Clients should be educated about the proper methods that will be used to position and reposition them in bed while they are immobilized. External pressure can cause creases and denting which can impair the skin below in terms of its neurological and circulatory status. The circulatory system is jeopardized by immobility; some of these respiratory complications and risks include venous stasis, venous dilation, decreased blood pressure, edema, embolus formation, thrombophlebitis and orthostatic hypotension which is a risk factor that is often associated with client falls. These techniques will be discussed below immediately after this section. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the lower leg, but can occur anywhere within the cardiovascular system. The stockings have a square marker around the heel to guide correct placement on the heel. The incentive spirometer encourages a client to complete slow, deep breathing to keep their bronchioles open. Nursing Interventions for Impaired Physical Mobility. Intervention of this condition includes prevention of dependent disabilities, restoring mobility when possible, as well as maintaining or preserving the existing mobility. Special patient care includes changing position, exercises, nutrition and giving a safe environment, etc. Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, percussion and vibration. These devices are ordered by the doctor in terms of millimeters of mercury that they will apply to the lower extremities. Wound margins can be described as open, attached, unattached, well defined and with a healing ridge. [3], There are several nursing diagnoses related to mobility. 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. 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. Some of these joint disorders can be prevented with frequent and proper positioning of the client in correct bodily alignment, the provision of range of motion exercises to all joints several times a day, and the use of devices like a hand roll and a bed board to prevent contractures of the hands and feet, respectively. Many of these costly complications of immobility can, and should be, prevented whenever possible. 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 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. For example when the length of the sound is 4 cm and the width of the wound is 3 cm and the depth of the wound is 1 cm, the wound dimension is 12 cm because 4 x 3 x 1 = 12 cm. The complications and hazards associated with immobility and according to bodily system are described below: As the result of immobility, the urinary system can be adversely affected with urinary retention, urinary stasis, renal calculi, urinary incontinence and urinary tract infections. The later signs of compartment syndrome include burning pain secondary to ischemia, paresthesia secondary to neurological impairment, hypoesthesia secondary to sensory nerve damage, pulselessness, and cool and pale skin. The lateral position is a side lying position with the upper most knee bent and often maintained in that position with a pillow; the Fowler's position is a sitting position with the head of the bed up and elevated; the dorsal recumbent position and supine position are lying on the back with or without a pillow for the head; the prone position is lying on the stomach; and the Sim's position is a semi prone position. ROM exercises facilitate movement of specific joints and Administer medications if warranted and consider nonpharmacologic measures such as repositioning, splinting, and heat/cold application to reduce musculoskeletal discomfort. They should never touch the floor or any other surface such as a part of the bed because this will interfere with the traction's ordered weight. See Table 9.4 for potential complications of immobility by body system and additional preventative measures that will keep clients as healthy as possible. Prevention and management of limb contractures in neuromuscular diseases. Assess the respiratory system, including respiratory rate, oxygen saturation, lung sounds, chest wall movement and symmetry, and depth and effort of respirations. This relatively inexpensive type of debridement can be done with a damp dressing, hydrotherapy, and manually scrubbing the affected area to remove the debris. 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. 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. RegisteredNursing.org does not guarantee the accuracy or results of any of this information. These efforts are even more intense and comprehensive when the client has one or more risk factors associated with impaired skin integrity, as discussed previously in this section. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. 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. 1. Extension occurs when the arm is straightened back to starting position, increasing the angle between the elbow joint. When assisting with ROM exercises, the nursing assistant must support any joints below the joint being exercised to prevent injury. Typically, larger joints such as shoulders, elbows, hips, knees, and ankles are included in ROM exercises, but ROM can be also applied to smaller joints such as the fingers and wrists. When applying TED hose, find the heel marker first. The wound remains vulnerable to injury until full healing is completed with good tensile strength. As teenagers become adults, the nurse provides education about the effects of alcohol and other drugs on balance and safety while driving. Promoting clients independence in completing their ADLs and encouraging activity as tolerated can help prevent all these complications of immobility. American Academy of Nursing's Expert Panel on Acute and Critical Care. Hip Fracture Nursing Care Plan For example, clients who undergo knee replacement surgery may be prescribed a passive range of motion machine that continuously flexes and extends the patients knee while they are lying in bed. 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. These hazards of immobility can be prevented with range of motion exercises and in bed exercises such as isotonic, isometric and isokinetic muscular exercises. The best way for nursing assistants to prevent DVT is to assist clients to ambulate or otherwise complete as much activity as they can tolerate. These hazards of immobility can be prevented with range of motion exercises and in bed exercises such as isotonic, isometric and isokinetic muscular exercises. 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. This process is referred to as autolysis. For example, some compression stockings may seem like slightly tight socks, whereas other stockings for clients with severe edema are custom-made to fit very tightly and may have a zipper for ease of application. The rules of treatment for these three colors are: Surgical debridement using a laser is perhaps the fastest of all methods of debridement and it is the method that is least likely to damage the healthy tissue surrounding the necrotic area. These positions are supported and maintained with pillow, bolsters and wedges when necessary to maintain anatomically correct bodily alignment. Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered mood, and depression. At each stage of growth and development, the nurse assesses a patients mobility and provides appropriate education. The externally placed skin traction must be applied firmly but without any potentially damaging pressure and in a smooth manner without any creases. What are the nursing interventions to prevent Promote excellence in nursing by enabling future and current nurses with the education and employment resources they need to succeed. 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. The skin area that has impaired skin integrity is also described according to its exact location and in reference to its anatomical location. 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. One of its disadvantages, when compared to some other method of debridement, is the need to anesthetize the client which, in itself, has some risks. Nursing diagnoses for the hazards of immobility and the client's mobility were also discussed above in these same sections. Manual traction, which is applied with the hands, is done to properly align a bone after a fracture so that a cast can be applied to the bone while it is in correct anatomical alignment. Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, When blood is not moving much due to client inactivity, it can coagulate (i.e, form a clot). For example, an area of skin breakdown can be described as on the posterior of the arm just inferior to the elbow or over the sacrum and coccyx. An example of primary intention healing is the suturing of an abdominal surgical wound after an appendectomy or the suturing of a traumatic laceration with Steri Strips or sutures when this traumatic wound is free of any contamination and infection. The cone should not be forced into the fingers but placed gently. Adduction refers to moving a limb towards the midline. Some of its disadvantages, however, include the fact that autolytic debridement is not as rapid as a surgical debridement in terms of its effectiveness and the fact that anerobic microbes may thrive under the dressing that is used for this type of debridement. 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. A second type of device is a palm protector that is softer than the cone and separates the fingers from one another. To avoid or minimize complications of immobility, mobilize the patient as soon as possible and to the fullest extent possible. Mechanical debridement is often the preferred form of treatment for pressure ulcers that only have a moderate amount of necrotic tissue that has to be removed. If constipation is suspected, palpate the patients left lower quadrant for signs of stool presence. Braces are applied to various parts of the body to provide support and alignment of the part. ROM exercises facilitate movement of specific joints and Identifying the Complications of Immobility, Assessing the Client for Mobility, Gait, Strength and Motor Skills, Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown, Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown, Applying a Knowledge of Nursing Procedures and Psychomotor Skills When Providing Care to Clients with Immobility, Coughing, Deep Breathing, Incentive Spirometry, Postural Drainage, Percussion, Vibration and Inspiratory Respiratory Exercises, Applying, Maintaining and Removing Orthopedic Devices, Applying and Maintaining Devices That are Used to Promote Venous Return, Educating the Client Regarding the Proper Methods Used When Repositioning an Immobilized Client, Maintaining the Client's Correct Body Alignment, Maintaining and Correcting the Adjustment of the Client's Traction Device, Implementing Measures to Promote Circulation, Evaluating the Client's Responses to Interventions to Prevent the Complications From Immobility, Adult Gerontology Nurse Practitioner Programs (AGNP), Womens Health Nurse Practitioner Programs, Advanced Practice Registered Nurse (APRN), Non Pharmacological Comfort Interventions, Basic Care & Comfort Practice Test Questions, Identify complications of immobility (e.g., skin breakdown, contractures), Assess the client for mobility, gait, strength and motor skills, Perform skin assessment and implement measures to maintain skin integrity and prevent skin breakdown (e.g., turning, repositioning, pressure-relieving support surfaces), Apply knowledge of nursing procedures and psychomotor skills when providing care to clients with immobility, Apply, maintain or remove orthopedic devices (e.g., traction, splints, braces, casts), Apply and maintain devices used to promote venous return (e.g., anti-embolic stockings, sequential compression devices), Educate the client regarding proper methods used when repositioning an immobilized client, Maintain the client's correct body alignment, Maintain/correct the adjustment of client's traction device (e.g., external fixation device, halo traction, skeletal traction), Implement measures to promote circulation (e.g., active or passive range of motion, positioning and mobilization), Evaluate the client's response to interventions to prevent complications from immobility, At risk for pressure ulcers related to immobility, Muscular weakness and muscular atrophy related to immobility, At risk for venous stasis and emboli related to immobility, At risk for altered and impaired respiratory functioning related to immobility, At risk for falls related to orthostatic hypotension secondary to immobility, At risk for osteoporosis and fractures related to the loss of calcium from the bones secondary to the lack of weight bearing activity, Plantar flexion contracture related to immobility, Loss of complete range of motion related to immobility, Are sitting to determine whether or not they need support while sitting, Change from a sitting position to standing, transferring from the bed to the chair, and sitting down on a chair or bed, At risk for impaired skin integrity related to immobility, At risk for impaired skin integrity related to poor skin turgor, Impaired skin integrity related to impaired tissue perfusion, At risk for impaired skin integrity related to boney prominences, Impaired skin integrity related to pressure, shearing and friction, Impaired skin integrity related to poor nutritional status, The screening of all clients for their potential for skin breakdown and then initiating special preventive measures, Performing skin assessments and reassessments on a regular basis, Keeping the client clean and dry at all times to prevent moisture and skin maceration as well as debris, Turning and positioning clients at least every two hours when the client is unable to move about in bed to turn and position on their own, Maintaining the client's nutritional and fluid needs, The utilization of supportive and assistive devices such as a wedge, pillow, and a pressure relieving mattress, The elimination of pressure, friction, shearing and moisture on the client's body and bodily parts, The client will perform active range of motion to all joints two times a day, The client will safely transfer from the bed to the chair with assistance, The client will demonstrate proper deep breathing and coughing, The client will ambulate 30 feet three times a day with a walker and the assistance of another, The client will increase their level of exercise and physical activity, The client will demonstrate the proper use of their assistive device, The client will maintain adequate respiratory functioning, Splint any painful or tender abdominal areas with a pillow or the client's hand, Take the deepest possible diaphragmatic breath through the nose, Repeat this coughing and deep breathing as often as necessary to clear the airways. { "13.01:_Mobility_Introduction" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "13.02:_Basic_Concepts" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "13.03:_Applying_the_Nursing_Process" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "13.04:_Putting_It_All_Together" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "13.05:_Learning_Activities" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "13.06:_XIII_Glossary" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()" }, { "00:_Front_Matter" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "01:_Scope_of_Practice" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "02:_Communication" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "03:_Diverse_Patients" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "04:_Nursing_Process" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "05:_Safety" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "06:_Cognitive_Impairments" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "07:_Sensory_Impairments" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "08:_Oxygenation" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "09:_Infection" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "10:_Integumentary" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "11:_Comfort" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "12:_Sleep_and_Rest" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "13:_Mobility" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "14:_Nutrition" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "15:_Fluids_and_Electrolytes" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "16:_Elimination" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "17:_Grief_and_Loss" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "18:_Spirituality" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "19:_Care_of_the_Older_Adult" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "20:_Answer_Key" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "zz:_Back_Matter" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()" }, [ "article:topic", "license:ccby", "showtoc:no", "authorname:ernstmeyerchristman", "program:openrn", "licenseversion:40", "source@https://wtcs.pressbooks.pub/nursingfundamentals" ], https://med.libretexts.org/@app/auth/3/login?returnto=https%3A%2F%2Fmed.libretexts.org%2FBookshelves%2FNursing%2FNursing_Fundamentals_(OpenRN)%2F13%253A_Mobility%2F13.03%253A_Applying_the_Nursing_Process, \( \newcommand{\vecs}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}}}\) \( \newcommand{\vecd}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash{#1}}} \)\(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\) \(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\)\(\newcommand{\AA}{\unicode[.8,0]{x212B}}\), evidence-based strategies to reduce functional decline, https://doi.org/10.1016/j.pmr.2012.06.009, https://hign.org/consultgeri/try-this-series/reducing-functional-decline-older-adults-during-hospitalization, https://hign.org/consultgeri-resources/try-this-series, source@https://wtcs.pressbooks.pub/nursingfundamentals, Limitation in independent, purposeful movement of the body or of one or more extremities.