Transcript Respiratory Failure

Patient mobility,
Range of Motion
exercises,
Pressure Area Care
Revised and edited March 2012 Michele Archdale
References: Tabbner’s Nursing Care 5E 2009
Why is positioning important?
• Good posture achieved when the body is in correct
alignment
• Prevent contractures: characterized by flexion & fixation & caused
by atrophy & shortening of muscle fibers or by loss of normal elasticity of
the skin
• Prevent injury / Ulcers Pressure Sores – tissues are compressed,
decreased blood supply to area, therefore, decreased oxygen to tissue &
cells die.
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Stimulate circulation
Promote lung expansion
Relieve pressure and joint tightness
Comfort & pain relief
Moving & Positioning
• Mobility – persons ability to move about freely.
• Immobility – person unable to move about freely, all body
systems at risk for impairment.
• It is important to maintain proper body alignment for the
patient at all times, this includes when turning or positioning
the patient.
– Aim – least possible stress on patient’s joints & skin.
Maintain body parts in correct alignment so they remain
functional and unstressed.
– Patients who are immobile need to be repositioned every
2 hrs. (2/24)
Application of proper body mechanics
“By applying the nursing process and using the critical
thinking approach, the nurse can develop
individualized care plans for clients with mobility
impairments or risk for immobility. A care plan is
designed to improve the client’s functional status,
promote self care, maintain psychological well being,
and reduce the hazards of immobility.”
(Potter and Perry, 2006)
Moving & Positioning: Nursing Process
• Assessment
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Comfort level & alignment while lying down
Risk factors - Ability to move, paralysis
Level of consciousness
Physical ability/motivation
Presence of tubes, equipment
Wounds
Pain
• Nursing Diagnosis
• Defining characteristics from the assessment
– Activity intolerance
– Impaired physical mobility
– Impaired skin integrity
Nursing Process (cont.)
• Planning
• Know expected outcomes – good alignment,
increased comfort
• Raise bed to comfortable working height
• Remove pillows & devices
• Obtain extra help if needed
• Explain procedure to client
• Gather necessary equipment
• Multitasking – wash at same time?
Nursing Process (cont.)
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Implementation
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Offer pain relief as
necessary
Consult care plan
Wash hands
Close door/curtain
Put bed in flat position
Move immobile patient up
in bed
Realign patient in correct
body alignment (pillows
etc.)
Nursing Process (cont.)
• Evaluation
• Assess body alignment, comfort
• Ongoing assessment of skin condition
• Use of proper body mechanics (nurse)
Tips for positioning the patient
• After turning – use aids i.e. pillows, towels, washcloths,
blankets, sandbags, footboards etc.
• Joints should be slightly flexed b/c prolonged extension
creates undue muscle tension & strain
• Supine
Types of Positions
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Supine (dorsal recumbent)
Prone (anterior recumbent)
Semi-recumbent
lateral
Sim’s
Coma
Dorsal
Lithotomy
Genupectoral (knee-chest)
Orthopnoeic; Dorsal Recumbent
A= supine
B= prone
C= semi recumbent
D= lateral
E= Sim’s
F= Coma
G= Dorsal
H= lithotomy
I= Genupectoral
Orthopnoeic
SUPINE
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Flat on back, pillow under head
Limbs – normal alignment
Pillow if needed to maintain normal position of feet
Relaxation of abdo muscles
Relieves tension on abdo area
Several hours after lumbar puncture to facilitate normal
circulation of CSF; helps to prevent severe headache
Low or flat pillow (prevents neck flexion)
Trochanter role (supports hip joint prevents external rotation)
Hand roll – used if hands are paralyzed (thumb & fingers
flexed around it)
High top sneakers, foot board, sandbags (support feet with
toes pointing upward. Prolonged plantar flexion leads to foot
drop (permanent plantar flexion & inability to dorsiflex)
• Disadvantages:
– Restriction of chest expansion – complications
– Difficulty toileting – retention
– Loss of independence – depression
– Increased work of heart – lying flat increased venous
return (preload)
– Pressure necrosis of skin
• Occipital- may be assessed.
• Sacral – pressure sores
• Heels – a special & serious risk in diabetic pts
– Postoperative backache
• Use of a lumbar support may be beneficial
Prone – anterior recumbent
• Head supported on small pillow
• Lies on abdo- pillow to ensure
natural curve of the spine &
relieves pressure on breasts
• Pillow may be placed under
ankles or toes extended over
mattress
• Comfortable positioning of arms
• Use support to
protect pressure
points, toes and
feet as done in
this picture.
• To relieve pressure on posterior surface of the
body – promote healing & relieve pain
e.g.burn, ulcer.
• Provision of access to posterior surface of
body.
• Promote drainage from respiratory tract –
elevation of foot end of bed?
• Disadvantages
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Restriction of chest expansion – complications
Loss of independence – depression
Difficulty with ADL’s – eating drinking toileting etc.
Counter indicated with spinal cord problems.
Prone Position 2
• Airway, airway,
airway!!!
• Pressure points
– Ladies’ breasts
– Men’s genitailia
Semi-recumbent
• Lies on back
• Three – four pillows supporting head, neck
and shoulders
• No specific indications – may be comfort only
related.
LATERAL
• Lies on side head supported with a pillow.
• Arms in front of the body – supported with
pillows.
• Legs flexed or extended.
• Pillows along the back and or between knees.
• Even if paralyzed on one side a patient can be
placed on that side. Take care not to pull on
the affected extremity.
• Left lateral – examination / treatment invoving
rectum.
• Lumbar puncture – spine flexed.
• Unconscious client – promotes maintenance
of clear airway.
• Prevents oral secretions entering trachea.
• Pressure problems
– The skin below the iliac
crest is at risk
– The underlying deltoid
can suffer ‘crush
syndrome’
– The underlying sciatic
nerve is at risk in
emaciated pts
– Axillary support is
essential to protect the
underlying brachial
plexus
Sims Position
• Not used frequently.
• Can be used for vaginal
examination – perhaps less
embarrassing.
• Upper leg drawn towards chest,
buttocks towards edge of bed.
• Lower arm placed behind client.
• Upper arm in front.
• Pressure points are different
from other positions, i.e. supine,
thereby preserving skin
integrity.
Coma
• Basically Sim’s position but without a pillow
under the head.
• Correct positioning of head essential for clear
airway – pillow may impede breathing.
• Temporary position during unconsciousness –
e.g fainting.
• Prevents tongue / oral secretions from
obstructing trachea.
• Disadvantages – prolonged use
– Restriction of chest expansion – complications
– Postural deformities – contractures
– Prolonged pressure on arm & shoulder placed behind
client– damage to brachial plexus.
Dorsal
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Lies on back – knees flexed and apart.
Soles of feet flat on bed.
Head supported by a pillow.
Indications:
– Insertion of urinary catheter.
– Vaginal examination
– Enema / rectal suppositories if unable to assume
left lateral position.
• Variation to dorsal –
lithotomy
– Gynaecological exam
– Birthing
• Disadvantages
– Embarrassing
– Nervous system complication
• Straight leg sling system
may cause nerve problems
– Compartment syndrome - This
can result from undue pressure
on the calf muscles
– Increased intra-abdominal
pressure enhances the
possibility of gastric
regurgitation
Genupectoral
• Knee – chest, client kneeling
• Indications:
– Specific examination of lower colon to facilitate insertion
of instruments.
– Management of specific obstetric emergencies.
• Disadvantages:
– Uncomfortable
– Embarrassing
– Difficult to maintain
– Could result in dizziness, fainting and falling.
Sitting positions
– There are three variations of a sitting position:
• The semi-upright, or semi-Fowler's, position, in which
the client sits at an angle of about 30 degrees,
supported by pillows, which are placed against the
backrest of the bed
• The upright, or Fowler's, position, in which the client is
in a full sitting position, with pillows placed to support
the upper body
• The orthopnoeic position, in which, from an upright
position, the individual leans onto an over-bed table
– A particular one of these sitting positions may be indicated:
• After abdominal or thoracic surgery. Less tension is exerted on an abdominal
wound, therefore comfort is promoted. Drainage by gravity from body cavities is
facilitated (e.g. when there has been a drainage tube inserted after surgery)
• To facilitate breathing and reduce dyspnoea. Because the diaphragm is able to
flatten, maximal chest expansion is promoted and the risk of lung congestion is
decreased. Leaning forward, as in the orthopnoeic position, helps to increase lung
capacity and therefore alleviate distressed breathing
• To facilitate independence, as a sitting position enables the client to see and
participate in ward activities. The activities of daily living (e.g. eating and drinking or
using toilet utensils) are also facilitated in this position.
– The disadvantages of a sitting position include:
• Difficulty maintaining the position, which may become tiring or uncomfortable
• Difficulty in sleeping
• Prolonged pressure on the buttocks and sacral area, which increases the risk of
decubitus ulcers
• Difficulty maintaining a comfortable body temperature: in cold weather it may be
hard to bring the bedclothes up to the shoulders, while in hot weather the client
may experience discomfort from the number of pillows required to maintain a
sitting position.
Other positions - Trendelenberg
• In the Trendelenburg position the body is laid flat on the back
with the feet higher than the head by 15-30 degrees, in
contrast to the reverse Trendelenburg position, where the
body is tilted in the opposite direction.
• This is a standard position used in abdominal and
gynaecological surgery. It allows better access to the pelvic
organs as gravity pulls the intestines away from the pelvis.
Clients in Bed
• Evaluate Comfort After Positioning for
Alignment
• Check for tubes, equipment, bed creases
• Reposition 2hrly
• Use Repositioning for effective ROM
• Use Supportive Devises for Positioning
Patient mobility
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Encourage independence at all times
Assess client
Physio input?
Attitudes play a part – socio-economic status, upbringing
Provide information & support
Functional decline associated with disuse.
Being fit makes it easier to perform daily activities & improves
recovery after illness.
• Prevalence of obesity – current trends 1 in 3 obese
• Obesity – leads to severe health problems
• Nurses role in education and encouragement.
Types of Range of Motion
• Nurses may need to assist and
encourage ROM exercise when
activity is limited.
– Active Range Of Motion
– Passive Range Of Motion
– Active Assistive Range of Motion (We
assist patient)
• ROM is the extent of movement
that a joint is normally capable of.
ROM Goals
• To keep patient in the
best physical shape
possible.
• To increase joint
mobility.
• To increase circulation
to the affected part.
Assessing Joint Mobility
• The ROM is
appropriate to
each joint.
Precautions with ROM
– Infection or inflammation around a joint.
– Pain
– Osteoporosis
– Arthritis
Limitations
Swelling, tenderness & pain are
among factors that limit ROM.
Passive ROM
• The patient is unable to
move independently and
someone else
manipulates body parts.
Active-Assistive ROM
• The nurse provides minimal support as
the patient moves through ROM.
Active ROM
• The patient moves
independently
through a full ROM
for each joint.
Hip ROM
• Hip ROM includes
flexion, extension
and lateral &
external rotation
• Adduction &
Abduction
Hand Movements (ROM)
• ROM in wrist includes
flexion, extension.
• ROM in hands include
abduction, adduction,
flexion, extension,
opposition and
circumduction of the
thumb.
Restraints
• Device used to immobilize a client or an extremity
• A temporary means to control behavior
• Restraints are used to:
• Prevent falls & wandering
• Protect from self-injury (pulling out tubes)
• Prevent violence toward others
• Restraints deprive a fundamental right to control your own body.
• While restraint-free care is ideal, there are times that restraints become
necessary to protect the patient & others from harm.
• Highly agitated, violent individual – Physical/Chemical restraints
• Intubated patient – pulling out endotracheal tube
• Suicide patient - ? Chemical restraints
Goals of Restraint Use
• To avoid the use of restraints whenever possible.
• Encourage alternatives
• Family member to sit with patient
• Geri chair vs. bed
• Consider restraints as a temporary measure – decrease
likelihood of injury from restraint use.
• Remove restraints as soon as the patient is no longer at risk
for injury.
• Trial periods of removal of restraint.
Use of Restraints
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Review organisational policy.
Use only when absolutely necessary.
Least restrictive measure.
Attending physician is responsible for the assessment,
ordering & continuation of restraint.
• Can be instituted on your nursing judgment – must
have a doctors order ASAP.
• Continued use of restraints must be reviewed daily by
the RN & documented on the health record. Will
require 1/24 monitoring / restraint chart.
– Always explain what you do & why, to reduce
anxiety & promote cooperation.
Complications assoc. with
restraints
• Hazards of immobility
• Pressure sores, pneumonia, constipation, incontinence, contractures,
decreased mobility, decreased muscle strength, increased dependence
• Altered thought processes
• Humiliation, fear, anger & decreased self-esteem
• Strangulation
• Compromised circulation
• Lacerations, bruising, impaired skin integrity
• Must release restraint every 1 - 2 hours for
assessment & ROM
Physical Restraints – device that limits a clients
ability to move
• Side rails – stop patient from rolling out, but does not
stop them from climbing out – side rail down when
working on that side.
• Jackets & Belts – patient who is confused & climbing
over rails may need a jacket or belt to restrain them to
bed. Sleeveless with cross over ties, allows relative
freedom in bed.
• Arm & Leg – Undesirable, limits patients movement,
injury to wrist/ankle from friction rubbing against skin
– use extra padding. Restrain in a slightly flexed
position, if too tight could impair circulation. Never tie
to a bed rail.
Suggestions to promote restraint minimisation
Reducing risk of wandering
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Bed, chair or wrist alarms
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Exit door alarm
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Electronic movement sensors
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Planned night-time activities for those who wander at night
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Daytime recreational and social activities
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Activity areas at the end of each corridor
Reduce incidence of agitation and aggression
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Easy access to safe outdoor areas
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Structural design of units modified to enhance visibility of residents
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Rocker and recliner chairs
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Outlets for industrious or anxious behaviour; for example, physical,
occupational and recreational therapies
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Soothing music
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Diversions such as television or radio
(adapted from Joanna Briggs Institute 2002b)
(Funnell, Rita. Tabbner's Nursing Care, 5th Edition. Elsevier Australia, 12/1/2008. p. 373).
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Forms of restraint, in order of restrictiveness
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Restricting body extremities; for example, securing hands, wrists or ankles to the
arms or legs of a chair or to bed rails, using body restraining vests
Restricting body movements by other means; for example, safety belts or vests
Restricting movement in the environment by secluding a client in a dedicated
seclusion room.
Restricting movement in the environment by restriction within a ward or unit
Restricting activities of daily living; for example, selection of preferred foods,
television programs, social activities or choice of visitors or people to meet or
socialise with
Denial of purposeful or meaningful activities, such as access to preferred leisure or
work pursuits
Restricting choice of treatment; for example, in some cases people with mental
health, intellectual or cognitive impairment are given treatment not of their
choosing that is mandated by the legal system (courts)
Restricting access to personal belongings; for example, use of own money
Restricting the expression of personal feelings or views; for example, censoring
expressions of emotion (expressions of anger or frustration may be controlled and
vocabulary normally used may be censored, e.g. swearing). This form of restriction
and control is more common in mental health nursing than in other areas
(adapted from Olsen 1998)
Supporting Documentation
• Rationale for the use of restraints, including a statement
describing the behavior of the patient.
• Previous unsuccessful measures or the reason alternatives are
not feasible.
• Decision to restrain with the type of restraint selected and
date & time of application.
• Observations regarding the placement of the restraint, its
condition and the patient’s condition, including the frequency
of observation (not just at the end of your shift)
• Assessment of the need for ongoing application of restraint.
• Care of the patient which may include re-positioning,
toileting, mobilization and/or skin care