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Hazards of Immobility in Nursing Care

The correct answer is D. Secretions may block bronchioles.

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Zsuzsanna Mester
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101 views54 pages

Hazards of Immobility in Nursing Care

The correct answer is D. Secretions may block bronchioles.

Uploaded by

Zsuzsanna Mester
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd

Basic Human Needs

Mobility & the Hazards of


Immobility
Mobility serves many purposes
 Performance of ADL
 Satisfaction of basic needs
 Self-defense
 Expression of emotion
 Recreational activities
 Need intact & functioning M/S & nervous
system to achieve mobility
Principles of Body Mechanics
 Body Mechanics-coordinated efforts of
M/S & nervous systems to maintain
balance, posture & body alignment during
lifting, bending, moving, & performing
ADL’s
 Proper use of body mechanics reduces risk
for injury and ensures safe care
Principles of Body Mechanics
 Alignment

 Balance

 Gravity

 Friction
Regulation of Movement
 Skeletal system
 Skeletal system functions
 Characteristics of bone, joints,ligaments,
tendons, cartilage
 Skeletal muscle
 Muscle tone
 Nervous system
Pathological Influences of
Mobility
 Postural Abnormalities
 Impaired Muscle Development
 Damage to CNS
 Direct Trauma to M/S System
Systemic Changes Associated
With Immobility
 Metabolic changes:
 Endocrine metabolism affected
 (decrease in BMR)
 Disrupts metabolic functioning
 Fluid & Lyte Imbalances
 Decreased calories & protein
 Negative Nitrogen Balance
 Calcium Resorption affected
 Functioning of GI tract
Respiratory Changes
 Lack of exercise & movement put client at
risk for:
 Atelectasis-Collapse of alveoli leading to
partial collapse of lung
 Hypostatic Pneumonia- Inflammation of
lung tissue from stasis or pooling of
secretions
 Both decrease oxygenation, prolong
recovery, & add to discomfort
Cardiovascular Changes
 Orthostatic hypotension

 Increased workload of heart due to


decrease in venous return to the heart

 Risk for thrombus (Virchow’s Triad)


Musculoskeletal Changes
 Muscle effects (muscle atrophy)

 Skeletal effects- Disuse osteoporosis,


contractures and foot drop
Urinary Elimination Changes
 Stasis and pooling of urine in renal pelvis
leads to increased risk for infection and
renal calculi
 Risk for dehydration and decreased urine
output
 UTI’s due to foley catheter
Other Changes
 Integumentary changes (Risk assessment
tool for skin breakdown, proper skin
hygiene)
 Psychosocial effects (Depression from
immobility)

 Developmental Changes
Nursing Process & Immobility
 Assessment
 Assess immobilized client for hazards of
immobility
 ROM exercises (P&P pgs. 1435-1439)
Nursing Process: Nursing
Diagnosis
 You tell me!!!
Implementation
 Health Promotion
 Acute Care:
 Metabolic system
 Respiratory system
 Cardiovascular system
 Musculoskeletal system
 Elimination system
Metabolic System
 Evaluate muscle atrophy
 I&O
 Monitor lab data (BUN, albumin, protein,
electrolytes)
 Assess wound healing
 Assess edema
 Assess for dehydration (Skin turgor, mucous
membranes)
 Assess nutritional status (protein and vitamin
supplements, enteral feedings, TPN)
Respiratory System
 Frequent respiratory assessment
 Ascultate lung sounds
 Inspect chest wall movement
 Promote lung expansion and stasis of pulmonary
secrections
 Deep breathing and coughing exercises
 Incentive spirometer
 Chest physiotherapy
 Suctioning
 Hydration
 Positioning every 2 hours
Cardiovascular System
 Vital sign monitoring
 Assess for orthostatic changes (Baseline BP)
 Reduce workload of heart
 Peripheral pulse assessment
 Assessment of edema (hearts inability to handle
increased work load)
 Prevent thrombus formation
 Assessment of VTE/DVT (Calf circumference)
Prevent Thrombus Formation
 Anticoagulants (Lovenox, Heparin)

 TED Stockings

 Calf pumping exercises

 Sequential compression stockings


Musculoskeletal System
 Assessment of muscle tone, strength, loss
of muscle mass, contractures
 Assess for risk of disuse osteoporosis
 Assessment of ROM
 Passive ROM for all immobilized joints
 Physical therapy consult
 Prevent foot drop and contractures
Elimination System
 I&O each shift
 Assess for fluid & electrolyte imbalances
 Bowel assessment
 Adequate hydration
 Incontinent considerations
 Assess bladder distention
Positioning techniques
 Footboard
 Trocanter roll
 Trapeze bar
 Pillows
 Splints
 Abductor pillow
 ROM exercises
Practice Scenario
 A 72 year old client is recovering
following abdominal surgery for colon
cancer. Which hazards of immobility is
this client at risk for and why?
 How would you as the nurse prevent post-
operative complications associated with
this client’s condition?
Clicker Question
 Which nursing assessment of the
immobilized client would prompt the nurse
to take further action?
 A. Client complaining of fatique
 B. Urinary output of 50 ml/hr
 C. White blood cell count of 9.5
 D. Absence of bowel sounds
Clicker Question
 During an exercise session, the nurse assists the
client to dorsiflex and plantarflex the foot,
explaining the client needs to exercise the foot to
maintain function. The nurse recognizes this
type of exercise activity as:
 A. Active range of motion
 B. Passive range of motion
 C. Isometric exercise
 D. Isotonic exercise
Clicker Question
 Which of the following patients is most at
risk for thrombus formation?
 A. Patient with renal failure
 B. Patient with severe abdominal pain
 C. Patient with a total hip replacement
 D. Patient with right sided heart failure
Clicker Question
 Which of the following is true concerning
the physiologic effects of immobility?
 A. Serum calcium levels decrease.
 B. Hypertension develops because of
increased cardiac workload.
 C. Caloric intake often increases.
 D. Secretions may block bronchioles.

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