Immobility & Body Mechanics

Refers to the ability to engage in activity and free movement, which includes walking, running, sitting, standing, lifting, pushing, pulling and performing ADLs (Activities of Daily Living)

Is a therapeutic intervention that achieves:Rest for clients who are exhaustedDecreases bodys O2 consumptionReduces pain and discomfortTo reverse effects of gravity-abdominal herniaAfter 48 hr of bed rest-structural changes in joints and shorten muscles occur7 days are needed to restore function lost after 1 day of bed rest (Eliopoulos, 1999)

Metabolic: decrease in BMR r/t decreased energy requirements, which is directly r/t cellular 02 demandsResults in > % body fat & loss of lean body massAltered carbohydrates ,proteins, fats metabolismFluid and electrolyte imbalances

Orthostatic hypotension due to prolonged bed rest. Drop of 15 mm Hg or more in systolic BP with position changeDecrease circulating volume, pooling of blood in lower extremities(edema), decreased autonomic response results in decrease in venous return, central venous pressure, stroke volume, increase in HR=>>>cardiac workload,02 demandDue to stasis >>> risk thrombus formation

Increase activity slowly but progressivelyAvoid crossing legs, pressure behind kneeEncourage antiembolic leg exercises q 2 hours, other isometric exercisesAnt embolic hoseGradually raise client noting BP, HR, assess dizziness/lightheadedness

Decrease in lung expansion, generalized respiratory muscle weakness, and stasis of secretionsDecreased hemoglobin levelsAtelectasis --collapse of alveoli resulting in decrease of 02 / C02 exchange

Hypostatic pneumonia inflammation of the lung from stasis or pooling of secretions

Change of position q 1 2 hr which allows elastic recoil property of lungs and clears dependent lung secretions

Cough and deep breath q 2 hr, incentive spirometry, chest physiotherapy

Fluids to 3000 ml / 24 h to thin secretions

Decrease in appetite, peristalsis, constipation

NI: high fiber foods, fluids to 3000 ml/24hrSmall frequent foods of choiceMonitor bowel sounds q shiftMonitor bowel patterns 24 hoursStool softeners daily as ordered

Muscle atrophyLoss of strength and decreased enduranceJoint contracturesDecreased stability or balanceDisuse osteoporosis, a disorder characterized by bone reabsorption-results from impaired calcium metabolism

Frequent ROM: active, passive, active assist q 4 hours

Develop an individualized progressive exercise program

Isometric and isotonic exercises q 4 hours

Urine formed by the kidney must enter the bladder against gravity due to recumbent positionUreters insufficient to overcome gravity, renal pelvis may fill with urine-urinary stasis which increases risk for UTI & renal calculiRenal calculi-calcium stones lodged in in renal pelvis and pass through ureters

Position change q 1-2 hoursPosition 30 degrees of higher to enhance gravitational forces required for normal urine flow through kidney, ureters, bladderI & O q 8 hoursFluids to 3000 ml 24 hoursRD for diet plan r/t calcium intake

Increase isolation, passive behavior, changes in sleep/wake cycles, stressors, sensory deprivation/overload

Decrease in self-identity, self-esteem, coping strategies

Anticipate changes-provide routine and informal socializationinteract with staff q 1-2 hoursPlace in room with othersEncourage family and friends to visit-spaceActivity and recreational consultSchedule nursing cares from 10pm-7am to minimize interruptions

Increase in dependenceRegression in development

NI: care should stimulate client mentally, focus on activities that promote cognitive awareness, allow client to make care decisions, allow to be as independent as condition permits

Previously called: a decubitus ulcerA pressure soreA pressure ulcerA bedsore is a wound caused by unrelieved pressure that damages underlying tissueJury still out: caused by external pressure transmitted inward or from the bone and proceeds outward

Pressure ulcers is a wound caused by unrelieved pressure that damages underlying tissue. The pressure interferes with the tissue blood supply, leading to vascular compromise, tissue anoxia, and cell deathTend to be located over bony prominences: *elbows, posterior calf, *sacrum/coccyx ischial tuberosities, trochanter, lateral malleous, *heel, lateral edge of foot also: ears, occiput, great toe region

AHCPR: Agency for Health Care Policy and Research establish guidelines to identify at-risk individuals needing prevention and the specific factors placing them at risk

Risk assessment tool: Braden Scale or Norton Scale are most commonly used.

Assesses sensory perception: ability to respond meaningfully to pressure-related discomfortMoisture: degree to which skin is exposed to moistureActivity: degree of physical activityMobility: ability to change and control body positionNutrition: usual intake pattern

Friction and Shear:Each category measured from 1-4 with low score having most limitationOverall score: Maximum of 23, little or no risk A score of 16 or < indicates at risk A score of 9 or < indicates high riskImplement preventive measures for at risk and high risk clients

Tissue ischemia is localized absence of blood or major reduction of resulting in mechanical obstruction. The reduction of blood floe caused blanching (to become pale-blotchy)When obstruction of blood flow is removed normally there will be reactive hyperemia, the blood vessels dilate and skin is redWill last for less than 1 hr and is effective

only if there is no necrosis of tissue

Abnormal reactive hyperemia is an excessive vasodilatation and induration in response to pressure. Skin appears bright pink and there is localized edema under the skinmay last up to 2 weeks after pressure is removed

Shearing force: sliding down in bedFriction: linens on the bedMoisture: diaphoresis urine, wounds, fecesPoor nutrition: neg nitrogen balanceAnemia: < 02 carrying capacityObesity: poor vascular supply, weightAge: epidermis thins with age, < blood flowLOC: drowsy, sedated, comatose=1position

Non blanchable erythema of intact skin.Does not resolve in 30 minutes but remains for longer than 2 hours after pressure is relievedThis occurs as an acute inflammatory response involving the epidermis

There is partial thickness loss

Pressure area appears as an abrasion, blister, or shallow crater surrounded by erythema and induration

Ulcer involves full-thickness tissue destruction involving subcutaneous tissue, as well as epidermis and dermis

The muscle layer is in tact

Requires Wound Nurse consult, may require surgical intervention

Includes all of above changes, plus, extensive damage involving muscle, bone, or supporting structures such as tendons or joint capsule

Requires Wound Nurse consult and surgical intervention

Emphasis is on prevention !!!Autolysis: uses bodys own enzymes and moisture to re-hydrate, soften and liquefy necrotic tissueUse occlusive or semi-occlusive dressings: hydrocolloids, hydrogels, transparent filmsUsed with wounds with little drainage and uninfected

Very selective, with no damage to surrounding skinSafe, using the bodys own defense mechanisms to clean the wound of necrotic tissueEffective, versatile and easy to performLittle or no pain for the client

Not as rapid as surgical debridement

Wound must be monitored closely for signs of infection

May promote anaerobic growth if an occlusive hydrocolloidal is used

Chemical enzymes are fast acting products that produce slough of necrotic tissue. Some enzymatic debriders are selective, while some are not.Best uses: on any wound with a large amount of necrotic tissueEscar formation

Fast acting

Minimal or no damage to healthy tissue with proper application

ExpensiveRequires a prescriptionApplication must be performed carefully only to necrotic tissueMay require secondary dressingInflammation or discomfort may occur

Uses force to remove necrotic tissue, for example wet-to-dry, whirlpool treatment, or wound irrigation devices

Cost of the actual material is low

May traumatize healthy or healing tissueTime consumingCan be painfulHydrotherapy can cause tissue maceration and water borne pathogens may cause contamination or infectionDisinfecting additives may harm health tissues

Cutting dead tissue away from the woundConsidered the fastest and most effective type of debridementCan be done at bedside, surgical suite, or in an outpatient settingShould be considered when infection such as cellulitis or sepsis suspected

Wounds with a large amount of necrotic tissueUsed in conjunction with infected tissueFast and selectiveCant be extremely effective

PainfulCostly, esp if operating room is requiredRequires transport of client to OR

Maggot larvae placed in wound and ingests the microorganismsUsed extensively in Europe and is gaining popularity in the US

Develop and post a turning scheduleUse a pressure-reducing devicesAssess pressure points dailyAfter urinating or stooling cleanse, rinse, dryEstablish a bowel/bladder programbarrierMonitor intake and output q 8 hrUse trapeze and foot boardsProtect friction-prone areas

Proper diet: good protein intake, Vitamin C, supplements between meals if necessaryUse lift sheets, hoyer lift, smooth rollerPersonal hygiene measureskeep clean dry and linens wrinkle free. Avoid use of alkaline and deodorant soaps due to dryness. Use emollients to preserve natural state of skin moisture

Coordinated effort of the musculoskeletal system to maintain posture, balance, and body alignment during lifting, bending, etc.

Refers to the relationship of body parts to one another.

Reduces muscle strainMaintains muscle toneContributes to balanceContributes to system functioning

Directly related to alignment and achieved when:COG is lowStable (wide) base of supportVertical line from COG thru base of support

Imaginary vertical line which goes thru center of body

Point at which all of the mass of an object is centered; in the adult, who is in a standing position it is in the pelvis;

Foundation of an objectTo stabilize: lower your center of gravity and broaden your base of support

Force exerted by gravity on the body.

Force that occurs in a direction to oppose movement.

Reduce surface area Passive object produces more frictionLift rather than pull object

Use wide base of supportKeep COG lowKeep line of gravity passing through base of supportFace direction of movement when possible

Roll, pull, push objects rather than liftUse largest & strongest musclesKeep object close to COG Reduce area of contact

Move object on flat level, smooth surface

Bed: Deep breath, neck rolls, knees to chest, pelvic tilts, head raising, leg lifts, foot dorsi and planter flex, ankle rotations, rolling, arms over head, side to side, palms up and rotateChair: deep breathing, head rolls, knee to chest, head to knees, shoulder rolls, hands on head, leg lifts, ankle rotation, push down of legs, lean forward, lift up.Use Thera bands handball

Refers to the presence of a blood clot in one of the veinsRisks: prescribed bedrestGeneral anesthesia for clients > 40 years of ageLeg trauma resulting in immobilizationPrevious venous insufficiencyObesityOral contraceptivesMalignancy

Anti embolic hose: TED are effective in providing support to vasculature while client is in bed

Compression Hose: JOBST are effective in providing support to vasculature while client is ambulatoryALWAYS apply BEFORE client gets out of bed in the AM. Often removed at HS.`