An incentive spirometer consists of a plastic chamber with a ball, a mouthpiece and tubing. Some wounds and wound drainage have odors and others do not. See Figure 9.6[7] for an image of locating the heel marker. They should be applied upon awakening because edema is usually at its lowest point after lying in bed overnight. [10], For bed-bound patients, elevate the head of the bed to 30 to 45 degrees, unless medically contraindicated, and turn and reposition the patient every two hours. Routine exercising and mobilization also enhance the client's circulatory function in addition to preventing complications of immobility such as muscular weakness and venous stasis. Preventive measures and the treatments of these skin integrity disorders will be discussed below in the section entitled "Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown". This technique entails the placing a cupped hand over the lung areas and doing gentle tapping on the area for about one minute while the client is hyper inflating their lungs and holding the breath as long as possible. The rules of treatment for these three colors are: Surgical debridement using a laser is perhaps the fastest of all methods of debridement and it is the method that is least likely to damage the healthy tissue surrounding the necrotic area. It is an essential part of living. For example, hip abduction is the movement of the leg away from the midline of the body. Assess the respiratory system, including respiratory rate, oxygen saturation, lung sounds, chest wall movement and symmetry, and depth and effort of respirations. Constipation, impaction and difficult to evacuate feces can occur as the result of immobility and the lack of exercise that is needed to promote normal bowel functioning. The externally placed skin traction must be applied firmly but without any potentially damaging pressure and in a smooth manner without any creases. These efforts are even more intense and comprehensive when the client has one or more risk factors associated with impaired skin integrity, as discussed previously in this section. (2018). Chapter 8: Body Mechanics and Patient Mobility Flashcards Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered mood, and depression. As previously discussed skin integrity can be maintained and skin breakdown can be prevented with a number of different interventions such as turning and repositioning the client at least every two hours, special pressure relieving mattresses, and the avoidance of all pressure, friction and shearing. The margins around the wound are also assessed and described in terms of their color, their characteristics and their texture which can be classified and documented as macerated, edematous, swollen, indurated or normal. A staff member may provide verbal cues to complete the action, but the movement is done independently by the client. Prevention Complications of Immobility Promote adequate elimination Hydration Toilet/Bedside These stockings are gently and smoothly pulled over the client's legs without any wrinkles or uneven pressure. Some commonly used braces are neck braces, back braces, and elbow braces. When the pulling traction force is greater than the counter traction force of the client's body, the client will slide to the source of the traction. An example of primary intention healing is the suturing of an abdominal surgical wound after an appendectomy or the suturing of a traumatic laceration with Steri Strips or sutures when this traumatic wound is free of any contamination and infection. Lastly, skin traction applies the traction force to the skin overlying the affected bone. Ask the patient about the date of their last bowel movement, and monitor stool patterns and stool characteristics. When someone is recovering from a severe illness or injury, their mobility is often reduced, and they may be unable to perform ADLs. Encourage the patient to perform activities of daily living (ADLs) as independently as possible and participate in prescribed physical therapy. When assisting a client with ROM activities, the nursing assistant must follow the plan of care established by the licensed therapist. Report completion of the activity to the nurse who documents frequency and effectiveness of this intervention.[5]. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Associations task force on competency and education for the nursing team members. Monitor for signs of vertigo and orthostatic hypotension and assist the patient to a sitting or lying position if they occur. These hazards of immobility can be prevented with range of motion exercises and in bed exercises such as isotonic, isometric and isokinetic muscular exercises. Range of motion exercises can be active, active assisted and passive. The plan is tailored to the needs of the individual and will include the specific joints to move. Extension occurs when the arm is straightened back to starting position, increasing the angle between the elbow joint. Manual traction, which is applied with the hands, is done to properly align a bone after a fracture so that a cast can be applied to the bone while it is in correct anatomical alignment. Adduction refers to moving a limb towards the midline. Some of these preventive techniques include: The Braden Scale for Predicting Pressure Ulcers and the Norton Pressure Ulcer Scale are two of the most popular standardized screening tools that are used to screen and assess clients in order to determine if they are at risk for skin breakdown. People must be able to move to protect themselves from trauma and to meet their basic needs. Inspiratory muscle training techniques entail instructing the client to lie in a comfortable supine position, torelax, and then to take deep breaths with a mouth piece with an increasingly smaller lumen so that the clienthas to progressively take deeper and deeper breaths using their diaphragm while overcoming the resistance of the obstructive mouth piece. Simply defined, full range of motion is defined as the maximum movement of a joint specific to that joint. ROM exercises facilitate movement of specific joints and promote mobility of the extremities. Accessibility StatementFor more information contact us atinfo@libretexts.org. Affected skin areas can be assessed and described as macerated, edematous, swollen, indurated or normal. For example, serous drainage is clear or a slight yellowish color because it consists of serum which is the clear portion of the blood; sanguineous drainage is bloody and red because it consists of red blood cells; serosanguinous drainage is pinkish in color because it is a combination of serum and red blood cells; and purulent drainage can be yellow, green, rust color or brown and this drainage indicates the presence of infection and thick pus. These hazards of immobility can be prevented with range of motion exercises and in bed exercises such as isotonic, isometric and isokinetic muscular exercises. Passive range of motion is movement applied to an individuals joint by another person or by a passive motion machine. This process is referred to as autolysis. [3], There are several nursing diagnoses related to mobility. The length and width of all areas are measured and the depth of wounds is also measured. The correct application of antiembolism stockings entails the application of these stockings while the client is lying in bed and before rising. Compartment syndrome is a medical emergency which, left untreated, can lead to the loss of the affected limb. Members of the nursing care team and other health care professionals like physical therapists must, therefore, promote client mobility and prevent immobility whenever possible. The LibreTexts libraries arePowered by NICE CXone Expertand are supported by the Department of Education Open Textbook Pilot Project, the UC Davis Office of the Provost, the UC Davis Library, the California State University Affordable Learning Solutions Program, and Merlot. Traction is used for the external fixation of a fracture, it is used to maintain anatomically correct alignment, it is used to reduce pain and it is used to decrease muscle spasms. WebActive and passive range of motion (ROM) exercises prevent complications of immobility in the musculoskeletal system. (OpenRN) via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request. Several terms are used to refer to certain body movements during range of motion exercises, such as abduction, adduction, flexion, and extension. Traction, when ordered, should be continuous and not interrupted. See Figure 9.7[8] for a demonstration of these techniques. Health care team members play a vital role in preventing the physical and mental decline in functioning that can occur from immobility by proactively implementing interventions. 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. Ways that the client can assist with position changes. Nursing Interventions for Impaired Physical Mobility. Intervention of this condition includes prevention of dependent disabilities, restoring mobility when possible, as well as maintaining or preserving the existing mobility. Special patient care includes changing position, exercises, nutrition and giving a safe environment, etc. WebNursing interventions While many interventions depend on the underlying cause of the patients immobility, the nursing interventions in this article will focus on aspects of Do not send them to the laundry or put them on a heater to dry because this can cause shrinking and ruin the hose. When removed at night, the compression stockings should be washed by hand in the sink with soap and water and then hung to air dry. In fact, percussion is most often done in combination with postural drainage. The client should attempt to hold their breath for as long as possible (at least five seconds) and then exhale and rest for a few seconds. Some casts are solid and others are what are referred to as a bivalve cast which has two pieces. For example, use the Banner Mobility Assessment Tool to determine the patients current mobility status and needs for safe patient handling. A joint should never be forced to achieve full ROM if there is resistance. Compression stockings require a physicians order and should be applied in the morning and taken off at night. This technique entails the positioning of the client in different positions so that all areas of the lungs and airways are able to be drained of respiratory secretions using the force of gravity. Some of these intrinsic factors include the client's urinary and/or fecal incontinence, poor nutritional and fluid intake, diabetes, hyperthermia, hypothermia, hypotension, a decreased cardiac output, obesity, an altered sensory perception, some medications, an alteration in terms of the client's perfusion and peripheral circulation, some of the normal changes of the aging process, cachexia and emaciation, an alteration in terms of the client's metabolic status, and the client's body build as well as the size of their boney prominences. Some of the disadvantages of mechanical debridement include the fact that it nonselective and, as such can damage healthy tissue, it can cause pain, it is more subject to an infection than other forms of debridement, and it is more time consuming on the part of the person performing this procedure, when compared to other methods of debridement. One of its disadvantages, when compared to some other method of debridement, is the need to anesthetize the client which, in itself, has some risks. For example, an area of skin breakdown can be described as on the posterior of the arm just inferior to the elbow or over the sacrum and coccyx. After the heel of the stocking is placed properly on the clients heel, check that the hose is not twisted. Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, Planning Interventions. 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. At the current time, automatic sequential compression devices are used in health care facilities and they have virtually replaced the use of compression hose; however, compression stockings continue to be used in other areas including the client's home, for example. Casts must be applied in a smooth manner and they should also be allowed to dry without any external pressure applied to them. Fiberglass casts are lighter in terms of weight than plaster casts; and bivalve casts, unlike solid casts, permit some swelling after the traumatic fracture and, as such, prevent compartment syndrome, a complication associated with casting. Automatic sequential compression devices can have sleeves to accommodate for pressure on the legs as well as the foot. Fractures are treated to prevent deformity. Some nursing diagnoses related to immobility can include: Mobility is defined as the "ability to move freely, easily, rhythmically, and purposefully in the environment. For example, if a person has their fingers spread wide apart, bringing them back together is adduction. To avoid or minimize complications of immobility, See Figure 9.4[4] for an image of a client using an incentive spirometer. Percussion is also performed by the nurse or the certified respiratory therapist. 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. Pressure ulcers are costly both in terms of health care costs and the human costs that the client suffers as the result of a pressure ulcer including, but not limited to, pain, sepsis, cellulitis, and osteomyelitis. The RYB Color Code of Wounds is sometimes used by nurses to guide the treatment options. Topical antibiotics that are often used to treat wounds, as based on the identified offending microorganism, include, among others: Nursing care consists of all of the phases of the nursing process including assessment, nursing diagnosis, planning implementation and evaluation. Some of the advantages associated with chemical debridement include its relatively rapid, action and its ability to be selective and not damage healthy surrounding tissue. 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. Refer to the Objective and Subjective Signs of Pain subsection in Chapter 6.3 to review observations to make and report. These bowel alterations are further confounded when the client is not getting adequate fluid intake. For example, clients who undergo knee replacement surgery may be prescribed a passive range of motion machine that continuously flexes and extends the patients knee while they are lying in bed. Braces are applied to various parts of the body to provide support and alignment of the part. Postural drainage is done by the nurse or the certified respiratory therapist. Deep-vein thrombosis (DVT) is a common complication for clients experiencing immobility. The nurse or respiratory therapist initially teaches the client how to use the incentive spirometer but encouraging and observing clients complete this action every hour is commonly delegated to a nursing assistant. Encourage or perform active or passive range of motion exercises as prescribed by the physical therapist. This page titled 13.3: Applying the Nursing Process is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Ernstmeyer & Christman (Eds.) The skin underneath skin traction must be inspected on a regular and ongoing basis to prevent some of the possible complications associated with this type of traction including blistering, skin breakdown, compartment syndrome, circulatory impairment, neurological impairment, and areas of necrosis. Promote excellence in nursing by enabling future and current nurses with the education and employment resources they need to succeed. However, as the client sits or stands upright during the day, blood tends to pool in the lower legs. While providing ROM, the nursing assistant must observe for objective and subjective signs of pain. The amount of pressure the hose applies to the legs is prescribed. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). When mobilization and ambulation are impaired as the result of muscular weakness and/or impairments of their gait, balance and coordination, the client should be provided with rehabilitation and restorative care to facilitate this mobilization and ambulation. We also acknowledge previous National Science Foundation support under grant numbers 1246120, 1525057, and 1413739. Active assist range of motion is joint movement by an individual with partial assistance from an outside force. Underlying bed tissue reflects the extent to which the wound is healing, regenerating and renewing. These devices are ordered by the doctor in terms of millimeters of mercury that they will apply to the lower extremities.