Immobility & Body Mechanics

Refers to the ability to engage in activity and free movement, which includes walking, running, sitting, standing, lifting, pushing, pulling and performing ADLs (Activities of Daily Living)

Is a therapeutic intervention that achieves: Rest for clients who are exhausted Decreases bodys O2 consumption Reduces pain and discomfort To reverse effects of gravity-abdominal hernia After 48 hr of bed rest-structural changes in joints and shorten muscles occur 7 days are needed to restore function lost after 1 day of bed rest (Eliopoulos, 1999)

Metabolic: decrease in BMR r/t decreased energy requirements, which is directly r/t cellular 02 demands Results in > % body fat & loss of lean body mass Altered carbohydrates ,proteins, fats metabolism Fluid and electrolyte imbalances

Orthostatic hypotension due to prolonged bed rest. Drop of 15 mm Hg or more in systolic BP with position change Decrease circulating volume, pooling of blood in lower extremities(edema), decreased autonomic response results in decrease in venous return, central venous pressure, stroke volume, increase in HR=>>>cardiac workload,02 demand Due to stasis >>> risk thrombus formation

Increase activity slowly but progressively Avoid crossing legs, pressure behind knee Encourage antiembolic leg exercises q 2 hours, other isometric exercises Ant embolic hose Gradually raise client noting BP, HR, assess dizziness/lightheadedness

Decrease in lung expansion, generalized respiratory muscle weakness, and stasis of secretions Decreased hemoglobin levels Atelectasis --collapse of alveoli resulting in decrease of 02 / C02 exchange Hypostatic pneumonia inflammation of the lung from stasis or pooling of secretions

Change of position q 1 2 hr which allows elastic recoil property of lungs and clears dependent lung secretions Cough and deep breath q 2 hr, incentive spirometry, chest physiotherapy Fluids to 3000 ml / 24 h to thin secretions

Decrease in appetite, peristalsis, constipation

NI: high fiber foods, fluids to 3000 ml/24hr Small frequent foods of choice Monitor bowel sounds q shift Monitor bowel patterns 24 hours Stool softeners daily as ordered

Muscle atrophy Loss of strength and decreased endurance Joint contractures Decreased stability or balance Disuse osteoporosis, a disorder characterized by bone reabsorption-results from impaired calcium metabolism

Frequent ROM: active, passive, active assist q 4 hours Develop an individualized progressive exercise program
Isometric and isotonic exercises q 4 hours

Urine formed by the kidney must enter the bladder against gravity due to recumbent position Ureters insufficient to overcome gravity, renal pelvis may fill with urine-urinary stasis which increases risk for UTI & renal calculi Renal calculi-calcium stones lodged in in renal pelvis and pass through ureters

Position change q 1-2 hours Position 30 degrees of higher to enhance gravitational forces required for normal urine flow through kidney, ureters, bladder I & O q 8 hours Fluids to 3000 ml 24 hours RD for diet plan r/t calcium intake

Increase isolation, passive behavior, changes in sleep/wake cycles, stressors, sensory deprivation/overload
Decrease in self-identity, self-esteem, coping strategies

Anticipate changes-provide routine and informal socializationinteract with staff q 1-2 hours Place in room with others Encourage family and friends to visit-space Activity and recreational consult Schedule nursing cares from 10pm-7am to minimize interruptions

Increase in dependence Regression in development NI: care should stimulate client mentally, focus on activities that promote cognitive awareness, allow client to make care decisions, allow to be as independent as condition permits

Previously called: a decubitus ulcer A pressure sore A pressure ulcer A bedsore is a wound caused by unrelieved pressure that damages underlying tissue

Jury still out: caused by external pressure transmitted inward or from the bone and proceeds outward

Pressure ulcers is a wound caused by unrelieved pressure that damages underlying tissue. The pressure interferes with the tissue blood supply, leading to vascular compromise, tissue anoxia, and cell death Tend to be located over bony prominences: *elbows, posterior calf, *sacrum/coccyx ischial tuberosities, trochanter, lateral malleous, *heel, lateral edge of foot also: ears, occiput, great toe region

AHCPR: Agency for Health Care Policy and Research establish guidelines to identify atrisk individuals needing prevention and the specific factors placing them at risk
Risk assessment tool: Braden Scale or Norton Scale are most commonly used.

Assesses sensory perception: ability to respond meaningfully to pressure-related discomfort Moisture: degree to which skin is exposed to moisture Activity: degree of physical activity Mobility: ability to change and control body position Nutrition: usual intake pattern

Friction and Shear: Each category measured from 1-4 with low score having most limitation Overall score: Maximum of 23, little or no risk A score of 16 or < indicates at risk A score of 9 or < indicates high risk Implement preventive measures for at risk and high risk clients

Tissue ischemia is localized absence of blood or major reduction of resulting in mechanical obstruction. The reduction of blood floe caused blanching (to become pale-blotchy) When obstruction of blood flow is removed normally there will be reactive hyperemia, the blood vessels dilate and skin is red Will last for less than 1 hr and is effective

only if there is no necrosis of tissue

Abnormal reactive hyperemia is an excessive vasodilatation and induration in response to pressure. Skin appears bright pink and there is localized edema under the skinmay last up to 2 weeks after pressure is removed

Shearing force: sliding down in bed Friction: linens on the bed Moisture: diaphoresis urine, wounds, feces Poor nutrition: neg nitrogen balance Anemia: < 02 carrying capacity Obesity: poor vascular supply, weight Age: epidermis thins with age, < blood flow LOC: drowsy, sedated, comatose=1position

Non blanchable erythema of intact skin. Does not resolve in 30 minutes but remains for longer than 2 hours after pressure is relieved This occurs as an acute inflammatory response involving the epidermis

There is partial thickness loss

Pressure area appears as an abrasion, blister, or shallow crater surrounded by erythema and induration

Ulcer involves full-thickness tissue destruction involving subcutaneous tissue, as well as epidermis and dermis
The muscle layer is in tact Requires Wound Nurse consult, may require surgical intervention

Includes all of above changes, plus, extensive damage involving muscle, bone, or supporting structures such as tendons or joint capsule
Requires Wound Nurse consult and surgical intervention

Emphasis is on prevention !!! Autolysis: uses bodys own enzymes and moisture to re-hydrate, soften and liquefy necrotic tissue Use occlusive or semi-occlusive dressings: hydrocolloids, hydrogels, transparent films Used with wounds with little drainage and uninfected

Very selective, with no damage to surrounding skin Safe, using the bodys own defense mechanisms to clean the wound of necrotic tissue Effective, versatile and easy to perform Little or no pain for the client

Not as rapid as surgical debridement

Wound must be monitored closely for signs of infection May promote anaerobic growth if an occlusive hydrocolloidal is used

Chemical enzymes are fast acting products that produce slough of necrotic tissue. Some enzymatic debriders are selective, while some are not. Best uses: on any wound with a large amount of necrotic tissue Escar formation

Fast acting
Minimal or no damage to healthy tissue with proper application

Expensive Requires a prescription Application must be performed carefully only to necrotic tissue May require secondary dressing Inflammation or discomfort may occur

Uses force to remove necrotic tissue, for example wet-to-dry, whirlpool treatment, or wound irrigation devices

Cost of the actual material is low

May traumatize healthy or healing tissue Time consuming Can be painful Hydrotherapy can cause tissue maceration and water borne pathogens may cause contamination or infection Disinfecting additives may harm health tissues

Cutting dead tissue away from the wound Considered the fastest and most effective type of debridement Can be done at bedside, surgical suite, or in an outpatient setting Should be considered when infection such as cellulitis or sepsis suspected

Wounds with a large amount of necrotic tissue Used in conjunction with infected tissue Fast and selective Cant be extremely effective

Painful Costly, esp if operating room is required Requires transport of client to OR

Maggot larvae placed in wound and ingests the microorganisms Used extensively in Europe and is gaining popularity in the US

Develop and post a turning schedule Use a pressure-reducing devices Assess pressure points daily After urinating or stooling cleanse, rinse, dry Establish a bowel/bladder program barrier Monitor intake and output q 8 hr Use trapeze and foot boards Protect friction-prone areas

Proper diet: good protein intake, Vitamin C, supplements between meals if necessary Use lift sheets, hoyer lift, smooth roller Personal hygiene measureskeep clean dry and linens wrinkle free. Avoid use of alkaline and deodorant soaps due to dryness. Use emollients to preserve natural state of skin moisture

Coordinated effort of the musculoskeletal system to maintain posture, balance, and body alignment during lifting, bending, etc.

Refers to the relationship of body parts to one another.

Reduces muscle strain Maintains muscle tone Contributes to balance Contributes to system functioning

Directly related to alignment and achieved when: COG is low Stable (wide) base of support Vertical line from COG thru base of support

Imaginary vertical line which goes thru center of body

Point at which all of the mass of an object is centered; in the adult, who is in a standing position it is in the pelvis;

Foundation of an object To stabilize: lower your center of gravity and broaden your base of support

Force exerted by gravity on the body.

Force that occurs in a direction to oppose movement.

Reduce surface area Passive object produces more friction Lift rather than pull object

Use wide base of support Keep COG low Keep line of gravity passing through base of support Face direction of movement when possible

Roll, pull, push objects rather than lift Use largest & strongest muscles Keep object close to COG Reduce area of contact

Move object on flat level, smooth surface

Bed: Deep breath, neck rolls, knees to chest, pelvic tilts, head raising, leg lifts, foot dorsi and planter flex, ankle rotations, rolling, arms over head, side to side, palms up and rotate Chair: deep breathing, head rolls, knee to chest, head to knees, shoulder rolls, hands on head, leg lifts, ankle rotation, push down of legs, lean forward, lift up. Use Thera bands handball

Refers to the presence of a blood clot in one of the veins

Risks: prescribed bedrest General anesthesia for clients > 40 years of age Leg trauma resulting in immobilization Previous venous insufficiency Obesity Oral contraceptives Malignancy

Anti embolic hose: TED are effective in providing support to vasculature while client is in bed
Compression Hose: JOBST are effective in providing support to vasculature while client is ambulatoryALWAYS apply BEFORE client gets out of bed in the AM. Often removed at HS.`