Fun - Mobility and Immobility

Mobility

ability to move about freely

Mobility refers to adapting to and having self-awareness of the environment.

Functional musculoskeletal and nervous systems are essential for mobility

Immobility

inability to move freely and independently at will

The risk of complications increases with the degree of immobility and the length of time or immobilization. 

Periods of immobility or prolonged bed rest can cause MAJOR physiological and psychosocial effects.

Mobility vs Immobility

Mobility can be seen as a continuum

Patients can move back and forth on continuum

For some…immobility continues indefinitely!

IMMOBILITY CAN BE….

• Temporary: Following a knee arthroplasty

• Permanent: Paraplegic

• Sudden Onset: Fractured leg, Laboring mother

• Slow Onset: Multiple Sclerosis

• KNOW THESE AND DRAW OUT PATIENT EXAMPLES!!!!

VENOUS RETURN

Promoting venous return to the heart is a key component in reducing

complications of immobility

Antiembolic stockings (TED hose)

SCDs

Positioning

ROM exercises

SEQUENTIAL COMPRESSION DEVICES

-Apply the sleeves

to the client’s lower

legs

-Attach the sleeves

to the inflator

-Turn on the device

-Monitor circulation

and skin

-Remove Q 8 hours

for assessment of

calves

ANTIEMBOLIC STOCKINGS

can go under SCD

Not commonly used

like compression socks

IMMOBILITY EFFECTS

EVERY SYSTEM IN THE BODY

A S S E S S M E N T

always start with assessment

assessment starts when walk into room

IMMOBILITY IMPACT ON

NEUROLOGICAL AND

PSYCHOSOCIAL SYSTEMS

• Causes

– Altered sensory perception

– Ineffective coping

– Depression/Anxiety

– Changes in self-concept

– Withdrawal

– Altered sleep/wake cycle

– Hostility

– Inappropriate laugher

– Passivity

Nursing diagnosis: Ineffective coping

ASSESS: INTEGUMENTARY

Goal

Assess

 Goal: Maintain intact skin!

• Assess:

– Skin breakdown, color, warmth

– Assess for pallor, redness (light skin clients) and assess for purple or blue (dark skin clients)

– Check bony prominences (elbows, knees, heels)

– Skin turgor

– Assess Q2 hours

– Urinary or bowel incontinence: NO DIAPERS!!!!

– Utilize pressure injury risk scale (Norton or Braden)

IMMOBILITY IMPACT ON INTEGUMENTARY SYSTEM

 Increased pressure on the skin

• Cause decreased circulation to the tissue → ischemia → pressure injury

Nursing Diagnosis: Risk for impaired skin integrity

Pressure sores areas

back of head and ears

shoulder

elbow

lower back and buttocks

Hips

inner knee

heel

NURSING CARE FOR INTEGUMENTARY

SYSTEM

• Identify high risk clients for pressure injury development quickly!

• Position using pillows, foot boots, trochanter rolls, splints, wedges (Think CPL)

• Turn Q2 hours (MD order and/or hospital protocol)

• Limit sitting in a chair to 1 hour

• Encourage patient to shift their weight Q15 minutes while sitting

• Use a therapeutic bed or mattress

• Monitor nutritional intake (check albumin)

• Provide skin and perineal car

ASSESS: RESPIRATORY

GOAL

ASSESS

QUESTIONS

 Goal: Maintain airway patency, achieve optimal lung expansion and gas

exchange, and mobilize airway secretions

• THINK ABCs!

• Assess:

– Chest wall movement (equal? Unequal?)

– Auscultate lungs at least Q2H (diminished breath sounds, crackles,

wheezes?) *remember ABCs!

• Diminished breath sounds: atelectasis

• Adventitious breath sounds: pneumonia or other lung disease

– Watch for productive cough and note the color, amount, and

consistency of secretions

– Respiratory rate?

– Oxygen saturation?

– Supplemental oxygen?

– Cyanosis?

– Work of breathing?

IMMOBILITY IMPACT ON RESPIRATORY

SYSTEM

 Causes decreased respiratory movement → decreased oxygenation and gas

exchange

• Causes stasis of respiratory secretions → pneumonia (adventitious breath sounds)

• Causes decreased and weakened respiratory muscles → atelectasis (decreased breath sounds)

• Decreased cough response

Nursing Diagnosis: Ineffective airway clearance or Impaired Gas Exchange

NURSING CARE FOR RESPIRATORY

SYSTEM

• Reposition the patient Q2 hours or per protocol

• Chest physiotherapy

• Auscultate lungs often and after treatments

• Monitor patient’s ability to expectorate secretions

• Use suction if needed

• Cough, and deep breath Q 1-2 hours

• Turn Q2 hours

• Incentive spirometer

• 2,000 mL of fluid a day (unless restricted)

assess → intervene → reassess

PULMONARY EMBOLISM

 LIFE-THREATENING occlusion of blood flow to one or more of the pulmonary arteries

by a clot

• Clot originates in the venous system of lower extremities

• Looks like: SOB, chest pain, anxiety, hemoptysis*, decreased BP, rapid HR

• Notify MD immediately

• Position patient in high-fowlers  improve oxygenation and respirations

• Obtain O2 saturation and all VS

• Administer O2

• Prepare to obtain ABGs and to give thrombolytics or anticoagulants

AS A NURSE…

We should promote physical activity and exercise for our patients in a safe manner

• Encourage patients to perform ADLs (activities of daily living)

– Dressing, Eating, Hygiene (brushing teeth & hair), etc.

• Physical Activity: “any movement produced by the skeletal muscles that results in

energy expenditure”

– Physical Therapy

– Ambulation

– ADLs

– Transferring and positioning

FACTORS THAT AFFECT MOBILITY

Alterations in the muscles (atrophy)

• Injury to muscles (tear)

• Poor posture

• Impaired CNS (blunt trauma to head, stroke, etc.)

• Health status (weight, presence of disease)

• Age

NURSING CARE

FOR

NEUROLOGICAL

AND

PSYCHOSOCIAL

SYSTEMS

Assist in coping skills

Maintain orientation (time, calendar)

Develop a schedule

Involve clients in care

Provide stimuli (books, TV, etc.)

Maintain body image

Improve socialization

Consult for counseling

Test Q: who is at highest risk of negative effects of immobility

look at who can not do any movement for themselves

If she asks a question like pt complains of right calf pain has SCD first do

first do assessment NOT call provider

if remove SCD and see clot u can

u can call provider cuz have done assessment

looked at legs condition under device, skin breakdown, swelling, temp (hot/cold), pain, pulse