Moving and Positioning - Chapter 16 Notes (Nursing Fundamentals)

Effects of Immobility

  • Immobility occurs as a result of a lack of activity and movement, often due to illness, injury, or medical restrictions.
  • When movement is restricted, body systems immediately react.
  • Physicians rarely prescribe strict bedrest due to the numerous complications.

Complications of Immobility

  • Blood clots: A gel-like mass formed by platelets and fibrin in the blood, which can obstruct blood flow.
  • Pneumonia: Inflammation of the lung, often caused by infection, particularly hypostatic pneumonia (see Respiratory System).
  • Bone demineralization: Loss of bone density and calcium, making bones weaker and more prone to fractures.
  • Kidney stones: Hard deposits made of minerals and salts that form inside the kidneys.
  • Constipation: Infrequent or difficult bowel movements, often due to slowed peristalsis.
  • Pressure injuries (also known as decubitus ulcers or bedsores): Localized damage to the skin and underlying soft tissue, usually over a bony prominence, resulting from sustained pressure.
  • Urinary retention: The inability to completely empty the bladder.
  • Depression: A mood disorder causing a persistent feeling of sadness and loss of interest, often seen in prolonged immobility.

Effects on Musculoskeletal System

  • Muscle atrophy: Wasting or decrease in size of muscle tissue due to disuse.
  • Decreased joint flexibility.
  • Decreased range of motion (ROM).
  • Contractures: Permanent shortening of muscle or connective tissue, leading to deformity and rigidity of joints.
  • Risk of osteoporosis: A condition in which bones become weak and brittle due to tissue loss, often resulting from hormonal changes or deficiency of calcium or vitamin D.

Nursing Measurements to Prevent Musculoskeletal Complications

  • Maintain proper body alignment:
    • Keep the head, trunk, and hips positioned in a straight line.
    • The legs should be positioned so that the toes always point in the same direction as the anterior or ventral side of the body.
  • Trochanter rolls: Long, rolled towels or blankets placed beside the hips to prevent external rotation of the hips and legs.
  • Use range-of-motion (ROM) exercises: A series of activities designed to move each joint through all of its natural actions to decrease the incidence of muscle atrophy and contractures.

Effects on Cardiovascular System

  • Venous stasis: Pooling of blood in the leg veins due to decreased muscle contraction and gravity, increasing the risk of clot formation.
  • Blood clot (Deep Vein Thrombosis, DVT): A blood clot that forms in a deep vein, most commonly in the legs.
  • Embolus (Pulmonary embolus, PE): A blood clot or other foreign material that travels through the bloodstream and lodges in a blood vessel, often in the lungs (pulmonary embolus).
  • Myocardial infarction (MI): Commonly known as a heart attack, it occurs when blood flow to a part of the heart is blocked, causing heart muscle damage.
  • Cerebrovascular accident (CVA): Commonly known as a stroke, it occurs when blood flow to a part of the brain is interrupted, causing brain cell damage.
  • Orthostatic hypotension: A sudden drop in blood pressure when standing up from a sitting or lying position.
  • Syncope: Temporary loss of consciousness or fainting, usually due to a sudden drop in blood flow to the brain.

Nursing Measures to Prevent Cardiovascular Complications

  • Encourage movements of the extremities.
  • Apply ordered devices to prevent pooling of blood in the legs (e.g., sequential compression devices, elastic stockings).
  • Encourage movement of the extremities, especially dorsiflexion and plantar flexion of the feet (foot pumps).
  • Change the patient’s position frequently.
  • Change the patient’s position from horizontal to vertical gradually.
  • Remain with the patient the first few times he or she gets out of bed.

Effects on the Respiratory System

  • Respiratory muscle weakness.
  • Pulmonary emboli (see Cardiovascular System).
  • Hypostatic pneumonia (Healthcare-Associated Infections, HAIs): Inflammation of the lung lobes from fluid accumulation due to immobility and lack of deep breathing.
  • Atelectasis: Partial or complete collapse of a lung or a section (lobe) of a lung.
  • Hypoxemia: An abnormally low concentration of oxygen in the blood.

Nursing Measures to Prevent Respiratory Complications

  • Turn the patient from side to side at least every 2 hours.
  • Elevate the head of the bed 45 degrees or more (Fowler's or Semi-Fowler's position).
  • Encourage cough and deep breathing exercises every hour.
  • Encourage the patient to use an incentive spirometer.

Effects on Gastrointestinal System

  • Decreased appetite.
  • Lack of peristalsis: The wave-like muscular contractions that move food through the digestive tract, leading to slowed digestion.
  • Constipation: Difficult or infrequent bowel movements.
  • Flatulence: Accumulation of gas in the gastrointestinal tract, leading to discomfort.
  • Distention: Swelling or bloating of the abdomen due to trapped gas or stool.
  • Indigestion.

Nursing Measures to Prevent Gastrointestinal Complications

  • Ensure that the patient repositions at least every 2 hours.
  • Early ambulation (walking).
  • Inquire about the patient’s food likes and dislikes.
  • Help the patient select well-balanced, nutritious meals from the menu.
  • Encourage the patient to choose foods with fiber.
  • Provide a laxative or stool softener as needed.

Effects on Urinary System

  • Urinary tract infection (UTI): An infection in any part of the urinary system (kidneys, ureters, bladder, and urethra).
  • At risk for kidney stones: Hardened mineral and salt deposits that form in the kidneys.
  • Urinary retention: Inability to fully empty the bladder.

Nursing Measures to Prevent Urinary Complications

  • Provide adequate fluid intake to prevent concentrated urine.
  • Assist the patient to urinate in a sitting position.
  • Assess the patient’s output.

Effects on Integumentary System

  • Pressure injury (AKA decubitus, or skin breakdown): Localized damage to the skin and underlying soft tissue, usually over a bony prominence, resulting from sustained pressure.
  • Shearing: Skin layers slide over each other, causing blood vessels to stretch and break.
  • Friction: Rubbing of skin surfaces together, which can cause abrasions or open areas.

Nursing Measures to Prevent Integumentary Complications

  • Provide adequate nutrition.
  • Reposition patients in bed at least every 2 hours.
  • Inspect bony prominences for redness at least every 2 hours.
  • Use mild soaps for cleansing the skin.
  • Provide an appropriate surface for the patient (e.g., pressure-reducing mattress).
  • Apply lotions and ointments to the skin to keep hydrated and protect the skin.

Effects on Nervous System

  • Compression neuropathy: Nerve damage resulting from sustained pressure on a nerve, leading to impaired sensation or motor function.
  • Impaired neuropathy.
  • Plantar flexion (foot drop): A condition characterized by the inability to lift the front part of the foot due to weakness or paralysis of the muscles involved in dorsiflexion.

Nursing Measures to Prevent Nervous System Complications

  • Ask specific questions related to person, place, and time to assess orientation.
  • Use a foot splint or high-topped tennis shoes to prevent foot drop.
  • Perform neurological checks regularly.
  • Provide clues to the correct date and time.
  • Gently reorient him or her by supplying the correct information.

Devices for Lifting and Moving Patients

  • Logroll: A technique used to turn a patient without flexing or extending the spinal column, used for spinal surgery or injury.
  • Transfer belts: Devices worn by patients to provide a secure grip for caregivers aiding in transfers.
  • Slide sheets: Low-friction sheets used to facilitate patient movement and reduce shearing.
  • Slide boards: Rigid devices used to bridge gaps during transfers, allowing patients to slide across.
  • Sit-to-stand lifts.
  • Lifts.
  • Manual transfers.

Assisting With Ambulation

  • Fowler’s position: A standard patient position in which the patient is placed in a semi-upright sitting position.
  • Semi-Fowler’s position: Similar to Fowler's, but with the head of the bed elevated 30-45 degrees.
  • Transfer techniques: Methods used to safely move a patient from one surface to another.
  • Body mechanics: The use of the body in an efficient and careful way to prevent injury to oneself and others.
  • Transfer devices.

Clicker Question

  • When a patient has undergone spinal surgery or has a spinal injury, it is necessary to turn his or her body as one unit. This procedure is known as the
    • Transfer
    • Lift
    • Logroll
    • Trochanter roll

Answer 2

  • Correct Answer: C. Logroll
    • This procedure is known as a logroll because the patient is turned in the same way a log would be rolled.

Effects on Psychological State

  • Depression.
  • Anxiety.
  • Hostility.
  • Fear.
  • Sensory deprivation.
  • Difficulty sleeping.

Nursing Measures to Prevent Psychological Complications

  • Ensure that the patient has distractions (e.g., books, TV, music).
  • Try to involve his or her senses with pleasant smells, tastes, sounds, and sights.
  • Encourage him or her to remain awake and alert most of the day.
  • Allow the patient to do as much as possible for himself or herself.
  • Encourage visits with family and friends.

Review Question: Venous Stasis

  • Venous stasis is an example of which type of immobility complication?
    • Musculoskeletal
    • Cardiovascular
    • Respiratory
    • Gastrointestinal

Answer

  • B. Cardiovascular
    • Bedrest results in a 50% reduction of blood flow to the legs and contributes to venous stasis, or pooling of blood in the veins of the lower legs.

Other Note: Quantitative Detail

  • Bedrest
    ightarrow BF{legs}^{bedrest} = 0.5 imes BF{legs}^{normal}
  • This illustrates the 50% reduction in leg blood flow during bedrest