Transcript Chapter_021_LO

Chapter 21
Immobility
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Learning Objectives
• Describe common problems associated with immobility.
• Discuss the impact of exercise and positioning on
preventing complications related to immobility.
• Identify the risk factors for pressure ulcers.
• Describe the stages of pressure ulcers.
• Describe methods of preventing and treating pressure
ulcers.
• Discuss the effects of immobility on respiratory status,
nutrition, and elimination.
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Immobility
• Restriction imposed on all or part of the body
• Physical factors, such as joint disease,
paralysis, or pain; psychological factors, such
as depression or fear
• Therapy
• Pain relief; prevent further injury of a part, as in a
fractured bone
• Reduced workload of the heart in a cardiac
condition
• Healing and repair
• To reverse the effects of gravity, as in abdominal
hernias and prolapsed organs
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Immobility
• Psychosocial changes can impair mobility:
depression, dementia, bereavement, lack of
motivation, fear of falling, isolation, loss of
friends
• Older adult’s environment can promote or
hinder mobility
• An unsafe home setting, hospitalization, or
institutionalization associated with reduced activity
• Hospitalized older adult may quickly become
debilitated and dependent as a result of inactivity;
pain; drugs; various therapies, such as bed rest or
traction; and an unfamiliar environment
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Nursing Assessment and
Intervention
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Exercise
• A well individual of any age can walk,
participate in aerobic exercises, swim, engage
in sports activities, garden, or do housework
• Ill and disabled can engage in some form of
exercise regardless of severity of their disease
• Active
• Performed by the patients
• Passive
• Movement of patient’s body performed by therapist
or nurse without assistance from the patient
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Range-of-Motion Exercises
• Helps prevent disabilities of the musculoskeletal
system as well as other systems
• Muscular activity maintains range of motion (ROM) by
allowing the joint to remain flexible and functional
• Contracture
• Shortening of muscles and tendons
• When little or no movement of a joint, its structures change
• Normal muscle tissue is replaced by fibrous tissue
• Muscles shorten and lose their elasticity
• Rotation, flexion, extension, abduction, adduction
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Isometric Exercises
• Muscle tone without moving the joint
• Muscle is contracted and held for several seconds
• Muscle then relaxed few seconds and contracted
again
• Especially helpful in maintaining muscle
strength after a fracture
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Positioning
• Change patient’s position at least every 2 hours
to prevent undue pressure on the skin
• Maintain joints in their functional positions so that
they are not abnormally flexed or extended
• Use footboards, splints, and bed boards to
maintain proper positioning for patients in bed
• Avoid positioning the patient with the knees and
hips flexed
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Skin Integrity
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Pressure Ulcers
• Localized areas of tissue necrosis that develop
when soft tissue is compressed between a
bony prominence and an external surface for a
prolonged period
• Pressure points: areas over bony prominences,
such as the elbows, hips, shoulders, and
sacrum
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Figure 21-1
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Development of Pressure Ulcers
• Erythema: beginning of a pressure ulcer and a
sign that capillaries in the area have become
congested because of impaired blood flow
• Can occur within an hour or two in person with
healthy skin and adequate circulation
• Factors in addition to immobility that contribute
to the development of pressure ulcers are
shearing forces and chemical irritants such as
urine, sedation, and poor nutrition
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Preventing Pressure Ulcers
• First step: identify those at risk
• Norton scale
• The scores for all five categories are added
• If the total score is greater than 14, there is little risk of
pressure ulcer development
• If the score is less than 14, there is significant risk
• Any patient with a score of less than 14 needs to begin a
formal pressure ulcer prevention program as soon as the
risk is recognized
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Figure 21-3
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Prevention Protocol
• Reposition the bed patient at least every 2 hours
• Position so not resting on pressure points of the skin
• Teach wheelchair patients to shift their weight every
15 minutes if able. Patients who cannot do this should
be repositioned at least hourly
• Keep bed linens dry, smooth, and free of wrinkles
• Gently cleanse the skin when soiled and at regular
intervals, using warm water and a mild cleansing agent
• Use moisturizers, lubricants, protective films, barriers,
and dressings to reduce friction and shearing
• Avoid friction when moving patients to prevent skin
damage
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Prevention Protocol
• In bed, keep head lowered as much as possible to
reduce shearing force caused by sliding down
• Special mattress or bed reduces pressure, such as an
egg crate foam (minimum 2 inches thick), static air,
alternating air, gel, fluidized air, or water mattress
• Sheepskin boots prevent shearing forces to the feet
and pillows or wedges prevent heel pressure
• Protect the skin from moisture (absorbent pads or
briefs for incontinence, etc.)
• Measures that enhance patient mobility: trapeze bars
• Instruct the patient and family about risk factors and
strategies for preventing pressure ulcers
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Figure 21-4
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Stages of Pressure Ulcers
• Stage I
• Erythema (redness) that does not blanch when
pressed
• Color: from red to the dusky blue; called cyanosis
• Irregular and ill-defined area of pressure reflects the
shape of the object creating the pressure or the
bony prominence underlying the skin
• Pain and tenderness may be present, with swelling
and hardening of the tissue and associated heat
• Little destruction of tissue; the condition is reversible
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Stages of Pressure Ulcers
• Stage II
• Some skin loss in the epidermis and dermis
• A shallow ulcer develops and appears
blistered, cracked, or abraded (scraped)
• The ulcer is surrounded by a broad, irregular,
and painful reddened area that is warmer
than normal
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Stages of Pressure Ulcers
• Stage III
• Full-thickness skin loss involving damage or
necrosis of the dermis and subcutaneous
tissue
• A crater-like sore with a distinct outer margin
formed as the epidermis thickens and rolls
over the edge toward the ulcer base
• Wound may be infected; usually open and
draining, with a loss of fluid and protein
• Fever, dehydration, anemia, leukocytosis
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Stages of Pressure Ulcers
• Stage IV
• Full-thickness skin loss with extensive
destruction of the deeper underlying muscle
and possibly of the bone tissue
• Ulcer usually extensively infected; may
appear black, with exudation, foul odor, and
purulent drainage
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Figure 21-5
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Figure 21-2
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Stages of Pressure Ulcers
• Stages I and II
• Cleaned with mild soap and water or normal saline
• Avoid using pastes, creams, ointments, and powder
because they may promote infection in the ulcer
• Avoid using alcohol, antiseptics, disinfectants,
topical and oral antibiotics, and massage:
effectiveness has not been proved, and they may
actually cause harm
• The most effective dressing for a stage I or II
pressure provides a moist environment and
maintains a temperature close to body temperature
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Stages of Pressure Ulcers
• Stages III and IV
• More extensive treatment and supportive
care
• Irrigation devices: spray bottles, bulb and
piston syringes, others
• Débridement of necrotic tissue usually for
granulation of new, healthy tissue
• Wet-to-dry dressings and whirlpool baths used
for small amounts of débridement
• Surgery preferred for advanced cases
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Respiratory Status
• When a person is immobile or does not take
deep breaths, thick secretions can accumulate
and pool in the lower respiratory structures
• Interfere with the normal exchange of gases,
can cause areas of the lung to collapse
(atelectasis), and provide environment for
pathogen growth
• Hypostatic pneumonia
•
A lung infection associated with immobility
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Respiratory Status
• Individuals who are at risk for impaired gas
exchange related to immobility
• Are given drugs that depress respirations, such as
general anesthetic agents, narcotics, or sedatives
• Wear tight binders or bandages that limit chest
expansion
• Have abdominal distention from gas, fluid, or feces
• Lie in one position for extended periods
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Respiratory Status
• Nursing interventions
• Frequent turning and position changes and
coughing and deep breathing exercises
• Must be done every 2 hours to be effective
• Coughing/deep breathing done at the same time to
allow for periods of rest and for best results
• Monitor the patient’s respiratory status
• Count respiratory rate, observe respiratory effort
and chest movement, listen for crackles in the lung
fields
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Food and Fluid Intake
• Anorexia
• Most common problem of immobility
• Factors: anxiety about dependence on others and
decreased metabolic needs resulting from inactivity
• Inadequate fluid intake
• Getting up may be difficult and time consuming or
may not think to drink regularly
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Food and Fluid Intake
• Accurate records of dietary and fluid intakes
• Small, frequent meals better than three large
meals for patients with anorexia
• Dietary supplements that are high in protein
• Offer fluids, even small sips of water, juice, or
other liquids, at least every hour
• Fluids need to be within reach for easy access
• Encourage visiting family members to offer
fluids
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Elimination: Constipation
• Changes in the usual routine and environment,
inability to defecate on a bedpan because of
embarrassment or discomfort, and weakened
muscle tone
• From many medications: slow intestinal motility
• Valsalva maneuver or vasovagal reflex
• Straining to defecate causes an increase in intraabdominal pressure
• Can lead to cardiovascular alterations,
lightheadedness, and fainting
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Elimination: Constipation
• Confused patients may ignore the normal urge
to have a bowel movement
• Fecal impaction
• Hardened or puttylike feces in the rectum and
sigmoid colon
• Symptoms: painful defecation, a feeling of fullness
in the rectum, abdominal distention, and sometimes
cramps and watery stool
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Elimination: Constipation
• Encourage foods with adequate roughage,
fluids, and as much activity as possible
• If possible, patients should use a bedside
commode or be taken to the bathroom rather
than trying to use a bedpan
• Laxatives should be used sparingly; however,
stool softeners may be helpful if the stools are
hard and difficult to pass
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Elimination: Urinary Incontinence
• When body in reclining position, kidney must force
urine into the ureters against the pull of gravity
• The peristaltic action of the ureters is not strong
enough to maintain a constant flow of urine
• If body in a supine (lying down) position for even a few
days, the flow becomes sluggish and the urine pools
• Lying in bed also can cause loss of control of the
urinary sphincter muscles
• Functional incontinence
• Unable to respond to the urge to void in time
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Elimination: Urinary Incontinence
• Prevention
• Toileting program
• Scheduled toiletings with adjustments in schedule based
on the patient’s voiding patterns
• If voiding patterns cannot be assessed, patients should be
taken to the bathroom or commode or offered a bedpan
every 2 hours during waking hours
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