Chapter 28: Immobility (IRAT/GRAT #1) Flashcards
body mechanics
the coordinated efforts of the musculoskeletal and nervous systems
body alignment
(posture) positioning of the joints, tendons, ligaments and muscles while standing, sitting or lying.
Benefits of correct body alignment
- reduces strain on musculoskeletal structures
- aids in maintaining adequate muscle tone
- promotes comfort
- contributes to balance and conservation of energy
impaired balance
a major threat to physical safety and contributes to a fear of falling and self-imposed restrictions on activity leading to decrease in muscle tone and an increase in risk for skin breakdown, pulmonary complications and social isolation.
shear
the force exerted against the skin while the skin remains stationary and the body structures move
(ex. sliding down the in the bed by gravity forces when HOB is increased. the tissues blood vessels are stretched and damaged resulting in decreased blood flow to deep tissues leading to pressure ulcers)
Posture and Movement
directly related to the skeleton and the shape of development of skeletal muscles
muscle tone
the normal state of muscle tension.
prolonged bed rest/immobility results in:
decreased activity level, activity tolerance and muscle tone
Primary motor cortex
the majority of motor fibers descend from the primary motor cortex (motor strip) and cross at the level of the medulla.
The fibers from the right motor cortex initiate
voluntary movement for the left side of the body
The fibers from the left motor cortex initiate
voluntary movement for the right side of the body
Afferent neurons
sensory
Efferent neurons
motor
What influences mobility?
- Posture
- Muscle Abnormalities
- Damage to CNS
- Trauma to musculoskeletal system
Posture abnormalities
- assess for body alignment and ROM
- postural abnormalities can cause pain, impaired alignment or mobility or both
Muscle abnormalities
dystrophies (degeneration of skeletal muscle fibers)
Any damage to any component of the CNS that regulates voluntary movement results in
impaired body alignment, balance and mobility
Direct trauma to the musculoskeletal system results in
bruises, contusions, sprains and fractures.
Factors influencing mobility-immobility: Bed rest
- muscular deconditioning associated with lack of physical activity is apparent in just a few days.
- disuse atrophy
An average health person on bed rest loses muscle strength from baseline at a rate of
3% per day
disuse atrophy
the tendency of cells and tissue to atrophy in size and function in response to prolonged inactivity from: bed rest, casting, and local nerve damage
Metabolic Changes: Changes in mobility alter
endocrine metabolism, calcium resorption and functioning of the GI system.
The endocrine system maintains and regulates vital functions such as:
response to stress and injury, growth and development (Ca resorption), reproduction, maintenance of the internal environment (Na+, K+, acid/base balance), energy production/use/storage.
How does changes in mobility alter the GI system?
decreases metabolic rate, alters metabolism of carbs, and fats. Thus leading to decrease in peristalsis, psuedodiarrhea (results from fecal impaction), constipation.
Immobility causes a release of _______ into the circulation
Ca+.
Respiratory changes as a result of immobility
- atelectasis
- hypostatic pneumonia
- decline of the patients ability to take a deep breath and cough
atelectasis
collapse of the alveoli: secretions block bronchioles
hypostatic pneumonia
inflammation of the lung R/T stasis or pooling of secretions
cardiovascular changes due to immobility
- orthostatic hypotension
- increased cardiac workload
- thrombus formation
orthostatic hypotension
drop of blood pressure greater than 20mm Hg in systolic pressure or 10mm Hg in diastolic pressure.
symptoms of nausea, dizziness, light-headedness, tachycardia, pallor, or fainting when patient changes from supine to standing position
increased cardiac workload results in
an increase of O2 consumption.
the heart works harder and less efficiently.
Thrombosis formation
accumulation of the cellular elements of blood attached to the interior wall of a vein or artery form.
Thrombosis can cause
damage to the vessel wall, alterations of blood flow and alterations in blood constituents (clotting factors)
musculoskeletal changes due to immobility
- loss of lean body mass r/t protein breakdown
- muscle weakness: disuse atrophy
- osteoporosis: Ca+ resorption
- joint contractures
joint contractures
- abnormal and potentially permanent fixation of the joint.
- when it occurs, joint cannot achieve full ROM
What causes the formation of joint contractures?
- flexor muscles are stronger than extensor muscles leading to the formation of contractures
- disuse atrophy and shortening of the muscle fibers
Foot drop
debilitating contracture that causes the foot to be permanently fixed in plantar flexion
-draw alphabet with your feet.
urinary elimination changes due to immobility
- can cause renal stasis
- urine flow often diminished r/t diminished intake
- inadequate perineal care after BM’s develops (increases risk for contamination by E. coli)
renal stasis
- peristaltic contractions of the ureters are insufficient to overcome gravity therefore the the renal pelvis fills before urine enters the ureters.
- this can result in UTI’s and renal calculi (kidney stones) due to hypercalcemia.
integumentary changes due to immobility
-increased risk for pressure ulcers
skin breakdown can occur in as little as 3 hours.
pressure ulcer
impairment of the skin as a result of prolonged ischemia (decreased blood supply) in tissues.
psychological effects of immobility
depression, isolation, stress over family obligations and finances
developmental changes due to immobility: Adults
loss of mobility can lead to changes in role, loss of job and self concept.
developmental changes due to immobility: Older Adults
- loss of bone mass due to decreased physical activity, hormonal changes and bone resorption. Weaker bones. Makes them less coordinated.
- medications: alter blood pressure, sense of balance thus increasing risks for falls. Increases their physical dependence.
immobilization of some older adults results from
degenerative diseases and chronic illness/co-morbidities
Immobilization of the older adult increases their physical dependence, when providing nursing care,
encourage the patient to perform as many self-care activities as possible
When assessing a patient, assess ROM for
stiffness, swelling, pain, and limited movement
ROM exercises
- all patients require ROM exercises to reduce the hazards of immobility.
- ROM begins as soon as the ability to move is lost.
- consult PT and OT for their expertise on ROM and exercises.
What can nurses do to prevent pneumonia in immobile patients?
encourage the use of incentive spirometer, coughing and deep breathing exercises
What can nurses do to provide optimum nutrition to immobile patients?
-dietary consult for optimum nutrition:
high protein, high calorie diet is needed for tissue repair. Vit C and Zinc for wound healing.
How often should you reposition an immobile patient?
every 2 hours. Use specialty beds when indicated.
The nurse should continually assess what two systems in an immobile patient?
the GI and GU systems
Why should a nurse use elastic stockings and sequential compression devices in an immobile patient?
- to prevent thrombus formation (DVT) and increase venous return.
- However, a nurse should not apply elastic stocking if any there are any skin lesions/gangrenous condition.
If you have an immobile patient on a blood thinner,
continually assess symptoms and signs for bleeding
Why should a nurse never massage legs/calves in an immobile patient?
it risks dislodging a thrombus
Nursing Process: Assessment for Mobility/Immobility
ROM, Gait, Body Alignment, Elimination, Psychosocial Assessment and Metabolic, Respiratory, Cardiovascular, Musculoskeletal and Integumentary Systems.
Possible nursing diagnoses include
ineffective airway clearance, impaired physical mobility, risk for impaired skin integrity, risk for falls and social isolation.
Nursing Process: Plans for Mobility/Immobility
-goals and outcomes, setting priorities, interdisciplinary teamwork
Nursing Process: Implementation for Mobility/Immobility
- prevention of work related injuries (self care), of elimination disturbances, and of skin breakdown.
- promote exercise/ROM
- patient teaching: osteoporosis
- nutritional consideration
- measures to prevent atelectasis and pneumonia, and thrombus/DVT
- assess for orthostatic hypotension
- psychosocial considerations
