nursing interventions to prevent complications of immobility

American Academy of Nursing's Expert Panel on Acute and Critical Care. Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered mood, and depression. Many of these costly complications of immobility can, and should be, prevented whenever possible. Legal. Lastly, skin traction applies the traction force to the skin overlying the affected bone. Monitor oxygenation levels and provide supplemental oxygen as prescribed to maintain adequate oxygenation, especially during ambulation. For specific steps in applying TED hose, see the Application of Compression Stockings (TED Hose) Skills Checklist at the end of the chapter. These devices are ordered by the doctor in terms of millimeters of mercury that they will apply to the lower extremities. Coughing is expected, and clients should be encouraged to expel any mucus (not swallow it). Primary intention healing is facilitated with wounds without infection. If the clot breaks free, it can travel to the lungs and become fatal. Conditions such as osteoarthritis, orthostatic hypotension, inner ear dysfunction, osteoporosis resulting in hip fractures, stroke, and Parkinsons disease are among the most common causes of immobility in old age. The three types of wound healing are primary intention healing, secondary intention healing and tertiary intention healing. Automatic sequential compression devices consist of a pump, a one time single patient use sleeve, and hosing that connects the sleeve to the pump. Deep-vein thrombosis (DVT) is a common complication for clients experiencing immobility. 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. 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. (Eds.). Some traumatic wounds are healed with tertiary intention. This method is not used as much today as it was previously used. Passive range of motion is movement applied to an individuals joint by another person or by a passive motion machine. If orthostatic hypotension is suspected, measure the patients vital signs while he or she is supine, sitting, and standing before encouraging ambulation. Instructing the patient to perform simple exercises around their We use this action every day when we step to the side, get out of bed, and get out of the car. 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 Members of the nursing care team and other health care professionals like physical therapists must, therefore, promote client mobility and prevent immobility whenever possible. Because mobility issues are directly related to musculoskeletal disorders, perform a thorough assessment of the musculoskeletal system and its effect on the patients mobility status. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. The eschar is gently crosshatched with a scalpel so that the introduced enzymes can penetrate all layers of it. Assess for potential signs of atelectasis and pneumonia. 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. External pressure can cause creases and denting which can impair the skin below in terms of its neurological and circulatory status. 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. 9.4: Complications of Immobility - Medicine LibreTexts Odors can be described as malodorous, pungent, foul, or musty; and some pathogens like pseudomonas have a characteristic odor. Prevention and management of limb contractures in neuromuscular diseases. The RYB Color Code of Wounds is sometimes used by nurses to guide the treatment options. Risks of immobility are well-known, and complications are viewed as avoidable. Segmenting ADLs refers to breaking up tasks to accommodate the clients activity intolerance. These risk factors are assessed by the nurse to determine the etiology of an identified deficit and to recognize that, because of one or more risk factors, a client is at risk for impairments in terms of their mobility, gait, strength and motor skills. The bones lose calcium as a result of the lack of weight bearing activity and this can lead to disuse osteoporosis, hypercalcemia, and fractures. Assess muscle strength and coordination, and then assess mobility skills in the following order: mobility in bed, dangling on the bed with supported and unsupported sitting, weight-bearing while transferring from sitting to standing or to a chair, standing and walking with assistance, and walking independently. Both of these standardized screening tools are deemed valid and reliable for identifying those at risk. The nurse should tilt the bed when this occurs and this can be prevented by keeping the client's head of the bed up at the maximum of less than a 20 degree angle. The Applying Prosthetics and Orthotics section in Chapter 8 describes devices such as a foot split to prevent musculoskeletal contracture. Potential for Complications from Surgical Procedures and Health Encourage or perform active or passive range of motion exercises as prescribed by the physical therapist. Compression stockings, or antiembolism stockings or hose, and automatic sequential compression devices are used to promote venous return and prevent emboli, both of which can occur as the result of patient immobilization and other causes such as deep vein thrombosis. Gait is a function of a number of different things including balance, coordination, muscular strength, and joint mobility. In fact, percussion is most often done in combination with postural drainage. These and even more complex and advanced standardized tests and tools are also used during a physical therapist's assessment of the client. The correct application of antiembolism stockings entails the application of these stockings while the client is lying in bed and before rising. Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered mood, and depression. 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associate degree in nursing. For example, a patient undergoing a cardiac catheterization may be mobilized within a few hours following the procedure, whereas a patient undergoing total knee arthroplasty may begin mobilizing 24 hours following the surgery. See Figure 9.8[9] for heel placement. Refer to the Objective and Subjective Signs of Pain subsection in Chapter 6.3 to review observations to make and report. Abduction refers to the movement of a limb away from the bodys midline. For example, a client who has had limited mobility for several years may have a joint that can only be moved a few inches, but it is important to maintain that mobility, no matter how small. 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". Encourage their participation in the setting of realistic goals for mobility and modify these goals as needed for safety. The stockings have a square marker around the heel to guide correct placement on the heel. As teenagers become adults, the nurse provides education about the effects of alcohol and other drugs on balance and safety while driving. All of these measures are used not only for immobilized clients but also for many post-operative clients. [8],[9], For patients at risk for developing pneumonia due to immobility, encourage adequate fluid intake to liquefy pulmonary secretions, and teach deep breathing and coughing exercises to prevent atelectasis. Casts can be made with plaster or fiberglass. Some of the factors that impact on the skin and its integrity include intrinsic and extrinsic factors and forces. In addition to anti embolism stockings and sequential compression devices, as previously discussed, active or passive range of motion, positioning and mobilization are also measures that promote circulation. Legal. The procedure for autolytic debridement entails the use of a semi-occlusive, occlusive, hydrocolloid, alginate, or hydrogel treatment and a transparent dressing to keep the area moist while the body uses its own enzymes like its fibrinolytic, proteolytic, and collagenolytic enzymes, as well as its on white blood cells to debride a wound and remove its eschar and slough. Active range of motion is movement of a joint by the individual with no outside force aiding in the movement. All trademarks are the property of their respective trademark holders. Apply and maintain the weights so that they hang freely. Range of motion exercises can be active, active assisted and passive. 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. Nursing interventions promote a patients mobility and prevent effects of immobility. For example, the client may be encouraged to bend their knees and then exert pressure on their heels as they are being moved up in bed. Promote excellence in nursing by enabling future and current nurses with the education and employment resources they need to succeed. 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.

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