Chapter 25 Mechanical Immobilization

Some people are inactive and physically immobile due to overall debilitating conditions. Others have impaired mobility resulting from trauma or its treatment. ◦Orthoses ◦Orthopedic devices used to support or align a body part and prevent/correct deformities ◦Splints,immobilizers, braces, slings, casts, etc. Caring for individuals with orthopedic devices requires specialized training

Purposes Most who require mechanical immobilization have suffered trauma to the musculoskeletal system Such injuries are painful and heal slower than injuries to soft tissue Require a period of inactivity to allow new cells to restore integrity to damaged structures

Purposes Mechanical immobilization of body part is used to accomplish the following: ◦Reduce pain and muscle spasms; support and align skeletal injuries ◦Restrict movement and maintain functional position while injuries heal; allow activity while restricting movement of injured area ◦Prevent further structural damage/deformity

Mechanical Immobilizing Devices The use of various devices can achieve therapeutic benefits Examples include splints, slings, casts, and traction

Splints ◦Device to immobilize/protect an injured body part ◦Used before or instead of casts

Splints Splint types include: ◦Emergency ◦First aid for suspected sprains/fractures ◦Commercial ◦More effective than improvised splints ◦Variety of designs depending on injury

Splints ◦Inflatable ◦Also called “pneumatic splints” ◦Become rigid when filled with air ◦Limit motion, control bleeding/swelling ◦Injured part inserted into deflated splint ◦Air infused and splint molds to injured body part ◦Fill to point which allows indentation with fingertips ◦Injury should be checked and treated within minutes after application

Inflatable Splints

Splints ◦Traction ◦Metal devices that immobilize and pull on contracted muscles ◦Not as easy to apply as inflatable splints ◦May require special training for application to prevent further injury

Traction Splints

Other Splints Commercial splints ◦More effective than improvised splints ◦Include: oImmobilizers oMolded splints oCervical collars

Commercial Splints Immobilizers ◦Made from cloth and foam ◦Held in place with velcro straps ◦Limit motion in the area of a painful but healing injury such as neck and knee ◦Removed for brief periods during hygiene and dressing

Commercial Splints Molded Splints ◦Made of rigid materials and used for chronic injuries/diseases ◦Appropriate for repetitive motion disorders (carpal tunnel syndrome) ◦Provide prolonged support and limit movement to prevent further injury and pain ◦Maintain body part in functional position to prevent contractures/muscle atrophy during immobility

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Cervical Collars ◦Foam or rigid splint placed around neck ◦Treat athletic neck injuries/trauma resulting in neck sprains/strains (whiplash) ◦Mild/moderate injury- foam collar ◦Severe-rigid collar ◦Size based on circumference of neck and distance between chin and shoulders

Commercial Splints Cervical Collars ◦When applying, place head in neutral position with front of collar positioned well beneath chin and slid upward until chin supported ◦Opening centered at back of neck ◦Velcro straps secure collar in position ◦Client should be able to breathe and swallow effortlessly ◦Can wear continuously for 10 days-2 weeks ◦Remove to do gentle ROM; sooner performed, quicker recovery ◦Assess neuromuscular function during recovery

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Mechanical Immobilizing Devices Slings Cloth device to elevate, cradle, support body part Effectiveness requires proper application

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Mechanical Immobilizing Devices Braces Types of braces –Prophylactic-prevent/reduce severity of injury –Rehabilitative-protected motion of injured joint that was treated operatively –Functional-provide stability for an unstable joint Braces usually worn during active periods Typically made of metal or leather Improper application/ill fitting can cause discomfort, deformity, skin ulcerations due to friction/prolonged pressure

Rehabilitative Brace

Casts Rigid mold placed around injured body part after realignment Casts are used to immobilize injured body structures Made of Plaster of Paris or Fiberglass

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Casts Types of casts oCylinder (may be bivalved) oEncircles arm/leg leaving toes/fingers exposed oExtends from joint above and below injury oBody (may be bivalved) oLarger form of cylinger; encircles trunk of body oSpica oEncircles one/both arms or legs and trunk/chest oMay have abduction bar; shoulder or hip

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Cast Materials

Cast Application Nurse prepares client Assembles cast materials Assists physician during cast application

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Casts (cont’d) Cast care ◦Assess skin integrity (color, motion, sensation; CMS) ◦Apply petals to roughened areas

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Cast removal Electric cast cutter may frighten clients due to noise Skin care important after cast removal

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Traction Traction: pulling effect exerted on a part of the skeletal system ◦Pull of traction offset by patient’s own body weight ◦Involves use of weights connected to patient with ropes, pulleys, slings, etc. Uses ◦Reduce muscle spasms; Realign bones ◦Relieve pain; Prevent deformities

Traction types include: – Manual – Pulling on body using hands and strength – Used frequently to replace dislocation – Skin – Devices applied to skin such as pelvic belt, Buck’s/Russell’s traction – Skeletal- pulls directly on bone with wires, pins, tongs into bone

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Traction care – External fixator – Pin site care to prevent infection Effective traction depends on consistent application of traction principles

External Fixators Metal devices surgically inserted into or through one or more broken bones to stabilize during healing

Principles for Maintaining Effective Traction

Fractures -General Gerontologic Considerations Common causes of hip fractures in older adults Longer healing time due to brittle bones Stiffer joints due to decreased synovial joint fluid

Due to diminished tactile sensation, older adults may be unaware of skin pressure from cast, brace, etc. Remove indwelling catheters as soon as possible after surgery to prevent incontinence and urinary tract infections Cautious use of narcotics for pain management to avoid adverse effects Fractures -General Gerontologic Considerations

Implement measures to increase bone density in older adults to prevent fractures: ◦Drink liquid supplements high in nutrients; include protein, calcium, and zinc in diet to promote healing in a musculoskeletal injury ◦Encourage sun exposure for vitamin D absorption

Post-orthopedic surgery interventions for older adults ◦Bladder training schedules to maintain or regain continence ◦Appropriate rolling technique when using fracture-style bedpan

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General Gerontologic Considerations (cont’d) Nonsurgical treatment of fractures of the upper extremities includes: ◦Immobilization ◦Occupational and physical therapy to regain function and range of motion

Debilitated clients require physical conditioning before they can ambulate again Some techniques for increasing strength and weight bearing include ◦isometric exercises for lower limbs ◦Isotonic for upper arms ◦Dangling at bedside ◦Use of a tilt table

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Preparing for Ambulation Isometric exercises: –Promote muscle tone and strength –2 types include: –Quadriceps setting: client alternately tenses and relaxes the quadriceps muscles –Gluteal setting: client contracts and relaxes the gluteal muscles to strengthen and tone them Easily performed in bed or chair Initiated long before ambulation begins

Quadriceps and Gluteal Setting Exercises

Upper arm strengthening: flexion and extension of the arms and wrists; raising and lowering weights with the hands; squeezing a ball or spring grip; modified hand push-ups in bed Dangling: normalizes blood pressure Using a tilt table Preparing for Ambulation

Assistive Devices Devices to support and assist walking: –Parallel bars (handrails) provide practice in ambulating –Walking belt applied around client’s waist provides secure grip to prevent injury while ambulating

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Ambulatory Aids Crutches: generally used in pairs and made of wood or aluminum –Axillary- fit under axilla –Forearm -cuff for arm; no axillary bar –Platform -support forearm; for people who cannot bear weight with hands/wrists

Crutch-walking gaits: pattern of walking when ambulating with crutches ◦Four-point gait -bilateral weakness; one crutch opposite foot ◦Three-point gait -both crutches followed by follow through leg ◦Two-point gait -same as 4 point but movement in unison ◦Swing-through gait -both crutches and legs

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Cane: a hand-held ambulation device made of wood or aluminum –Rubber tips reduce possibility of slipping –Different handles and bases –Handle should be parallel with hip –Should be on stronger side of body

Using a Cane

Prosthetic Limbs Temporary prosthetic limb: immediate postoperative prosthesis (IPOP) Permanent prosthetic components delayed for several weeks or months to be sure: ◦Incision has healed ◦Stump size is relatively stable ◦Custom-made to conform to stump and meet client needs

Prosthetic Limbs (cont’d) Prosthetic components include: –Below the knee: socket, shank, ankle/foot system –Above the knee: below-the-knee components plus a knee system Ambulation with a lower limb prosthesis requires strength and endurance

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General Gerontologic Considerations Functional ability involves mobility and making adaptations to compensate for changes occurring with aging or disease processes May need encouragement and support integrating adaptations into their activities of daily living and maintaining their self-concept and body image Maintaining independence is important to older adults

General Gerontologic Considerations (cont’d) Mobility facilitates staying active and independent As a person ages, he or she may develop flexion of the spine which alters the center of gravity and may increase falls Ensure adequate lighting without laying electric cords in passageways Elevate toilet seats; install grab bars Rearrange home furnishings

Chapter 18 ANTIINFLAMMATORY, MUSCULOSKELETAL, AND ANTIARTHRITIS MEDICATIONS 64

Muscular and Skeletal Systems Bones, joints, muscles, and ligaments Antiinflammatory and analgesic drugs Skeletal muscle relaxants Drugs used to treat arthritis Drugs used to treat gout 65

The Inflammatory Response Triggers to inflammation Phases of the inflammatory response Symptoms of inflammation Cellular response 66

Salicylates Aspirin (ASA) Action Analgesic, antipyretic, and antiinflammatory effects Stop the production of prostaglandins Uses Treatment of mild to moderate pain; reduces the risk of myocardial infarctions and stroke, as well as transient ischemic attacks (TIAs) in men First-line therapy for various forms of arthritis, fever, myalgia, neuralgia, arthralgia, headache, and dysmenorrhea Systemic lupus erythematosus, acute rheumatic fever 67

Antiinflammatory and Analgesic Agents Aspirin: acetylsalicylic acid (ASA) ◦Acetaminophen ◦NSAIDs 68

Salicylates Aspirin(cont.) Adverse Reactions Tinnitus, visual disturbances, edema, urticaria, anorexia, epigastric discomfort, and nausea Drug Interactions Alcohol use increases the chance for GI bleeding; NSAIDs; sulfonamides, sulfonylureas; phenytoin 69

Salicylates (cont.) Nursing Implications Assessment, diagnosis, planning, implementation, and evaluation Patient Teaching Administration time, adverse effects; time for drug effectiveness; implications for drug interactions and when to contact the healthcare provider; storage and safety; other routes of administration if PO is not tolerated 70

Acetaminophen Over-the-counter drug used to treat fever and pain; no antiinflammatory effect Action: antipyretic – direct action of the hypothalamic heat-regulating center; blocks pyogenic cytokines through vasodilation and sweating Use: chronic, nonmalignant pain; osteoarthritis Adverse reactions: rare blood response; liver toxicity; overdosage can be fatal Drug interactions and hepatotoxicity 71

Nonsteroidal Antiinflammatory Drugs …..NSAIDS Action: unknown; may block prostaglandins; analgesic, antiinflammatory, and antipyretic effects Uses: rheumatic disease, degenerative joint disease, osteoarthritis, and acute musculoskeletal problems Adverse reactions: GI most common Drug interactions Nursing implications and patient teaching. 72

Williams' Basic Nutrition & Diet Therapy CHAPTER 15 WEIGHT MANAGEMENT COPYRIGHT © 2013 MOSBY, INC., AN IMPRINT OF ELSEVIER INC. ALL RIGHTS RESERVED th Edition

Lesson 15.1: Causes of Obesity and Risks of Food Fads  Underlying causes of obesity include a host of various genetic, environmental, and psychological factors.  Short-term food patterns, or fads, often stem from food misinformation that appeals to some human psychological need but does not necessarily meet physiologic needs. 74 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Introduction (p. 280) Currently in the United States ◦34.2% of adults are overweight ◦33.8% are obese ◦5.7% are extremely obese ◦16.9% of children and adolescents are obese COPYRIGHT © 2013 MOSBY, INC., AN IMPRINT OF ELSEVIER INC. ALL RIGHTS RESERVED. 75

Introduction (cont’d) (p. 280) Overweight and obesity, by age: United States, COPYRIGHT © 2013 MOSBY, INC., AN IMPRINT OF ELSEVIER INC. ALL RIGHTS RESERVED. 76

Obesity and Weight Control (p. 280) Body weight and body fat ◦Definitions ◦Body composition Measures of weight maintenance goals ◦Standard height/weight tables ◦Healthy weight range ◦Individual variation ◦Necessity of body fat COPYRIGHT © 2013 MOSBY, INC., AN IMPRINT OF ELSEVIER INC. ALL RIGHTS RESERVED. 77

Obesity and Health (p. 286) Weight extremes: clinically severe obesity is health hazard Overweight and health problems: hypertension, diabetes, heart disease, arthritis, cancer COPYRIGHT © 2013 MOSBY, INC., AN IMPRINT OF ELSEVIER INC. ALL RIGHTS RESERVED. 78

Causes of Obesity (p. 286)  Basic energy balance  Hormonal control: leptin and ghrelin  Genetic and family factors  Genetic control: obesity highly associated with genetics  Family reinforcement: teach food habits and exert social pressure  Physiologic factors: number of fat cells in the body  Other environmental factors: availability of energy- dense, fast foods, convenient foods 79 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Individual Differences and Extreme Practices (p. 288)  Individual energy balance levels  Extreme practices  Fad diets  Scientific inaccuracies and misinformation  Failure to address the necessity of changing long- term habits 80 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Extreme Practices (p. 289)  Fasting: negative health effects, rebound effect  Specific macronutrient restrictions: no evidence to support, carry health risks  Clothing and body wraps: cause temporary water loss  Drugs: FDA regulates, should be combined with lifestyle changes  Surgery: gastric restriction, malabsorptive procedures, lipectomy 81 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Surgical Treatments for Obesity (p. 293) 82 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Lesson 15.2: Weight Management Tools and Risks of Being Underweight  Realistic weight management focuses on individual needs and health promotion, including meal pattern planning and regular physical activity.  Severe underweight carries physiologic and psychological risk to the body. 83 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

A Sound Weight Management Program (p. 294)  Essential characteristics: food and exercise behaviors  Behavior modification  Basic principles  Basic strategies and actions Defining problem behavior Recording and analyzing baseline behavior Planning behavior management strategy 84 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Dietary Principles (p. 294)  Dietary principles  Realistic goals: ½ to 1 lb per week loss  Negative energy balance: 500 to 1000 kcal/day  Nutritional adequacy: choose nutrient-dense foods  Cultural appeal: to allow permanent change in habits  Energy readjustment to maintain weight: when desired weight is reached 85 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Basic Energy Balance Components (p. 295)  Energy input: food behaviors  Energy output: exercise behaviors 86 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Principles of a Sound Food Plan (p. 296)  Energy balance: modifications to energy intake and output  Nutrient balance: carbohydrate, protein, fat proportions  Distribution balance: spread food throughout the day  Food guide: American Dietetic Association  Preventive approach: overweight children become obese adults 87 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Food Misinformation and Fads (p. 300)  Types of claims  Food cures: certain foods cure specific conditions  Harmful foods: certain foods are harmful  Food combinations: specific combinations restore health  “Natural” foods: only “natural” foods can meet body needs 88 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Food Misinformation and Fads (cont’d) (p. 301)  Erroneous claims  Dangers  To health  Often expensive  Perpetuates superstitions  Distrust of modern food market  Vulnerable groups  Elderly, young persons, obese persons, athletes and coaches, entertainers 89 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Underweight (p. 302)  General causes  Wasting disease  Poor food intake  Malabsorption  Hormonal imbalance  Energy imbalance  Poor living situation 90 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Dietary Treatment (p. 303)  High-calorie diet  High protein  High carbohydrate  Moderate fat  Adequate sources of vitamins and minerals 91 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Disordered Eating (p. 303)  Definition of normal eating  Disordered eating  Anorexia nervosa: results in self-imposed starvation  Bulimia nervosa: binge-and-purge cycle  Binge eating disorder: often follows stress or anxiety  Significant mortality rates, slow recovery  Treatment 92 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Williams' Basic Nutrition & Diet Therapy Chapter 16 Nutrition and Physical Fitness Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved th Edition

Lesson 16.1: Physical Activity and Health  Regular physical activity is an important part of a healthy lifestyle and relies on healthy muscle structure.  Different levels of physical activity draw on a variety of body fuel sources.  Sedentary lifestyles are a contributing factor to poor health. 94 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Physical Activity Recommendations and Benefits (p. 311)  Guidelines and recommendations  Technology contributes to sedentary lifestyle  About 39% of Americans do not engage in physical activity on a regular basis 95 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Guidelines and Recommendations (p. 311)  Definitions of physical activity and exercise  Physical Activity Guidelines for Americans based on:  Intensity  Frequency  Duration 96 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Physical Activity Guidelines for Americans (p. 312)  Children and adolescents: aerobic, muscle- strengthening, bone-strengthening  Adults: 150 minutes of moderate-intensity aerobic physical activity/week  Older adults: same as adults, or, as physically active as conditions allow 97 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Health Benefits (p. 314)  Coronary heart disease  Heart muscle strengthened  Blood cholesterol levels improved  Oxygen-carrying capacity increased  Hypertension reduced  Diabetes effects reduced 98 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Health Benefits (cont’d) (p. 314)  Weight management: energy output increased  Bone disease: weight-bearing activities increase osteoblast activity  Mental health: exercise stimulates endorphins, improves quality of life 99 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Types of Physical Activity (p. 316)  Activities of daily living  Should be enjoyable  Incorporate into daily life  Resistance training  Builds, maintains muscle and bone strength  Should include 8 to 10 exercises, 2 to 3 days/week for novices  Aerobic exercise  Swimming, running, bicycling, aerobic dancing  Simple form is walking 100 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Types of Physical Activity (cont’d) (p. 318)  Weight-bearing exercise  Walking, jogging, aerobic dancing  Important for bone structure and strength 101 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Aerobic Exercises for Physical Fitness (p. 317) 102 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Energy Expenditure During Various Activities (p. 318) 103 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Meeting Personal Needs (p. 318)  Health status and personal gains  Assess health and resources before starting  Moderation and regularity  Achieving aerobic benefits  Raise pulse to 60% to 90% of maximal heart rate  20 minutes, 3 to 6 times per week  Exercise preparation and care  Warm up before  Cool down after  Listen to the body 104 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Dietary Needs During Exercise (p. 319)  Muscle action and body fuels  Structure and function  Fuel sources: carbohydrates and some fats  Oxygen: body’s ability to deliver oxygen is a limiting factor in exercise Cardiovascular fitness: aerobic capacity Body composition: lean body mass, fat, water, bone 105 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Fluid and Energy Needs (p. 319)  Fluid  Body releases heat through sweating  Water lost must be replaced  Energy and nutrient stores  Exercise raises energy needs  Proper diet choices are essential 106 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Macronutrient and Micronutrient Recommendations (p. 320)  Carbohydrate: preferred fuel  Fat: no more than 30% of total daily energy intake  Protein: insignificant contribution during exercise  Vitamins and minerals: intake increases as food intake increases 107 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Lesson 16.2: Nutrition for Training and Competition  A healthy personal exercise program combines both strengthening and aerobic activities. 108 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Athletic Performance (p. 321)  General training diet  Prevents malnutrition and risk of injury and infection  Carbohydrate General training: 6 to 7 g/kg body weight Endurance: 7 to 10 g/kg body weight per day 109 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

General Training Diet (p. 321)  Prevents malnutrition and risk of injury and infection  Carbohydrate  General training: 6 to 7 g/kg body weight 110 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

General Training Diet (cont’d) (p. 322)  Fat  20% to 35% of the total kilocalories  High-fat meal could hinder performance  Protein  1.2 to 1.7 g/kg body weight per day 111 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Competition (p. 323)  Carbohydrate loading  The week before an event  Tapering exercise while increasing carbohydrate intake  Pregame meal  Usually light meal 3 to 4 hours before event 112 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Competition (cont’d) (p. 324)  Hydration  Fluid needs depend on many factors  Thirst mechanism cannot keep up  Hydrate before, during, after exercise 113 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Hydration (p. 324) 114 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Energy During and After Exercise (p. 325)  Competition (cont’d)  Energy during exercise Activity less than 1 hour: no intake needed Longer endurance events: 30 to 60 g/hr carbohydrate  Energy after exercise Fluid and carbohydrate replacement beverage immediately after endurance event Not as effective if delayed 2 hours or more Protein intake also beneficial 115 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Ergogenic Aids and Misinformation (p. 326)  Popular but very few have proven effective  Steroid side effects can be devastating  Athletes and coaches susceptible to misinformation 116 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.