Immobility Systemic Effects
What are adverse effects of immobility on the integumentary system?
Deceased circulation to tissue causing ischemia, which can lead to pressure injury
Integumentary Assessment
Observe the skin for breakdown, warmth & change in color
Look for pallor or redness in fair-skinned clients & purple or blue discoloration in dark-skinned clients
Observe bony prominences
Check skin turgor
Use a pressure injury risk scale
Observe urinary or bowel incontinence
DVT
notify provider
elevate the legs
avoid pressure
anticipate anticoagulants (lovenox, alteplase)
Acute pain
protective, temporary, usually self-limiting, has a direct cause & resolves without tissue healing
physiological responses (sympathetic nervous system) fight-or-flight responses (tachycardia, hypertension, anxiety, diaphoresis, muscle tension)
behavioral responses include grimacing, moaning, flinching & guarding
Intervetntions include treatment of the underlying problem
Substances that decrease pain transmission
serotonin
endorphins
What are adverse effects of immobility on the respiratory system?
Decreased respiratory movement resulting in decreased oxygenation & carbon dioxide exchange
Stasis of secretions, decreased, and weakened respiratory muscles, resulting in atelectasis & hypostatic pneumonia
Decreased cough response
Respiratory & Cardiovascular assessment
every 2 hrs
observe chest wall movement for symmetry
auscultate lungs & identify diminished breath sounds, crackles, or wheezes
observe for productive cough and note the color, amount, & consistency of secretions
measure orthostatic blood pressure & pulse
palpate apical & peripheral pulse
auscultate the heart at the apex for S3
palpate for edema in the sacrum, legs & feet
palpate the skin for warmth in peripheral areas: nose, ear lobes, hands & feet
assess for DVT
measure the circumference of both calves & thighs
Pulmonary Embolism
prepare to give thrombolytics or anticoagulant
position client in a high-fowler's position
obtain pulse oximetry
administer oxygen
prepare to obtain blood gas analysis
monitor vital signs frequently
Chronic pain
not productive, is ongoing or recurs frequently, lasting longer than 6 months & persisting beyond tissue healing
physiological responses of not usually alter vital signs, clients can have depression, fatigue, & decreased level of functioning is not usually life-threatening depression, fatigue, & decreased level of functioning. Is not usually life-threatening
psychosocial implications can lead to disability
management aims at symptomatic relief. Pain does not always respond to interventions
malignant or non malignant
Substances that increase pain
Substance P
prostaglandins
bradykinin
histamine
What are adverse effects of immobility on the neurological system?
altered sensory perception
ineffective coping
changes in emotional status: depression, alteration in self-concept, and anxiety
behavioral changes: withdrawal, altered sleep/wake pattern, hostility, inappropriate laughter, & passivity
Metabolic & Elimination Assessment
Record anthropometric measurements of height, weight & skin folds
I&O's
food intake
urinary & bowel elimination status
assess wound healing
auscultate bowel sounds
skin turgor
lab values electrolytes, blood total protein, & BUN
Assess the bladder for distention
Observe urine for color, amount, clarity, & frequency
Auscultate bowel sounds
Observe feces for color, amount, frequency & consistency
Pressure Ulcer
position using corrective devices
turn every 1-2 hours
teach clients who can move independently to move every 15 minutes
provide devices to decrease pressure
therapeutic mattress
monitor nutritional intake
Provide skin and perineal care
Nociceptive Pain
pain arises from damage to or inflammation of tissue, which is a noxious stimulus
it is usually throbbing, aching & localized
this pain typically responds to opioids & non-opioid medications
PAIN IS WHAT THE PATIENT SAYS IT IS
Report using pain scale
Use a symptom analysis to obtain subjective data
What are adverse effects of immobility on the metabolic, gastrointestinal, & genitourinary system?
Altered endocrine system
decreased basal metabolic rate
changes in protein, carbs, & fat metabolism
decreased appetite
negative nitrogen balance
decreased protein resulting in loss of muscle
loss of weight
alterations in calcium, fluid & electrolytes
reabsorption of calcium from bones
decreased urinary elimination of calcium, resulting in hypercalcemia
decreased peristalsis
decreased fluid intake
constipation, increase risk for fecal impaction
urinary stasis
change in calcium metabolism w/hypercalcemia, resulting in renal calculi
decreased fluid intake & increased use of indwelling urinary catheters resulting in UTI
Musculoskeletal assessment
Range of Motion capability
Assess muscle tone & mass
Observe for contractures
Monitor Gait
Monitor Nutritional intake of calcium
Monitor use of assistive devices to assist w/ADLS
Neuropathic
pain arises from abnormal or damaged pain nerves
includes phantom ljmb pain, pain below the level of a spinal chord injury, and diabetic neuropathy
neuropathic pain is usually intense, shouting, burning, or describes as "pins & needles"
typically responds to adjuvant medications (antidepressants, antispasmodic agents, skeletal muscle relaxants) topical medications can provide relief for peripheral neuropathic pain
Causes of acute & chronic pain
trauma
surgery
cancer
arthritis
fibromyalgia
neuropathy
diagnostic or treatment procedures (injection, intubation, radiation)
What are adverse effects of immobility on the musculoskeletal system?
Decreased muscle endurance, strength & mass
impaired balance
atrophy of muscles
decreased stability
altered calcium metabolism
osteoporosis
pathological fractures
contractures
foot drop
altered joint mobility
Psychosocial Assessment
Mental Status
Behavior & decision making skills
mobility status
observe for unusual alterations in sleep/wake pattern
coping skills, especially for loss
ADLs
Family support & relationships
Social activities
Factors that affect the pain experience
age
fatigue
genetic sensitivity
cognitive function
prior experiences
anxiety/fear
support systems and coping styles
culture