Report completion of the activity to the nurse who documents frequency and effectiveness of this intervention.[5]. When assisting a client with ROM activities, the nursing assistant must follow the plan of care established by the licensed therapist. At the current time, automatic sequential compression devices are used in health care facilities and they have virtually replaced the use of compression hose; however, compression stockings continue to be used in other areas including the client's home, for example. [4] See Table 13.3 for the definition and selected defining characteristics of this diagnosis. Nurses assist patients with range of motion exercises several times a day when patients are not completely independent in terms of their own performance of range of motion exercises. See Figure 9.3[3] for an image of a passive motion machine. Autolytic debridement is most often used to treat Stage 3 and Stage 4 pressure ulcers. External fixation devices, halo traction, skeletal traction, and Crutchfield or Vinke cervical tongs are immobilization techniques that are used for fractures and other serious disorders. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the lower leg, but can occur anywhere within the cardiovascular system. Insure that the counter traction force is less than the pulling traction force. Lastly, skin traction applies the traction force to the skin overlying the affected bone. Joint mobility and range of motion are assessed for the client. Shearing can be prevented by elevating the head of the bed no more than 30 degrees unless contraindicated, using a lift or a lifting team, if you have one, by transferring clients carefully, getting help when turning and positioning a client, getting as much client cooperation as possible during turning, positioning and transfers, using a pressure relieving bed, and lubricating the skin with a lubricating moisturizer to prevent the damaging skin effects associated with pressure, friction and shearing. (OpenRN) via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request. [2], View evidence-based strategies to reduce functional decline in hospitalized older adults provided by The Hartford Institute for Geriatric Nursing. Some of these complications can be prevented with leg exercises, the use of sequential compression devices or antiembolism stockings, and the initiation of falls risk prevention measures when an immobilized client is adversely affected with orthostatic hypotension. ROM exercises facilitate movement of specific joints and Adduction refers to moving a limb towards the midline. For example, a client who has had limited mobility for several years may have a joint that can only be moved a few inches, but it is important to maintain that mobility, no matter how small. While the client is in an upright semi-Fowler's position or sitting in the chair, the client is instructed to put the mouth piece tightly into their mouth and to take the deepest possible diaphragmatic breath while observing the ball rise to the level of their goal. Compartment syndrome is a medical emergency which, left untreated, can lead to the loss of the affected limb. Hospitalization poses a risk for altered functional status of older adults due to acute illness, decreased mobility, and the negative effects of bedrest. In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of mobility and immobility in order to: The hazards or complications of immobility, such as skin breakdown, pressure ulcers, contractures, muscular weakness, muscular atrophy, disuse osteoporosis, renal calculi, urinary stasis, urinary retention, urinary incontinence, urinary tract infections, atelectasis, pneumonia, decreased respiratory vital capacity, venous stasis, venous insufficiency, orthostatic hypotension, decreased cardiac reserve, edema, emboli, thrombophlebitis, constipation and the loss of calcium from the bones, are highly costly in terms of health care dollars and in terms of client suffering. Identifying the Complications of Immobility, Assessing the Client for Mobility, Gait, Strength and Motor Skills, Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown, Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown, Applying a Knowledge of Nursing Procedures and Psychomotor Skills When Providing Care to Clients with Immobility, Coughing, Deep Breathing, Incentive Spirometry, Postural Drainage, Percussion, Vibration and Inspiratory Respiratory Exercises, Applying, Maintaining and Removing Orthopedic Devices, Applying and Maintaining Devices That are Used to Promote Venous Return, Educating the Client Regarding the Proper Methods Used When Repositioning an Immobilized Client, Maintaining the Client's Correct Body Alignment, Maintaining and Correcting the Adjustment of the Client's Traction Device, Implementing Measures to Promote Circulation, Evaluating the Client's Responses to Interventions to Prevent the Complications From Immobility, Adult Gerontology Nurse Practitioner Programs (AGNP), Womens Health Nurse Practitioner Programs, Advanced Practice Registered Nurse (APRN), Non Pharmacological Comfort Interventions, Basic Care & Comfort Practice Test Questions, Identify complications of immobility (e.g., skin breakdown, contractures), Assess the client for mobility, gait, strength and motor skills, Perform skin assessment and implement measures to maintain skin integrity and prevent skin breakdown (e.g., turning, repositioning, pressure-relieving support surfaces), Apply knowledge of nursing procedures and psychomotor skills when providing care to clients with immobility, Apply, maintain or remove orthopedic devices (e.g., traction, splints, braces, casts), Apply and maintain devices used to promote venous return (e.g., anti-embolic stockings, sequential compression devices), Educate the client regarding proper methods used when repositioning an immobilized client, Maintain the client's correct body alignment, Maintain/correct the adjustment of client's traction device (e.g., external fixation device, halo traction, skeletal traction), Implement measures to promote circulation (e.g., active or passive range of motion, positioning and mobilization), Evaluate the client's response to interventions to prevent complications from immobility, At risk for pressure ulcers related to immobility, Muscular weakness and muscular atrophy related to immobility, At risk for venous stasis and emboli related to immobility, At risk for altered and impaired respiratory functioning related to immobility, At risk for falls related to orthostatic hypotension secondary to immobility, At risk for osteoporosis and fractures related to the loss of calcium from the bones secondary to the lack of weight bearing activity, Plantar flexion contracture related to immobility, Loss of complete range of motion related to immobility, Are sitting to determine whether or not they need support while sitting, Change from a sitting position to standing, transferring from the bed to the chair, and sitting down on a chair or bed, At risk for impaired skin integrity related to immobility, At risk for impaired skin integrity related to poor skin turgor, Impaired skin integrity related to impaired tissue perfusion, At risk for impaired skin integrity related to boney prominences, Impaired skin integrity related to pressure, shearing and friction, Impaired skin integrity related to poor nutritional status, The screening of all clients for their potential for skin breakdown and then initiating special preventive measures, Performing skin assessments and reassessments on a regular basis, Keeping the client clean and dry at all times to prevent moisture and skin maceration as well as debris, Turning and positioning clients at least every two hours when the client is unable to move about in bed to turn and position on their own, Maintaining the client's nutritional and fluid needs, The utilization of supportive and assistive devices such as a wedge, pillow, and a pressure relieving mattress, The elimination of pressure, friction, shearing and moisture on the client's body and bodily parts, The client will perform active range of motion to all joints two times a day, The client will safely transfer from the bed to the chair with assistance, The client will demonstrate proper deep breathing and coughing, The client will ambulate 30 feet three times a day with a walker and the assistance of another, The client will increase their level of exercise and physical activity, The client will demonstrate the proper use of their assistive device, The client will maintain adequate respiratory functioning, Splint any painful or tender abdominal areas with a pillow or the client's hand, Take the deepest possible diaphragmatic breath through the nose, Repeat this coughing and deep breathing as often as necessary to clear the airways. Underlying bed tissue reflects the extent to which the wound is healing, regenerating and renewing. Some of the disadvantages of mechanical debridement include the fact that it nonselective and, as such can damage healthy tissue, it can cause pain, it is more subject to an infection than other forms of debridement, and it is more time consuming on the part of the person performing this procedure, when compared to other methods of debridement. The client should attempt to hold their breath for as long as possible (at least five seconds) and then exhale and rest for a few seconds. If neither of these devices is available, a washcloth can be rolled and placed underneath the fingers. Older adults are at increased risk for immobility. They should never touch the floor or any other surface such as a part of the bed because this will interfere with the traction's ordered weight. Simply defined, full range of motion is defined as the maximum movement of a joint specific to that joint. Ways that the client can assist with position changes. These stockings are gently and smoothly pulled over the client's legs without any wrinkles or uneven pressure. The client should be coached and taught to: An incentive spirometer is used to coach the client in terms of deep breathing and coughing. Immobility can also lead to shallow, ineffective respirations, decreased respiratory movement, and a decrease in terms of the client's vital capacity. Some of the expected client outcomes relating to immobility and mobility can include specific goals such as: The interventions for immobility according to system that can be adversely affected with immobility, in addition to the constant monitoring of the client, assessments and reassessments for these hazards, include: Clients are encouraged to cough, deep breathe, use an incentive spirometer, and perform inspiratory respiratory exercises, and the nurse, or the certified respiratory therapist, will also perform postural drainage, percussion, and vibration to correct and prevent the collection of respiratory secretions in the client's airway which can result from immobility and some respiratory diseases and disorders. The rationale for the need for frequent position changes, The different positions that they will be used, The devices, such as pillows and bolsters, that will be used to maintain the position and proper bodily alignment. Routine exercising and mobilization also enhance the client's circulatory function in addition to preventing complications of immobility such as muscular weakness and venous stasis. Ask the patient about the date of their last bowel movement, and monitor stool patterns and stool characteristics. The circulatory system is jeopardized by immobility; some of these respiratory complications and risks include venous stasis, venous dilation, decreased blood pressure, edema, embolus formation, thrombophlebitis and orthostatic hypotension which is a risk factor that is often associated with client falls. This relatively inexpensive type of debridement can be done with a damp dressing, hydrotherapy, and manually scrubbing the affected area to remove the debris. Flexion is movement that decreases the angle between two bones and extension is movement that increases the angle between two bones. Parents are educated about these developmental milestones during well-child visits. The resistance indicator on the right side should be monitored to ensure they are not breathing in too quickly. To prevent a decrease in lung function, reduce the build-up of fluids in the airways, and prevent pneumonia, clients are often prescribed incentive spirometry to keep their bronchioles open. The treatment plan includes the removal of the cast and, at times, a fasciotomy or epimysiotomy are indicated. Some of the orthopedic devices that nurses apply, maintain and remove include traction devices, splints, braces and casts: Traction, simply defined, is a physical pulling force that exerts pulling on the bodily part. Refer to the Objective and Subjective Signs of Pain subsection in Chapter 6.3 to review observations to make and report. When applying TED hose, find the heel marker first. Therefore, nursing assistants must be diligent in their actions and observations to maintain their clients health and prevent complications. At times a tilt table can be used to prevent this damage by placing the client in a position of weight bearing to avoid these complications. These efforts are even more intense and comprehensive when the client has one or more risk factors associated with impaired skin integrity, as discussed previously in this section. The eschar is gently crosshatched with a scalpel so that the introduced enzymes can penetrate all layers of it. The plan is tailored to the needs of the individual and will include the specific joints to move. If orthostatic hypotension is suspected, measure the patients vital signs while he or she is supine, sitting, and standing before encouraging ambulation. Mobility can be assessed by using direct observation of the client's movements and mobility and using some standardized tests such as the Timed Get Up and Go Test with which the nurse assesses the client's ability to rise from a chair, walk, and then return to the chair and sit, the Assessment Tool for Safe Patient Handling and Movement, the Egress test which the nurse uses to assess the client's ability to sit and then stand, march in place and advance forward with each foot and return to the same position. Some of the nursing diagnoses related to skin and skin integrity can include: All skin areas that are not within normal limits and indicate any signs of skin breakdown are assessed and described according to its color, size, location, odor, drainage, margins, texture, distribution and underlying bed tissue. Both of these standardized screening tools are deemed valid and reliable for identifying those at risk. See Figure 9.6[7] for an image of locating the heel marker. Postural drainage is done by the nurse or the certified respiratory therapist. PLEASE NOTE: The contents of this website are for informational purposes only. Pressure occludes the vessels that oxygenate the area and it also causes cellular damage because harmful substances, such as toxins, accumulate in the area where the pressure is exerted. Sometimes a clients lack of endurance in completing activities requires the nursing assistant to segment their ADLs. Also, the skin around the surgical site for skeletal traction must also be inspected for any signs of infection. The LibreTexts libraries arePowered by NICE CXone Expertand are supported by the Department of Education Open Textbook Pilot Project, the UC Davis Office of the Provost, the UC Davis Library, the California State University Affordable Learning Solutions Program, and Merlot. Several terms are used to refer to certain body movements during range of motion exercises, such as abduction, adduction, flexion, and extension. Assess the respiratory system, including respiratory rate, oxygen saturation, lung sounds, chest wall movement and symmetry, and depth and effort of respirations. Immobility and complete bed rest can lead to life threatening physical and psychological complications and consequences. Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, percussion and vibration. What are the nursing interventions to prevent Compression stockings promote the return of fluid back into circulation by gently providing pressure on veins. Constipation, impaction and difficult to evacuate feces can occur as the result of immobility and the lack of exercise that is needed to promote normal bowel functioning. The prevention of the complications associated with immobility include early out of bed activity as soon as possible after surgery and complication related (2018). Traction is often set up by the nurse and, at times, a traction team may be used for the setup of the doctor's ordered traction. To avoid or minimize complications of immobility, mobilize the patient as soon as Deep-vein thrombosis (DVT) is a common complication for clients experiencing immobility. Pressure ulcers are also referred to as stasis ulcers, trophic ulcers, and ischemic ulcers; they can result from the mechanic forces of pressure, friction and shearing, all of which can, and should, be prevented.