nursing interventions to prevent complications of immobility

Preventive measures and the treatments of these skin integrity disorders will be discussed below in the section entitled "Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown". American Academy of Nursing's Expert Panel on Acute and Critical Care. The correct application of antiembolism stockings entails the application of these stockings while the client is lying in bed and before rising. Some wounds, like surgical incisions, are planned wounds and others such as those occurring secondary to a trauma or a pressure ulcer are considered unplanned wounds. WebState the nursing interventions used to prevent complications of immobility. Fractures can also be categorized and categorized according to it pattern. When working with school-age children, nurses provide education to prevent injury that can occur with activity, such as using helmets and knee pads to prevent injury while bicycling and skateboarding. After the client is assessed, the mobility of the client, in addition to other functional activities, can be graded and classified as follows in terms of this level of functional ability: The skin, which is the first line of defense against infection, should be intact and not broken, it should be warm and without any excessive moisture, and the skin should also have good elasticity, which is referred to as good skin turgor. Some of its disadvantages, however, include the fact that autolytic debridement is not as rapid as a surgical debridement in terms of its effectiveness and the fact that anerobic microbes may thrive under the dressing that is used for this type of debridement. The best way for nursing assistants to prevent DVT is to assist clients to ambulate or otherwise complete as much activity as they can tolerate. Vibration is highly similar to percussion except vibration is done by placing the palm of the hand on the lung area and doing rapid vibrating movements on the area while the client is positioned for postural drainage. Traction is often set up by the nurse and, at times, a traction team may be used for the setup of the doctor's ordered traction. The client should attempt to hold their breath for as long as possible (at least five seconds) and then exhale and rest for a few seconds. The nurse or respiratory therapist initially teaches the client how to use the incentive spirometer but encouraging and observing clients complete this action every hour is commonly delegated to a nursing assistant. Compression fractures occur when the fractured bone collapses as occurs with vertebral spinal fractures. Active and passive range of motion (ROM) exercises prevent complications of immobility in the musculoskeletal system. Clients often have two or more pairs of compression stockings to ensure they dry completely before wearing them again in the morning. Skeletal traction is applied directly to an affected bone with a continuous traction force and with the use of a surgically inserted Steinman pin that is placed into the distal end of the affected bone. Wound drainage is also described in terms of its color and characteristics. Assess for the presence of urinary tract abnormalities related to immobility, such as suprapubic distention or tenderness that can result from urinary retention. The three types of wound healing are primary intention healing, secondary intention healing and tertiary intention healing. Conditions such as osteoarthritis, orthostatic hypotension, inner ear dysfunction, osteoporosis resulting in hip fractures, stroke, and Parkinsons disease are among the most common causes of immobility in old age. Like automatic sequential compression, compression stockings are fitted for the specific client after measuring the client's legs and checking the doctor's order for the amount of pressure that these stockings should exert on the client's leg. This relatively inexpensive type of debridement can be done with a damp dressing, hydrotherapy, and manually scrubbing the affected area to remove the debris. Mobility is vital to independence; a fully immobilized person is as vulnerable and dependent as an infant" (Berman and Synder, 2012). See the steps for providing ROM for the shoulder and hip joints in the ROM Exercises for the Shoulder and ROM Exercises for the Hip and Knee Skills Checklists later in this chapter. For example, if a person has their fingers spread wide apart, bringing them back together is adduction. For example, hip abduction is the movement of the leg away from the midline of the body. Therefore, nursing assistants must be diligent in their actions and observations to maintain their clients health and prevent complications. Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, percussion and vibration. Coughing, deep breathing and the use of an incentive spirometer are described as hyperinflation exercises because, when done properly, these respiratory techniques hyper inflate the lung to facilitate the loosening and mobilization of respiratory secretions. Deep-vein thrombosis (DVT) is a common complication for clients experiencing immobility. [2], View evidence-based strategies to reduce functional decline in hospitalized older adults provided by The Hartford Institute for Geriatric Nursing. [8],[9], For patients at risk for developing pneumonia due to immobility, encourage adequate fluid intake to liquefy pulmonary secretions, and teach deep breathing and coughing exercises to prevent atelectasis. Determine the patients progress towards their specific SMART outcomes. Educate the patient about appropriately using assistive devices and other fall precautions. To avoid or minimize complications of immobility, mobilize the patient as soon as possible and to the fullest extent possible. Monitor 24-hour trend of intake and output, as well as for symptoms of dysuria, urgency, or frequency. Accessibility StatementFor more information contact us atinfo@libretexts.org. The homeostasis phase is marked with vasoconstriction, platelet formation, thrombin formation and the formation of a fibrin mesh for healing; the inflammation phase is characterized with the signs and symptoms of inflammation including edema, swelling, pain, in addition to the beginning of debris removal to prevent infection through the process of phagocytosis; the proliferative and granulation phase is marked with the fibroblastic production of collagen and granulation tissue; and, lastly, the maturation phase of wound healing is characterized with the still fragile skin after the wound healing process that can last up to two years after a wound. They should be applied upon awakening because edema is usually at its lowest point after lying in bed overnight. The area of an abnormality is measured with a disposable rule in terms of centimeters. The bones lose calcium as a result of the lack of weight bearing activity and this can lead to disuse osteoporosis, hypercalcemia, and fractures. Some of these compression stockings are knee high and others are thigh high. This page titled 9.4: Complications of Immobility is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Myra Sandquist Reuter via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request. Traction is used for the external fixation of a fracture, it is used to maintain anatomically correct alignment, it is used to reduce pain and it is used to decrease muscle spasms. When the pulling traction force is greater than the counter traction force of the client's body, the client will slide to the source of the traction. Corn starch is NOT used. Some splints, like an inflatable arm splint, a Downey splint and a Sager splint, are temporarily placed on clients by paramedics in the field prior to their arrival at the emergency department of a hospital. Similar to compression hose, sequential compression sleeves are also fitted according to the client's measurements and they come in both thigh high and knee high sleeves. The procedure for deep breathing and coughing is as below. The resistance indicator on the right side should be monitored to ensure they are not breathing in too quickly. This blockage reduces blood flow to the affected area. An avulsion fracture occurs when a fragment of the fractured bone is pulled off the bone at its tendon or ligamentous attachment. Monitor vital signs before, during, and after physical activity and institute appropriate fall prevention strategies as indicated. Typically, larger joints such as shoulders, elbows, hips, knees, and ankles are included in ROM exercises, but ROM can be also applied to smaller joints such as the fingers and wrists. Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered mood, and depression. Some nursing diagnoses related to immobility can include: At risk for pressure ulcers related to immobility Muscular weakness and muscular atrophy related to immobility Permanent care can prevent some of the potential complications of being bedridden and largely immobile but, unfortunately, these patients' immobility at some point results in at least one or even multiple complications. RYB stands for the colors of red, yellow and black. We also acknowledge previous National Science Foundation support under grant numbers 1246120, 1525057, and 1413739. Note if urinary incontinence is occurring due to the inability of the patient to reach the restroom in time.[1]. For example, the client is positioned prone and in a 45 degree Trendelenburg position to drain the posterior bronchus, a 45 degree Trendelenburg position to drain the posterior bronchus and on the left side to drain the lateral bronchus. Active range of motion is movement of a joint by the individual with no outside force aiding in the movement. Affected skin areas can be assessed and described as macerated, edematous, swollen, indurated or normal. Encourage their participation in the setting of realistic goals for mobility and modify these goals as needed for safety. Promote excellence in nursing by enabling future and current nurses with the education and employment resources they need to succeed. These sleeves, like compression hose, require that the nurse regularly check them to insure that they remain in place and they, too, should also be removed at least one time a day so that the nurse can inspect the skin underneath it and also to check the skin for its color and warmth. Autolytic debridement is most often used to treat Stage 3 and Stage 4 pressure ulcers. All of these measures are used not only for immobilized clients but also for many post-operative clients. See Figure 9.7[8] for a demonstration of these techniques. Hamilton Russell traction is an example of balanced traction. When passive range of motion is applied, the joint of an individual receiving the exercise is completely relaxed while the outside force moves the body part. See Table 9.4 for potential complications of immobility by body system and additional preventative measures that will keep clients as healthy as possible. The RYB Color Code of Wounds is sometimes used by nurses to guide the treatment options. Fractures are treated to prevent deformity. Nurses assist patients with range of motion exercises several times a day when patients are not completely independent in terms of their own performance of range of motion exercises. Pressure occludes the vessels that oxygenate the area and it also causes cellular damage because harmful substances, such as toxins, accumulate in the area where the pressure is exerted.
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