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Chapter 47: Mobility and Immobility Bonnie M. Wivell, MS, RN, CNS.

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Presentation on theme: "Chapter 47: Mobility and Immobility Bonnie M. Wivell, MS, RN, CNS."— Presentation transcript:

1 Chapter 47: Mobility and Immobility Bonnie M. Wivell, MS, RN, CNS

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

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

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

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

6 Skeletal Muscle Ability of muscles to contract and relax are the working elements of movement 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 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 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) 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 Muscle tone helps maintain functional positions such as sitting or standing

7 The Nervous System The motor strip is the major voluntary motor area and is located in the cerebral cortex 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 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 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 Impulses descend from motor strip to spinal cord Impulse exits the spinal cord through efferent motor nerves and travels through the nerves Impulse exits the spinal cord through efferent motor nerves and travels through the nerves

8 The Nervous System Cont’d. Neurotransmitters or chemicals transfer electric impulses from the nerve to the muscle Neurotransmitters or chemicals transfer electric impulses from the nerve to the muscle Neurotransmitters stimulate the muscles causing movement Neurotransmitters stimulate the muscles causing movement Movement is impaired by disorders that alter Movement is impaired by disorders that alter –Neurotransmitter production –Transfer of impulses from the nerve to the muscle –Activation of muscle activity

9 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 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 Impaired muscle development: patients with muscular dystrophy experience progressive, symmetrical weakness and wasting of skeletal muscle groups, with increasing disability and deformity

10 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 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 Trauma to the Musculoskeletal System: direct trauma results in bruises, contusions, sprains, and fractures

11 Mobility and Immobility Mobility refers to a person’s ability to move about freely and immobility refers to the inability to do so Mobility refers to a person’s 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 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 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

12 The Effects of Immobility Metabolic changes Metabolic changes –Negative nitrogen balance –Calcium resorption (loss) GI changes GI changes –Constipation → Impaction → Mechanical Obstruction Respiratory changes Respiratory changes –Atelectasis → Pneumonia Cardiovascular changes Cardiovascular changes –Orthostatic hypotension –Increased cardiac workload –Thrombus formation (Virchow’s triad)

13 The Effects of Immobility Cont’d. Musculoskeletal changes Musculoskeletal changes – ↑ protein breakdown → ↓ lean body mass –Osteoporosis –Joint contractures  Foot drop Changes in urinary elimination Changes in urinary elimination –Urinary stasis –Renal calculi Integumentary changes Integumentary changes –Pressure ulcers

14 Older Adults Immobility can lead to…. 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.

15 Mobility ROM = amount of movement at a joint ROM = amount of movement at a joint –Active/Passive –See pages 1232 – 1236 Gait = style of walking Gait = style of walking Exercise and activity tolerance: age and illness can affect this Exercise and activity tolerance: age and illness can affect this Body Alignment 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

16 Range of Motion

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21 Safe Patient Handling Protecting the Patient and Health Care worker 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 Plan ahead based on patient assessment

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26 Assistive Devices for Patient Movement All devices must be appropriate for patient All devices must be appropriate for patient –Weight limit –Reason for Device –Measured to patient Canes Canes Walkers Walkers Wheel chairs Wheel chairs Crutches Crutches

27 Gait Belt

28 Wearing a Gait Belt

29 Using a Gait Belt

30 Ambulating With a Walker

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32 Assessment Metabolic Metabolic –I&O –Lab values –Height and weight –Nutritional intake Respiratory Respiratory –Auscultate lungs CV CV –Pulses/Cap refill –Edema/DVT MSK MSK –Muscle tone/strength –Contractures Integument Integument –Breakdown –Color changes Elimination Elimination –I&O –Bowel sounds –Frequency and consistency of stool –Dietary intake Psychosocial Psychosocial –Anxiety –Depression –Sleep deprivation

33 Plan Goals and outcomes individualized Goals and outcomes individualized Set priorities Set priorities Collaborative care: team approach Collaborative care: team approach

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

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

36 Interventions Cont’d. CV 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

37 Interventions Cont’d. MSK MSK –ROM –CPM in orthopedics Integument Integument –Screen for risk (Braden Scale) –Prevention –Position changes

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39 Interventions Cont’d. Elimination Elimination –Adequate hydration –If incontinent, provide frequent skin care –Catheterize prn –Foods high in fiber –Stool softners/cathartics prn Psychosocial 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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41 Positioning

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45 Semi Fowler’s Position

46 Sim’s or Left Lateral Position

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48 Now let’s write a nursing care plan regarding immobility

49 Chapter 48: Skin Integrity and Wound Care

50 Skin Two layers 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

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

52 Pathogenesis Pressure Intensity Pressure Intensity –Tissue ischemia can occur due to capillary occlusion for a prolonged period of time –Patient’s 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 (doesn’t occur in darkly pigmented skin)

53 Pathogenesis Cont’d. Pressure Duration Pressure Duration –Low pressure over a prolonged time period –High-intensity pressure over shot period Tissue Tolerance 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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57 Risk Factors Impaired sensory perception Impaired sensory perception Impaired mobility Impaired mobility Alteration in LOC Alteration in LOC Shear Shear Friction Friction Moisture Moisture

58 Classification of Pressure Ulcers Stage I: Intact skin with non-blanchable redness of a localized area 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 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 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 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 Unstageable if bed is full of slough or eschar

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60 STAGE I ULCER- GREATER TROCHANTER

61 STAGE II ULCER – ISCHEAL TUBEROSITY

62 STAGE III

63 STAGE IV ISCHEAL TUBEROSITY AND SACRUM

64 Definitions Granulation tissue = red moist tissue composed of new blood vessels; indicates healing 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 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 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 Exudate = Type (consistency), Amount, Color, and Odor of wound drainage; part of your assessment

65 Process of Wound Healing Primary intention = edges are well approximated or closed; risk of infection low; heals quickly; minimal scar formation 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 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

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

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

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

69 Wound Assessment Type: abrasion, laceration, puncture, etc. Type: abrasion, laceration, puncture, etc. Appearance: red, inflamed, clean, dirty Appearance: red, inflamed, clean, dirty Drainage: TACO Drainage: TACO Drains Drains Closures Closures Palpation Palpation Cultures Cultures

70 Interventions Prevention Prevention Frequent skin assessment Frequent skin assessment Keep skin clean and dry Keep skin clean and dry Don’t use soaps and hot water Don’t use soaps and hot water Apply moisturizers Apply moisturizers Control/contain incontinence, perspiration or wound drainage Control/contain incontinence, perspiration or wound drainage Positioning Positioning Therapeutic bed/mattress Therapeutic bed/mattress

71 Wound Management Clean wounds with noncytotoxic wound cleansers Clean wounds with noncytotoxic wound cleansers –Normal saline –Commercial wound cleansers Cytotoxic cleansers used for chemical debridement Cytotoxic cleansers used for chemical debridement –Dakin’s solution (sodium hypochlorite soln) –Acetic acid –Providone-iodine –Hydrogen Peroxide

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

73 Wound Management Cont’d. Topical growth factors regulate healing of chronic wounds Topical growth factors regulate healing of chronic wounds Education of client and caregivers is important Education of client and caregivers is important Nutritional status Nutritional status Protein status = necessary for healing; rebuilds epidermal tissue Protein status = necessary for healing; rebuilds epidermal tissue Hemoglobin = decreases delivery of O2 to tissues leading to further ischemia Hemoglobin = decreases delivery of O2 to tissues leading to further ischemia

74 74 Dressings Dry or moist Dry or moist –Gauze Hydrocolloid Hydrocolloid –Protects the wound from surface contamination Hydrogel Hydrogel –Maintains a moist surface to support healing Wound V.A.C. Wound V.A.C. –Uses negative pressure to support healing

75 Types of Dressings Brands vary by institution Brands vary by institution Follow recommendations of wound care nurse Follow recommendations of wound care nurse See page 1313 of text See page 1313 of text Wound VAC (vacuum assisted closure) Wound VAC (vacuum assisted closure) –Negative pressure –See pages

76 Other Wound Devices Drains Drains –Hemovac –Jackson-Pratt Closures Closures –Staples –Sutures Binders Binders Montgomery straps Montgomery straps Slings Slings Sitz baths Sitz baths

77 77 Heat and Cold Therapy Assessment for temperature tolerance Assessment for temperature tolerance Bodily responses to heat and cold Bodily responses to heat and cold Factors influencing heat and cold tolerance Factors influencing heat and cold tolerance Education Education W8 W8 W8 W8

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

79 Plan (stage I ulcer) On-going skin assessment On-going skin assessment Nutritional assessment Nutritional assessment Pressure relief for affected areas Pressure relief for affected areas Preventative care for intact skin Preventative care for intact skin

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

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

82 Rationale Decreasing the duration of pressure on skin will prevent further skin breakdown. (Perry and Potter, p. 1281) 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) 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) Family caregivers require education and counseling for interventions to be effective. (Perry and Potter, p. 1310)

83 Outcome Evaluation By discharge date, patient had developed stage I ulcer 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 Patient has gained 3lbs by discharge and serum proteins have increased Family has decided on transfer to LTC for further patient care Family has decided on transfer to LTC for further patient care


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