Nursing assistants are often expected to encourage clients to use their incentive spirometer hourly. Ask the patient about the date of their last bowel movement, and monitor stool patterns and stool characteristics. 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. When assisting with ROM exercises, the nursing assistant must support any joints below the joint being exercised to prevent injury. 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. If neither of these devices is available, a washcloth can be rolled and placed underneath the fingers. Abduction refers to the movement of a limb away from the bodys midline. The risk factors associated with immobility are client deconditioning, a cognitive impairment, spasticity, poor cardiac functioning and poor tolerance for activity, inadequate muscular strength, impaired balance, improper bodily posture and alignment, an impaired gait, pain, the use of sedating medications, joint pain and stiffness in addition to other skeletal problems, obesity, and neurological impairments in addition to a physiological health problem that mandates that the client be on complete bed rest. The joints are affected with stiffness, pain, impaired range of motion and contractures including foot drop which is a plantar flexion contracture. Segmenting ADLs refers to breaking up tasks to accommodate the clients activity intolerance. The advantages of this kind of wound debridement include its effectiveness, its ease in terms of performing it, its relative safety, and lack of pain for the client. For example, a patient undergoing a cardiac catheterization may be mobilized within a few hours following the procedure, whereas a patient undergoing total knee arthroplasty may begin mobilizing 24 hours following the surgery. The plan is tailored to the needs of the individual and will include the specific joints to move. Alene Burke RN, MSN is a nationally recognized nursing educator. In addition to traction and splints, many fractures are also casted. All of these measures are used not only for immobilized clients but also for many post-operative clients. For specific steps in applying TED hose, see the Application of Compression Stockings (TED Hose) Skills Checklist at the end of the chapter. 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 Encourage or perform active or passive range of motion exercises as prescribed by the physical therapist. Secondary intention healing, also referred to as healing by second intention, is done for contaminated wounds in order to prevent infections, to prevent the formation of abscesses and to promote healing from the bottom up to the outer surface of the skin so that any potential infection is not closed in at the bottom of the wound. When implementing interventions to promote mobility, in addition to reviewing the current orders regarding assistance and weight-bearing, assess the patients current status. The circulatory system is jeopardized by immobility; some of these respiratory complications and risks include venous stasis, venous dilation, decreased blood pressure, edema, embolus formation, thrombophlebitis and orthostatic hypotension which is a risk factor that is often associated with client falls. Patients able to perform full joint movement on their own and without the assistance of another should be encouraged to do so several times a day to promote circulatory functioning and also to maintain full joint mobility. Some of the orthopedic devices that nurses apply, maintain and remove include traction devices, splints, braces and casts: Traction, simply defined, is a physical pulling force that exerts pulling on the bodily part. While providing ROM, the nursing assistant must observe for objective and subjective signs of pain. Make any adjustments before proceeding because the hose will be very difficult to adjust after it is pulled up the leg. Monitor and document the patients response to activity, such as heart rate, blood pressure, dyspnea, and skin color.[13],[14]. The three basic traction techniques can also be classified as manual traction, skeletal traction and skin traction. External fixation devices, halo traction, skeletal traction, and Crutchfield or Vinke cervical tongs are immobilization techniques that are used for fractures and other serious disorders. Clients often have two or more pairs of compression stockings to ensure they dry completely before wearing them again in the morning. Some of these compression stockings are knee high and others are thigh high. [5], A sample nursing diagnosis in PES format is, Impaired Physical Mobility related to decrease in muscle strength as evidenced by slow movement and alteration in gait., A sample overall goal for a patient with Impaired Physical Mobility is, The patient will participate in activities of daily living to the fullest extent possible for their condition., A sample SMART outcome is, The patient will demonstrate appropriate use of adaptive equipment (e.g., a walker) for safe ambulation by the end of the shift.. The cone should not be forced into the fingers but placed gently. When assisting a client with ROM activities, the nursing assistant must follow the plan of care established by the licensed therapist. 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. The weights are gently applied, as ordered, and left to hang freely and without any interference. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the lower leg, but can occur anywhere within the cardiovascular system. The client should be reminded and encourage to take at least 10 breaths using the incentive spirometer at least every 2 hours while they are awake. Administer medications if warranted and consider nonpharmacologic measures such as repositioning, splinting, and heat/cold application to reduce musculoskeletal discomfort. Because changes in joints can occur after just three days of immobility, ROM exercises should be started by the nursing assistant as soon as they are directed by the nurse as safe to do so. Compression stockings may be knee length or hip length. PLEASE NOTE: The contents of this website are for informational purposes only. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). In fact, many insurance companies do not reimburse health care agencies for complications resulting from immobility, like pressure injuries, because they are viewed as avoidable with the proper care. Prior assessment of wound etiology is critical for the We use this action every day when we step to the side, get out of bed, and get out of the car. Some of the nursing diagnoses related to skin and skin integrity can include: All skin areas that are not within normal limits and indicate any signs of skin breakdown are assessed and described according to its color, size, location, odor, drainage, margins, texture, distribution and underlying bed tissue. It is an essential part of living. [4] See Table 13.3 for the definition and selected defining characteristics of this diagnosis. They should breathe in slowly and as deeply as possible through the tubing, with the goal of raising the piston to their prescribed level. If turned inside out, put your hand inside the hose, hold at the top of the heel marker with your thumb and forefinger, and then pull the top of the stocking down to the heel marker. Passive range of motion is movement applied to an individuals joint by another person or by a passive motion machine. Monitor the patients level of pain by using a valid pain intensity rating scale. Compartment syndrome is a medical emergency which, left untreated, can lead to the loss of the affected limb. This process is referred to as autolysis. Educate the patient about appropriately using assistive devices and other fall precautions. 9.4: Complications of Immobility - Medicine LibreTexts The wound remains vulnerable to injury until full healing is completed with good tensile strength. Patients who have mobility trouble are at risk for skin breakdown, ulcers, circulation, atrophy, constipation, and joint stiffness among other complications. There are many ways that nurses can assist with procedures and psychomotor skills to help immobile clients. Protect the skin as needed to minimize the potential for breakdown, and advocate for devices to prevent contractures, as needed.[11],[12]. To prevent a decrease in lung function, reduce the build-up of fluids in the airways, and prevent pneumonia, clients are often prescribed incentive spirometry to keep their bronchioles open. Assess for the presence of lower extremity edema and for signs of a potential deep vein thrombosis (DVT). Splints are also used the immobilization of the spine, to support a weakened area of articulation such as a knee from damage and to support it after a knee replacement, for example. 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. These devices are ordered by the doctor in terms of millimeters of mercury that they will apply to the lower extremities. Coordination can be adversely affected with a neurological disorder of the cerebellum, cerebral cortex and basal ganglia; muscular strength can be impaired with things like muscular atrophy, spasticity, nutritional deficits, paresis, flaccidity and other causes; and joint mobility can be impaired disuse, arthritis and other disorders of the bone. Hip Fracture Nursing Care Plan 13.3 Applying the Nursing Process Nursing Fundamentals For example, a client who has had limited mobility for several years may have a joint that can only be moved a few inches, but it is important to maintain that mobility, no matter how small.