Immobility Flashcards
Causes of immobility
• Bedrest
• Physical restriction/ limitation of movement—casts, traction
• Damage to the CNS
• Direct trauma to the MS system
Hazards of immobility
• Psychological: Can make you sad not moving
• Nutrition/metabolic: not digest food as well
• Respiratory: lungs can’t expand as well
• Cardiovascular: heart is working overtime to get blood to body
• Musculoskeletal: lose endurance
• Urinary tract: sits still, can lead to bladder/kidney infxns
• Skin: pressure injuries
Assessment: physical exam neuro
- Orientation
• Person, time, place, situation (why are they here) - month, year, what season we’re in
- Level of Consciousness (LOC)
• Alert: awake but can still be confused
• Lethargic (Somnolent): extreme drowsiness
• Stupor (Semicomatose): responds unpurposefully to painful stimuli
• Coma: unresponsive
Glasgow coma scale
- Normal 15
- Patient in coma scores 7 or less
- Eye opening: spontaneously (4), to speech (3), to pain (2), none (1)
- verbal response: oriented (5), confused (4), inappropriate (3), incomprehensible (2), none (1)
- motor response: obeys commands (6), localizes to pain (5), withdraws from pain (4), flexion to pain (3), extension to pain (2), none(1)
Pressure injuries: stages of injuries
• Stage 1: Reddening of skin which does not disappear when pressure relieved
• Stage 2: Superficial circulatory & tissue damage. May appear as blister.
• Stage 3: Destruction of subcutaneous layers
• Stage 4: Destruction of subcutaneous capillaries, muscle mass & possibly bone —> poor blood flow. Can show muscles, tendons, sometimes bone
What does the Braden Scale evaluate?
A. Skin integrity at bony prominences, including any wounds
B. Risk factors that place the patient at risk for skin breakdown (18 or below) (CORRECT)
C. The amount of repositioning that the patient can tolerate
D. The factors that place the patient at risk for poor healing
The effects of immobility on the cardiac system include which of the following? (Select all that apply.)
A. Thrombus formation: heart isn’t able to adequately pump the blood thru. Blood may slow down. Form a clot in the leg (CORRECT)
B. Increased cardiac workload (CORRECT)
C. Increased apical pulse (CORRECT) (heart is working harder)
D. Increased capillary refill
E. Orthostatic hypotension (CORRECT)
The nurse is performing an assessment of an immobilized client. Which of the following causes them to take action?
A. Heart rate 88
B. Reddened area on sacrum (CORRECT)
C. Nonproductive cough
D. Voiding clear yellow urine
Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?
A. Isometric exercises
B. Administration of low-dose heparin
C. Suctioning every 4 hours (excessive)
D. Use of incentive spirometer every 1-2 hours while awake (CORRECT)
ASSESSMENT: PHYSICAL EXAM CARDIOVASCULAR & RESPIRATORY
- Heart & Lung Sounds: is heart beating? Do lungs sound clear to auscultation?
- Activity Tolerance
- Orthostatic Hypotension (BP DROPS)
- Signs of Thrombophlebitis (clotting of vein/inflammation of vein)
• Redness, Tenderness, Swelling - result of immobility
ASSESSMENT: PHYSICAL EXAM GI/GU SYSTEMS
- Abdominal distention/ bowel sounds
- Urinary output
- Bowel movement regularity
- Bowel and bladder continence
- can make you constipated if u aren’t moving
ASSESSMENT: PHYSICAL EXAM SKIN INTEGRITY
- Bruises, cuts, scratches, scars —> could be from bones being in one place for so long
- Condition of skin
- Risk factors—sensory/perception, moisture, activity, mobility, nutrition, friction/shear
sites for pressure ulcer development
- pts need to be up and moving
- if they can’t move, we need to be turning these pts every 2 hours, putting pillows under them, putting protective pads @ areas that are at risk
braden scale
- score 18 or below = risk for skin breakdown
- Sensory Perception: Completely limited(1), Very limited(2), Slightly limited(3), No impairment(4)
- Moisture: Constantly moist (1), Very moist (2), Occasionally moist (3), Rarely moist (4)
- Activity: Bedfast (1), Chairfast (2), Walks occasionally (3), Walks frequently (4)
- Mobility: Completely immobile (1), Very limited (2)
Slightly limited (3), No limitations (4) - Nutrition: Very poor (1), Probably inadequate (2),
Adequate (3), Excellent (4) - Friction & sheer: Problem (1), Potential problem (2), No apparent problem (3)
ASSESSMENT: PHYSICAL EXAM MOBILITY
- ROM, Muscle Strength –> see if they can move their arms and legs around
- Coordination
- Ability to Perform ADL –> can they use a wash cloth, can they wash their face, can they put their clothes on, etc
- Assistive Devices Needed –> do they need a walker, a cane
- Get Up & Go Test –> how long does it take them to complete it (7-10 sec)
timed get up and go test
- begin timing
- rise from standard arm chair
- walk to line on floor (approximately 10 ft away from chair)
- turn and return to chair
- sit in chair again
- end timing
impaired mobility
- Difficulty or inability to facilitate movement
- Risk for impaired skin integrity
- Increased chance of injury of damage to the skin
- if you have the risk, we’re going to put in place interventions to help prevent the skin damage from happening
impaired tissue integrity
- Damage to mucous membranes, corneal integumentary or subcutaneous tissues
- there is skin breakdown
nursing intervention categories
- Pressure management
- Wound care
maintain existing fxn (musculoskeletal)
- Provide sufficient stimuli –> get them up and move them around
- Ensure use of assistive devices
- Maximize residual function
maintain limb mobility and prevent contractures
- Work with OT/PT
- ROM
- Proper alignment
- Exercises
- Gluteal setting
- Quadriceps setting
Promote Optimal Respiratory Functioning (Respiratory)
- TCDB q 2 hours –> turn, cough, deep breaths, helps get secretions moving around
- Incentive spirometer q 1-2 hours –> inhale and this helps open the lungs
- Force fluids (2000ml-3000ml) –> helps thin out any secretions
- Chest PT/ suctioning PRN –> only do when it is necessary
Improve Venous Blood Flow (Cardiovascular)
- Leg exercises, ROM exercises
- Change position q 2h
- NEVER massage legs –> if someone has a clot, you could dislodge it and it could move around the body
- Sequential compression stockings
- Anti-emboli ted hose
- Administer anticoagulants when ordered
- Lovenox
antiemboli stockings
- help push that blood up from the legs and help keep their blood from pooling in the lower extremities
foot drop contracture
- complication of immobility
prevent urinary stasis (GU)
- 2000-3000 ml/ day
- Monitor I&O
prevent constipation (GI)
- 2000-3000 ml/ day
- Dietary fiber
Reduce monotony/ Provide opportunities for control
- asking what types of fluids they want to drink, what foods they want to eat
maintain skin integrity
- Any sustained pressure >32 mm Hg can lead to skin breakdown
- Assess skin at least 2x/day
- Reduce shearing/friction
- Keep skin clean & dry
- NEVER massage reddened areas
- Keep heels off of bed
- Maintain/ improve nutritional status
- Maintain proper positioning/ alignment
elevate heel
- relieve pressure off the heels
30 ° LATERAL POSITION
- prevents skin breakdown
- look at pic on slide – pg 28 immobility preclass
maintain skin integrity (cont)
- Use specialized beds PRN
- Gel pads for those confined to wheelchairs
- Post stroke
- Spinal Cord Injured
- NEVER use donut shaped pads
what cushions should you never use?
DONUT SHAPED
evaluation
- ensure the pt has good functioning of all body parts
- respiratory
low airloss bed
- lets air out
- helps prevent pressure ulcers
