Chapter 47: Mobility and Immobility

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Chapter 47 Mobility and Immobility

• Bonnie M. Wivell, MS, RN, CNS

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The Nature of Movement

• Coordination between the musculoskeletal system
  and the nervous system.
• Alignment and Balance
• The positioning of the joints, tendons, ligaments
  and muscles while standing, sitting, and lying
• Gravity and Friction
• Gravity is the force of weight downward
• Friction is force that opposes movement

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Physiology and Regulation of Movement

• Long bones contribute to height
• Short bones occur in clusters
• Flat bones provide structural contour
• Irregular bones make up the vertebral column and
  some bones of the skull
• Functions of MSK
• Protects vital organs
• Aids in calcium regulation
• Production and storage of blood

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Joints

• Synostotic bones joined by bones no movement
  example skull
• Cartilaginous cartilage unites bony components
  allows for growth while providing stability
  example 1st sternocostal joint
• Fibrous ligament or membrane unites two bony
  surfaces limited movement Example tib/fib
• Synovial A true joint freely movable
• Pivotal
• Ball and socket
• Hinge

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Ligaments/Tendons/Cartilage

• Ligaments white, shin, flexible bands of
  fibrous tissue binding joints together and
  connecting bones and cartilages
• Tendons white, glistening, fibrous bands of
  tissue that connect muscle to bone strong,
  flexible
• Cartilage nonvascular, supporting connective
  tissue

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Skeletal Muscle

• Ability of muscles to contract and relax are the
  working elements of movement
• Muscles are made of fibers that contract when
  stimulated by an electrochemical impulse that
  travels from the nerve to the muscle
• Muscles associated with posture converge at a
  common tendon
• Lower extremities, Trunk, Neck, Back
• Coordination and regulation of different muscle
  groups depend on muscle tone (normal state of
  balanced muscle tension)
• Muscle tone helps maintain functional positions
  such as sitting or standing

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The Nervous System

• The motor strip is the major voluntary motor area
  and is located in the cerebral cortex
• A majority of motor fibers descend from the motor
  strip and cross at the level of the medulla
• Motor fibers from right motor strip control
  voluntary movement on left side of body and motor
  fibers on left control movement on right side of
  body
• Impulses descend from motor strip to spinal cord
• Impulse exits the spinal cord through efferent
  motor nerves and travels through the nerves

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The Nervous System Contd.

• Neurotransmitters or chemicals transfer electric
  impulses from the nerve to the muscle
• Neurotransmitters stimulate the muscles causing
  movement
• Movement is impaired by disorders that alter
• Neurotransmitter production
• Transfer of impulses from the nerve to the muscle
• Activation of muscle activity

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Pathological Influences on Mobility

• Postural abnormalities congenital or acquired
  postural abnormalities affect the efficiency of
  the MSK system as well as body alignment,
  balance, and appearance
• Can cause pain, impair alignment or mobility
• Impaired muscle development patients with
  muscular dystrophy experience progressive,
  symmetrical weakness and wasting of skeletal
  muscle groups, with increasing disability and
  deformity

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Pathological Influences on Mobility

• Damage to the Central Nervous System damage to
  any component of the CNS that regulates voluntary
  movement results in impaired body alignment,
  balance, and mobility
• Complete transection of the spinal cord results
  in a bilateral loss of voluntary motor control
  below the level of trauma
• Damage to the cerebellum causes problems with
  balance and motor impairment is directly related
  to amount and location of destruction
• Trauma to the Musculoskeletal System direct
  trauma results in bruises, contusions, sprains,
  and fractures

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Mobility and Immobility

• Mobility refers to a persons ability to move
  about freely and immobility refers to the
  inability to do so
• The effects of muscular deconditioning associated
  with lack of physical activity are often apparent
  in a matter of days
• Disuse atrophy describes the tendency of cells
  and tissue to reduce in size and function in
  response to prolonged inactivity resulting from
  bed rest, trauma, casting, or local nerve damage

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The Effects of Immobility

• Metabolic changes
• Negative nitrogen balance
• Calcium resorption (loss)
• GI changes
• Constipation ? Impaction ? Mechanical Obstruction
• Respiratory changes
• Atelectasis ? Pneumonia
• Cardiovascular changes
• Orthostatic hypotension
• Increased cardiac workload
• Thrombus formation (Virchows triad)

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The Effects of Immobility Contd.

• Musculoskeletal changes
• ? protein breakdown ? ? lean body mass
• Osteoporosis
• Joint contractures
• Foot drop
• Changes in urinary elimination
• Urinary stasis
• Renal calculi
• Integumentary changes
• Pressure ulcers

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Older Adults

• Immobility can lead to.
• Loss of mobility and functional decline
• Weakness, fatigue, and increased risk for falls
• Shallow breathing resulting in pneumonia
• Inadequate turning/repositioning results in skin
  breakdown and pressure ulcers
• Anorexia and insufficient assistance with eating
  leads to malnutrition
• Multiple interruptions and noise impair sleep,
  causing fatigue, depression, and confusion.

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Mobility

• ROM amount of movement at a joint
• Active/Passive
• See pages 1232 1236
• Gait style of walking
• Exercise and activity tolerance age and illness
  can affect this
• Body Alignment
• Standing/Sitting/Lying
• Patients with impaired mobility, decreased
  sensation, impaired circulation, and lack of
  voluntary muscle control are at risk for damage
  to the MSK system when lying down

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Range of Motion
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Safe Patient Handling

• Protecting the Patient and Health Care worker
• Manually lifting and transferring clients
  contributes to the high incidence of work-related
  MSK problems and back injury
• Lift teams/lift equipment
• Ergonomics training
• Plan ahead based on patient assessment

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Assistive Devices for Patient Movement

• All devices must be appropriate for patient
• Weight limit
• Reason for Device
• Measured to patient
• Canes
• Walkers
• Wheel chairs
• Crutches

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Gait Belt
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Wearing a Gait Belt
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Using a Gait Belt
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Ambulating With a Walker
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Assessment

• Metabolic
• IO
• Lab values
• Height and weight
• Nutritional intake
• Respiratory
• Auscultate lungs
• CV
• Pulses/Cap refill
• Edema/DVT
• MSK
• Muscle tone/strength
• Contractures

• Integument
• Breakdown
• Color changes
• Elimination
• IO
• Bowel sounds
• Frequency and consistency of stool
• Dietary intake
• Psychosocial
• Anxiety
• Depression
• Sleep deprivation

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Plan

• Goals and outcomes individualized
• Set priorities
• Collaborative care team approach

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Interventions

• Health promotion
• Education
• Prevention
• Early detection
• Prevention of work-related MSK injuries
• Use of ergonomics
• Exercise
• Bone health
• Screening
• Maintain independence with ADLs
• Assistive ambulatory devices

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Interventions Contd.

• Metabolic
• High-protein, high-calorie diet
• Vitamin B for skin integrity and wound healing
• Vitamin C for replacing protein stores
• TPN
• Enteral feedings
• Respiratory
• Turn, cough, and deep breathe (TCDB)
• Chest physiotherapy (CPT)
• 2000 mL of fluid daily if not contraindicated

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Interventions Contd.

• CV
• Mobilize ASAP, dangle or sit in chair at minimum
• Isometric Exercise
• Discourage use of valsalva maneuver
• DVT prophylaxis
• TEDS apply properly, remove at least bid
• Avoid crossing legs, sitting for prolonged
  periods of time, wearing constrictive clothing,
  putting pillows under the knees, and massaging
  legs
• Meds

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Interventions Contd.

• MSK
• ROM
• CPM in orthopedics
• Integument
• Screen for risk (Braden Scale)
• Prevention
• Position changes

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Interventions Contd.

• Elimination
• Adequate hydration
• If incontinent, provide frequent skin care
• Catheterize prn
• Foods high in fiber
• Stool softners/cathartics prn
• Psychosocial
• Schedule care to prevent interruption of sleep
• Depression screening (GDS)
• Provide stimulation and re-orient prn
• Involve clients in own care as much as possible

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Positioning
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Semi Fowlers Position
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Sims or Left Lateral Position
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Now lets write a nursing care plan regarding
immobility
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Chapter 48 Skin Integrity and Wound Care
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Skin

• Two layers
• Epidermis has several layers
• Stratum corneum thin, outermost layer
• Allows for evaporation of water from skin
• Permits absorption of topical meds
• Basal layer
• Dermis provides strength, support and
  protection of underlying muscles, bones, and
  organs

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Pressure Ulcers

• Impaired skin integrity (damage to the skin)
  related to unrelieved, prolonged pressure and/or
  shearing/friction
• AKA Pressure sore, decubitus ulcer, bedsore
• Localized injury to the skin or other underlying
  tissue, usually over a body prominence

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Pathogenesis

• Pressure Intensity
• Tissue ischemia can occur due to capillary
  occlusion for a prolonged period of time
• Patients with decreased sensation cannot respond
  to discomfort associated with ischemia hence
  tissue death results
• Blanching occurs when normal red tones of the
  light skinned client is absent (doesnt occur in
  darkly pigmented skin)

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Pathogenesis Contd.

• Pressure Duration
• Low pressure over a prolonged time period
• High-intensity pressure over shot period
• Tissue Tolerance
• Depends on integrity of the tissue and the
  supporting structures
• Shear, friction and moisture make skin more
  susceptible to damage from pressure
• Ability of underlying skin structures to assist
  with redistribution of pressure
• Affected by poor nutrition, increased aging, and
  low BP

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Risk Factors

• Impaired sensory perception
• Impaired mobility
• Alteration in LOC
• Shear
• Friction
• Moisture

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Classification of Pressure Ulcers

• Stage I Intact skin with non-blanchable redness
  of a localized area
• Stage II Partial-thickness skin loss involving
  epidermis, dermis or both superficial abrasion,
  blister, or shallow crater
• Stage III Full-thickness tissue loss
  subcutaneous fat may be visible, slough may be
  present may include undermining and tunneling
• Stage IV Full-thickness tissue loss with exposed
  bone, tendon, or muscle slough or eschar may be
  present on some parts often includes undermining
  and tunneling
• Unstageable if bed is full of slough or eschar

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STAGE I ULCER- GREATER TROCHANTER
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STAGE II ULCER ISCHEAL TUBEROSITY
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STAGE III
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STAGE IV ISCHEAL TUBEROSITY AND SACRUM
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Definitions

• Granulation tissue red moist tissue composed of
  new blood vessels indicates healing
• Slough stringy substance attached to wound bed
  needs removed before wound can heal
• Eschar black or brown necrotic tissue must be
  removed before wound can heal
• Exudate Type (consistency), Amount, Color, and
  Odor of wound drainage part of your assessment

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Process of Wound Healing

• Primary intention edges are well approximated
  or closed risk of infection low heals quickly
  minimal scar formation
• Example surgical wound
• Secondary intention wound is left open until
  becomes filled with scar tissue chance of
  infection is great longer healing time
• Example burn, pressure ulcer, severe laceration

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Complications of Wound Healing

• Hemorrhage/hematoma
• Infection
• Second most common health care associated
  infection
• Dehiscence partial or total separation of wound
  layers
• Evisceration protrusion of visceral organs
  through wound opening
• Fistulas abnormal passage between two organs or
  between organs and the outside of the body

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Prediction and Prevention of Pressure Ulcers

• Risk Assessment
• Braden Scale (see slide in chapter 47)
• Prevention
• Factors influencing pressure ulcer formation and
  wound healing
• Nutrition
• Tissue perfusion
• Infection
• Age
• Psychosocial impact (true impact unknown)

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Assessment

• Assess skin for signs of ulcer development
• Pressure ulcer assessment
• Risk assessment
• Mobility
• Nutritional status
• Body fluids
• Pain

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Wound Assessment

• Type abrasion, laceration, puncture, etc.
• Appearance red, inflamed, clean, dirty
• Drainage TACO
• Drains
• Closures
• Palpation
• Cultures

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Interventions

• Prevention
• Frequent skin assessment
• Keep skin clean and dry
• Dont use soaps and hot water
• Apply moisturizers
• Control/contain incontinence, perspiration or
  wound drainage
• Positioning
• Therapeutic bed/mattress

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Wound Management

• Clean wounds with noncytotoxic wound cleansers
• Normal saline
• Commercial wound cleansers
• Cytotoxic cleansers used for chemical debridement
• Dakins solution (sodium hypochlorite soln)
• Acetic acid
• Providone-iodine
• Hydrogen Peroxide

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Debridement

• Removal of nonviable, necrotic tissue
• Mechanical
• Wet-to-dry saline gauze dressing
• Wound irrigation
• Autolytic
• Uses synthetic dressings that allow the eschar to
  be self-digested by enzymes in wound fluids
• Chemical
• Topical enzyme preparations (Dakins, sterile
  maggots)
• Surgical
• Removal of devitalized tissue b use of scalpel,
  scissors or other sharp instrument

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Wound Management Contd.

• Topical growth factors regulate healing of
  chronic wounds
• Education of client and caregivers is important
• Nutritional status
• Protein status necessary for healing rebuilds
  epidermal tissue
• Hemoglobin decreases delivery of O2 to tissues
  leading to further ischemia

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Dressings

• Dry or moist
• Gauze
• Hydrocolloid
• Protects the wound from surface contamination
• Hydrogel
• Maintains a moist surface to support healing
• Wound V.A.C.
• Uses negative pressure to support healing

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Types of Dressings

• Brands vary by institution
• Follow recommendations of wound care nurse
• See page 1313 of text
• Wound VAC (vacuum assisted closure)
• Negative pressure
• See pages 1321-1323

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Other Wound Devices

• Drains
• Hemovac
• Jackson-Pratt
• Closures
• Staples
• Sutures
• Binders
• Montgomery straps
• Slings
• Sitz baths

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Heat and Cold Therapy

• Assessment for temperature tolerance
• Bodily responses to heat and cold
• Factors influencing heat and cold tolerance
• Education
• http//www.youtube.com/watch?vHx26HCML3W8

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Nursing Diagnosis

• Impaired Skin Integrity r/t immobility as
  evidenced by stage III decubitus ulcer on coccyx

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Plan (stage I ulcer)

• On-going skin assessment
• Nutritional assessment
• Pressure relief for affected areas
• Preventative care for intact skin

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Goals

• Pt. will not have increase in size of pressure
  ulcer during hospitalization
• Pt. will not develop infection in pressure ulcer
  during hospitalization
• Pt. will have nutritional needs identified by
  dietitian
• Patient and family will develop a plan (with
  assistance of nursing) for preventing further
  skin breakdown

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Interventions

• RN to assess skin q shift
• Dietician to complete nutritional assessment and
  recommend a diet within 24 hours
• Assistive personnel to reposition patient q 2
  hours using the following schedule
• 8am supine
• 10 am left side
• 12 noon prone
• 2pm right side.

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Rationale

• Decreasing the duration of pressure on skin will
  prevent further skin breakdown. (Perry and
  Potter, p. 1281)
• Wound healing requires proper nutrition. (Perry
  and Potter, p. 1290)
• Family caregivers require education and
  counseling for interventions to be effective.
  (Perry and Potter, p. 1310)

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Outcome Evaluation

• By discharge date, patient had developed stage I
  ulcer
• Evaluate and update plan for ulcer prevention
• Patient has gained 3lbs by discharge and serum
  proteins have increased
• Family has decided on transfer to LTC for further
  patient care