily, rhythmically, and purposefully in the environment. Administer medications if warranted and consider nonpharmacologic measures such as repositioning, splinting, and heat/cold application to reduce musculoskeletal discomfort. The plan is tailored to the needs of the individual and will include the specific joints to move. Mechanical debridement is often the preferred form of treatment for pressure ulcers that only have a moderate amount of necrotic tissue that has to be removed. Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, 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. Affected skin areas can be assessed and described as macerated, edematous, swollen, indurated or normal. Regular socks or slippers can be placed over the TEDs for warmth if desired. In addition to traction and splints, many fractures are also casted. Joint mobility and range of motion are assessed for the client. Some of these compression stockings are knee high and others are thigh high. Perform hourly rounding to check on the patients needs and prevent falls. However, as the client sits or stands upright during the day, blood tends to pool in the lower legs. To avoid or minimize complications of immobility, Traction forces are classified and categorized as Inline or running traction and balanced traction. This process is referred to as autolysis. Muscles are adversely affected with weakness and atrophy as the result of immobility. WebPhysiologic changes including the release of inflammatory mediators, increased fatigue and reduction in body mass, and a decline in pulmonary function occurring after abdominal Table 9.4 Potential Complications of Immobility and Preventative Measures. 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. Deep-vein thrombosis (DVT) is a common complication for clients experiencing immobility. Educate the patient about appropriately using assistive devices and other fall precautions. Compression stockings, or antiembolism stockings or hose, and automatic sequential compression devices are used to promote venous return and prevent emboli, both of which can occur as the result of patient immobilization and other causes such as deep vein thrombosis. Nursing diagnoses for the hazards of immobility and the client's mobility were also discussed above in these same sections. After the heel of the stocking is placed properly on the clients heel, check that the hose is not twisted. Autolytic debridement promotes the body's use of its own enzymes to debride the wound. Passive range of motion is movement applied to an individuals joint by another person or by a passive motion machine. 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. At each stage of growth and development, the nurse assesses a patients mobility and provides appropriate education. An oblique fracture is one that occurs at an angle across the fractured bone. Make any adjustments before proceeding because the hose will be very difficult to adjust after it is pulled up the leg. Wrinkles and uneven pressure can cause venous stasis. Assess for the presence of lower extremity edema and for signs of a potential deep vein thrombosis (DVT). For example, an area of skin breakdown can be described as on the posterior of the arm just inferior to the elbow or over the sacrum and coccyx. The treatment plan includes the removal of the cast and, at times, a fasciotomy or epimysiotomy are indicated. 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. 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. The eschar is gently crosshatched with a scalpel so that the introduced enzymes can penetrate all layers of it. Like automatic sequential compression, compression stockings are fitted for the specific client after measuring the client's legs and checking the doctor's order for the amount of pressure that these stockings should exert on the client's leg. Wound margins can be described as open, attached, unattached, well defined and with a healing ridge. Perform active range of motion to all joints two times a day, Safely transfer from the bed to the chair with assistance, Demonstrate proper deep breathing and coughing, Ambulate 30 feet three times a day with a walker and the assistance of another, Increase their level of exercise and physical activity, Demonstrate the proper use of their assistive device while ambulating, Maintain their skin integrity and not have any signs of skin breakdown, Maintain adequate respiratory functioning. Some of the factors that impact on the skin and its integrity include intrinsic and extrinsic factors and forces. 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. PLEASE NOTE: The contents of this website are for informational purposes only. 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. Encourage or perform active or passive range of motion exercises as prescribed by the physical therapist. The incentive spirometer encourages a client to complete slow, deep breathing to keep their bronchioles open. Demonstrate placement of patient in various positions, such as Fowler's, supine (dorsal), 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. ROM exercises facilitate movement of specific joints and 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. Do not send them to the laundry or put them on a heater to dry because this can cause shrinking and ruin the hose. An impacted fracture is one that occurs when a bone fragment of the fractured bone is pushed and wedged into another bone fragment of the fractured bone. Because immobility can negatively affect several body systems, perform a thorough assessment for patients with impaired mobility. Some casts are solid and others are what are referred to as a bivalve cast which has two pieces. Casts can be made with plaster or fiberglass. 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. 1. 7. This page titled 13.3: Applying the Nursing Process is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Ernstmeyer & Christman (Eds.) WebState the nursing interventions used to prevent complications of immobility. A transverse fracture is one that occurs straight across the fractured bone. Balance and equilibrium can be impaired when the client is affected with a middle ear disorder that affects the vestibule and/or the semicircular canal of the ear's cochlea, poor posture, and a musculoskeletal or neurological disorder; muscular coordination is the ability of the person to smoothly and safely use gross motor and fine motor coordination. These devices are connected to traction. Assess the gastrointestinal system by inspecting for distension, auscultating bowel sounds, and palpating the abdomen for tenderness. Accessibility StatementFor more information contact us atinfo@libretexts.org. (OpenRN) via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request. The procedure for deep breathing and coughing is as below.