1. Discuss nursing interventions that prevent complications of immobility.Prevention Complications of Immobility

Promote adequate elimination Hydration Toilet/Bedside commode whenever possible Fiber supplements Stool softeners PRN laxatives

Prevent pressure ulcers Pressure reduction Pressure relief Repositioning every 2 hr Teach shift weight every 15 minutes Pull sheet to prevent shear Overbed trapeze Perineal hygiene

Individualized exercise program Progressive Active Range of Motion exercises Passive Range of Motion exercises CPM – (continuous passive motion) machine

Prevent deformity Positioning

Trochanter roll: prevents external rotation Hand rolls: hand in functional position Hand-wrist splints Foot boards High –top-sneakers

2. Identify head- to- toe nursing assessments that indicate complications of immobility.Nursing Diagnosis: Impaired Physical Mobility

Limitation of physical mobility

Risks related to: Bed rest

Restriction of movement related to devices (ie: casts, traction) Voluntary restriction (ie: fear of falling) Pain or deformity Muscular deconditioning

Nursing Assessment: Musculoskeletal Effects of Immobility Muscular Deconditioning

Lack of physical activity Bed rest = 3% muscle strength/day Disuse atrophy – pathological reduction in normal size of muscle fibers

Assessment muscle strength, ROM ability to perform ADLs Ability to walk, gait Activity tolerance Risk for falls

Joint contracture Fixation joint Disuse, atrophy, shortening muscle fibers Joint non-functional position

Impaired Calcium metabolism – loss of calcium from bone Disuse osteoporosis Pathologic fractures

Assessment Body alignment Joint position Joint mobility Pain (joint, bone) Functional use of joint Gait Falls

Nursing Assessment: Systemic Effects of Immobility

Respiratoryo Atelectasis (collapse of alveoli)o Hypostatic pneumonia (inflammation lung r/t stasis of secretions)

Assessmento Lung sounds: clear, crackles, wheezeso Oxygenation: mucous membranes, nail beds, cognition, respiratory effort (use accessory

muscle, air hunger)o Assess Pulse Oximetry

Integumentaryo Pressure ulcers caused by prolonged ischemia to tissueo Skin shear injury

Assessmento Inspect skin o Look for non-blanching erythemia over boney prominences

Cardiovascularo Increase cardiac workload

Decrease cardiac outputo Orthostatic hypotension

Drop 20 mm/hg systolic Drop 10 mm/hg diastolic

Assessmento Fatigueo Edemao Auscultate lungs: crackleso Orthostatic BP

Cardiovascular Risk thrombus formation

Loss integrity vessel wall (injury) Abnormality blood flow (slowed blood flow in LE r/t bedrest) Alteration blood constituents (ie: change in clotting factors or increased platelet activity)

Assessmento Pulseso Edema: compare legso Homan’s sign: calf pain on dorsiflexiono Paino Erythemao Warmth

GI: decreased appetite, slowing peristalsis, constipation, fecal impaction (diarrhea caused by stool obstruction)

GU: incomplete bladder emptying (loss help of gravity when supine)

Urinary stasis Increases risk kidney stones UTI

Assessment Abdomen: distention, bowel sounds, tenderness, abnormal tympany, bowel pattern GU: I & O, assess urine for concentration, odor, incontinence, UTI (urgency,

frequency, dysuria)

Nutrition: deficiency in calories and protein (R/T decreased appetite)o Decrease in metabolic rate, changes in metabolism of CHO, fats, proteino Negative nitrogen balance

More nitrogen excreted than ingested(food) Weight loss Decrease muscle mass Weakness

Assessmento Weighto Calorie counto Muscle strength, sizeo Lab studies: Albumin, Pre-albumin

Psychological/SocialDepression

Sleep-wake disturbances Impaired coping Change self concept

Older Adults Effects of immobility accelerated! Functional decline Delirium

Assessmento Affect, eating, somatic complaints, verbalizations of despair, negativityo Ability to get to sleep and stay asleep, daytime sleepingo Cognition: abrupt change in cognitiono Ability perform ADLs

Complications of a fracture: infection Compartment syndrome Venus thromboembolism Fat embolism syndrome Muscle atrophy Contracture Footdrop Pain Muscle spasms Pressure ulcers

Open fractures and soft tissue injuries have incidence Osteomyelitis

State the symptoms of fat embolism.

Fat Embolism Syndrome (FES) Characterized by the presence of fat globules in tissues and organs after a traumatic

skeletal injury Tissues most often affected:

Lungs Brain Heart Kidneys Skin

Fractures that most often cause FES: Long bones Ribs Tibia Pelvis

Clinical Manifestations Usually occur 24 to 48 hours after injury Interstitial pneumonitis Produce symptoms of ARDS

Clinical Manifestations Symptoms of ARDS:

o Chest paino Tachypneao Cyanosiso PaO2 o Dyspneao Apprehensiono Tachycardia

Rapid and acute course Feeling of impending disaster Client may become comatose in a short time

Collaborative Care Treatment directed at prevention Careful immobilization of a long bone fracture Most important preventative factor Symptom management Fluid resuscitation Oxygen Reposition as little as possible

State the symptoms of pulmonary embolismState the symptoms of compartment syndrome.Compartment Syndrome

elevated intracompartmental pressure within a confined myofascial compartment compromises the neurovascular function of tissues within that space. Causes capillary perfusion to be reduced below a level necessary for tissue viability Acute – fractures, burns, knee or leg surgery Exertional – intensive exercise Crush injuries

Two basic etiologies create compartment syndrome: Decreased compartment size

o Restrictive dressingso Splintso Casts

Increased compartment contento Bleedingo Edema

Clinical ManifestationsSix Ps:

• Paresthesia• Pain • Pressure• Pallor• Paralysis

• Pulselessness

Client may present with one or all of the six Ps!

Absence of peripheral pulse Ominous late sign

Myoglobinuria Dark reddish-brown urine

Collaborative Care Prompt, accurate diagnosis is critical Early recognition is the key Do not apply ice or elevate above heart level Remove/loosen the bandage and bivalve the cast Traction weight reduction Surgical decompression (fasciotomy)

Complications of FracturesVenous Thrombosis

Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture, especially hip fracture

Precipitating factors:o Venous stasis caused by incorrectly applied casts or tractiono Local pressure on a veino Immobility

State interventions for the client with a sprain/ sprain.

Musculoskeletal Injuries Sprains

Injury to ligaments Wrenching and twisting Classified according to amount of ligament fibers torn

Strains Excessive stretch of a muscle and tendon

Musculoskeletal Injuries Nursing Assessment of Strains and Sprains

Pain Edema Decrease in function

Bruising

Nursing Preventionso Primaryo Secondary

RICE (rest, ice, compression, elevation) Mild analgesics

Musculoskeletal Injuries Dislocations – complete separation articular surfaces of a joint Subluxation – partial separation Nursing Assessment

Joint asymmetry Pain Tenderness Loss of function Edema

Nursing Preventions Medical emergency Pain control Joint protection Gradual increase ROM (support joint)

Desrcibe Fractures:

What is a fracture A disruption or break in the continuity of the structure of bone Traumatic injuries account for the majority of fracturesFracture LocationWhat is a fracture?What is a fracture?What is a fracture?Stress Fracture tiny cracks in a bone occur during high-impact repetitive activity most common in the weight-bearing bones of lower leg and foot osteoporosis Fractures Closed (simple) Open (compound)

Classified by appearance, position, and alignment of the bone fragments

Stable fractures Occur when a piece of the periosteum is intact across the fracture External or internal fixation has rendered the fragments stationary

Unstable fractures Grossly displaced Site of poor fixation

Immediate localized pain Muscle spasms Guarding

Function Inability to bear weight or use affected part

Edema and swelling Deformity (but not all fractures!) Ecchymosis Crepitation

Nursing Assessment after an injuryEmergency

o ABCs Bleeding Vital signs Level of consciousness Pulses

Pain

Site of injuryLacerations

Skin color and temp Ecchymosis Hematoma Edema Loss of function, alignment Muscle strength Joint crepitation

Limb below injury Pulses

Paresthesias Change in sensation Capillary refill Temperature

Fracture Healing

• Fracture hematoma• Granulation tissue• Callus formation• Ossification• Consolidation• Remodeling

Reduction Anatomic realignment of bone fragments Immobilization Maintain alignment Restoration of normal function

Closed reduction Nonsurgical Manual realignment

Open reduction Surgical procedure Placement of wire, screws, plates, pins, rods, nails

Application of a pulling force to an injured part of the body while countertraction pulls in the opposite direction

Collaborative Care Fracture Reduction/Immobilization Traction

Skin traction (short-term) Skeletal traction (longer periods)

Purpose of traction: Prevent or reduce muscle spasm Immobilization Reduction Treat a pathologic condition Neck – degenerative disc disease Back – muscle spasms

Collaborative Care Fracture Immobilization Casts

Immobilization after closed reductionCollaborative Care Fracture Immobilization

Short arm cast Long arm cast

Long leg cast Short leg cast

Collaborative Care Fracture Immobilization

Body jacket cast Hip spica cast

Collaborative Care Fracture Immobilization External fixation

Metallic device composed of pins that are inserted into the bone and attached to external rods

“skeletal traction”Collaborative Care Fracture Immobilization Internal fixation

Pins, plates, intramedullary rods, and screws

Surgically inserted at the time of realignment

Collaborative Care Drug Therapy Pain managment

Muscle relaxant Analgesics

Tetanus-diphtheria toxoid or immunoglobulin Bone-penetrating antibiotic

Cephalosporin

Nursing Management Nursing Assessment Brief history of the accident Mechanism of injury Collaborative care (reduction/immobilization)

Nursing Assessment after fracture reduction and immobilizationNeuro-vascular assessment

Color (pink, pale, cyanotic) Temperature (hot, warm, cool, cold) Capillary refill (3 second rule!) Peripheral pulses (present, equal, strong, by Doppler, absent) Edema

Nursing Assessment after fracture reduction and immobilizationNeuro-vascular assessment

Sensation numbness, tingling decreased, hypersensation,

Motor function Hand – abduction/adduction fingers, supination/pronation hand Leg – dorsiflexion and plantar flexion Equal strenght

Pain Location Quality Intensity 1-10

Nursing DiagnosesFracture reduction and immobilization

Risk for peripheral neuro-vascular dysfunction Acute pain Risk for infection Risk for impaired skin integrity Impaired physical mobility Ineffective therapeutic regimen management

Facture reduction and immobilizationPlanning Physiologic healing with no associated complications Pain relief Achieve maximal rehabilitation potential

Facture reduction and immobilization Primary Preventions Fall prevention Use of seat belts Stretching before exercising Participate in moderate exercise

Fracture reduction and immobilization Secondary Preventions Preoperative management Inform of immobilization device and expected activity limitations Skin preparation Postoperative management Monitor vital signs Frequent neurovascular assessments Carefully monitored mobility Pain management Hydration High fiber diet

Facture reduction and immobilization Secondary Preventions

Skin Traction Neurovascular assessment Use trapeze for repositioning Ensure proper functioning of tractioning equipment

Body alignment Weights hang freely

Skin care and repositioning to prevent pressure ulcers

Skeletal Traction Pin site care

Pin should be immobile Assess for infection Removal of exudate

Facture reduction and immobilzation Secondary Preventions

Cast care Frequent neurovascular assessments Teach patient signs of complications

Increased pain Edema Discoloration of digits Burning/tingling under cast Odor “sores” under cast

Elevation of extremity above level of the heart Exercise joints above and below the cast

Facture reduction and immobilizationSecondary Preventions Spiritual Variable Psychosocial Variable

Management of ADLs Social support systems

Change in family constellation – change in role expectations Financial

Evaluate presence of posttraumatic stress disorder

Facture reduction and immobilizationSecondary Preventions Ambulation Usually started in mobility training when able to sit in bed and dangle feet over the side

Weight bearing: None, Partial, Total Assistive devices

o Caneo Walkero Crutches

Fracture reduction and immobilization Evaluation Normal neurovascular examination Tolerable or no pain No evidence of infection No evidence of skin breakdown Crutches correctly used Minimal loss of muscle mass of affected extremity Identify assessment findings for a broken hipFractures: Hip Fracture More common in older adults

The Older Adult with Hip Fracture Physiological VariableStressors Type of fracture Type of surgery

Postoperative concerns DVT PE Infection Weight-bearing/ambulation Nutrition Pain

The Older Adult with Hip Fracture

Developmental Variableo Sexual activityo Neurocognitive complications

Psychological VariableStressors

o Deleriumo Depressiono Agitation/aggression

Sociocultural Variableo Social support systemso Managing ADL’s

Spiritual VariableStressors

o Search for meaningo Community/religious support systems

Fractures: Hip Fracture Clinical Manifestations

o External rotationo Muscle spasmo Shortening of affected extremityo Paino Tenderness

Collaborative Careo ORIF (open reduction, internal fixation)

Femoral head replaced with prosthesis Plate/screws/ pins/intramedullary rod

Nursing Assessment Hip Fracture

Lateral rotation leg One leg shorter

Fractures: Hip FracturePost-Operative Preventions Vital signs I & O Cough & Deep breathing Incentive spirometry Pain management Prophylactic anticoagulation

LMWH Heparin (SQ) Coumadin

Incisional care Assess for infection, bleeding

Neurovascular assessment Proper joint alignment

o Abductor pillow Hip precautions

o Avoid flexion > 90 Use raised toilet seat

o No adduction No leg crossing

o No internal rotation

“Hip Precautions”Older Adult with Hip Fracture Hip prosthesis dislocation

Increased pain at surgical site, swelling, immobilization Acute groin pain Abnormal external or internal rotation Inability to move leg “popping” sensation

Older Adult with Hip Fracture Nursing Diagnosis

Acute pain Impaired physical mobility Impaired skin integrity Risk or impaired urinary elimination Risk for ineffective coping Risk for disturbed thought processes Risk for ineffective health maintenance

Collaborative Diagnosis Hemorrhage Infection Peripheral neurovascular dysfunction DVT Pulmonary complications Pressure ulcer Joint dislocation

Describe care of client after knee replacement: A compression dressing may be used to immobilize the knee in extension immediately

after the operation Great emphasis is placed on postoperative physical therapy Isometric quadriceps begins the first day after surgery Progresses to straight leg raises and gentle rom to increase muscle strength

State interventions for the client with osteoporosis: Preventions focus on adequate calcium supply exercise