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:

  • 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

Identifying the Complications of Immobility

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. Many of these costly complications of immobility can, and should be, prevented whenever possible.

Immobility and complete bed rest can lead to life threatening physical and psychological complications and consequences. Members of the nursing care team and other health care professionals like physical therapists must, therefore, promote client mobility and prevent immobility whenever possible. Immobility can adversely affect all physiological bodily systems.

The complications and hazards associated with immobility and according to bodily system are described below:

Urinary System

As the result of immobility, the urinary system can be adversely affected with urinary retention, urinary stasis, renal calculi, urinary incontinence and urinary tract infections.

Gastrointestinal System

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. These bowel alterations are further confounded when the client is not getting adequate fluid intake.

Musculoskeletal System

The muscles, joints and bones are adversely affected by immobility.

The bones lose calcium as a result of the lack of weight bearing activity and this can lead to disuse osteoporosis, hypercalcemia, and fractures. 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.

The joints are affected with stiffness, pain, impaired range of motion and contractures including foot drop which is a plantar flexion contracture. 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.

Muscles are adversely affected with weakness and atrophy as the result of immobility. These hazards of immobility can be prevented with range of motion exercises and in bed exercises such as isotonic, isometric and isokinetic muscular exercises.

Respiratory System

Some adverse respiratory system effects relating to immobility include the thickening of respiratory secretions, the pooling of respiratory secretions and an increased inability of the client to mobilize and expectorate these secretions, all of which can lead to atelectasis, hypostatic pneumonia, and respiratory tract infections. Immobility can also lead to shallow, ineffective respirations, decreased respiratory movement, and a decrease in terms of the client's vital capacity.

Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, percussion and vibration. These techniques will be discussed below immediately after this section.

Circulatory System

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.

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.

Metabolic System

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.

Integumentary System

Immobility places clients at risk for skin breakdown, pressure ulcers, and poor skin turgor. Preventive measures and the treatments of these skin integrity disorders will be discussed below in the section entitled "Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown".

Psychological Alterations

Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered mood, and depression.

Some nursing diagnoses related to immobility can include:

  • 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
  • Apathy related to immobility
  • Loss of complete range of motion related to immobility

Assessing the Client for Mobility, Gait, Strength and Motor Skills

Mobility is defined as the "ability to move freely, easily, rhythmically, and purposefully in the environment. It is an essential part of living. People must be able to move to protect themselves from trauma and to meet their basic needs. Mobility is vital to independence; a fully immobilized person is as vulnerable and dependent as an infant" (Berman and Synder, 2012).

The risk factors associated with immobility are client deconditioning, a cognitive impairment, spasticity, poor cardiac functioning and poor tolerance for activity, inadequate muscular strength, impaired balance, improper bodily posture and alignment, an impaired gait, pain, the use of sedating medications, joint pain and stiffness in addition to other skeletal problems, obesity, and neurological impairments in addition to a physiological health problem that mandates that the client be on complete bed rest.

These risk factors are assessed by the nurse to determine the etiology of an identified deficit and to recognize that, because of one or more risk factors, a client is at risk for impairments in terms of their mobility, gait, strength and motor skills.

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. These and even more complex and advanced standardized tests and tools are also used during a physical therapist's assessment of the client.

Mobility abilities and impairments can be also assessed by observing the client while they:

  • Move about in bed
  • 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
  • Stand and walk

Simply defined, gait is the way the person walks, or ambulates. Gait is a function of a number of different things including balance, coordination, muscular strength, and joint mobility.

Balance and equilibrium can be impaired when the client is affected with a middle ear disorder that affects the vestibule and/or the semicircular canal of the ear's cochlea, poor posture, and a musculoskeletal or neurological disorder; muscular coordination is the ability of the person to smoothly and safely use gross motor and fine motor coordination. Coordination can be adversely affected with a neurological disorder of the cerebellum, cerebral cortex and basal ganglia; muscular strength can be impaired with things like muscular atrophy, spasticity, nutritional deficits, paresis, flaccidity and other causes; and joint mobility can be impaired disuse, arthritis and other disorders of the bone.

Muscular strength is classified on a scale of zero to five, as below.

  • Zero: No muscular contraction
  • One: No muscular movement, only a quiver is noted
  • Two: Muscular movement but only when assisted with gravity
  • Three: Muscular movement against gravity but not against resistance
  • Four: Muscular movement against resistance
  • Five: Full muscular movement and strength

Joint mobility and range of motion are assessed for the client. Simply defined, full range of motion is defined as the maximum movement of a joint specific to that joint. For example, the elbow should normally be able to perform extension, flexion, rotation for supination and notation for pronation and the neck should be fully able to perform extension, flexion, lateral flexion, hyperextension and rotation.

After the client is assessed, the mobility of the client, in addition to other functional activities, can be graded and classified as follows in terms of this level of functional ability:

  • Level 0: The client is completely independent in terms of mobility
  • Level 1: The client needs an assistive device
  • Level 2: The client needs an assistive device and the coaching and supervision of another person
  • Level 3: The client needs an assistive device and the direct assistance of another person
  • Level 4: The client is totally dependent on others for their mobility needs

Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown

Skin Assessment

The skin, which is the first line of defense against infection, should be intact and not broken, it should be warm and without any excessive moisture, and the skin should also have good elasticity, which is referred to as good skin turgor.

Some of the factors that impact on the skin and its integrity include intrinsic and extrinsic factors and forces. Some of these intrinsic factors include the client's urinary and/or fecal incontinence, poor nutritional and fluid intake, diabetes, hyperthermia, hypothermia, hypotension, a decreased cardiac output, obesity, an altered sensory perception, some medications, an alteration in terms of the client's perfusion and peripheral circulation, some of the normal changes of the aging process, cachexia and emaciation, an alteration in terms of the client's metabolic status, and the client's body build as well as the size of their boney prominences.

Some of the extrinsic factors that impact on the skin and its integrity are environmental humidity, chemical irritants, extremes in terms of hot and cold weather, radiation, and mechanical forces such as pressure, shearing and friction.

Some of the nursing diagnoses related to skin and skin integrity can include:

  • 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

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.

Color

The skin is described in terms of its color which can be yellow, ecchymosed, purple, green, blanched and reddened, for example.

Size

The area of an abnormality is measured with a disposable rule in terms of centimeters. The length and width of all areas are measured and the depth of wounds is also measured. The depth of a wound is measured using a sterile cotton applicator which is then compared to the disposable rule for an accurate measurement. After the wound is assessed and measured, the wound dimension is calculated by multiplying the length by the width by the depth of the wound. For example when the length of the sound is 4 cm and the width of the wound is 3 cm and the depth of the wound is 1 cm, the wound dimension is 12 cm because 4 x 3 x 1 = 12 cm.

Location

The skin area that has impaired skin integrity is also described according to its exact location and in reference to its anatomical location. For example, an area of skin breakdown can be described as on the posterior of the arm just inferior to the elbow or over the sacrum and coccyx. Some assessment forms allow the nurse to draw the area of concern on it to graphically show both the location and the relative size of the skin area that is affected with impaired skin integrity.

Odor

Some wounds and wound drainage have odors and others do not. Odors can be described as malodorous, pungent, foul, or musty; and some pathogens like pseudomonas have a characteristic odor.

Drainage or Exudate

Wound discharge, which is also referred to as wound exudate, is assessed and described as the lack of any drainage or the presence of some drainage which be described in terms of color, amount and characteristics.

The quantity or amount of drainage can be described as minimal, moderate or excessive and copious when a wound drain is not being used to measure drainage precisely. Wound drainage is also described in terms of its color and characteristics. 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.

Texture

Affected skin areas can be assessed and described as macerated, edematous, swollen, indurated or normal.

Distribution

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.

Margins

The margins around the wound are also assessed and described in terms of their color, their characteristics and their texture which can be classified and documented as macerated, edematous, swollen, indurated or normal. Wound margins can be described as open, attached, unattached, well defined and with a healing ridge.

Underlying Bed Tissue:

Underlying bed tissue reflects the extent to which the wound is healing, regenerating and renewing. The stages of wound healing are the homeostasis phase, the inflammation phase which is also referred to as the exudate and lag phase, the proliferative and granulation phase, and the maturation phase.

The homeostasis phase is marked with vasoconstriction, platelet formation, thrombin formation and the formation of a fibrin mesh for healing; the inflammation phase is characterized with the signs and symptoms of inflammation including edema, swelling, pain, in addition to the beginning of debris removal to prevent infection through the process of phagocytosis; the proliferative and granulation phase is marked with the fibroblastic production of collagen and granulation tissue; and, lastly, the maturation phase of wound healing is characterized with the still fragile skin after the wound healing process that can last up to two years after a wound. The wound remains vulnerable to injury until full healing is completed with good tensile strength.

Some wounds, like surgical incisions, are planned wounds and others such as those occurring secondary to a trauma or a pressure ulcer are considered unplanned wounds. Nurses assess wounds in respect to their type of wound as well as the other factors discussed above.

The three types of wound healing are primary intention healing, secondary intention healing and tertiary intention healing.

Primary Intention Healing

Primary intention healing is facilitated with wounds without infection. The wound edges are approximated and closed with a closure technique such as suturing, Steri Strips, and surgical glues. An example of primary intention healing is the suturing of an abdominal surgical wound after an appendectomy or the suturing of a traumatic laceration with Steri Strips or sutures when this traumatic wound is free of any contamination and infection.

Secondary Intension Healing

Secondary intention healing, also referred to as healing by second intention, is done for contaminated wounds in order to prevent infections, to prevent the formation of abscesses and to promote healing from the bottom up to the outer surface of the skin so that any potential infection is not closed in at the bottom of the wound. These open wounds are irrigated with a sterile solution and then packed to keep them open and, over time, they will heal on their own. The resulting scar is more obvious than those scars that result from primary intention healing.

Tertiary Intension Healing

Tertiary intention healing, also referred to as healing by tertiary intention, is a combination of secondary and primary healing. 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 traumatic wounds are healed with tertiary intention.

Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown

Nurses maintain skin integrity and prevent skin breakdown in a number of different ways. 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 best way to maintain skin integrity and to prevent skin breakdown is to prevent them from occurring in the first place. Some of these preventive techniques include:

  • 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 Braden Scale for Predicting Pressure Ulcers and the Norton Pressure Ulcer Scale are two of the most popular standardized screening tools that are used to screen and assess clients in order to determine if they are at risk for skin breakdown. Both of these standardized screening tools are deemed valid and reliable for identifying those at risk.

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.

Pressure

Pressure, particularly over boney prominences, areas of poor tissue perfusion, and areas affected with poor circulation, is a physical force associated with the development of pressure ulcers and skin breakdown. 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.

Pressure can be eliminated and reduced with out of bed activity, pressure relieving surfaces, the provision of sitting and lying surfaces free of any objects and wrinkles, and by turning and repositioning clients frequently to prevent this damaging mechanic force.

Friction

Friction occurs when a person's body is being rubbed against a surface such as a bed.

Shearing is a combination of both pressure and friction that can cause some distortion of the client's skin and its underlying tissues. 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. Corn starch is NOT used.

Pressure ulcers are costly both in terms of health care costs and the human costs that the client suffers as the result of a pressure ulcer including, but not limited to, pain, sepsis, cellulitis, and osteomyelitis. When pressure ulcers are not prevented, the nurse must assess and care for it. Pressure ulcers are staged from the least severe to the most severe from Stage 1 to Stage 5. These stages are:

  • Stage I: The skin remains unbroken and intact. The skin among those with a light skin tone may have some redness or blanching of the affected area; and those with darker skin tones may have a blue, purple or ashen tinge to the affected area. Additionally, all clients may have some sensitivity and burning, coolness or increased warmth to the affected area.
  • Stage II: The closed and intact skin is now open. The epidermis and the dermis are damaged. The wound may appear as a blister, crack or a wound that is pink in color.
  • Stage III: The wound is now considered a deep wound; the subcutaneous tissue and all the layers of the skin, including the epidermis and dermis and even adipose tissue may be exposed and affected. The wound has a blood tinged drainage as well as dark areas and yellow colored area of dead and necrotic tissue, referred to as eschar and slough, respectively, appear.
  • Stage IV: The deep pressure ulcer extends to underlying areas including the muscle, fascia, connective tissue, tendons, and even the bone under the skin and subcutaneous tissue. Signs of necrotic tissue including eschar and slough are evident.

The treatment of pressure ulcers is complex and it often includes a combination of treatments and therapies. The RYB Color Code of Wounds is sometimes used by nurses to guide the treatment options. RYB stands for the colors of red, yellow and black. The rules of treatment for these three colors are:

  • Red: Protect the area. A new reddened area is protected from further harm and damage with interventions such as turning and positioning the client, keeping the client's skin clean and dry, keeping bed linens wrinkle and object free and avoiding all pressure, friction and shearing. When the wound is red as the result of healing of a previous pressure, the healing of this pressure ulcer is in the stage of granulation with renewal tissue that remains fragile and prone to another breakdown so it has to be protected with a barrier film, covering with a dressing such as a hydrocolloid film, turning and positioning the client and avoiding pressure, friction and shearing; and the healing of this wound is maintained and promoted with gentle cleansing of this area using a solution that is not cytotoxic.
  • Yellow: Cleanse the area. This wound needs cleansing using an alginate dressing, a hydrogel dressing or damp normal saline dressings to remove the slough and purulent wound drainage.
  • Black: Debridement of the area to remove the black necrotic eschar. There are several methods of debridement including surgical laser debridement, mechanical debridement, autolytic debridement, enzymatic debridement and sharp instrument debridement.

Surgical Debridement

Surgical debridement using a laser is perhaps the fastest of all methods of debridement and it is the method that is least likely to damage the healthy tissue surrounding the necrotic area. One of its disadvantages, when compared to some other method of debridement, is the need to anesthetize the client which, in itself, has some risks.

Mechanical Debridement

Mechanical debridement is often the preferred form of treatment for pressure ulcers that only have a moderate amount of necrotic tissue that has to be removed. This relatively inexpensive type of debridement can be done with a damp dressing, hydrotherapy, and manually scrubbing the affected area to remove the debris. This method is not used as much today as it was previously used. 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.

Autolytic Debridement

Autolytic debridement promotes the body's use of its own enzymes to debride the wound. This process is referred to as autolysis. Autolytic debridement is most often used to treat Stage 3 and Stage 4 pressure ulcers.

The procedure for autolytic debridement entails the use of a semi-occlusive, occlusive, hydrocolloid, alginate, or hydrogel treatment and a transparent dressing to keep the area moist while the body uses its own enzymes like its fibrinolytic, proteolytic, and collagenolytic enzymes, as well as its on white blood cells to debride a wound and remove its eschar and slough.

The advantages of this kind of wound debridement include its effectiveness, its ease in terms of performing it, its relative safety, and lack of pain for the client. Some of its disadvantages, however, include the fact that autolytic debridement is not as rapid as a surgical debridement in terms of its effectiveness and the fact that anerobic microbes may thrive under the dressing that is used for this type of debridement.

Enzymatic Chemical Debridement

Enzymatic chemical debridement can be used on wounds with at least moderate amounts of necrosis and eschar, including pressure ulcers and burns.

The enzymes introduced for this type of debridement are maintained within a moist environment so that they can destroy cellular debris, slough and eschar. The eschar is gently crosshatched with a scalpel so that the introduced enzymes can penetrate all layers of it.

Some of the advantages associated with chemical debridement include its relatively rapid, action and its ability to be selective and not damage healthy surrounding tissue. Some of its disadvantages include local irritation, its relatively high cost, and the need for frequent dressing changes once or twice a day.

Sharp Instrument Debridement

This method of debridement entails the removal of necrotic tissue using a scalpel, forceps and scissors by the doctor. This method is the most rapid of all debridement methods but it can lead to client pain and discomfort.

Topical antibiotics that are often used to treat wounds, as based on the identified offending microorganism, include, among others:

  • Cadexomer iodine
  • Gentamicin
  • Metroidazole
  • Mupirocin
  • Polymyxin B sulphate
  • Silver sulfadiazine

Applying a Knowledge of Nursing Procedures and Psychomotor Skills When Providing Care to Clients with Immobility

Nursing care consists of all of the phases of the nursing process including assessment, nursing diagnosis, planning implementation and evaluation.

In terms of assessment, the nurse assesses and reassess the client for actual and potential complications of immobility as fully discussed above under the section entitled "Identifying the Complications of Immobility" and the clients' needs in reference to mobility, gait, strength and motor skills as fully discussed in the section entitled "Assessing the Client for Mobility, Gait, Strength and Motor Skills"

Nursing diagnoses for the hazards of immobility and the client's mobility were also discussed above in these same sections.

Planning is done according to the actual and potential health problems that were assessed and then expected client outcomes or goals and interventions are planned to meet these needs. Some of the expected client outcomes relating to immobility and mobility can include specific goals such as:

  • 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 be free of venous stasis
  • 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 skin integrity
  • The client will maintain adequate respiratory functioning

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:

  • Urinary System: Maintain adequate fluid intake, measure, document and monitor the client's intake and output to insure an adequate fluid balance status.
  • Gastrointestinal System: Maintain an adequate fluid intake, encourage a high fiber diet, encourage out of bed activity including ambulation unless it is contraindicated, and the administration of treatments such as stool softeners, fiber additives, enemas, and laxatives, as ordered.
  • Musculoskeletal System: Range of motion exercises to all bodily parts, muscle strengthening exercises including isotonic, isometric and isokinetic exercises, aids to assist in positioning the client in correct bodily alignment, and early weight bearing activity
  • Respiratory System: Encouraging the client to perform deep breathing and coughing, and the provision of postural drainage, percussion, inspiratory respiratory exercises and vibration. Coughing, deep breathing, postural drainage, percussion, vibration and inspiratory respiratory exercises will be detailed in the section immediately following this one.
  • Circulatory System: Active or passive range of motion, positioning, mobilization, 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.
  • Metabolic System: The encouragement and provision of a healthy diet with ample protein
  • Integumentary System: Maintain good nutrition, encourage fluids, turn and position every two hours and maintain clean and dry skin without any pressure, friction or shearing.
  • Psychological Alterations: Providing an adequate amount of stimulation, encourage visits and other diversions

Coughing, Deep Breathing, Incentive Spirometry, Postural Drainage, Percussion, Vibration and Inspiratory Respiratory Exercises

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.

Postural drainage, percussion and vibration are often referred to as pulmonary hygiene measures and pulmonary physiotherapy measures. Coughing, deep breathing and the use of an incentive spirometer are described as hyperinflation exercises because, when done properly, these respiratory techniques hyper inflate the lung to facilitate the loosening and mobilization of respiratory secretions. All of these measures are used not only for immobilized clients but also for many post-operative clients.

The procedure for deep breathing and coughing is as below. The client should be coached and taught to:

  • Splint any painful or tender abdominal areas with a pillow or the client's hand
  • Take the deepest possible diaphragmatic breath through the nose
  • Exhale through the mouth
  • Do this deep breathing three times
  • Cough after the third breath
  • Repeat this coughing and deep breathing as often as necessary to clear the airways

An incentive spirometer is used to coach the client in terms of deep breathing and coughing. An incentive spirometer consists of a plastic chamber with a ball, a mouthpiece and tubing. 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. The client should be reminded and encourage to take at least 10 breaths using the incentive spirometer at least every 2 hours while they are awake.

Postural drainage is done by the nurse or the certified respiratory therapist. 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. For example, the client is positioned prone and in a 45 degree Trendelenburg position to drain the posterior bronchus, a 45 degree Trendelenburg position to drain the posterior bronchus and on the left side to drain the lateral bronchus.

Percussion is also performed by the nurse or the certified respiratory therapist. This technique entails the placing a cupped hand over the lung areas and doing gentle tapping on the area for about one minute while the client is hyper inflating their lungs and holding the breath as long as possible. The client is placed in the same positions that are used for postural drainage, as discussed immediately above. In fact, percussion is most often done in combination with postural drainage.

Vibration is highly similar to percussion except vibration is done by placing the palm of the hand on the lung area and doing rapid vibrating movements on the area while the client is positioned for postural drainage.

Inspiratory muscle training techniques entail instructing the client to lie in a comfortable supine position, to relax, and then to take deep breaths with a mouth piece with an increasingly smaller lumen so that the client has to progressively take deeper and deeper breaths using their diaphragm while overcoming the resistance of the obstructive mouth piece.

Applying, Maintaining and Removing Orthopedic Devices

Some of the orthopedic devices that nurses apply, maintain and remove include traction devices, splints, braces and casts:

Traction

Traction, simply defined, is a physical pulling force that exerts pulling on the bodily part. Traction is used for the external fixation of a fracture, it is used to maintain anatomically correct alignment, it is used to reduce pain and it is used to decrease muscle spasms.

Traction forces are classified and categorized as Inline or running traction and balanced traction. Balanced traction utilizes the weight of the client's bodily part, rather than externally placed weights, to exert the traction force to the body. Hamilton Russell traction is an example of balanced traction. Inline traction, also referred to as running traction and Buck's skin traction, exerts the traction force along the long axis of the bone and along one plane.

The three basic traction techniques can also be classified as manual traction, skeletal traction and skin traction. 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. Skeletal traction is applied directly to an affected bone with a continuous traction force and with the use of a surgically inserted Steinman pin that is placed into the distal end of the affected bone.

Lastly, skin traction applies the traction force to the skin overlying the affected bone. The purpose of skin traction is to decrease pain and muscular spasms after a fracture has been surgically repaired with internal fixation. Skin traction is the most commonly used type of traction.

The externally placed skin traction must be applied firmly but without any potentially damaging pressure and in a smooth manner without any creases. The weights are gently applied, as ordered, and left to hang freely and without any interference. The skin underneath skin traction must be inspected on a regular and ongoing basis to prevent some of the possible complications associated with this type of traction including blistering, skin breakdown, compartment syndrome, circulatory impairment, neurological impairment, and areas of necrosis. Also, the skin around the surgical site for skeletal traction must also be inspected for any signs of infection.

Splints

The primary purposes of splinting for limb fractures are to protect soft tissue from further damage, to reduce the client's pain, to reduce the possibility of a fat embolism, and to minimize painful muscular spasms. 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. Splints are also used the immobilization of the spine, to support a weakened area of articulation such as a knee from damage and to support it after a knee replacement, for example.

Braces

Braces are applied to various parts of the body to provide support and alignment of the part. Some commonly used braces are neck braces, back braces, and elbow braces.

Casts

Skeletal fractures are classified and described in several ways, many of which are not mutually exclusive.

A complete fracture involves the entire cross section of the fractured bone; an incomplete fracture affects only part of the bone and not the entire cross section; stable fractures are defined as fractures that are not likely to be displaced, therefore, reduction is not indicated; an unstable fracture, unlike a stable fracture, necessitates reduction because it is likely that this fracture is displaced; a closed fracture is defined as one that does not break through the surface of the skin and this type of fracture and this type of fracture is also referred to as a simple fracture; an opened fracture, on the other hand, breaks through the skin surface to the exterior of the body and, as such, an opened fracture is prone to infection because the skin lacks integrity; and a pathological fracture is one that results from a disease process rather than undue stress or trauma as other fractures do.

Fractures can also be categorized and categorized according to it pattern.

These patterns include:

  • A greenstick fracture occurs when only one side of the bone is fractured.
  • An avulsion fracture occurs when a fragment of the fractured bone is pulled off the bone at its tendon or ligamentous attachment.
  • A comminuted fracture is one that splinters the fractured bone into small fragments as a result of a traumatic force.
  • A transverse fracture is one that occurs straight across the fractured bone.
  • An oblique fracture is one that occurs at an angle across the fractured bone.
  • A spiral fracture occurs when the pattern twists around the fractured bone.
  • An impacted fracture is one that occurs when a bone fragment of the fractured bone is pushed and wedged into another bone fragment of the fractured bone.
  • Compression fractures occur when the fractured bone collapses as occurs with vertebral spinal fractures.
  • A depressed fracture occurs when bone fragments of the fractured bone is pushed in beyond the surrounding skin. This type of fracture occurs with depressed skull fractures.

Fractures are treated to prevent deformity. In addition to traction and splints, many fractures are also casted. Casts can be made with plaster or fiberglass. Some casts are solid and others are what are referred to as a bivalve cast which has two pieces. Fiberglass casts are lighter in terms of weight than plaster casts; and bivalve casts, unlike solid casts, permit some swelling after the traumatic fracture and, as such, prevent compartment syndrome, a complication associated with casting.

Casts must be applied in a smooth manner and they should also be allowed to dry without any external pressure applied to them. External pressure can cause creases and denting which can impair the skin below in terms of its neurological and circulatory status.

The signs and symptoms of compartment syndrome include intense pain that cannot be relieved with raising the affected limb and/or the client's ordered analgesic medications. The later signs of compartment syndrome include burning pain secondary to ischemia, paresthesia secondary to neurological impairment, hypoesthesia secondary to sensory nerve damage, pulselessness, and cool and pale skin.

Compartment syndrome is a medical emergency which, left untreated, can lead to the loss of the affected limb. The treatment plan includes the removal of the cast and, at times, a fasciotomy or epimysiotomy are indicated.

Applying and Maintaining Devices That are Used to Promote Venous Return

Compression stockings, or antiembolism stockings or hose, and automatic sequential compression devices are used to promote venous return and prevent emboli, both of which can occur as the result of patient immobilization and other causes such as deep vein thrombosis. At times, these devices are routinely ordered for post-operative clients to promote venous return. These devices are ordered by the doctor in terms of millimeters of mercury that they will apply to the lower extremities.

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.

The correct application of antiembolism stockings entails the application of these stockings while the client is lying in bed and before rising. Like automatic sequential compression, compression stockings are fitted for the specific client after measuring the client's legs and checking the doctor's order for the amount of pressure that these stockings should exert on the client's leg. Some of these compression stockings are knee high and others are thigh high. These stockings are gently and smoothly pulled over the client's legs without any wrinkles or uneven pressure. Wrinkles and uneven pressure can cause venous stasis. After they are applied, they should be regularly checked to insure that they remain in place and without any wrinkling and they should also be removed at least one time a day so that the nurse can inspect the skin underneath it and also to check the skin for its color and warmth which can, at times, indicate a circulatory impairment.

Automatic sequential compression devices consist of a pump, a one time single patient use sleeve, and hosing that connects the sleeve to the pump. Automatic sequential compression devices can have sleeves to accommodate for pressure on the legs as well as the foot. Similar to compression hose, sequential compression sleeves are also fitted according to the client's measurements and they come in both thigh high and knee high sleeves. Unlike compression hose that exerts continuous pressure on the lower extremities, automatic sequential compression devices deliver intermittent pressure at the ordered pressure and as set on the pump.

These sleeves, like compression hose, require that the nurse regularly check them to insure that they remain in place and they, too, should also be removed at least one time a day so that the nurse can inspect the skin underneath it and also to check the skin for its color and warmth.

Educating the Client Regarding the Proper Methods Used When Repositioning an Immobilized Client

Clients should be educated about the proper methods that will be used to position and reposition them in bed while they are immobilized. Some of the elements of this teaching should include:

  • 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
  • Ways that the client can assist with position changes. For example, the client may be encouraged to bend their knees and then exert pressure on their heels as they are being moved up in bed.
  • The rationale for maintaining an angle of no more than 30 degrees to prevent skin breakdown
  • Signs and symptoms like a burning or sore feeling on a bodily part that must be reported to the nurse
  • The purpose of and the procedure for a mechanical lift if the client will be using one
  • The purpose of the lifting team if the facility has one

Maintaining the Client's Correct Body Alignment

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.

The lateral position is a side lying position with the upper most knee bent and often maintained in that position with a pillow; the Fowler's position is a sitting position with the head of the bed up and elevated; the dorsal recumbent position and supine position are lying on the back with or without a pillow for the head; the prone position is lying on the stomach; and the Sim's position is a semi prone position.

These positions are supported and maintained with pillow, bolsters and wedges when necessary to maintain anatomically correct bodily alignment.

Maintaining and Correcting the Adjustment of the Client's Traction Device

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. These devices are connected to traction.

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. When applying traction, the client should be placed in the supine position and boney prominences should be protected from friction and shearing. Traction, when ordered, should be continuous and not interrupted.

The procedure for setting up traction is as follows:

  • Lubricate the pulleys with a silicone spray
  • Add the precise weight that was ordered by the doctor
  • Apply and maintain the weights so that they hang freely. 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.
  • Insure that the counter traction force is less than the pulling traction force. When the pulling traction force is greater than the counter traction force of the client's body, the client will slide to the source of the traction. The nurse should tilt the bed when this occurs and this can be prevented by keeping the client's head of the bed up at the maximum of less than a 20 degree angle.

The neurological condition of the areas of traction must be frequently assessed and inspected, the skin should be assessed and cared for, and the client should be repositioned as much as possible in a frequent manner, typically every 2 to 4 hours.

Implementing Measures to Promote Circulation

In addition to anti embolism stockings and sequential compression devices, as previously discussed, active or passive range of motion, positioning and mobilization are also measures that promote circulation.

Range of Motion

Range of motion exercises can be active, active assisted and passive. Patients able to perform full joint movement on their own and without the assistance of another should be encouraged to do so several times a day to promote circulatory functioning and also to maintain full joint mobility. The nurse should monitor these clients to insure that they are performing these active range of motion exercises in the correct manner and to the greatest possible extent of movement for all of the joints of the body.

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. Passive range of motion is done by the nurse when the client is not able to even assist with range of motion exercise. Patients in a coma, for example, should be given complete passive range of motion to all joints several times a day.

Positioning and Repositioning

Positioning and repositioning were fully discussed previously in the section entitled "Maintaining the Client's Correct Body Alignment". Positioning and repositioning in correct bodily alignment enhances circulation, musculoskeletal integrity and skin integrity.

Routine Exercising and Mobilization

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. 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.

Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown

As previously discussed skin integrity can be maintained and skin breakdown can be prevented with a number of different interventions such as turning and repositioning the client at least every two hours, special pressure relieving mattresses, and the avoidance of all pressure, friction and shearing.

Evaluating the Client's Responses to Interventions to Prevent the Complications From Immobility

The nurse determines whether or not the client's expected outcomes were accomplished after preventive measures were implemented to prevent the complications associated with immobility. For example, the nurse will determine whether or the client is able to:

  • Perform active range of motion to all joints two times a day
  • Safely transfer from the bed to the chair with assistance
  • Be free of venous stasis
  • 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

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