Effects of Immobility
Any disorder which impairs:
Nervous System
Musculoskeletal System
Cardiovascular System
Vestibular System
Effects on Musculoskeletal System
~Disuse osteoporosis: bones demineralize (osteoporosis) Loss of Calcium
~Disuse atrophy: unused muscles atrophy
~Contractures: a shortening of the muscle
~Stiffness and pain of the joint: collagen tissue "ankyloses" -> as bone demineralizes, excess Ca bec
Effects on Cardiovascular System (1 of 6)
~Tachycardia (less blood flow to the coronary arteries)
~Increased used of Valsalva maneuver (increases pressure in veins of the thorax)
~Orthostatic hypertension (blood pooling of the blood in lower extremities)
~Venous dilation (blood pooling results in
Parameters of Orthostatic Hypotension
HR increased by 15%
Drop in systolic BP by 15 mmHg
Drop in diastolic BP by 10 mmHg
Effects on Respiratory System
~Decreased respiratory movement (shallow breathing and client rarely sighs)
~Pooling of secretions (rarely sighs, lack of coughing)
~Atelectasis or secretions pool in one area of lung (collapse of lobe or lung)
~Hypostatic Pneumonia (pooled secretions = e
Effects of the Metabolic System
~Decreased BMR (slows down perastalsis)
~Negative nitrogen balance (increased catabolism) -> malnutrition
~Anorexia (decreased BMR)
~Negative calcium balance (greater calcium is extracted from bones than can be replaced)
~Delayed wound healing (protein in
Effects on the Urinary System
~Urinary Stasis (incomplete emptying of kidneys and bladder)
~Renal Calculi (excess amount of calcium -> calcium salts precipitate to form renal stones)
~Urinary Retention (bladder doesnt empty completely, decreased muscle tone)
~Urinary Infection (increa
Effects on Gl System
~Constipation (decreased peristalsis, inadequate hydration, diet)
~Increased Use of Valsalva Manuever
Effects on the Integumentary System
~Reduced skin turgor (atrophy of skin)
~Skin breakdown (decreased circulation to the skin and pressure of immobility)
Effects on the Psychoneurological System
~Decreased endorphins (lack of exercise)
~Decreased self esteem (increased dependence on others)
~Decreased stimuli
Assessments/Interventions: Musculoskeletal System
~Check muscle tone
~Assessement of ROM
~Falls Risk
~ROM (passive and active)
Assessments/Interventions: Cardiovascular System
~BP monitoring (check for orthostatic changes)
~Evaluate peripheral pulses
~Check for venous stasis and edema
~Education regarding Valsalva maneuver (encourage to breathe thru mouth)
~Prevent DVT: Use of SCD or Ted Hose
Assessments/Interventions: Respiratory System
~Encourage cough and deep breathing
~Use incentive spirometer
~Auscultate the lungs
Assessments/Interventions: Metabolic System
~Check height, weight and skinfold thickness (evaluate muscle atrophy)
~Provide HIGH protein, HIGH calorie diet
~Monitor Lab values (serum protein, albumin and BUN)
Assessments/Interventions: Urinary System
~Monitor I & O
~Hydration
Assessments/Interventions: GI System
~Monitor food intake and elimination patterns
~Assess bowel sounds
~Diet HIGH in fiber, fruits and vegetables
Assessments/Interventions: Integumentary System
~Assess for skin breakdown
~Turn Q 2 hours
~Evaluate risk of breakdown using (Braden Scale)
~Skin Care Q shift
Assessments/Interventions: Psychoneurological System
~Evaluate for confusion, feelings of boredom and isolation, depression
~Maintain sleep cycle
~Prevent social isolation
~Encourage client to perform ADLs
Risk Factor
Any situation, habit, social or environment condition, physiological or psychological condition, developmental or intellectual condition, or spiritual or other VARIABLE that INCREASES the VULNERABILITY of an individual group to an illness or accident
Internal Variables: Biological dimension
~Genetic make-up
~Gender
~Age
~Developmental level
~Psychological Dimensions (mind body interaction & self concept)
~Cognitive Dimensions (lifestyle choices & spiritual and religious beliefs)
External Variables
~Environment
~Standards of Living
Database for Risk Assessment: Health History
1. Demographics: age, gender and ethnicity
2. Past health hx: accidents or injuries, chronic disease
3. Family hx: heart disease, diabetes, breast cancer, arthritis, alcoholism
Database for Risk Assessment: Review of System (ROS)
~Non-modifiable risks (Heredity, Age, Gender, Post-Menopausal women)
~Modifiable risks (Elevated serum lipids, hypertension, cigarette smoking, obesity, sedentary lifestyle)
Sensitive information: Health History or ROS
Stress: a condition in which a person experiences changes in the normal balanced state
Holmes and Rahe Social Readjustment Rating Scale (rates positive and negative life events)
Braden Scale
Assess the development of pressure ulcers (decubitus ulcers or bedsores)
Etiology of Pressure Ulcer
~Caused by localized ischemia
~Tissue compressed between bed and bony area
~After compression -> area of pale skin
~After pressure is relieved -> bright red, called "reactive hyperemia"
~If redness disappears -> no permanent damage
~If redness persists ->
Risk Factors: Pressure Ulcers
~Friction and shearing
~Immobility
~Inadequate nutrition
~Incontinence
~Decreased mental status
~Diminished sensation
~Excessive body heat
~Advancing age
~Chronic medical conditions
Maceration
Tissue is softened
Excoriation aka denuded
Loss of superficial layer
Stage 1: Pressure Ulcers
Non-blanchable erythema, signals a potential ulceration
Stage 2: Pressure Ulcers
Partial thickness loss, abrasion, blister, shallow crater which involves the epidermis and possibly the dermis
Stage 3: Pressure Ulcers
Full thickness skin loss, involves damage or necrosis to the subcutaneous tissue that my extend down to the fascia but not thru the fascia
Stage 4: Pressure Ulcers
Full thickness skin loss with TISSUE NECROSIS or DAMAGE to the muscle, bone or supporting structures
Falls Risk Assessment
Designed to prevent clients from falling and to minimize injury from falls
Risk vs high risk clients
High risk with one or more risk factors, if admission is related to a fall, or if determined by the RN
High Risk Clients
~ID bands with yellow arm band
~Yellow safety tag on the door
~Order for FFP
~Implement high risk falls prevention measures
Falls Risk Test
Sit for short time, stand, walk more than 10 ft and then sit again
Interventions
~Take to bathroom every 2 hours during the day, every 4 hours at night
~Check for orthostatic changes, dizziness or lightheadedness when up
~Move closer to nursing station
~Bed/Chair exit alarm
~Reorient
~Encourage family involvement
~Sitter
~Bed in LOW p
Bed Entrapment
An event in which a patient is caught trapped or entangled in the space in or above the bed rail, mattress or hospital bed frame which may result in serious injury or death
Zones of Bed Entrapment
Within the rail
Between rail and mattress
Between split rails
Between end rail and side edge of head or foot board
Between head of foot board and mattress end
Physical Restraint
Bed rails are considered a physical restraint if it prohibits freedom of movement within the environment
Interventions: Bed Entrapment
~Monitor Q 1 hr
~Anticipate needs
~Use of wedges and padding between mattress and side rails
~Ensure call light within reach
~Move client closer to nursing station
~Consider sitter
~Use minimum bedrails for safety and comfort
Aspiration
The entry of gastric secretions, oropharyngeal secretions or food and fluids into the tracheobronchial tree due to dysfunction of normal protective mechanisms
Risk factors: Aspiration
Neurological or nueromuscular disease, trauma or SURGICAL PROCEDURES of the ORAL cavity and THROAT
Dysphagia
Refers to difficulty when swallowing
Can lead to aspiration, pneumonia, decreased nutritional status
Risk Factors: Dysphagia
Neurological and neuromuscular diseases; obstructive diseases of the GI tract