Post on 25-Dec-2015
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 client’s who are exhausted◦Decreases body’s 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 socialization—interact 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 at-risk 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 skin—may 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 body’s 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 body’s 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 measures—keep 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 client’s > 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 ambulatory—ALWAYS apply BEFORE client gets out of bed in the AM. Often removed at HS.`