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.`