Determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer ). 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. Coordination can be adversely affected with a neurological disorder of the cerebellum, cerebral cortex and basal ganglia; muscular strength can be impaired with things like muscular atrophy, spasticity, nutritional deficits, paresis, flaccidity and other causes; and joint mobility can be impaired disuse, arthritis and other disorders of the bone. The Applying Prosthetics and Orthotics section in Chapter 8 describes devices such as a foot split to prevent musculoskeletal contracture. After the wound is assessed and measured, the wound dimension is calculated by multiplying the length by the width by the depth of the wound. The three basic traction techniques can also be classified as manual traction, skeletal traction and skin traction. Encouraging activity as tolerated means involving the resident in movement while also adhering to mobility restrictions noted in the care plan and observing for respiratory changes that indicate the resident may be lacking endurance to maintain the activity. Some casts are solid and others are what are referred to as a bivalve cast which has two pieces. Vibration is highly similar to percussion except vibration is done by placing the palm of the hand on the lung area and doing rapid vibrating movements on the area while the client is positioned for postural drainage. 2023 Registered Nursing.org All Rights Reserved | About | Privacy | Terms | Contact Us. After they are applied, they should be regularly checked to insure that they remain in place and without any wrinkling and they should also be removed at least one time a day so that the nurse can inspect the skin underneath it and also to check the skin for its color and warmth which can, at times, indicate a circulatory impairment. These positions are supported and maintained with pillow, bolsters and wedges when necessary to maintain anatomically correct bodily alignment. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mmHg or more or in diastolic blood pressure of 10 mm Hg or more within three minutes of standing. Home / NCLEX-RN Exam / Mobility and Immobility: NCLEX-RN. Perform active range of motion to all joints two times a day, Safely transfer from the bed to the chair with assistance, Demonstrate proper deep breathing and coughing, Ambulate 30 feet three times a day with a walker and the assistance of another, Increase their level of exercise and physical activity, Demonstrate the proper use of their assistive device while ambulating, Maintain their skin integrity and not have any signs of skin breakdown, Maintain adequate respiratory functioning. Mobilization efforts, ranging from dangling on the edge of the bed, sitting up in a chair, and assisting with early ambulation, depend on the patients unique circumstances, such as their medical condition and surgery performed. 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. Coughing, deep breathing and the use of an incentive spirometer are described as hyperinflation exercises because, when done properly, these respiratory techniques hyper inflate the lung to facilitate the loosening and mobilization of respiratory secretions. The best way to maintain skin integrity and to prevent skin breakdown is to prevent them from occurring in the first place. Muscular strength is classified on a scale of zero to five, as below. The nurse should monitor these clients to insure that they are performing these active range of motion exercises in the correct manner and to the greatest possible extent of movement for all of the joints of the body. Balance and equilibrium can be impaired when the client is affected with a middle ear disorder that affects the vestibule and/or the semicircular canal of the ear's cochlea, poor posture, and a musculoskeletal or neurological disorder; muscular coordination is the ability of the person to smoothly and safely use gross motor and fine motor coordination. When a client experiences immobility, normally healthy alveoli can collapse and cause decreased lung function. Pressure ulcers are also referred to as stasis ulcers, trophic ulcers, and ischemic ulcers; they can result from the mechanic forces of pressure, friction and shearing, all of which can, and should, be prevented. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. The treatment plan includes the removal of the cast and, at times, a fasciotomy or epimysiotomy are indicated. If there is writing on the stocking, it should be on the outside and facing away from the skin when worn. An example of segmenting ADLs would be assisting a person to bathe in bed as independently as possible, letting them rest after bathing, and then returning later to assist them with dressing and grooming to get them ready for the day. Muscles are adversely affected with weakness and atrophy as the result of immobility. 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. 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. The joints are affected with stiffness, pain, impaired range of motion and contractures including foot drop which is a plantar flexion contracture. See Figure 9.8[9] for heel placement. 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. See Figure 9.4[4] for an image of a client using an incentive spirometer. Sometimes a clients lack of endurance in completing activities requires the nursing assistant to segment their ADLs. (n.d.). Assess for the presence of lower extremity edema and for signs of a potential deep vein thrombosis (DVT). These techniques will be discussed below immediately after this section. Some adverse respiratory system effects relating to immobility include the thickening of respiratory secretions, the pooling of respiratory secretions and an increased inability of the client to mobilize and expectorate these secretions, all of which can lead to atelectasis, hypostatic pneumonia, and respiratory tract infections. We also acknowledge previous National Science Foundation support under grant numbers 1246120, 1525057, and 1413739. 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. The bones lose calcium as a result of the lack of weight bearing activity and this can lead to disuse osteoporosis, hypercalcemia, and fractures. She got her bachelors of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. This blockage reduces blood flow to the affected area. The wound remains vulnerable to injury until full healing is completed with good tensile strength. Older adults are at increased risk for immobility. When working with school-age children, nurses provide education to prevent injury that can occur with activity, such as using helmets and knee pads to prevent injury while bicycling and skateboarding. Positioning and repositioning in correct bodily alignment enhances circulation, musculoskeletal integrity and skin integrity. 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. A depressed fracture occurs when bone fragments of the fractured bone is pushed in beyond the surrounding skin. If constipation is suspected, palpate the patients left lower quadrant for signs of stool presence. Skeletal traction is applied directly to an affected bone with a continuous traction force and with the use of a surgically inserted Steinman pin that is placed into the distal end of the affected bone. Compression stockings require a physicians order and should be applied in the morning and taken off at night. Balanced traction utilizes the weight of the client's bodily part, rather than externally placed weights, to exert the traction force to the body. For example, infants move their limbs, hold their head up, roll, sit, crawl, stand, and then eventually walk. Flexion is movement that decreases the angle between two bones and extension is movement that increases the angle between two bones. Postural drainage, percussion and vibration are often referred to as pulmonary hygiene measures and pulmonary physiotherapy measures. Like automatic sequential compression, compression stockings are fitted for the specific client after measuring the client's legs and checking the doctor's order for the amount of pressure that these stockings should exert on the client's leg. Automatic sequential compression devices consist of a pump, a one time single patient use sleeve, and hosing that connects the sleeve to the pump. Tertiary intention healing begins with several days of open wound irrigations and packing, which is secondary healing, followed by the closure of the wound edges with approximation and suturing which is primary healing. For example, the client is positioned prone and in a 45 degree Trendelenburg position to drain the posterior bronchus, a 45 degree Trendelenburg position to drain the posterior bronchus and on the left side to drain the lateral bronchus. Compression stockings promote the return of fluid back into circulation by gently providing pressure on veins. When assisting a client with ROM activities, the nursing assistant must follow the plan of care established by the licensed therapist. Lastly, skin traction applies the traction force to the skin overlying the affected bone. Enzymatic chemical debridement can be used on wounds with at least moderate amounts of necrosis and eschar, including pressure ulcers and burns. WebState the nursing interventions used to prevent complications of immobility. For example, if a person has their fingers spread wide apart, bringing them back together is adduction. Skeletal fractures are classified and described in several ways, many of which are not mutually exclusive. A joint should never be forced to achieve full ROM if there is resistance. (n.d.). 1. Make any adjustments before proceeding because the hose will be very difficult to adjust after it is pulled up the leg. 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 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. The muscles, joints and bones are adversely affected by immobility. Parents are educated about these developmental milestones during well-child visits. See Figure 9.1[1] for an image of a cone and palm protector, and Figure 9.2[2] for images showing application of these devices. When pressure ulcers are not prevented, the nurse must assess and care for it. The stages of wound healing are the homeostasis phase, the inflammation phase which is also referred to as the exudate and lag phase, the proliferative and granulation phase, and the maturation phase. 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. Friction occurs when a person's body is being rubbed against a surface such as a bed. This method is not used as much today as it was previously used. Traction is often set up by the nurse and, at times, a traction team may be used for the setup of the doctor's ordered traction. The RYB Color Code of Wounds is sometimes used by nurses to guide the treatment options. The quantity or amount of drainage can be described as minimal, moderate or excessive and copious when a wound drain is not being used to measure drainage precisely. Monitor and document the patients response to activity, such as heart rate, blood pressure, dyspnea, and skin color.[13],[14]. Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, Some traumatic wounds are healed with tertiary intention. At each stage of growth and development, the nurse assesses a patients mobility and provides appropriate education. Mobility is vital to independence; a fully immobilized person is as vulnerable and dependent as an infant" (Berman and Synder, 2012). An oblique fracture is one that occurs at an angle across the fractured bone. The skin is described in terms of its color which can be yellow, ecchymosed, purple, green, blanched and reddened, for example. A transverse fracture is one that occurs straight across the fractured bone. Determine the patients progress towards their specific SMART outcomes. Deep-vein thrombosis (DVT) is a common complication for clients experiencing immobility. See Figure 9.7[8] for a demonstration of these techniques. 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. Pressure occludes the vessels that oxygenate the area and it also causes cellular damage because harmful substances, such as toxins, accumulate in the area where the pressure is exerted. Immobility and complete bed rest can lead to life threatening physical and psychological complications and consequences. Herdman, T. H., & Kamitsuru, S. At times a tilt table can be used to prevent this damage by placing the client in a position of weight bearing to avoid these complications. Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered mood, and depression. Some nursing diagnoses related to immobility can include: At risk for pressure ulcers related to immobility Muscular weakness and muscular atrophy related to immobility When passive range of motion is applied, the joint of an individual receiving the exercise is completely relaxed while the outside force moves the body part. For example, the elbow should normally be able to perform extension, flexion, rotation for supination and notation for pronation and the neck should be fully able to perform extension, flexion, lateral flexion, hyperextension and rotation. Demonstrate placement of patient in various positions, such as Fowler's, supine (dorsal), Nursing assistants are often expected to encourage clients to use their incentive spirometer hourly. Clients should be educated about the proper methods that will be used to position and reposition them in bed while they are immobilized. The procedure for setting up traction is as follows: The neurological condition of the areas of traction must be frequently assessed and inspected, the skin should be assessed and cared for, and the client should be repositioned as much as possible in a frequent manner, typically every 2 to 4 hours. Apply and maintain the weights so that they hang freely. 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. PLEASE NOTE: The contents of this website are for informational purposes only. The homeostasis phase is marked with vasoconstriction, platelet formation, thrombin formation and the formation of a fibrin mesh for healing; the inflammation phase is characterized with the signs and symptoms of inflammation including edema, swelling, pain, in addition to the beginning of debris removal to prevent infection through the process of phagocytosis; the proliferative and granulation phase is marked with the fibroblastic production of collagen and granulation tissue; and, lastly, the maturation phase of wound healing is characterized with the still fragile skin after the wound healing process that can last up to two years after a wound. Some nursing diagnoses related to immobility can include: Mobility is defined as the "ability to move freely, easily, rhythmically, and purposefully in the environment. The length and width of all areas are measured and the depth of wounds is also measured. Therefore, nursing assistants must be diligent in their actions and observations to maintain their clients health and prevent complications. After the client is assessed, the mobility of the client, in addition to other functional activities, can be graded and classified as follows in terms of this level of functional ability: The skin, which is the first line of defense against infection, should be intact and not broken, it should be warm and without any excessive moisture, and the skin should also have good elasticity, which is referred to as good skin turgor. Encourage rest between activities. Splints are also used the immobilization of the spine, to support a weakened area of articulation such as a knee from damage and to support it after a knee replacement, for example. When you have the hose positioned correctly, pull the remainder of the stocking up to the knee or hip, depending upon the length of the hose. Active assist range of motion is joint movement by an individual with partial assistance from an outside force. Assess for the presence of urinary tract abnormalities related to immobility, such as suprapubic distention or tenderness that can result from urinary retention. Encourage the patient to perform activities of daily living (ADLs) as independently as possible and participate in prescribed physical therapy. In terms of assessment, the nurse assesses and reassess the client for actual and potential complications of immobility as fully discussed above under the section entitled Identifying the Complications of Immobility" and the clients' needs in reference to mobility, gait, strength and motor skills as fully discussed in the section entitled "Assessing the Client for Mobility, Gait, Strength and Motor Skills". While the client is in an upright semi-Fowler's position or sitting in the chair, the client is instructed to put the mouth piece tightly into their mouth and to take the deepest possible diaphragmatic breath while observing the ball rise to the level of their goal. Percussion is also performed by the nurse or the certified respiratory therapist. The first type of hand device is a cone that slides into the palm of the hand and is kept in place with a soft elastic band. There are additional devices that can prevent a clients hand contracture, as well as prevent their fingernails from creating open skin areas in their palm. Promote excellence in nursing by enabling future and current nurses with the education and employment resources they need to succeed. 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. Nurses maintain skin integrity and prevent skin breakdown in a number of different ways. Some wounds and wound drainage have odors and others do not. The metabolic system alterations associated with immobility are a decreased rate of metabolism which can lead to unintended weight gain, a negative calcium balance secondary to the loss of calcium from the bones during immobilization, a negative nitrogen balance secondary to an increase in terms of catabolic protein breakdown, and anorexia. Tertiary intention healing, also referred to as healing by tertiary intention, is a combination of secondary and primary healing. They are commonly used for clients with swelling of their extremities (edema) caused by cardiac conditions that cause fluid retention. Extension occurs when the arm is straightened back to starting position, increasing the angle between the elbow joint. The externally placed skin traction must be applied firmly but without any potentially damaging pressure and in a smooth manner without any creases. This method is the most rapid of all debridement methods but it can lead to client pain and discomfort. Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered mood, and depression.
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