this is foundations of nursing topic 3 chapter 39 immobility optimal Mobility correlates with positive client outcomes people need Mobility to work enjoy their Leisure Time and communicate emotions both verbally and non-verbally Mobility is also essential for self-defense activities of daily living and recreational activities many functions of the body depend on Mobility intact musculoskeletal and nervous systems are necessary for optimal physical mobility and functioning when clients lose the ability to remain mobile and active it is essential for the nurse to apply critical thinking when applying the nursing process to make relevant and accurate clinical judgments regarding interventions that are necessary to prevent complications and improve existing function as a nurse you need to learn how each client's physical and psychological conditions affect body movement including balance body alignment posture and physical activity body mechanics describes the coordinated efforts of the musculoskeletal and nervous systems the body mechanics applied in the lifting and positioning techniques historically used in nursing practice often caused debilitating injuries to nurses and other Health Care staff correct body alignment reduces strain on musculoskeletal structures AIDS in maintaining adequate muscle tone promotes comfort and contributes to balance and the conservation of energy without balance control the center of gravity is displaced disease injury pain physical development such as the aging process and Life Changes like pregnancy compromise the ability to remain balanced medications can cause dizziness that can negatively affect balance unsteady clients fall if their center of gravity becomes unbalanced because of the gravitational pull on their weight friction is a force that occurs in a direction to oppose movement the greater the surface area of the object that is moved the greater the friction a larger object produces greater resistance to movement for example a client who is obese produces greater resistance when moved against a bed surface than a client who has normal weight in addition the force exerted against the skin while the skin remains stationary and the Bony structures move is called shear by using mechanical lifting equipment such as full body hydraulic lifts when moving a client friction tearing or shearing of delicate skin is prevented and its use protects you and other Healthcare staff from injury the skeletal system provides attachments for muscles and ligaments and The Leverage necessary for Mobility bones are important for mobilization because they are firm rigid and elastic the aging process as well as some nutritional and disease processes have the potential to change the components of bone which affects mobility the skeletal system provides vital organs such as the skull around the brain and the ribs around the heart and lungs and AIDS in calcium regulation the internal structure of long bones contains bone marrow participates in red blood cell production and acts as a reservoir for blood the region where two or more bones attach is referred to as a joint ligaments are white shiny flexible bands of fibrous tissue that bind joints together connect bones and cartilages and Aid joint flexibility and support tendons are white glistening fibrous bands of tissue that connect muscle to Bone and are strong flexible and inelastic cartilage is non-vascular without blood vessels supporting connective tissue locally chiefly in the joints and thorax trachea larynx nose and ear movement of bones and joints involves active processes that are carefully integrated to achieve coordination skeletal muscles because of their ability to contract and relax are the working elements of movement the nervous system regulates movement and posture movement is impaired by disorders that alter neurotransmitter production transfer of impulses from the nerve to the muscle or activation of muscle activity many pathological conditions affect Mobility knowledge of these conditions is important for you to apply when you assess your clients Mobility status to anticipate the health problems they will face and the interventions required disorders of stance or posture result from an inequality of tone in muscle groups because of a loss of normal postural reflexes resulting in posturing of the limbs postural abnormalities can also be congenital such as scoliosis and can disrupt equilibrium and balance some postural abnormalities limit the range of motion table 39.1 in your textbook describes the various postural disorders the picture on this slide is of a client with Parkinson's disease and describes the various symptoms that this disease can cause notice the client's stooped posture two types of abnormalities affecting muscles include changes in muscle tone and changes in muscle movement one type of abnormality in muscle tone is hypotonia it is just decreased muscle tone with little or no resistance during passive muscle movement it is common in clients with cerebellar damage clients with hypotonia Tire easily and have difficulty rising from a sitting position sitting down without support and walking up and down stairs another type of abnormality is the change in muscle movement that occurs when there is central nervous system dysfunction that alters muscle innervation some muscle movement disorders result from too little dopamine to stimulate muscles While others have too much dopamine finally there are movement disorders that are not associated with muscle mass strength or tone but instead are neurological disorders conditions such as Parkinson's and Huntington's disease cause insufficient or excessive movement or involuntary movement damage to or dysfunction of any component of the CNS that regulates voluntary movement results in impaired body alignment and posture balance and Mobility prolonged bed rest is associated with sensory motor dysfunction that commonly manifests postural instability and a dysregulated sense of balance this together with reduced muscle mass mass and strength increases the risk of Falls trauma from a head injury ischemia from a stroke or bacterial infections such as meningitis can damage the cerebellum or the motor strip in the cerebral cortex damage to the cerebellum causes problems with balance and motor impairment is directly related to the amount of destruction of the motor strip direct trauma to the musculoskeletal system results in bruises contusions tears sprains and fractures treatment of fractures often includes positioning the fractured bone in proper alignment and immobilizing it to promote healing and restore function even this temporary immobilization results in some muscle atrophy loss of muscle tone and Joint stiffness one of the most common pathological influences on Mobility comes in the form of joint disease such as arthritis osteoarthritis is one of the most common causes of chronic disability in adults due to pain and altered joint function typically affecting knees and hips joint disease creates pain and Alters Mobility as a result of that pain in addition to pathological bone and cartilage changes Mobility refers to a person's ability to move about freely and immobility refers to the inability to do so think of Mobility as a Continuum with Mobility on one end and immobility on the other and varying degrees of partial immobility between the endpoints immobility has serious consequences physical inactivity can have strong deconditioning effects on the human body on Bones muscles and the cardiovascular system periods of immobility due to disability or injury or prolonged bed rest during hospitalization can cause major physiological psychological and social effects these effects are gradual or immediate and Vary from client to client all body systems work more efficiently with some form of movement when there is an alteration in Mobility each body system is at risk for impairment changes in Mobility alter endocrine metabolism calcium resorption and functioning of the gastrointestinal system when injury or stress occurs the endocrine system triggers a series of responses aimed at maintaining blood pressure and preserving life immobility disrupts normal metabolic processes decreasing the metabolic rate altering the metabolism of carbohydrates fats and proteins causing fluid electrolyte and calcium imbalances and causing GI disturbances such as decreased appetite and slowing of peristalsis lack of movement and exercise places clients at risk for Respiratory complications clients who are immobile are at high risk for developing pulmonary atelectasis which is a collapse of the alveoli and hypostatic pneumonia and inflammation of the lung from stasis or pooling of secretions both conditions cause decreased oxygenation and prolonged recovery add to a client's discomfort immobilization also affects the cardiovascular system frequently resulting in orthostatic hypotension increased cardiac workload and thrombus formation when patients are immobilized there can be a decrease in circulating fluid volume pooling of blood in the lower extremities and decreased autonomic response occur these are especially evident in the older adult as the workload of the heart increases so does its oxygen consumption therefore the heart Works harder and less efficiently during periods of prolonged rest as immobilization increases cardiac output Falls further decreasing cardiac efficiency and increasing workload patients who are immobile are also at risk for thrombus formation a thrombus is an accumulation of platelets fibrin clotting factors and the cellular elements of the blood attached to the interior wall of a vein or artery which sometimes occludes or closes off the Lumen of the vessel one of the dangers of a deep vein thrombosis also known as a DVT is the development of a pulmonary embolus or PE a PE occurs when a part of the thrombus or clot breaks off and travels to the lungs and then blocks the pulmonary artery altering the blood supply to lung tissue PE has a variety of presenting features ranging from no symptoms to shock or sudden death the figure on this slide is a depiction of a thrombus formation immobility causes permanent or temporary impairment of musculoskeletal structures because of protein breakdown a client loses lean body mass during immobility the reduced muscle mass makes it difficult for clients to sustain activity without increased fatigue prolonged immobility often leads to disuse atrophy loss of endurance decreased muscle mass and strength and Joint instability Place clients at risk for Falls immobility can lead to Joint contractures a joint contracture is an abnormal and possibly permanent condition characterized by fixation of a joint disuse atrophy and shortening of the muscle fibers cause joint contractures when a contracture occurs The Joint cannot achieve full range of motion contractures sometimes leave a joint or joints in a non-functional position immobility Alters a client's urinary elimination in the upright position urine flows out of the renal pelvis and into the ureters and bladder because of gravitational forces when a client is recumbent or flat the kidneys and ureters move toward a More Level plane you're informed by the kidney needs to enter the bladder unaided by gravity because the peristaltic contractions of the ureters are insufficient to overcome Gravity the renal pelvis fills before urine enters the ureters this condition is called urinary stasis and increases the risk of urinary tract infection and renal calculi the changes in metabolism that accompany immobility add to the harmful effect of pressure on the skin this makes immobility a major risk factor for pressure injuries a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device when a client lies in bed or sits in a chair the weight of the body is on bony prominences the longer the pressure is applied the longer the period of ischemia and therefore the risk of skin breakdown increases nursing research shows that immobilization often leads to emotional and behavioral responses sensory alterations and changes in coping illnesses that result in limited or impaired mobility can cause social isolation and loneliness because immobilization removes a client from a daily routine the client has more time to worry about disability worrying contributes to depression causing patients to withdraw and become unable to participate in their own care as an infant grows musculoskeletal development permits support of weight for standing and walking posture is awkward because the head and upper trunk are carried forward because body weight is not distributed evenly along a line of gravity posture is normally off balance and Falls occur often prolonged immobilization delays progression of a child's gross motor skills intellectual development and musculoskeletal development the Adolescent stage usually begins with a tremendous increase in growth when the activity level is reduced because of trauma illness or surgery the Adolescent is often behind peers in gaining independence and accomplishing certain skills such as obtaining a driver's license social isolation is the concern for this age group when immobilization occurs the healthy adult also has the necessary musculoskeletal development and coordination to carry out their activities of daily living when periods of prolonged immobility occur all physiological systems are at risk a progressive loss of total bone mass in older adults results from decreased physical activity hormonal changes and Bone resorption the effect of bone losses weaker bones older adults often walk more slowly take smaller steps and appear less coordinated prescribed medications often alter their sense of balance or affect their blood pressure when they change position too quickly increasing their risk for Falls and injuries older adults often experience functional status changes secondary to hospitalization and altered Mobility status immobilization of older adults increases their physical dependence on others and accelerates functional losses critical thinking in making clinical judgments about the approach to the care of a client who is immobilized can be complicated the physical effects of any restrictions in movement caused by a sudden illness or injury coupled with any pre-existing health conditions such as heart disease diabetes or a previous injury require you to consider a broad number of potential complications the key is anticipation during the nursing process always anticipate a client's potential risks as well as actual risks related to immobility as you gather data analyze and identify diagnoses and select and deliver interventions application of scientific knowledge and experience in the care of clients experiencing immobility will promote early recognition of problems witnessing the effects of immobility prepares you to identify problems earlier for subsequent clients be willing to collaborate with other health professionals such as physical therapists and registered dietitians who can give valuable insight as to the nature of immobility problems and appropriate Interventional strategies apply the nursing process and use critical thinking in making sound clinical judgments about your approach to a client's care the nursing process provides a clinical decision-making approach for you to develop and Implement an individualized plan that will reduce threats posed by immobility and maintain or improve existing physical function clients with pre-existing Mobility impairments and those who are at risk for immobility will greatly benefit from a care plan that improves the client's functional status promotes self-care and maintains psychological well-being it is impossible for you to know how a person who is less mobile and suddenly dependent on others feels remember that your patient is a full partner in making decisions that contribute to the plan of care your assessment must explore how any limitations in Mobility are perceived by the patient as well as expectations of care begin the assessment of movement while the patient is lying down and proceed to assessing the sitting position in bed ability to transfer to a chair and finally walking assess what the patient can do independently if assistance is needed assess the degree of help required foreign gate is the manner or style of walking including Rhythm Cadence length of stride and speed assessing gait allows for conclusions about balance posture and the ability to walk without assistance assess a client's exercise history by asking what exercise the patient normally engages in and the normal amount of exercise performed daily and weekly if a client does not exercise regularly you will want to focus on assessing activity tolerance the first step in assessing body alignment is to put the client at ease so they do not assume unnatural or rigid positions observe the appearance and position of your clients extremities and measure the range of motion of your client's joints during your assessment of body alignment the figures shown on the slide is the correct body alignment for a client who is standing body alignment should be assessed with the client standing sitting in line if possible a client who presents with impaired mobility requires you to assess for actual cues and potential physiological impairments associated with immobility while performing a head-to-toe physical assessment table 39.4 in the textbook discusses the various systems how they are assessed and abnormal findings that you should be aware of as you conduct your assessment consider your knowledge of how immobility affects physiological functioning specifically in relationship to the client's health problems this information will allow you to recognize risks for complications be sure your assessment also focuses on the client's psychosocial and developmental dimensions let's look at our case study Ms Eileen Thomas who is 82 is admitted for a fractured right hip she is on complete bed rest in Buck's traction Buck's traction is used to keep the leg in an extended position without hip flexion Sergio is the nursing student assigned to Ms Thomas what hazards could miss Thomas face from being immobilized in bed at her age these could include bone loss osteoporosis and increased risk of fractures older adults with chronic illness develop pronounced effects of immobility more quickly than younger clients these include more pronounced effects of decreased circulating fluid volume more pronounced effects of pooling of blood in lower extremities a greater decrease in autonomic response a greater risk of contractures cardiac issues as older adults often do not tolerate The increased cardiac workload that comes with recumbent positioning and a more significant impact on the older adults Independence and functional status critical analysis of all assessment data comparing findings with the anticipated effects of Mobility alterations reveals patterns of data indicating a nursing diagnosis there are two diagnoses most directly related to Mobility problems impaired mobility and risk for disuse syndrome the diagnosis of impaired mobility applies to a client who has some limitation but is not completely immobile the diagnosis of risk for disuse syndrome applies to the client who is immobile and at risk for multi-system problems because of inactivity there are numerous nursing diagnoses that might apply to clients with Mobility limitations because immobility affects multiple body systems these are listed on the slide during planning critical thinking and sound clinical judgment will guide you to synthesize what you know about immobility and a client's condition the client's nursing diagnoses their resources available environmental conditions your past clinical experiences and clinical standards to develop a plan of care involving a client in clinical decisions about your approach to restoring Mobility is essential to obtain client involvement during planning you confirm the priority level of Nursing diagnoses and other health problems and then generate solutions by identifying outcomes and choosing interventions to meet or resolve those outcomes the analysis of a client's nursing diagnosis sets the stage for outcome identification a nursing diagnosis labels a health problem an outcome is the measurable change such as an adjustment in Behavior physical state or perception of their health problem that must be achieved to improve or minimize the health problem selection of appropriate client-centered outcomes leads to the formation of an individualized plan with relevant nursing interventions understanding what a client can physically do compared with what the client potentially and realistically can achieve helps you set realistic outcomes the effect that problems have on a client's mental and physical health determines the immediacy of any problems set priorities when planning care to ensure that immediate needs are met first care of the client experiencing alterations and Mobility requires a team approach collaborate with other health care team members such as physical or occupational therapists when it is essential to consider Mobility needs health promotion activities include a variety of interventions such as education prevention and early detection to prevent alterations in Mobility these activities apply to health care workers and clients the rate of work-related injuries in health care settings has increased in recent years nurses stand and move throughout the day have regular contact with clients and often are involved in lifting clients as a result over exertion and bodily reaction are the most prevalent events leading to occupational injuries and illnesses for registered nurses the causes of these events are excessive physical effort bending twisting lifting and repetitive motion back injuries are often the direct result of improper lifting and bending current safe patient handling algorithms support that using mechanical or other ergonomic assistive devices is the safest way to reposition and lift clients who are unable to do these activities themselves many agencies have developed special client lift teams and have instituted a minimal lift policy although many diseases and physical problems cause or contribute to immobility it is important to remember that exercise programs enhance feelings of well-being and improve endurance strength and health it is important to give patients options for how to stay active and how to change their behavior if exercise has not been their routine as a nurse you can encourage all patients to find a type of exercise that meets their lifestyle and particular health related needs once they recover for patients diagnosed with osteoporosis early evaluation and consultation with and referral to Health Care Providers dietitians and physical therapists are important interventions especially when these patients become immobilized the goal of the patient with osteoporosis is to maintain independence with activities of daily living assistive ambulatory devices adaptive clothing and safety bars help patients maintain Independence patients in acute care settings who experience altered physical Mobility are usually more debilitated than those in outpatient settings these patients are often at risk for the hazards of immobility such as impaired respiratory status orthostatic hypotension deep vein thrombosis and impaired skin integrity therefore design nursing interventions to reduce the impact of immobility on body systems and prepare patients for the restorative phase of care because the body needs protein to repair injured tissue and rebuild depleted protein stores consult with a registered dietitian to ensure that patients who are immobilized receive high protein high calorie diets clients who are immobilized and have reduced ventilation benefit from a variety of nursing interventions that promote lung expansion and removal of pulmonary secretions clients need to frequently fully expand their lungs to maintain elastic recoil in addition secretions accumulate in the dependent areas of the lungs often clients with restricted Mobility experience weakness and as this progresses the cough reflex gradually becomes inefficient and patients have less energy to breathe deeply deep breathing exercises incentive spirometry as shown in this picture and controlled coughing are among the nursing interventions available to expand the lungs dislodge and mobilize stagnant secretions and clear the lungs all of these interventions help reduce the risk of pneumonia the effects of bed rest or immobilization on the cardiovascular system include orthostatic hypotension increased cardiac workload and thrombus formation select an individualized nursing therapies to minimize or prevent these alterations as we learned in topic one when patients who are on bed rest or have been immobile moved to a sitting or standing position they often experience orthostatic hypotension they have an increased pulse rate a decreased pulse pressure and a drop in blood pressure if symptoms become severe enough the patient can faint to prevent injury Implement interventions that reduce or eliminate the effects of orthostatic hypotension mobilize the patient as soon as the physical condition allows even if this only involves dangling the legs at the bedside or moving to a chair this activity maintains muscle tone and increases venous return a nursing intervention that reduces cardiac workload involves instructing patients to avoid using Al valsava maneuver when moving up in bed defecating or lifting household objects during a valsava maneuver a patient holds the breath and strains which increases intrathoracic pressure and in turn decreases venous return in cardiac output teach patients to breathe out while defecating lifting or moving side to side or up in bed and to not hold their breath and strain to prevent thrombus formation the nurse plays a critical role in promoting mechanical prophylaxis in at-risk patients including early ambulation administration of anticoagulants applying intermittent sequential compression devices or scds or compression stockings and applying foot pumps the procedural guidelines for applying sequential compression devices and elastic stockings can be found in box 39.8 in your textbook Ms Thomas's mitral valve was replaced two months ago and since the time of the surgery she has been on anticoagulants she has had type 2 diabetes mellitus for the past 10 years and is a smoker she weighs 195 pounds and is 5 foot 7 inches tall she lives by herself and she attends Mass daily her pain is six on a scale of 0 to 10. What complications and special areas of concern can you identify for Ms Thomas as Ms Thomas awaits surgery Sergio knows that patients who smoke are an anticoagulants because of valve replacement surgery and have a fractured hip are at risk for complications related to the hazards of immobility Ms Thomas has diabetes which puts her at increased risk for skin breakdown infection circulatory problems and neuropathy additionally Sergio will need to address her mobility and social needs exercises to prevent excessive muscle atrophy and Joint contractures help maintain musculoskeletal function active range of motion should be encouraged for any client at risk from reduced musculoskeletal strength or functionality by improving joint Mobility clients with impaired nervous skeletal or muscular system functioning and increased weakness and fatigue often require help from nurses for positioning and maintenance of proper body alignment while in bed or sitting several positioning devices are available for positioning and maintaining good body alignment for patients friction reducing sheets and boards are available to make it easier to move clients up in bed or laterally to the side use of friction reducing sheets reduces shear and friction on the skin pillows are positioning AIDS and are sometimes readily available before using a pillow determine whether it is the proper size if an appropriate size pillow is unavailable rolled up sheets towels or blankets can be used as positioning AIDS a trochanter role prevents external rotation of the hips when a client is in a Supine position this is especially useful in clients who have lost the ability to move the lower extremities the trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bed frame it allows a client to pull with the upper extremities to raise the trunk off the bed assistant transfer from bed to wheelchair or perform upper arm extremities in the supported Fowler position the head of the bed is elevated 45 to 60 degrees and the client's knees are slightly elevated without pressure to restrict circulation in the lower legs support needs to permit flexion of the hips and knees and proper alignment of the normal Curves in the cervical thoracic and lumbar vertebrae clients in the Supine position rest on their backs use pillows trochanteroles and hand rolls or arm splints to increase comfort and reduce injury to the skin or musculoskeletal system shoulders are supported and the elbows are slightly flexed to control shoulder rotation a foot support prevents foot drop and maintains proper alignment the prone position is one used rarely because many individuals especially older adults are simply uncomfortable in the position however the prone position is considered first line therapy for critically ill clients with severe acute respiratory distress syndrome such as clients with covid-19 to reduce lung trauma and optimize the ventilation and perfusion to regions in the lungs often the head is turned to the side but if a pillow is under the head it needs to be thin enough to prevent cervical flexion or extension and maintain alignment of the lumbar spine placing a pillow under the lower leg permits dorsiflexion of the ankles and some knee flexion which promote relaxation in the sideline or lateral position a client rests on the side with the major portion of body weight on the dependent hip and shoulder a 30 degree lateral position on the side is recommended for clients at risk for pressure injuries the client needs to maintain the structural curves of the spine the head needs to be supported in line with the midline of the trunk and rotation of the spine needs to be avoided the lateral recumbent position differs from the sideline position in the distribution of the client's weight in the lateral recumbent position the client lies on a side with the same hip and lower extremity straight and the opposite hip and knee bent when moving a patient during repositioning the priority always is a safe transfer patients require various levels of assistance to move up in bed move to the sideline position or sit up at the side of the bed always ask patients to help to their fullest extent possible during positioning refer to skill 39.1 in the textbook for details on moving and positioning clients in bed the major risk to the skin from restricted Mobility is the formation of pressure injuries interventions aimed at prevention include turning and positioning and the use of therapeutic support surfaces and devices such as low air loss mattresses heel boots and flotation mattresses to relieve pressure usually the time that a client sits uninterrupted in a chair is limited to one hour this interval is shortened in clients who are at very high risk for skin breakdown consider Eileen Thomas's medical history of type 2 diabetes mellitus heart valve replacement surgery two months ago and being an active smoker what are some nursing interventions that Sergio could initiate to prevent respiratory complication related to her immobility some nursing interventions include deep breathing and coughing every two hours while the patient is awake turning every one to two hours while awake and using the incentive spirometer five times every 30 minutes while awake during the first 24 to 48 hours post-operatively follow the safety guidelines for safely repositioning a client be sure to raise the level of the bed to a comfortable working height level with your elbows position the client supine clients who weigh less than 200 pounds use a friction reducing device such as a slide board or slide sheet and have two to three Caregivers for patients who weigh more than 200 pounds use a friction reducing device and at least three caregivers let's do a practice question you notice a respiratory change in your immobilized post-operative client the change you note is most consistent with a atelectasis B hypertension C orthostatic hypotension D coagulation of blood the correct answer is a atelectasis which is a respiratory change atelectasis is the collapse of alveoli in the lungs this information was referenced from Potter Perry stockert and Hall 2023 Fundamentals of Nursing if you have questions about any of the content presented in this video please contact your assigned course instructor thank you