Chapter 21. Immobility. Elsevier items and derived items 2007 by Saunders, an imprint of Elsevier, Inc.

Transcription

1 Chapter 21 Immobility 1

2 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 2

3 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 3

4 Nursing Assessment and Intervention 4

5 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 5

6 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 6

7 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 7

8 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 8

9 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 9

10 Figure

11 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 11

12 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 12

13 Figure

14 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 14

15 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 15

16 Figure

17 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 17

18 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 18

19 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 19

20 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 20

21 Figure

22 Figure

23 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 23

24 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 24

25 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 25

26 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 26

27 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 27

28 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 28

29 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 29

30 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 30

31 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 31

32 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 32

33 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 33

34 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 34