COMPLICATIONS of PROLONGED BED REST Marija Buttery Version 4 2012

Pressure Area Care (PAC) What are pressure ulcers? What are pressure sores? What are decubitis ulcers? What causes them? How do we prevent them?

Pressure Ulcers Any lesion caused by unrelieved pressure resulting in damage of underlying tissue (AHCPR 1994) Pressure ulcers can occur anywhere on the body Pressure Ulcers, Pressure Sores and Decubitis Ulcers are all the same thing

Pressure ulcer staging Stage I Persistent redness Stage II Partial thickness skin loss Stage III Full thickness skin loss (subcutaneous) Stage IV Full thickness loss (to fascia)

Pressure Area Care One of the vital roles of the nurse after assessment is to prevent damage/illness. There are a variety of patients who we assess and determine as being at increased risk of developing pressure sores. Implementation of Norton Risk Assessment scale, Braden Scale, Gosnell Scale (and possibly others) is meant to reduce development of new pressure ulcers in high risk patients

Pressure ulcer causes Prolonged pressure Shear Friction Duration and intensity Location Extended pressure that blocks flow to the tissue between the source of pressure and the bone Shear Friction

Pressure ulcer etiology Pressure exerted by bony prominences on the body that stop capillary flow to the tissues. Deprives tissues of oxygen and nutrients causing cell death. Pressure greater than 32mmHg exerted by bony prominences disrupts blood flow.

Pressure ulcer etiology Function of both time and pressure 70mmHg pressure for two hours produces irreversible injury greater pressure takes less time lower pressure takes more time obese may be much lower; emaciated may be much higher risk TURNING SCHEDULES MUST BE INDIVIDUALISED!!!!

Pressure Prevention The main prevention of these ulcers is to stop the damage before it starts. This includes all three causes: pressure friction shearing Management also includes assessment, monitoring and evaluation of the person as a whole and improving aspects such as nutrition fluid balance skin integrity movement/mobility underlying health conditions cognitive function

Pressure Causing ‘Things’ Class discussion Sheets and blankets Monitors Tubing (oxygen, drips and drains etc.) Clothing (including nappies)

WHERE ARE THE POTENTIAL PRESSURE POINTS? Positions Supine Prone Lateral Orthopnoeic

MOBILITY To care for clients who have limited mobility, the nurse needs to understand the physical and psychological effects of immobility, the complications these may lead to and nursing interventions that can prevent these complications. One of the nurses roles is to encourage mobility, whether that be passive or active.

MOBILITY The provision of various devices may help the client to be more independent. It may also assist the nurse in not having to use as much of their own physical force to ambulate the patient. Assessment of the patients mobility should be assessed each time they require assistance, whether that be in bed or out. This constant update of information allows for the nurse to better protect themselves against injury and be in a better position to provide the most appropriate assistance to their client.

USE OF MOBILITY AIDS Ensure the equipment is in working condition Adjust the aid to the correct height for the individual Ensure the patient knows how to use the walking aid correctly Maintain a safe environment Evaluation

MOBILITY AND EXERCISE The musculoskeletal, nervous and cardiovascular systems combine to allow for movement. Exercise can be active or passive. Active exercise involves voluntary effort. Passive exercise is movement by another individual.

Why Exercise? Stimulation Promote circulation Muscle tone and strength Joint mobility Relaxation - can promote sleep Combat boredom Combat stress

Complications Of Decreased Mobility and Bed Rest Pressure on bony prominences – decubitis ulcers Decreased use of muscles and joints – muscle wasting and contractures Venous stasis – Deep Vein Thrombosis (DVT) Pulmonary Stasis – lung congestion Urinary Stasis – infection or calculi Decreased intestinal peristalsis – constipation Decreased vasomotor tone – hypotension Decreased independence – depression, boredom, anxiety Foot drop

Thrombosis Some people are at greater risk of a DVT forming than others If a DVT does form it needs to be treated quickly to prevent the clot from breaking , travelling around the body causing greater damage such as Cerebrovascular Accident (CVA) Myocardial Infarction (MI) Pulmonary Embolis (PE) Treatment includes restricting mobility, medication to reduce blood clotting, and treating the symptoms

Sequential Calf Compression Sequential Compression Devices (SCD) - also known as calf stimulators, for prevention of DVT. Should be used in conjunction with anti-embolic stockings Sorrentino, S.A., (2004) Assisting with Patient Care 2nd Ed (Mosby: St Louis) Fig 29 – 11 “Sequential compression device” P 610

Relief of Pressure On Feet ‘Pleat’ in the sheets/blankets Bed Cradle - reduces the pressure on the top of the feet for pain relief or the prevention of foot drop (another complication of prolonged bed rest) Sorrentino, S.A., (2004) Assisting with Patient Care 2nd Ed (Mosby: St Louis) Fig 24-10 “A bed cradle” P 488

The Lungs Pooling of secretions in the lungs from prolonged bed rest and lack of movement can lead to lung damage and pneumonia. Deep breathing and huffing exercises are needed to expand the lungs and expectorate the secretions Kozier, B; Erb, G; Berman, A J & Burke, K., (2000) Fundamentals of Nursing: concepts, process and practice 6th Ed (Prentice Hall Health: New Jersey) Fig 41-4 “Pooling of secretions in the lungs of an immobile person” P 1015

The Kidneys Pooling of urine in the urinary bladder from lying in one position increases the risks of urinary tract infections Kozier, B; Erb, G; Berman, A J & Burke, K., 6th Ed. Fundamentals of Nursing: concepts, process and practice (New Jersey: Prentice Hall Health; 2000) Fig 41-6 “Pooling of urine in the urinary bladder.” P 1016

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