Musculoskeletal - Immobility, Fall Prevention, Rhabdomyolysis, Compartment Syndrome

Immobility - NEGATIVE OUTCOMES

• physiological changes: increased HR, decreased vital capacity, atelectasis, pneumonia, muscular weakness, urinary retention, constipation, pain

• pressure injuries

• sleep deprivation

• delirium

• prolonged ventilator days, ICU stay, and/or hospital stay

Immobility - CONTRAINDICATIONS for MOBILITY PROGRESSION (Hint: MOVE)

• M (myocardial instability) - chest pain, ischemia, arrhythmia requiring antiarrhythmic in the past 24 hours

• O (oxygenation issues) - pulse oximetry <90%, respiratory rate <10 breaths/min or >35 breaths/min, extreme fatigue/dyspnea (IF RECEIVING MECHANICAL VENTILATION, FiO2 60% or greater and/or PEEP >10 cm H2O)

• V (vasopressor) - increase in dose needed in the past 2 hours or the patient has 2 or more vasopressors infusing

• E (engagement issues) - patient does not respond to verbal stimulation or follow commands

Strategies to Address the Challenges of Early Progressive Mobility for Acutely ILL

• develop/utilize nurse-driven protocol for the progression of patient mobility

• minimize sedation

• provide effective, safe patient handling equipment

• maintain safety of lines and tubes

• schedule and coordinate mobilization with interdisciplinary team; that MUST be a team effort with the physician and nursing leadership

• address any patient discomfort and explain rationale for and importance of moving to the patient and his/her family

• assess for hemodynamic stability

  • if patient is unstable, attempt position changes and/or continuous lateral rotation therapy and provide passive range of motion

• provide education on the rationale for mobility, the protocol involved, and the equipment used

• consult physical therapy team for more complex mobility changes

Fall Prevention - RISK FACTORS

• age >65 years

• history of a fall in the past year

• orthostatic hypotension

• impaired mobility or gait

• altered mental status

• incontinence

• need for assistive devices

• medications, especially those that were recently ordered (such as benzodiazepines, diuretics, antihypertensives)

• medical devices that limit mobility (such as urinary catheters, monitor leads, IV lines)

• restraints

Fall Prevention - STRATEGIES

• routinely assess patient’s risk for falls using a validated fall risk assessment tool (such as Morse Fall Scale)

• communicate patient’s fall risk status (document in patient’s medical record, in signage, on the patient’s wristband, on whiteboards, and verbally) to all members of the healthcare team

• provide ongoing education about the patient’s high-risk status and the rationale for fall prevention strategies to the patient and his or her family

• adhere to hospital procedures and protocols regarding the assessments, interventions, and documentation related to fall risk factors and the utilization of preventative measures

• provide orientations and ongoing staff education

• ensure adequate staffing

• assess physical environment for safety issues and orient the patient to the environment

• accompany patient during mobilization in and out of bed and to the commode

• study and learn from past patient falls; perform a root cause analysis of each fall

• ensure that unit managers are engaged in and communicate about fall prevention in each hospital unit

Rhabdomyolysis - what is it? etiologies? Patho?

• potentially life-threatening syndrome due to the massive destruction of skeletal muscle cells

• ETIOLOGIES: crush injuries, prolonged immobility, compartment syndrome, hyperthermia, delirium tremens (DTs)

• PATHO: massive muscle injury results in the release of myoglobin, creatine kinase (CK), and potassium into the extracellular and intravascular spaces, with kidney injury occurring when the CK and myoglobin obstruct the renal tubules

Rhabdomyolysis - signs/symptoms

• dark, tea-colored urine

• low urine output

• urine dipstick positive for hemoglobin, but a urinalysis is negative for RBCs

• myoglobin in urine

• elevated CK > 10,000 U/L

• muscle cramping

• arrhythmias

Rhabdomyolysis - TREATMENT

• administer fluids (0.9 NS) to maintain a urine flow of about 300 mL/hour; it may be necessary to infuse up to 500 mL/hr to maintain a urine output of 300 mL/hr

• initiate a sodium bicarbonate infusion to alkalinize the urine

• administer mannitol

• monitor for/treat HYPERKALEMIA

• therapy should continue until the urine is cleared of any myoglobin

Compartment Syndrome - what is it? causes?

• the development of elevated pressure within the muscle fascia, which may lead to decreased blood flow, resulting in damage to the muscle tissue and nerves within the compartment

  • CAUSES: a crush injury to or surgery on a limb, a fracture, severe muscle hematoma or sprain, a constricting cast or bandage, and/or prolonged tourniquet or positioning during surgery that leads to a loss of blood supply to a limb

Compartment Syndrome - SIGNS/SYMPTOMS?

• pain (worse than expected based on an assessment of the injury), numbness, a loss of movement, a firm, “wooden” feeling upon palpation, and/or elevated intracompartmental pressure

  • loss of pulse and/or the development of pallor are not reliable clinical signs of compartment syndrome; they may occur late (after permanent damage has already been done)

Compartment Syndrome - MANAGEMENT

• measure the intracompartmental pressure as soon as compartment syndrome is suspected and continue to monitor the intracompartmental pressure as indicated

  • a normal compartment pressure = 0-8 mmHg

  • a compartment pressure > 30 mmHg = compartment syndrome; if that is the case, EMERGENT DECOMPRESSIVE FASCIOTOMY is indicated to prevent permanent nerve and/or vascular injuries

• maintain level of the affected limb AT THE LEVEL OF THE HEART (do NOT ELEVATED the limb higher than the level of the heart because elevation decreases arterial blood flow to the tissues)

• remove any bandages or casts

• provide pain control with opioids or NSAIDs

• approximately 3 hours after decompression procedures, monitor for postischemic tissue swelling due to altered capillary permeability (mannitol may be considered)

• monitor for the development of rhabdomyolysis