The client should sit upright (if possible), place the mouthpiece in their mouth, and create a tight seal with their lips around it. Because changes in joints can occur after just three days of immobility, ROM exercises should be started by the nursing assistant as soon as they are directed by the nurse as safe to do so. See Figure 9.9[10] for images of both types of applications of the toe opening of the stocking. WebTo prevent the further complications of immobility, nurses would usually perform the following interventions:. Tertiary intention healing, also referred to as healing by tertiary intention, is a combination of secondary and primary healing. WebNursing interventions While many interventions depend on the underlying cause of the patients immobility, the nursing interventions in this article will focus on aspects of Automatic sequential compression devices consist of a pump, a one time single patient use sleeve, and hosing that connects the sleeve to the pump. 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. Guarding the gut: early mobility after abdominal surgery 9: Promote Independence Through Rehabilitation/Restorative Care, { "9.01:_Introduction_to_Promote_Independence_Through_Rehabilitation_Restorative_Care" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "9.02:_The_Rehabilitation_Process" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "9.03:_Members_of_the_Therapy_Team" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "9.04:_Complications_of_Immobility" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "9.05:_Rehabilitation_Versus_Restorative_Care" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "9.06:_Promoting_Independence_During_ADLs" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "9.07:_Assisting_With_Sensory_Deficits" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "9.08:_Fall_Prevention" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "9.09:_Skills_Checklist-_Range_of_Motion_(ROM)_Exercises_for_the_Shoulder" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "9.10:_Skills_Checklist-_Range_of_Motion_(ROM)_for_the_Hip_and_Knee" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "9.11:_Skills_Checklist-_Application_of_Compression_Stockings_(TED_Hose)" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "9.12:_Learning_Activities" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "9.13:_IX_Glossary" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()" }, { "00:_Front_Matter" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "01:_Communicate_Professionally_Within_a_Health_Care_Setting" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "02:_Demonstrate_Professionalism_in_the_Workplace" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "03:_Maintain_a_Safe_Health_Care_Environment" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "04:_Adhere_to_Principles_of_Infection_Control" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "05:_Provide_for_Personal_Care_Needs_of_Clients" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "06:_Provide_for_Basic_Nursing_Care_Needs" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "07:_Demonstrate_Reporting_and_Documentation_of_Client_Data" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "08:_Utilize_Principles_of_Mobility_to_Assist_Clients" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "09:_Promote_Independence_Through_Rehabilitation_Restorative_Care" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "10:_Provide_Care_for_Clients_Experiencing_Acute_and_Chronic_Health_Conditions" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "11:_Apply_Knowledge_of_Body_Systems_to_Client_Care" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()", "zz:_Back_Matter" : "property get [Map MindTouch.Deki.Logic.ExtensionProcessorQueryProvider+<>c__DisplayClass228_0.b__1]()" }, [ "article:topic", "license:ccby", "showtoc:no", "licenseversion:40", "authorname:mreuter", "source@https://wtcs.pressbooks.pub/nurseassist" ], https://med.libretexts.org/@app/auth/3/login?returnto=https%3A%2F%2Fmed.libretexts.org%2FBookshelves%2FNursing%2FNursing_Assistant_(Reuter)%2F09%253A_Promote_Independence_Through_Rehabilitation_Restorative_Care%2F9.04%253A_Complications_of_Immobility, \( \newcommand{\vecs}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}}}\) \( \newcommand{\vecd}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash{#1}}} \)\(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\) \(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\)\(\newcommand{\AA}{\unicode[.8,0]{x212B}}\), 9.5: Rehabilitation Versus Restorative Care, Application of Compression Stockings (TED Hose), source@https://wtcs.pressbooks.pub/nurseassist, Assisting with active or passive range of motion (ROM) exercises, Applying splints or positioning devices as prescribed, Encouraging fluids (if not contraindicated), Providing bowel and bladder retraining if needed, Encouraging incentive spirometry or coughing and deep breathing, Applying compression stockings or other compression devices as ordered, Encouraging low sodium intake (as prescribed), Offering pleasurable individual activities if not interested in group activities, Encouraging visits by family, friends, or volunteers for 1:1 interaction, Cone to Prevent Hand Contracture (left) and a Palm Protector (right) by Myra Reuter for, Cone and Palm Protectors on Client" by Myra Reuter for, TED Hose Lengths.jpg" by Myra Reuter for, TED Hose Heel Marker.jpg" by Myra Reuter for, TED Hose Application Methods.jpg" by Myra Reuter for, Heel Marker on TED Hose.jpg by Myra Reuter for, Toes of TED Hose.jpg by Myra Reuter for. For example, the nurse will determine whether or the client is able to: SEE Basic Care & Comfort Practice Test Questions. If there is writing on the stocking, it should be on the outside and facing away from the skin when worn. Compression stockings promote the return of fluid back into circulation by gently providing pressure on veins. The distribution of impaired skin integrity can be described as generalized and across many areas of the body, localized to one area of the body, asymmetrical and on only one side of the body and also symmetrical which affects both sides of the body bilaterally. Immobility and complete bed rest can lead to life threatening physical and psychological complications and consequences. Use any of these techniques to place the stocking on the heel, and then check for proper placement of the heel marker before applying the rest of the stocking. 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. 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. Extension occurs when the arm is straightened back to starting position, increasing the angle between the elbow joint. Some splints, like an inflatable arm splint, a Downey splint and a Sager splint, are temporarily placed on clients by paramedics in the field prior to their arrival at the emergency department of a hospital. Perform active range of motion to all joints two times a day, Safely transfer from the bed to the chair with assistance, Demonstrate proper deep breathing and coughing, Ambulate 30 feet three times a day with a walker and the assistance of another, Increase their level of exercise and physical activity, Demonstrate the proper use of their assistive device while ambulating, Maintain their skin integrity and not have any signs of skin breakdown, Maintain adequate respiratory functioning. Determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer ). [2], View evidence-based strategies to reduce functional decline in hospitalized older adults provided by The Hartford Institute for Geriatric Nursing. For example, serous drainage is clear or a slight yellowish color because it consists of serum which is the clear portion of the blood; sanguineous drainage is bloody and red because it consists of red blood cells; serosanguinous drainage is pinkish in color because it is a combination of serum and red blood cells; and purulent drainage can be yellow, green, rust color or brown and this drainage indicates the presence of infection and thick pus. Hamilton Russell traction is an example of balanced traction. The three basic traction techniques can also be classified as manual traction, skeletal traction and skin traction. Prevention and management of limb contractures in neuromuscular diseases. Some of these joint disorders can be prevented with frequent and proper positioning of the client in correct bodily alignment, the provision of range of motion exercises to all joints several times a day, and the use of devices like a hand roll and a bed board to prevent contractures of the hands and feet, respectively. Decreased lung function can reduce a persons stamina and their ability to perform activities, referred to as activity intolerance. They should be applied upon awakening because edema is usually at its lowest point after lying in bed overnight. Parents are educated about these developmental milestones during well-child visits. The amount of pressure the hose applies to the legs is prescribed. Nursing diagnoses for the hazards of immobility and the client's mobility were also discussed above in these same sections. The skin is described in terms of its color which can be yellow, ecchymosed, purple, green, blanched and reddened, for example. When mobilization and ambulation are impaired as the result of muscular weakness and/or impairments of their gait, balance and coordination, the client should be provided with rehabilitation and restorative care to facilitate this mobilization and ambulation. It can be difficult to see this square but stretching the fabric around the heel area should make it more visible. This technique entails the positioning of the client in different positions so that all areas of the lungs and airways are able to be drained of respiratory secretions using the force of gravity. Inspiratory muscle training techniques entail instructing the client to lie in a comfortable supine position, torelax, and then to take deep breaths with a mouth piece with an increasingly smaller lumen so that the clienthas to progressively take deeper and deeper breaths using their diaphragm while overcoming the resistance of the obstructive mouth piece. The correct application of antiembolism stockings entails the application of these stockings while the client is lying in bed and before rising. Tertiary intention healing begins with several days of open wound irrigations and packing, which is secondary healing, followed by the closure of the wound edges with approximation and suturing which is primary healing. Some of the elements of this teaching should include: The client positions that are used for maintaining good bodily alignment and optimal physiological functioning include the Sims or the semi prone position, the Fowler's position, the dorsal recumbent position, the prone position and the lateral position. Assess for the presence of lower extremity edema and for signs of a potential deep vein thrombosis (DVT). When applying TED hose, find the heel marker first. For specific steps in applying TED hose, see the Application of Compression Stockings (TED Hose) Skills Checklist at the end of the chapter. 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. Muscular strength is classified on a scale of zero to five, as below. Assess for potential signs of atelectasis and pneumonia. Compression stockings may be knee length or hip length. 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. The metabolic system alterations associated with immobility are a decreased rate of metabolism which can lead to unintended weight gain, a negative calcium balance secondary to the loss of calcium from the bones during immobilization, a negative nitrogen balance secondary to an increase in terms of catabolic protein breakdown, and anorexia. Odors can be described as malodorous, pungent, foul, or musty; and some pathogens like pseudomonas have a characteristic odor. Monitor 24-hour trend of intake and output, as well as for symptoms of dysuria, urgency, or frequency. [7] See details about early mobilization protocols earlier in this chapter. For example, hip abduction is the movement of the leg away from the midline of the body. At times, these devices are routinely ordered for post-operative clients to promote venous return. Conditions such as osteoarthritis, orthostatic hypotension, inner ear dysfunction, osteoporosis resulting in hip fractures, stroke, and Parkinsons disease are among the most common causes of immobility in old age. Home / NCLEX-RN Exam / Mobility and Immobility: NCLEX-RN. WebThe nurse teaches the importance ofNursing measures to prevent integumentary complications include providing adequate nutrition because tissue cannot repair itself WebDiscuss nursing interventions that prevent complications of immobility. Clients often have two or more pairs of compression stockings to ensure they dry completely before wearing them again in the morning. Topical antibiotics that are often used to treat wounds, as based on the identified offending microorganism, include, among others: Nursing care consists of all of the phases of the nursing process including assessment, nursing diagnosis, planning implementation and evaluation. Casts must be applied in a smooth manner and they should also be allowed to dry without any external pressure applied to them. Manual traction, which is applied with the hands, is done to properly align a bone after a fracture so that a cast can be applied to the bone while it is in correct anatomical alignment. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. A second type of device is a palm protector that is softer than the cone and separates the fingers from one another. Immobility places clients at risk for skin breakdown, pressure ulcers, and poor skin turgor. Pressure ulcers are staged from the least severe to the most severe from Stage 1 to Stage 5. There are three types of ROM exercises: passive, active, and active assist.