7 - Hazards of Immobility

Question 1

Mobility

Answer 1

• 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

Question 2

What is bedrest?

Answer 2

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

Question 3

Why/when would bedrest be used?

Answer 3

• 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

Question 4

Immobility

Answer 4

• 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

Question 5

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?

Answer 5

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

Question 6

Risk of Deconditioning

Answer 6

• 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

Question 7

Immobility and Metabolic Rate

Answer 7

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

Question 8

Metabolic Changes due to Immobility

Answer 8

• 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

Question 9

Immobility and GI

Answer 9

• 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

Question 10

Respiratory and Immobility

Answer 10

• 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

Question 11

Cardiovascular and Immobility

Answer 11

• 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

Question 12

Deep Vein Thrombosis

Answer 12

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

Question 13

MSK and Immobility

Answer 13

• 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

Question 14

Mobilizing

Answer 14

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

Answer 15

• 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

Question 16

Integumentary and Immobility

Answer 16

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,

Question 17

Braden Scale for predicting pressure sore risk

Answer 17

• 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

Question 18

Stages of Pressure Ulcer

Answer 18

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

Question 19

Psychosocial Effects of Immobilization

Answer 19

• 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

Question 20

Ex. What can contribute to falls?

Answer 20

• Dementia
• Income

Question 21

Gait changes with aging

Answer 21

• 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

Question 23

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

Answer 23

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

Question 24

What is the Berg Balance Scale

Answer 24

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

Question 25

2 Most common Results of Falls

Answer 25

1. Hip fracture
2. Concussion/ head injury

Question 26

Consider these factors when preventing falls.

Answer 26

• 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

Question 27

What are restraints?

Answer 27

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

Question 28

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

Answer 28

• 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

Question 29

Types of Restraints

Answer 29

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

Question 30

Impacts of Restraints

Answer 30

• 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

Question 31

Restraint free care

Answer 31

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

Question 32

What you can do instead of using restraints?

Answer 32

• De-escalation techniques
• Building a therapeutic relationships

Question 33

Prior to considering use of restraints, you should….

Answer 33

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?

Question 34

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

Answer 34

• 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.

Question 35

What are the key expectations of restraint use?

Answer 35

• Assessment
  
  • Consent
  • Communication
  • Documentation