7 - Hazards of Immobility Flashcards

1
Q

Mobility

A
  • refers to a person’s ability to move about freely…
  • immobility refers to the inability to move about freely
  • Mobility and immobility are best understood as the end points of a continuum, with many degrees of partial mobility in between.
  • Some patients move back and forth on this continuum, but for other patients, immobility is absolute and continues indefinitely
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2
Q

What is bedrest?

A
  • Bed rest is an intervention that restricts patients to bed for therapeutic reasons
  • less commonly used
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3
Q

Why/when would bedrest be used?

A
  • To allow patients who are ill, debilitated, exhausted to rest
  • To reduce physical activity and the oxygen needs of the body
  • To reduce pain (e.g. postop pain) = amt of analgesic
  • To promote safety for patients recovering from the effects of sedation
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4
Q

Immobility

A
  • has effects that can be gradual or immediate and vary from patient to patient
  • The greater the extent and the longer the duration of immobility, the more pronounced are the consequences
  • Deconditioning (is the enemy)
  • it is the physiological decline in muscle strength, cardiovascular function, and endurance that occurs when someone is immobile or has limited physical activity for an extended period
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5
Q

EX. You are caring for a client who had a stroke one week ago and is now stable. You enter the room to transfer the client to a chair for breakfast. The client says they are too tired to get out of bed, and want to rest and recover. What is most important?

A

The client needs to mobilize
(esp bec they are stable and can)

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6
Q

Risk of Deconditioning

A
  • Deconditioning: loss of muscle and strength due to prolonged inactvity
    • When possible, it is imperative that patients, especially older persons, have limited bed rest
  • activity is more than movement from bed to chair
  • Loss of walking independence increases hospital stays, need for rehabilitation services, or nursing home placement
  • Deconditioning increases the risk for falls
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7
Q

Immobility and Metabolic Rate

A

Impact:
- alters the metabolism of carbohydrates, fats, and proteins
- fluid, electrolyte, and calcium imbalances
- gastrointestinal disturbances (dec appetite, slowing of peristalsis)

  • Note re: fever or wound healing and increased cellular oxygen requirements
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8
Q

Metabolic Changes due to Immobility

A
  • metabolic rate decrease
  • Immobility = dec appetite = deficiency in calories and protein
  • The body is constantly synthesizing proteins/breaking down into amino acids/forming other proteins
  • Immobility = the body excretes more nitrogen (end product of amino acid breakdown) than it ingests in proteins = negative nitrogen balance = tissue catabolism = weight loss, decreased muscle mass, weakness
  • Calcium
    • Hypercalcemia - increases risk of fracture
    • Hypercalcemia - calcium is high in the blood (serum levels), thus not high in the bone
    • Pathological fracture: from an underlying pathology
  • Immobility causes the release of calcium into circulation
  • If the kidneys are unable to respond appropriately, hypercalcemia results…impact?
    * Impact = risk of fracture; specifically pathological fractures
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9
Q

Immobility and GI

A
  • Impairments of gastrointestinal functioning caused by decreased mobility vary
  • Difficulty in passing stools (constipation) is a common symptom, although pseudodiarrhea may result
  • Over time, intestinal function becomes depressed, dehydration occurs, absorption ceases, and fluid and electrolyte disturbances worsen
  • Fecal impaction - fecal matter is unable to pass through
    • Causes pseudo diarrhea (frequent passage of small amounts of stool)
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10
Q

Respiratory and Immobility

A
  • Alveoli
  • Atelectasis
    • If alveoli become blocked or collapse
    • If this happens, they are unable to do gas exchange which puts pressure on oxygenation
  • Site of the blockage determines the severity - lung lobe or even a whole lung may collapse
  • Stasis & pooling of secretions
  • Risk for infection; pneumonia
  • Both conditions decrease oxygenation, prolong recovery, and add to discomfort

Prevention/interventions?
- Prevent pneumonia: vaccination

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11
Q

Cardiovascular and Immobility

A
  • Heart works harder and less efficiently during periods of prolonged rest, negatively affects cardiac output
  • Orthostatic hypotension
    • Can cause drop in bp
    • Likely to occur in elderly
    • Bad because can cause fainting and dizziness; increasing risk of falls
  • Symptoms include dizziness, light-headedness, nausea, tachycardia, pallor, or fainting with a change from lying/sitting to standing position
  • Decreased circulating fluid volume, pooling of blood in the lower extremities
  • Especially evident in older persons
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12
Q

Deep Vein Thrombosis

A

What is a thrombus vs. emboli?
- Thrombus: blood clot in blood vessels where plateletes
- Emboli: when it migrates somewhere else
○ Can go to heart or lungs causing pulmonary embolism, heart attack (which are all life-threatening)

Where is a thrombus most likely to occur?
- deep veins of legs

Why is this a concern?
- can travel through the bloodstream and cause a pulmonary embolism

Treatment?
- Compression socks
- Blood thinners (anti-coagulants)
○ Also increases risk of bleeding
- Warfarin
- Injection: fragment

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13
Q

MSK and Immobility

A
  • Loss of skeletal muscle mass, strength and function
  • Disuse atrophy - pathological reduction in normal size of muscle fibres (bed rest, trauma, casting, or local nerve damage)
  • Also impaired calcium metabolism and joint abnormalities
  • Is a marker of frailty
  • 80% of all fractures in women > 50 are related to: FALLS
  • Bone tissue is less dense, or is atrophied, and disuse osteoporosis results
  • Fragility fractures are responsible for excess mortality and morbidity

Treatment?
* Supplements: calcium, vitamin D (aids in calcium reabsorption), mobility/activity

  • Joint contracture: an abnormal and possibly permanent condition characterized by fixation of a joint - cannot obtain full ROM/nonfunctional position
  • Footdrop: the foot is permanently fixed in plantar flexion
    • Can avoid this with movement
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14
Q

Mobilizing

A

Should you reposition or mobilize your clients?
- YES

How often should you change position for your clients?
- Every 2 hours (q2)

Nurses infrequently initiated mobility events for hospitalized older patients and most often engaged patients in low-level activity (standing & transferring)

  • People are not being mobilized enough because
    ○ Nurses are busy
    ○ It is not prioritized
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15
Q
A
  • In the upright position, urine flows out of the renal pelvis and into the ureters and bladder because of GRAVITY
  • Urinary stasis - increases the risk of urinary tract infection and renal calculi
  • If immobility continues, fluid intake can DECREASE increasing the risk for DEHYDRATION
  • As a result, urinary output may decline around the fifth or sixth day after immobilization, therefore urine colour?
    • More concentrated; darker in color
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16
Q

Integumentary and Immobility

A

Pressure injury

  • localized damage to the skin and/or underlying soft tissue as a result of prolonged ischemia
  • Highly preventable but remain prevalent
    We change positions regularly…
  • In ischemia, cells start to die and can lead to pressure ulcers
    ○ Leads to risk of infection, pain,
17
Q

Braden Scale for predicting pressure sore risk

A
  • Sensory perception
  • Moisture
  • Activity
  • Mobility
  • Nutrition
  • Friction & Shear
    • If patient slides down bed, the friction can cause skin breaking (micro tears in tissue)
      rated 1-4 - lower the score = higher the risk
18
Q

Stages of Pressure Ulcer

A

Stage 1
- skin is unbroken, red, inflamed

Stage 2
- skin is broken on top layer of skin only

Stage 3
- injury extends to tissue under skin

Stage 4
- loss of skin and tissue
- exposed bones, cartilage, or tendon

19
Q

Psychosocial Effects of Immobilization

A
  • Immobilization can contribute to decreased social interaction, social isolation, sensory deprivation, loss of independence, and role changes
  • Patients who are immobilized can become depressed because of changes in role, self-concept, and other factors
20
Q

Ex. What can contribute to falls?

A
  • Dementia
  • Income
21
Q

Gait changes with aging

A
  • A narrower standing base
  • Wider side to side swaying when walking
  • Slower responses
  • Greater reliance on proprioception
  • Diminished arm swing
  • Increased care in gait
  • Steps are slower and there is a decrease in step height when taking a step
  • Changes in gait are less pronounced in people who remain active and are a healthy weight
  • Sedentary lifestyle, excess weight and smoking are associated with mobility problems
  • Exercise and strength training will improve mobility and function
22
Q
A
23
Q

The nurse is concerned that a LTC resident will fall if walking to the bathroom. What should the nurse do?

A

A. Advise resident thst they are concerned re: fall risk, and shouldn’t get up by themselves

B. Put up bed rails x4

C. Assess fall risk and adapt room environment accordingly (CORRECT)

D. All of the above

24
Q

What is the Berg Balance Scale

A
  • Measures balance ability in older adults whose balance is impaired by assessing functional tasks, effective in measuring balance post stroke
25
Q

2 Most common Results of Falls

A
  1. Hip fracture
  2. Concussion/ head injury
26
Q

Consider these factors when preventing falls.

A
  • Time of day
  • Light
  • Bathroom access/bedside commode/regular toileting
  • Use of bed rails
  • Noise/sound: e.g. quiet room vs. ICU vs. favourite music
  • Increase monitoring e.g. close to nsg station, 1:1/constant
  • Consider role of restraints: physical and chemical
  • Bed alarms
  • Floor mattress + height of bed
  • Hip protectors
  • Exercises: strength and balance
  • Footwear
  • Meds e.g. Vitamin D
27
Q

What are restraints?

A
  • Restraints are physical, environmental or chemical measures used to control the physical or behavioural activity of a person or a portion of their body
28
Q

A hospital or facility may only use restraints or confine a patient or use a monitoring device on him or her

A
  • if it is necessary to prevent serious bodily harm to him or her or to another person
  • if such other criteria as may be prescribed by regulation for restraining or confining a patient or for using a monitoring device on him or her are met
  • if it gives him or her greater freedom or greater enjoyment of life
  • if placing him or her under restraint, confining him or her or using a monitoring device on him or her, as the case may be, is authorized by a plan of treatment to which the patient (or his or her substitute decision-maker) has consented
29
Q

Types of Restraints

A

Physical
- Limit their movement
- Ex. Gerri chair
- Bed rails???

Environmental
- Controls a clients mobility - Ex. Secure unit; hospitals that have key pad that lock the door and prevent ppl form leaving the unit

Chemical
- Medicine

30
Q

Impacts of Restraints

A
  • Studies have found that restraints actually increase the severity of falls and can increase confusion, muscle atrophy, chronic constipation, incontinence, loss of bone mass and decubitus ulcers
  • Restraint use is also linked to emotional distress, including loss of dignity and independence, dehumanization, increased agitation and depression
  • In severe cases, clients have been seriously injured or have died after becoming trapped in a restraint, such as a bed rail
  • In mental health, the use of restraint is not consistent with a recovery model that focuses on client control, empowerment and involvement in their own care
    Importantly, associated with dementia, falls, challenging behaviours
31
Q

Restraint free care

A
  • Restraint-free care is now the standard of practice and an indicator of quality care in all health care settings
32
Q

What you can do instead of using restraints?

A
  • De-escalation techniques
  • Building a therapeutic relationships
33
Q

Prior to considering use of restraints, you should….

A

Explore client behaviours
- are often the manifestations of unmet needs

ex. Does the individual need to toilet?
Is there an infection?
Has the individual been started on new medication?
Does the client have conditions if aggravated can cause pain and discomfort resulting in agitation or anger? (e.g. kyphosis, spine fractures)
Family support?

34
Q

What can be done to avoid the use of a restraint?

A
  • Encourage the person to do the things they enjoy such as cards, television or music.
    Walk with the person.
  • Help the person to get to the bathroom at regular times,
    Make the person’s room safe by lowering the bed to avoid an injury if they roll or fall out of bed.
  • Make sure there is enough light for the person to see clearly.
  • Develop a routine by placing objects and furniture in the same place.
  • Have a friend or family member visit to sit with the person when they are restless, confused, upset or afraid.
  • Use an alarm that tells others when the person moves from a chair orbed so they can check to see if they need help.
35
Q

What are the key expectations of restraint use?

A
  • Assessment
    • Consent
    • Communication
    • Documentation