Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.
Chapter 28 Immobility Mobility is also essential for self-defense, activities of daily living (ADLs), and recreational activities. Many functions of the body depend on mobility. Intact musculoskeletal and nervous systems are necessary for optimal physical mobility and functioning. Clinical nursing practice related to mobility and immobility requires the incorporation of scientific and nursing knowledge and skills to provide competent care. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nature of Movement Body mechanics Alignment and balance Friction
Coordinated efforts of the musculoskeletal and nervous systems Alignment and balance Also refers to posture Gravity Weight force exerted on the body Friction Force that occurs in a direction opposite to movement Movement requires a coordinated effort between the musculoskeletal and nervous systems. Nurses pay attention to body mechanics to avoid injury to self and patients. Body mechanics are the coordinated efforts of the musculoskeletal and nervous systems. Today nurses use information about body alignment, balance, gravity, and friction when implementing nursing interventions such as positioning patients, determining the risk of patient falls, and selecting the safest way to move or transfer patients. Alignment and balance or posture refer to the positioning of joints, tendons, ligaments, and muscles while standing, sitting, or lying. Body alignment means that the individual’s center of gravity is stable. Without balance control the center of gravity is displaced. Individuals require balance for maintaining a static position (e.g., sitting) and moving (e.g., walking). Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility effect balance. Impaired balance is a major threat to mobility and physical safety and contributes to a fear of falling and self-imposed activity restrictions. Weight is the force exerted by gravity. The force of weight is always directed downward. This is why an unbalanced object falls. Individuals require balance for maintaining a static position (e.g., sitting) and moving (e.g., walking). Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility effect balance. Impaired balance is a major threat to mobility and physical safety and contributes to a fear of falling and self-imposed activity restrictions. People’s centers of gravity are usually at 55% to 57% of standing height and are in the midline, which is why only using principles of body mechanics in lifting patients often leads to injury of the nurse or health care professional The greater the surface area of the object that is moved, the greater the friction. Large objects produce greater resistance to movement. This is why nurses need to be aware of the friction that can cause a patient’s skin to shear or tear. The force exerted against the skin while the skin remains stationary and the bony structures move is called shear. Copyright © 2017, Elsevier Inc. All Rights Reserved. 2

Nature of Movement (Cont.)
Skeletal system Provides attachments for muscles and ligaments, protects vital organs, aids in calcium regulation Provides leverage for mobility Bones are long, short, flat, or irregular Joints Ligaments, tendons, and cartilage Bones are important for mobilization because they are firm, rigid, and elastic. The aging process changes the components of bone, which impacts mobility. Firmness results from inorganic salts such as calcium and phosphate that are in the bone matrix. It is related to the rigidity of the bone, which is necessary to keep long bones straight and enables bones to withstand weight bearing. Elasticity and skeletal flexibility change with age. Bones store calcium and release it into the circulation as needed. Patients with decreased calcium regulation and metabolism, and immobility, are at risk for developing osteoporosis and pathological fractures (fractures caused by weakened bone tissue). [Ask students: How does the skeletal system protect vital organs? Discuss: The skull around the brain and the ribs around the heart and lungs.] In addition, the internal structure of long bones contains bone marrow, participates in red blood cell (RBC) production, and acts as a reservoir for blood. Patients with altered bone marrow function or diminished RBC production fatigue easily because of reduced hemoglobin and oxygen-carrying ability. This fatigue decreases their mobility and increases the risk for falling, which impacts a patient’s mobility status. Joints are the connections between bones. Each joint is classified according to its structure and degree of mobility. There are three classifications of joints: cartilaginous, fibrous, and synovial. Ligaments are white, shiny, flexible bands of fibrous tissue binding joints together and connecting bones and cartilages, and aid joint flexibility and support. Tendons are white, glistening, fibrous bands of tissue that connect muscle to bone and are strong, flexible, and inelastic. Cartilage is nonvascular (without blood vessels) supporting connective tissue located chiefly in the joints and thorax, trachea, larynx, nose, and ear. The characteristics of the cartilage change with the aging process. [Ask students: What do bones store? Discuss: Bones store calcium and release it into the circulation as needed. Patients with decreased calcium regulation and metabolism are at risk for developing osteoporosis and pathological fractures (fractures caused by weakened bone tissue). In addition, the internal structure of long bones contains bone marrow, participates in red blood cell (RBC) production, and acts as a reservoir for blood.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nature of Movement (Cont.)
Muscle movement and posture Skeletal muscles are working elements of movement Nervous system Regulates movement and posture Movement of bones and joints involves active processes that are carefully integrated to achieve coordination. Skeletal muscles, because of their ability to contract and relax, are the working elements of movement. Anatomical structure and attachment to the skeleton enhance contractile elements of the skeletal muscle. The nervous system regulates movement and posture. The precentral gyrus, or motor strip, is the major voluntary motor area and is in the cerebral cortex. A majority of motor fibers descend from the motor strip and cross at the level of the medulla. Movement is impaired by disorders that alter neurotransmitter production, transfer of impulses from the nerve to the muscle, or activation of muscle. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Pathological Influences on Mobility
Postural abnormalities Muscle abnormalities Damage to central nervous system (CNS) Musculoskeletal trauma Congenital or acquired postural abnormalities affect the efficiency of the musculoskeletal system and body alignment, balance, and appearance. During assessment observe body alignment and range of motion (ROM). Postural abnormalities can cause pain, impair alignment or mobility, or both. Knowledge about the characteristics, causes, and treatment of common postural abnormalities is necessary for lifting, transfer, and positioning. [Review Table 28-1, Postural Abnormalities, with students.] Injury and disease lead to many alterations in musculoskeletal function. Damage to any component of the central nervous system that regulates voluntary movement results in impaired body alignment, balance, and mobility. Trauma from a head injury, ischemia from a stroke or brain attack (cerebrovascular accident [CVA]), or bacterial infection such as meningitis can damage the cerebellum or the motor strip in the cerebral cortex. Damage to the cerebellum causes problems with balance, and motor impairment is directly related to the amount of destruction of the motor strip. Trauma to the spinal cord also impairs mobility. Direct trauma to the musculoskeletal area can cause bruises, contusions, sprains, or fractures. Treatment often includes positioning the fractured bone in proper alignment and immobilizing it to promote healing and restore function. Even this temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Copyright © 2017, Elsevier Inc. All Rights Reserved. 5

Nursing Knowledge Base: Factors Influencing Mobility-Immobility
Mobility refers to a person’s ability to move about freely, and immobility refers to the inability to do so Bed rest Effects of muscular deconditioning Disuse atrophy Physiological Psychological Social You need to know how to apply scientific principles in the clinical setting to determine the safest way to move patients and to understand the effect of immobility on the physiological, psychosocial, and developmental aspects of patient care. To determine how to move patients safely, assess their ability to move. Think of mobility as a continuum, with mobility on one end, immobility on the other, and varying degrees of partial immobility between the end points. Some patients move back and forth between mobility and immobility, but for others immobility is absolute and continues indefinitely. Manually lifting and transferring patients contributes to the high incidence of work-related musculoskeletal problems and back injuries in nurses and other health care staff. Bed rest is an intervention that restricts patients to bed for therapeutic reasons. Nurses and health care providers most often prescribe this intervention. The effects of muscular deconditioning associated with lack of physical activity are often apparent in a matter of days. This cluster of symptoms is often referred to as the “hazards of immobility.” The individual of average weight and height without a chronic illness on bed rest loses muscle strength from baseline levels at a rate of 3% a day. Immobility also is associated with cardiovascular, skeletal, and other organ changes. The term disuse atrophy describes the tendency of cells and tissue to reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting, or local nerve damage. Periods of immobility or prolonged bed rest cause major physiological, psychological, and social effects. These effects are gradual or immediate and vary from patient to patient. The patient with complete mobility restrictions is continually at risk for the hazards of immobility. When possible, it is imperative that patients, especially the older adults, have limited bed rest and that their activity is more than bed to chair. The deconditioning related to reduced walking increases the risk for patient falls. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.
Systemic Effects Metabolic Endocrine, calcium absorption, and GI function Respiratory Atelectasis and hypostatic pneumonia Cardiovascular Orthostatic hypotension Thrombus Musculoskeletal changes Loss of endurance and muscle mass and decreased stability and balance Muscle effects Loss of muscle mass Muscle atrophy Skeletal effects Impaired calcium absorption Joint abnormalities Urinary elimination Urinary stasis Renal calculi Integumentary Pressure ulcer Ischemia All body systems work more efficiently with some form of movement. Exercise has positive outcomes for all major systems of the body. When there is an alteration in mobility, each body system is at risk for impairment. The severity of the impairment depends on the patient’s overall health, degree and length of immobility, and age. [Details of each body system are on subsequent slides.] Copyright © 2017, Elsevier Inc. All Rights Reserved. 7

Metabolic Changes Changes in mobility alter
Endocrine metabolism Calcium resorption Functioning of the GI system Endocrine system helps maintain homeostasis Immobility disrupts normal metabolic functioning Decreases metabolic rate Alters metabolism Causes GI distrubances The endocrine system, made up of hormone-secreting glands, maintains and regulates vital functions such as (1) response to stress and injury; (2) growth and development; (3) reproduction; (4) maintenance of the internal environment; and (5) energy production, use, and storage. When injury or stress occurs, the endocrine system triggers a series of responses aimed at maintaining blood pressure and preserving life. It is important in maintaining homeostasis. Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. In the presence of an infectious process, immobilized patients often have an increased basal metabolic rate (BMR) as a result of fever or wound healing because these increase cellular oxygen requirements. When the patient is immobile, his or her body often excretes more nitrogen (the end product of amino acid breakdown) than it ingests in proteins, resulting in negative nitrogen balance. Weight loss, decreased muscle mass, and weakness result from tissue catabolism (tissue breakdown). Immobility causes the release of calcium into the circulation. Normally the kidneys excrete the excess calcium. However, if the kidneys are unable to respond appropriately, hypercalcemia results. Pathological fractures occur if calcium resorption continues as the patient remains on bed rest or continues to be immobile. Impairments of gastrointestinal functioning caused by decreased mobility vary. Difficulty in passing stools (constipation) is a common symptom, although pseudodiarrhea often results from a fecal impaction (accumulation of hardened feces). Over time intestinal function becomes depressed, dehydration occurs, absorption ceases, and fluid and electrolyte disturbances worsen. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Respiratory Changes Immobile patients are at high risk for developing pulmonary complications Atelectasis Hypostatic pneumonia Lack of movement and exercise places patients at higher risk for respiratory complications. Patients who are immobile are at high risk for developing pulmonary complications. The most common respiratory complications are atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Both decreased oxygenation and prolonged recovery add to the patient’s discomfort. In atelectasis secretions block a bronchiole or a bronchus; and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. The site of the blockage affects the severity of atelectasis. Sometimes an entire lung lobe or a whole lung collapses. At some point in the development of these complications, there is a proportional decline in the patient’s ability to cough productively. Ultimately the distribution of mucus in the bronchi increases, particularly when the patient is in the supine, prone, or lateral position. Mucus accumulates in the dependent regions of the airways. Hypostatic pneumonia frequently results because mucus is an excellent place for bacteria to grow. [Shown is Figure 28-1: Pooling of secretions in dependent regions of lungs in supine position.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Quick Quiz! 1. You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with: A. atelectasis. B. hypertension. C. orthostatic hypotension. D. coagulation of blood. Answer: A Rationale: Atelectasis is the collapse of alveoli. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study Ms. Eileen Thomas, who is 82, is admitted for a fractured right hip. She is on complete bed rest in Buck’s traction. Sergio is the nursing student assigned to Ms. Thomas. [Ask students: What hazards could Ms. Thomas face from being immobilized in bed at her age? Discuss: Bone loss, osteoporosis, increased risk of fractures, older adults with chronic illness develop pronounced effects of immobility more quickly than younger patients, more pronounced effects of decreased circulating fluid volume, more pronounced effect of pooling of blood in lower extremities, greater decrease in autonomic response, greater risk of contractures, greater risk of ischemia, nutritional needs, developmental changes, cardiac issues as older adults often do not tolerate the increased cardiac workload that comes with recumbent position, and the more significant impact immobility has on the older adult’s independence and functional status.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Cardiovascular Changes
Orthostatic hypotension Increased cardiac workload Thrombus formation Orthostatic hypotension is a drop of blood pressure greater than 20 mm Hg in systolic pressure or 10 mmHg in diastolic pressure and symptoms of dizziness, light-headedness, nausea, tachycardia, pallor or fainting when the patient changes from the supine to standing position. In the immobilized patient decreased circulating fluid volume, pooling of blood in the lower extremities, and decreased autonomic response occur. These are especially evident in the older adult. As the workload of the heart increases, so does its oxygen consumption. Therefore the heart works harder and less efficiently during periods of prolonged rest. As immobilization increases, cardiac output falls, further decreasing cardiac efficiency and increasing workload. Patients who are immobile are also at risk for thrombus formation. A thrombus is an accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel. Three factors contribute to venous thrombus formation: (1) damage to the vessel wall (e.g., injury during surgical procedures), (2) alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity). These three factors are often referred to as Virchow’s triad. [Shown is Figure 28-2: Thrombus formation in a vessel.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Musculoskeletal Changes
Muscle effects Lean body mass loss Muscle weakness/ atrophy Skeletal effects Disuse osteoporosis Joint contracture The effects of immobility on the musculoskeletal system include permanent or temporary impairment or permanent disability. Restricted mobility sometimes results in loss of endurance, strength, and muscle mass and decreased stability and balance. Other effects of restricted mobility affecting the skeletal system are impaired calcium metabolism and joint mobility. Because of protein breakdown, the patient loses lean body mass. The reduced muscle mass is unable to sustain activity without increased fatigue. If immobility continues and the patient does not exercise, there is further loss of muscle mass. Muscle weakness always occurs with immobility, and prolonged immobility often leads to disuse atrophy. Muscle atrophy is a widely observed response to illness, decreased activities of daily living (ADLs), and immobilization. Loss of endurance, decreased muscle mass and strength, and joint instability (see Skeletal Effects) put patients at risk for falls. Immobilization causes two skeletal changes: impaired calcium metabolism and joint abnormalities. Because immobilization results in bone resorption, the bone tissue is less dense or atrophied, and disuse osteoporosis results. When disuse osteoporosis occurs, the patient is at risk for pathological fractures. Approximately 80% of people who have osteoporosis are female. Although primary osteoporosis is different in origin from the osteoporosis that results from immobility, it is imperative for nurses to recognize that immobilized patients are at high risk for accelerated bone loss if they have primary osteoporosis. A joint contracture is an abnormal and possibly permanent condition characterized by fixation of the joint. It is important to note that flexor muscles for joints are stronger than extensor muscles and therefore contribute to the formation of contractures. Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. When a contracture occurs, the joint cannot achieve full range of motion (ROM). Contractures sometimes leave a joint or joints in a nonfunctional position, as seen in patients who are permanently curled in a fetal position. Early prevention of contractures is essential. One common and debilitating contracture is footdrop. When footdrop occurs, the foot is permanently fixed in plantar flexion. Ambulation is difficult with the foot in this position because the patient cannot dorsiflex the foot. The patient with footdrop is unable to lift the toes off the ground. [Review Box 28-1, Evidence-Based Practice: Patient Contractures and Treatments to Reduce Future Contractures for At-Risk Patients, with students.] [Shown is Figure 28-3: Footdrop. Ankle is fixed in plantar flexion. Normally ankle is able to flex (dotted line), which eases walking.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Urinary Elimination Changes
Urinary stasis Renal calculi Infection In the upright position urine flows out of the renal pelvis and into the ureters and bladder because of gravitational forces. When the patient is recumbent or flat, the kidneys and ureters move toward a more level plane. Urine formed by the kidney needs to enter the bladder unaided by gravity. Because the peristaltic contractions of the ureters are insufficient to overcome gravity, the renal pelvis fills before urine enters the ureters. This condition is called urinary stasis and increases the risk of urinary tract infection and renal calculi. Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi because they frequently have hypercalcemia. As the period of immobility continues, fluid intake often diminishes. When combined with other problems such as fever, the risk for dehydration increases. As a result, urinary output declines on or about the fifth or sixth day after immobilization, and the urine becomes concentrated. This concentrated urine increases the risk for calculi formation and infection. Inappropriate perineal care after bowel movements, particularly in women, increases the risk of urinary tract contamination by Escherichia coli bacteria. Another cause of urinary tract infections in immobilized patients is the use of an indwelling urinary catheter. [Shown is Figure 28-4: Stasis of urine with reflux to ureters.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Integumentary Changes
Pressure ulcers Inflammation Ischemia Older adults at greater risk The changes in metabolism that accompany immobility add to the harmful effect of pressure on the skin in the immobilized patient. This makes immobility a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative. A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) in tissues. The ulcer is characterized initially by inflammation and usually forms over a bony prominence. Ischemia develops when pressure on the skin is greater than pressure inside the small peripheral blood vessels supplying blood to the skin. Tissue metabolism depends on the supply of oxygen and nutrients to and the elimination of metabolic wastes from the blood. Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation. When a patient lies in bed or sits in a chair, the weight of the body is on bony prominences. The longer the pressure is applied, the longer the period of ischemia and therefore the greater the risk of skin breakdown. The prevalence of pressure ulcers is highest in long-term care facilities with facility-acquired being the highest in adult intensive care units. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Psychosocial Effects Emotional and behavioral responses
Hostility, giddiness, fear, anxiety Sensory alterations Altered sleep patterns Changes in coping Depression, sadness, dejection Illnesses that result in limited or impaired mobility can cause social isolation and loneliness. Patients with restricted mobility may have some depression. Depression is an affective disorder characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion to reality. It results from worrying about present and future levels of health, finances, and family needs. Because immobilization removes the patient from a daily routine, he or she has more time to worry about disability. Worrying quickly increases the patient’s depression, causing withdrawal. Withdrawn patients often do not want to participate in their own care. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Developmental Changes
Infants, Toddlers, Preschoolers Prolonged immobility delays gross motor skills, intellectual development, or musculoskeletal development Adolescents Delayed in gaining independence and in accomplishing skills Social isolation can occur Adults Physiological systems are at risk Changes in family and social structures Older Adults Decreased physical activity Hormonal changes Bone reabsorption Developmental changes tend to be associated with immobility in the very young and older adults. The newborn infant’s spine is flexed and lacks the anteroposterior curves of the adult. As the baby grows, musculoskeletal development permits support of weight for standing and walking. Posture is awkward because the head and upper trunk are carried forward. Because body weight is not distributed evenly along a line of gravity, posture is off balance, and falls occur often. The infant, toddler, or preschooler is usually immobilized because of trauma or the need to correct a congenital skeletal abnormality. Prolonged immobilization delays the child’s gross motor skills, intellectual development, or musculoskeletal development. The adolescent stage usually begins with a tremendous increase in growth. When the activity level is reduced due to trauma, illness, or surgery the, adolescent are often behind peers in gaining independence and accomplishing certain skills such as obtaining a driver’s license. Social isolation is a concern for this age group when immobilization occurs. When periods of prolonged immobility occur in adults, all physiological systems are at risk. In addition, the role of the adult often changes with regard to the family or social structure. Some adults lose their jobs, which affects their self-concept. A progressive loss of total bone mass occurs with the older adult. Some of the possible causes of this loss include decreased physical activity, hormonal changes, and bone resorption. The effect of bone loss is weaker bones. Older adults often walk more slowly, take smaller steps, and appear less coordinated. Prescribed medications alter their sense of balance or affect their blood pressure when they change position too quickly, increasing their risk for falls and injuries. The outcomes of a fall include not only possible injury but also hospitalization, loss of independence, psychological effects, and quite possibly death. Older adults often experience functional status changes secondary to hospitalization and altered mobility status. [Review Box 28-2, Focus on Older Adults: Functional Decline in Hospitalized Immobile Older Adults, with students.] Immobilization of older adults increases their physical dependence on others and accelerates functional losses. When providing nursing care for an older adult, encourage the patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Copyright © 2017, Elsevier Inc. All Rights Reserved. 17

Case Study (Cont.) Ms. Thomas’ mitral valve was replaced 2 months ago, and since the time of the surgery, she has been on anticoagulants. She has had type 2 diabetes mellitus for the past 10 years and is a smoker. She weighs 195 lbs and is 5′7″ tall. She lives by herself, and she attends Mass daily. Her pain is 6 on a scale of 1 to 10. [Ask students: What complications and special areas of concern can you identify for Ms. Thomas? Discuss: As Ms. Thomas awaits surgery, Sergio knows that patients who smoke, are on anticoagulants because of valve replacement surgery, and have a fractured hip are at risk for complications related to the hazards of immobility. Ms. Thomas has diabetes, which puts her at increased risk for skin breakdown, infection, circulatory problems, and neuropathy. Additionally, Sergio will need to address her mobility and social needs.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Process: Assessment
See through the patient’s eyes Mobility Range of motion Planes of the body Sagittal Transverse Frontal Apply the nursing process and use a critical thinking approach in your care of patients. The nursing process provides a clinical decision-making approach for you to develop an individualized plan of care. When unsure of the patient’s abilities, begin assessment of mobility with the patient in the most supportive position, and move to higher levels according to his or her tolerance. Usually the nurse assesses for and asks questions about the patient’s degree of both mobility and immobility during physical examination. You convey respect for the patient’s preferences, values, and needs when implementing the nursing process and designing a plan of care with the patient. [Review Box 28-3, Nursing Assessment Questions, with students.] Assessment of patient mobility focuses on ROM, gait, exercise and activity tolerance, and body alignment. Generally the assessment of movement starts while the patient is lying and proceeds to assessing sitting positions in bed, transfers to chair, and finally walking. This helps to protect the patient’s safety. ROM is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, transverse, or frontal. The sagittal plane is a line that passes through the body from front to back, dividing it into a left and right side. The frontal plane passes through the body from side to side and divides it into front and back. The transverse plane is a horizontal line that divides the body into upper and lower portions. Ligaments, muscles, and the nature of the joint limit joint mobility in each of the planes. In the sagittal plane, movements are flexion and extension (e.g., fingers and elbows), dorsiflexion and plantar flexion (feet), and extension (e.g., hip). In the frontal plane, movements are abduction and adduction (e.g., arms and legs) and eversion and inversion (feet). In the transverse plane, movements are pronation and supination (hands) and internal and external rotation (hips). When assessing ROM, ask questions about and physically examine the patient for stiffness, swelling, pain, limited movement, and unequal movement. ROM exercises may be active, passive, or in between. [Review Table 28-2, Range-of-Motion Exercises, with students.] Consider the medical plan of care and the patient’s ability and need for assistance, teaching, or reinforcement before engaging in active ROM exercises. Contractures develop in joints not moved periodically through their full ROM. Assessment data from patients with limited joint movements vary based on the area affected: neck, shoulder, elbow, forearm, wrist, fingers and thumb, hip, knee, ankle and foot, and toes. [Shown is Figure 28-5: Planes of body.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Process: Assessment (Cont.)
Range of motion Contractures: develop in joints not moved periodically through their full ROM Neck, shoulder, elbow, forearm, wrist, fingers and thumb, hip, knee, ankle and foot, and toes A flexion contracture of the neck is a serious disability because the patient’s neck is permanently flexed with the chin close to or actually touching the chest. Assessment reveals altered body alignment, changes in the visual field, and decreased level of independent functioning. One feature of the shoulder that sets it apart from other joints in the body is that the strongest muscle controlling it, the deltoid, is in complete elongation in the normal position. No other muscle exerts its full strength when in complete elongation. Patients with limited movement in the shoulder have difficulty moving their arms. The elbow functions optimally at an angle of approximately 90 degrees. An elbow fixed in full extension is disabling and limits the patient’s independence. Most functions of the hand are best carried out with the forearm in moderate pronation. When the forearm is fixed in a position of full supination, the patient’s use of the hand is limited. The primary function of the wrist is to place the hand in slight dorsiflexion, the position of functioning. When the wrist is fixed in even a slightly flexed position, the grasp is weakened. The ROM in the fingers and thumb enables the patient to perform ADLs and activities requiring fine-motor skills such as carpentry, needlework, drawing, and painting. The functional position of the fingers and thumb is slight flexion of the thumb in opposition to the fingers. Because the lower extremities are concerned chiefly with locomotion and weight bearing, stability of the hip joint is more important than its mobility. Excessive abduction makes the affected leg appear too short, whereas excessive adduction makes it appear too long. In either case the patient has limited locomotion and walks with an obvious limp. Internal and external rotation contractures cause an abnormal and unbalanced gait. A primary function of the knee is stability, which is achieved by ROM, ligaments, and muscles. However, the knees cannot remain stable under weight-bearing conditions unless there is adequate quadriceps power to maintain the knee in full extension. An immobile knee joint results in serious disability. The degree of disability depends on the position in which the knee is stiffened. If it is fixed in full extension, the person needs to sit with the leg out in front. When the knee is flexed, the person limps while walking. The greater the flexion, the greater is the limp. Without full ROM of the ankle, gait deviations occur. If the joint is not stable, the person falls. When the person relaxes as in sleep or coma, the foot relaxes and assumes a position of plantar flexion. As a result, it becomes fixed in plantar flexion (footdrop), which impairs the ability to walk. Independently and increases the risk for falls. Excessive flexion of the toes results in clawing. When this is a permanent deformity, the foot is unable to rest flat on the floor, and the patient is unable to walk properly. Flexion contractures are the most common foot deformity associated with reduced joint mobility. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Mobility Gait (a particular manner or style of walking) Exercise (physical activity for conditioning the body, improving health, and maintaining fitness) Activity tolerance Physiological Emotional Developmental Assessing a patient’s gait allows you to draw conclusions about balance, posture, safety, and ability to walk without assistance. The mechanics of human gait involve coordination of the skeletal, neurological, and muscular systems of the human body. Nurses use exercise as therapy to correct a deformity or restore the overall body to a maximal state of health. Assessment of the patient’s energy level includes the physiological effects of exercise and activity tolerance. Activity tolerance is the type and amount of exercise or work that a person is able to perform. Assessment of activity tolerance is necessary when planning activity such as walking, ROM exercises, or ADLs. Activity tolerance assessment includes data from physiological, emotional, and developmental domains. As activity begins, monitor patients for symptoms such as dyspnea, fatigue, chest pain, and/or a change in vital signs. A weak or debilitated patient is unable to sustain even slight changes in activity because of the increased demand for energy. When the patient experiences decreased activity tolerance, carefully assess how much time he or she needs to recover. Decreasing recovery time indicates improving activity tolerance. People who are depressed, worried, or anxious are frequently unable to tolerate exercise. Developmental changes also affect activity tolerance. As the infant enters the toddler stage, the activity level increases, and the need for sleep declines. The child entering preschool or primary grades expends mental energy in learning and often requires more rest after school or before strenuous play. The adolescent going through puberty requires more rest because much body energy is expended for growth and hormone changes. Changes still occur through the adult years, but many of them are related to work and lifestyle choices. As the person grows older, activity tolerance changes. Muscle mass is reduced, and posture and bone composition change. Changes in the cardiorespiratory system such as decreased maximum heart rate and lung compliance, which affect the intensity of exercise, often occur. As age progresses, some older individuals still exercise but do so at a reduced intensity. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Mobility Body alignment is used for: Determining normal physical changes Identifying deviations in body alignment Patient awareness of posture Identifying postural learning needs of patients Identifying trauma, muscle damage, or nerve dysfunction Obtaining information on incorrect alignment (i.e., fatigue, malnutrition, psychological problems) Body alignment is the condition of joints, tendons, ligaments, and muscles in various body positions. Balance occurs when a wide base of support is present, the center of gravity falls within the base of support, and a vertical line falls from the center of gravity through the base of support. Perform assessment of body alignment with the patient standing, sitting, or lying down. This assessment has the following objectives: Determining normal physiological changes in body alignment resulting from growth and development. Identifying deviations in body alignment caused by incorrect posture. Providing opportunities for patients to observe their posture. Identifying learning needs of patients for maintaining correct body alignment. Identifying trauma, muscle damage, or nerve dysfunction. Obtaining information concerning other factors that contribute to incorrect alignment such as fatigue, malnutrition, and psychological problems. The first step in assessing body alignment is to put patients at ease so they do not assume unnatural or rigid positions. When assessing the body alignment of an immobilized or unconscious patient, remove pillows and positioning supports from the bed and place the patient in the supine position. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Body alignment Standing [Ask students: What does correct standing posture look like? Ask a student to demonstrate. Discuss: The characteristics listed below.] Characteristics of correct body alignment for the standing patient include the following: The head is erect and midline. When observed posteriorly, the shoulders and hips are straight and parallel. When observed posteriorly, the vertebral column is straight. When observed laterally, the head is erect, and the spinal curves are aligned in a reversed S pattern. The cervical vertebrae are anteriorly convex, the thoracic vertebrae are posteriorly convex, and the lumbar vertebrae are anteriorly convex. When observed laterally, the abdomen is comfortably tucked in, and the knees and ankles are slightly flexed. The person appears comfortable and does not seem conscious of the flexion of knees or ankles. The arms hang comfortably at the sides. The feet are slightly apart to achieve a base of support, and the toes are pointed forward. When viewing the patient from behind, the center of gravity is at the midline, and the line of gravity extends from the middle of the forehead to a midpoint between the feet. Laterally, the line of gravity runs vertically from the middle of the skull to the posterior third of the foot. [Shown is Figure 28-6: Correct body alignment when standing.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Body alignment Sitting [Ask students: What does correct sitting posture look like? Ask a student to demonstrate. Discuss: The characteristics listed below.] Characteristics of correct body alignment for the sitting patient include the following: The head is erect, and the neck and vertebral column are in straight alignment. Body weight is distributed evenly on the buttocks and thighs. The thighs are parallel and in a horizontal plane. Both feet are supported on the floor, and the ankles are flexed comfortably. With patients of short stature, use a footstool to ensure that ankles are flexed comfortably. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee. This space ensures that no pressure is present on the popliteal artery or nerve to decrease circulation or impair nerve function. The patient’s forearms are supported on the armrest, in the lap, or on a table in front of the chair. It is particularly important to assess alignment when sitting if the patient has muscle weakness, muscle paralysis, or nerve damage. Patients who have these problems have diminished sensation in the affected area and are unable to perceive pressure or decreased circulation. Proper alignment while sitting reduces the risk of musculoskeletal system damage in such a patient. The patient with severe respiratory disease sometimes assumes a posture of leaning on the table in front of the chair in an attempt to breathe more easily. This is called orthopnea. [Shown is Figure 28-7: Correct body alignment when sitting.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Body alignment Lying [Ask students: How would you achieve correct lying posture in an immobilized patient? Discuss: Removing positioning supports from the bed, except for pillows under the head, using an adequate mattress and proper positioning.] People who are conscious have voluntary muscle control and normal perception of pressure. As a result, they usually assume a position of comfort when lying down. Because their ROM, sensation, and circulation are within normal limits, they change positions when they perceive muscle strain and decreased circulation. Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position. Remove all positioning supports from the bed except for the pillow under the head and support the body with an adequate mattress. This position allows for full view of the spine and back and helps provide other baseline body alignment data such as whether the patient is able to remain positioned without aid. The vertebrae are aligned, and the position does not cause discomfort. Patients with impaired mobility (e.g., traction or arthritis), decreased sensation (e.g., hemiparesis following a cerebrovascular accident [CVA]), impaired circulation (e.g., diabetes), and lack of voluntary muscle control (e.g., spinal cord injury) are at risk for damage when lying down. [Shown is Figure 28-8: Correct body alignment when lying down.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Physiologic hazards of mobility Metabolic Respiratory Cardiovascular Musculoskeletal Integumentary Elimination Psychosocial Developmental Assess the patient for hazards of immobility by performing a head-to-toe physical assessment , as well as psychological and developmental dimensions. [Review Table 28-3, Assessment of the Physiological Hazards of Immobility, with students.] When assessing metabolic functioning, use anthropometric measurements (measures of height, weight, and skinfold thickness) to evaluate muscle atrophy. Analyze intake and output records for fluid balance. Dehydration and edema increase the rate of skin breakdown in a patient who is immobilized. Monitoring laboratory data such as levels of electrolytes, serum protein (albumin and total protein), and blood urea nitrogen (BUN) aid the nurse in determining metabolic functioning. Monitoring food intake and elimination patterns and assessing wound healing help to determine altered gastrointestinal functioning and potential metabolic problems. Perform a respiratory assessment at least every 2 hours for patients with restricted activity. The respiratory assessment includes inspecting the chest for wall movement and auscultating the lungs for decreased breath sounds, crackles, and wheezes. Cardiovascular nursing assessment of the patient who is immobilized includes blood pressure monitoring, evaluation of apical and peripheral pulses, and observation for signs of venous stasis. To assess for a deep vein thrombosis (DVT), remove the patient’s elastic stockings and/or sequential compression devices (SCDs) every 8 hours (or according to agency policy) and observe the calves for redness, warmth, and tenderness. Measure bilateral calf circumference and record it daily as an alternative assessment for DVT. Because DVTs also occur in the thigh, take thigh measurements daily if the patient is prone to thrombosis. A dislodged venous thrombus, called an embolus, can travel through the circulatory system to the lungs and impair circulation and oxygenation, resulting in tachycardia and shortness of breath. Venous emboli that travel to the lungs are sometimes life threatening. More than 90% of all pulmonary emboli begin in the deep veins of the lower extremities. Major musculoskeletal abnormalities to identify during nursing assessment include decreased muscle tone and strength, loss of muscle mass, and contractures. Early assessment of ROM is important because it establishes a baseline against which later measurements can be compared to evaluate whether a loss in joint mobility has occurred. Continually assess the patient’s skin for breakdown and color changes such as pallor or redness. Consistently use a standardized tool such as the Braden Scale. Frequent skin assessment, which can be as often as every hour, are based on patients mobility, hydration, and physiological status is essential to promptly identify changes in patients’ skin and underlying tissues. Evaluate the patient’s elimination status on each shift and total intake and output every 24 hours. Inadequate intake and output or fluid and electrolyte imbalances increase the risk for renal system impairment, ranging from recurrent infections to kidney failure. Dehydration also increases the risk for skin breakdown, thrombus formation, respiratory infections, and constipation. Assessment of bowel elimination status includes the adequacy of dietary choices, bowel sounds, and the frequency and consistency of bowel movements. During the psychosocial assessment, you will focus on the patient’s emotional state, behavior, and sleep-wake cycle. The developmental assessment looks at how immobility affects the normal development of patients across the life span. Design nursing interventions that maintain normal development, provide physical and psychosocial stimuli after identifying a child’s developmental needs, and assure the parents that developmental delays are usually temporary. Immobilization of a family member changes family functioning. Immobility has a significant effect on the older adult’s levels of health, independence, and functional status. Assessment also includes the patient’s home and community to identify factors that are risks to his or her mobility and safety. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Diagnosis Impaired physical mobility Risk for disuse syndrome
Ineffective airway clearance Ineffective coping Impaired urinary elimination Risk for impaired skin integrity Social isolation The two diagnoses most directly related to mobility problems are impaired physical mobility and risk for disuse syndrome. The diagnosis of impaired physical mobility applies to the patient who has some limitation but is not completely immobile. The diagnosis of risk for disuse syndrome applies to the patient who is immobile and at risk for multisystem problems because of inactivity. Assessment reveals clusters of data that indicate whether a patient is at risk or if an actual problem exists. The clusters of data include defining characteristics that support the diagnostic label and probable cause of the diagnosis. Locating the probable cause of the diagnosis (based on assessment data) is important to planning patient-centered goals and subsequent nursing interventions that will best help the patient. It is critical that nursing assessment activities identify and cluster defining characteristics that ultimately support the nursing diagnosis selected. [Review Box 28-4, Nursing Diagnosis Process: Impaired Physical Mobility Related to Left Hip/Leg Pain, with students.] During immobilization some patients experience decreased social interaction and stimuli. These patients frequently use the nurse’s call bell to request minor physical attention when their real need is greater socialization. Nursing diagnoses for health needs in developmental areas reflect changes from the patient’s normal activities. Immobility also leads to multiple complications (e.g., renal calculi, DVT, pulmonary emboli, or pneumonia). If these conditions develop, collaborate with the health care provider or nurse practitioner for prescribed therapy to intervene Copyright © 2017, Elsevier Inc. All Rights Reserved.

Planning Planning Goals and outcomes Setting priorities
Teamwork and collaboration Develop goals and expected outcomes to assist the patient in achieving his or her highest level of mobility and reducing the hazards of immobility. Set priorities when planning care to ensure that immediate needs are met first. This is particularly important when patients have multiple diagnoses. Plan therapies according to severity of risks to the patient; individualize the plan according to the patient’s developmental stage, level of health, and lifestyle. Do not overlook potential complications. Care of the patient experiencing alterations in mobility requires a team approach. Nurses often delegate some interventions to nursing assistive personnel. Collaborate with other health care team members, such as physical or occupational therapists, when it is essential to consider mobility needs. In anticipation of the patient’s discharge from an institution, make referrals or consult a case manager or a discharge planner to ensure that the patient’s needs are met at home. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Implementation: Health Promotion
Prevention of work-related musculoskeletal injuries Exercise Bone health in patients with osteoporosis Health promotion activities include a variety of interventions such as education, prevention, and early detection. [Ask students: What are some examples of health promotion activities that address mobility? Discuss: Prevention of work-related injury, fall prevention measures, exercise, and early detection of scoliosis.] The rate of work-related injury in health care settings is on the rise. Most of these injuries occur as a result of overexertion, which results in back injuries and other musculoskeletal problems. Back injuries are often the direct result of improper lifting and bending. Get help, if necessary, before starting a lifting task, and follow correct lifting procedures. The most common back injury is strain on the lumbar muscle group, which includes the muscles around the lumbar vertebrae. Nurses and other health care staff are especially at risk for injury to lumbar muscles when lifting, transferring, or positioning immobilized patients. Therefore be aware of agency policies and protocols that protect staff and patients from injury. Current evidence supports that using mechanical or other ergonomic assistive devices is the safest way to reposition and lift patients who are unable to do these activities themselves. Exercise programs enhance feelings of well-being and improve endurance, strength, and health. Exercise reduces the risk of many health problems such as cardiovascular disease, diabetes, and osteoporosis. Exercise has many positive health benefits. Assist patients in overcoming barriers to physical activity, and encourage them to perform activities that are within their ability. Take cultural practices into consideration. [Review Box 28-5, Cultural Aspects of Care: Cultural Influences on Mobility, with students.] For patients diagnosed with osteoporosis, early evaluation, consultation, and a team approach are important interventions, especially when they become immobilized. ADLs help a patient maintain independence. Assistive ambulatory devices, adaptive clothing, and safety bars help the patient maintain independence. Patient teaching needs to focus on limiting the severity of the disease through diet and activity. [Review Box 28-6, Patient Teaching: Teaching Patients With Osteoporosis, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Implementation: Acute Care
Metabolic Provide high-protein, high-calorie diet with vitamin B and C supplements. Respiratory Cough and deep breathe every 1 to 2 hours. Provide chest physiotherapy. Because the body needs protein to repair injured tissue and rebuild depleted protein stores, give the immobilized patient a high-protein, high-calorie diet. A high-calorie intake provides sufficient fuel to meet metabolic needs and replace subcutaneous tissue. Also ensure that the patient is taking vitamin B and C supplements when necessary. Supplementation with vitamin C is needed for skin integrity and wound healing; vitamin B complex assists in energy metabolism. If the patient is unable to eat, nutrition must be provided parenterally or enterally. For respiratory patients, they need to frequently fully expand their lungs to maintain their elastic recoil property. In addition, secretions accumulate in the dependent areas of the lungs. Often patients with restricted mobility experience weakness; and, as this progresses, the cough reflex gradually becomes inefficient. All of these factors put the patient at risk of developing pneumonia. The stasis of secretions in the lungs is life threatening for an immobilized patient. A variety of nursing interventions are available to expand the lungs, dislodge and mobilize stagnant secretions, and clear the lungs. All of these interventions help reduce the risk of pneumonia. Prevention begins with assessment. Assess the patient’s respiratory status per agency policy. Assessment findings that indicate pneumonia include productive cough with greenish-yellow sputum; fever; pain on breathing; and crackles, wheezes, and dyspnea. It is essential to implement pulmonary interventions in all patients, even those who do not have pneumonia. Encourage the patient to deep breathe and cough every 1 to 2 hours. Teach alert patients to deep breathe or yawn every hour or to use an incentive spirometer. Instruct the patient to take in three deep breaths and cough with the third exhalation. Chest physiotherapy (CPT) (percussion and positioning) is another effective method for preventing pneumonia and keeping the airway clear. CPT helps the patient drain secretions from specific segments of the bronchi and lungs into the trachea so he or she is able to cough and expel them. Ensure that patients who are immobile take an adequate fluid intake. Unless there is a medical contraindication, an adult needs to drink at least 1100 to 1400 mL of noncaffeinated fluids daily. This helps keep mucociliary clearance normal. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Consider Eileen Thomas’ medical history of type 2 diabetes mellitus, heart valve replacement surgery 2 months ago, and being an active smoker. [Ask students: Can you list three nursing interventions that you will initiate to prevent respiratory complications related to her immobility? Discuss: Deep breathing and coughing every 2 hours while awake, turning every 1 to 2 hours while awake, and incentive spirometer 5 times every 30 minutes while awake during the first 24 to 48 hours postoperatively.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Implementation: Acute Care (Cont.)
Cardiovascular Reducing orthostatic hypotension Reducing cardiac workload Preventing thrombus formation SCDs, thromboembolic disease (TED), hose, and leg exercises When patients who are on bed rest or are immobile move to a sitting or standing position, they often experience orthostatic hypotension. They have an increased pulse rate, a decreased pulse pressure, and a drop in blood pressure. If symptoms become severe enough, the patient can faint. Mobilize the patient as soon as the physical condition allows, even if this only involves dangling at the bedside or moving to a chair. Isometric exercises (i.e., activities that involve muscle tension without muscle shortening) have no beneficial effect on preventing orthostatic hypotension, but they improve activity tolerance. When getting an immobile patient up for the first time, assess the situation using a safe patient–handling algorithm. The nurse designs interventions to reduce cardiac workload, which is increased by immobility. A primary intervention is to discourage the patient from using the Valsalva maneuver. This increases intrathoracic pressure, which in turn decreases venous return and cardiac output. When the strain is released, venous return and cardiac output immediately increase, and systolic blood pressure and pulse pressure rise. Teach the patient to breathe out while moving side-to-side or up in bed. The most cost-effective way to address deep vein thrombosis (DVT) is through an aggressive program of prophylaxis. It begins with identification of patients at risk and continues throughout their immobilization. Leg, foot, and ankle exercises; regularly providing fluids; position changes; and patient teaching need to begin when the patient becomes immobile. Common dosage for heparin therapy for DVT prophylaxis is 5000 units given subcutaneously 2 hours before surgery and repeated every 8 to 12 hours until the patient is fully mobile or discharged. Common dosage of enoxaparin (Lovenox) (a low-molecular-weight heparin) in the prophylaxis of DVTs is 30 to 40 mg subcutaneously 2 hours before surgery and continued every 8 to 12 hours throughout the postoperative period. Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding such as hematuria, bruising, coffee ground–like vomitus or GI aspirate, guaiac-positive stools, and bleeding gums. SCDs and intermittent pneumatic compression (IPC) are used to prevent blot clots in the lower extremities. [Review Box 28-7, Procedural Guideline: Applying Elastic Stockings and Sequential Compression Devices, with students.] Elastic stockings (sometimes called antiembolitic stockings) also aid in maintaining external pressure on the muscles of the lower extremities and thus promote venous return. Proper positioning reduces the patient’s risk of thrombus formation because compression of the leg veins is minimized. ROM exercises reduce the risk of contractures and aid in preventing thrombi. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Implementation (Cont.)
Musculoskeletal system Prevent muscle atrophy and joint contractures Exercises to prevent excessive muscle atrophy and joint contractures help maintain musculoskeletal function. If the patient is unable to move part or all of the body, perform passive ROM exercises for all immobilized joints while bathing the patient and at least two or three more times a day. If one extremity is paralyzed, teach the patient to put each joint independently through its ROM. Patients on bed rest need to have active ROM exercises incorporated into their daily schedules. Teach patients to integrate exercises during ADLs. Some orthopedic conditions require more frequent passive ROM exercises to restore the function of the injured joint after surgery. Patients with such conditions need to use automatic equipment (continuous passive motion [CPM]) for passive ROM exercises). Copyright © 2017, Elsevier Inc. All Rights Reserved.

Implementation Integumentary system Elimination system
Reposition every 1 to 2 hours. Provide skin care. Elimination system Provide adequate hydration. Serve a diet rich in fluids, fruits, vegetables, and fiber. The major risk to the skin from restricted mobility is the formation of pressure ulcers. Repositioning every 2 hours and providing skin care will help to prevent pressure ulcers. Interventions aimed at prevention include positioning, skin care, and the use of therapeutic devices to relieve pressure. Change the immobilized patient’s position according to his or her activity level, perceptual ability, treatment protocols, and daily routines. Patients need between 2000 and 3000 mL of fluids per day to help prevent renal calculi and urinary tract infection (UTI). Monitor intake and output to ensure that fluid balance is maintained. Although turning every 1 to 2 hours is recommended for preventing ulcers, it is sometimes necessary to use devices for relieving pressure. Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. Reposition patients frequently because uninterrupted pressure causes skin breakdown. Teach patients to shift their weight every 15 minutes. Chair-bound patients need to have a device for the chair that reduces pressure. The nursing interventions for maintaining optimal urinary functioning are directed at keeping the patient well hydrated and preventing urinary stasis, calculi, and infections without causing bladder distention. Adequate hydration (e.g., at least 1100 to 1400 mL of noncaffeinated fluids daily) helps prevent renal calculi and urinary tract infections. Record the frequency and consistency of bowel movements. Provide a diet rich in fluids, fruits, vegetables, and fiber to facilitate normal peristalsis. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Psychosocial changes Developmental changes People who have a tendency toward depression or mood swings are at greater risk for developing psychosocial effects during bed rest or immobilization. Anticipate changes in the patient’s psychosocial status, and provide routine and informal socialization. Observe the patient’s ability to cope with restricted mobility. Nurses provide stimuli to maintain a patient’s orientation. Plan nursing activities so the patient is able to talk and interact with staff. Involve patients in their care whenever possible. Ideally, immobilized patients continue normal development. Nursing care needs to provide mental and physical stimulation, particularly for a young child. Older patients who are frail or have chronic illnesses are often at increased risk for the psychosocial hazards of immobility. Maintaining a calendar and clock with a large dial, conversing about current events and family members, and encouraging visits from significant others reduce the risk of social isolation. Nurses need to encourage older immobilized patients to perform as many ADLs as independently as possible. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Positioning Techniques
Trochanter roll Hand roll Trapeze bar Patients with impaired nervous, skeletal, or muscular system functioning and increased weakness and fatigability often require help from the nurse to attain proper body alignment while in bed or sitting. [Review Skill 28-1, Moving and Positioning Patients in Bed, with students.] Several positioning devices are available for maintaining good body alignment for patients, including pillows, positioning boots, ankle-foot orthoses (AFOs), blankets, sandbags, hand rolls, and splints. A trochanter roll prevents external rotation of the hips when the patient is in a supine position. To form a trochanter roll, fold a cotton bath blanket lengthwise to a width that extends from the greater trochanter of the femur to the lower border of the popliteal space. Place the blanket under the buttocks and roll it counterclockwise until the thigh is in neutral position or inward rotation. When the hip is aligned correctly, the patella faces directly upward. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers, which maintain a functional position. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bed frame. It allows the patient to pull with the upper extremities to raise the trunk off the bed, assist in transfer from bed to wheelchair, or perform upper arm exercises. It increases independence, maintains upper body strength, and decreases the shearing action from sliding across or up and down in bed. Following guidelines reduces the risk of injury to the musculoskeletal system when the patient is sitting or lying. When joints are unsupported, their alignment is impaired. Likewise, if joints are not positioned in a slightly flexed position, their mobility is decreased. During positioning also assess for pressure points. [Shown are Figure 28-10: Trochanter roll, and Figure 28-11: Patient using trapeze bar.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Positioning Techniques (Cont.)
Supported Fowler’s Supine Prone Side-lying Sims’ In the supported Fowler’s position, the head of the bed is elevated 45 to 60 degrees, and the patient’s knees are slightly elevated without pressure to restrict circulation in the lower legs. The following are common trouble areas for the patient in the supported Fowler’s position: Increased cervical flexion because the pillow at the head is too thick and the head thrusts forward. Extension of the knees, allowing the patient to slide to the foot of the bed. Pressure on the posterior aspect of the knees, decreasing circulation to the feet. External rotation of the hips. Arms hanging unsupported at the patient’s sides. Unsupported feet or pressure on the heels. Unprotected pressure points at the sacrum and heels. Increased shearing force on the back and heels when the head of the bed is raised greater than 60 degrees. Patients in the supine position rest on their backs. In the supine position the relationship of body parts is essentially the same as in good standing alignment except that the body is in the horizontal plane. The following are some common trouble areas for patients in the supine position: Pillow at the head that is too thick, increasing cervical flexion. Head flat on the mattress. Shoulders unsupported and internally rotated. Elbows extended. Thumb not in opposition to the fingers. Hips externally rotated. Unsupported feet. Unprotected pressure points at the occipital region of the head, vertebrae, coccyx, elbows, and heels. The patient in the prone position lies face or chest down. Often his or her head is turned to the side; but, if a pillow is under the head, it needs to be thin enough to prevent cervical flexion or extension and maintain alignment of the lumbar spine. Assess for and correct any of the following potential trouble points with patients in the prone position: Neck hyperextension. Hyperextension of the lumbar spine. Plantar flexion of the ankles. Unprotected pressure points at the chin, elbows, female breasts, hips, knees, and toes. In the side-lying (or lateral) position the patient rests on the side with the major portion of body weight on the dependent hip and shoulder. A 30-degree lateral position is recommended for patients at risk for pressure ulcers. The following trouble points are common in the side-lying position: Lateral flexion of the neck. Spinal curves out of normal alignment. Shoulder and hip joints internally rotated, adducted, or unsupported. Lack of foot support. Lack of protection for pressure points at the ear, shoulder, anterior iliac spine, trochanter, and ankles. Excessive lateral flexion of the spine if the patient has large hips and a pillow is not placed superior to the hips at the waist. Sims’ position differs from the side-lying position in the distribution of the patient’s weight. In Sims’ position the patient places the weight on the anterior ileum, humerus, and clavicle. Trouble points common in Sims’ position include the following: Internal rotation, adduction, or lack of support to the shoulders and hips. Lack of protection for pressure points at the ileum, humerus, clavicle, knees, and ankles. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Positioning Techniques (Cont.)
Moving patients Safety is first priority Ask patient to help as much as possible Determine if patient comprehends what is expected Determine patient’s comfort level Determine if you need assistance in moving the patient Always ask the patient to help to the fullest extent possible. To determine what the patient is able to do alone and how many people are needed to help move him or her in bed, assess him or her to determine whether the illness contradicts exertion (e.g., cardiovascular disease). Next, determine whether the patient comprehends what is expected. Then determine his or her comfort level. It is important to evaluate your personal strength and knowledge of the procedure. Finally, determine whether the patient is too heavy or immobile for you to move alone. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Implementation Restorative and continuing care IADLs ROM exercise
Walking The goal of restorative care for the patient who is immobile is to maximize functional mobility and independence and reduce residual functional deficits such as impaired gait and decreased endurance. The focus in restorative care is not only on ADLs that relate to physical self-care, but also on instrumental activities of daily living (IADLs). IADLs are activities that are necessary to be independent in society beyond eating, grooming, transferring, and toileting; they include such skills as shopping, preparing meals, banking, and taking medications. Work collaboratively with patients and other health care professionals. To ensure adequate joint mobility, teach the patient about ROM exercises. When performing passive ROM exercises, stand at the side of the bed closest to the joint being exercised. Perform passive ROM exercises using a head-to-toe sequence and moving from larger to smaller joints. If an extremity is to be moved or lifted, place a cupped hand under the joint to support it, support the joint by holding the adjacent distal and proximal areas or support the joint with one hand and cradle the distal portion of the extremity with the remaining arm. When a patient has a limited ability to walk, assess his or her activity tolerance, tolerance to the upright position (orthostatic hypotension), strength, presence of pain, coordination, and balance to determine the amount of assistance needed. Explain how far the patient should try to walk, who is going to help, when the walk will take place, and why walking is important. In addition, determine with the patient how much independence he or she can assume. Check the environment to be sure that there are no obstacles in the patient’s path. Provide support at the waist by using a gait belt so the patient’s center of gravity remains midline. Patients with hemiplegia (one-sided paralysis) or hemiparesis (one-sided weakness) often need assistance with walking. [Shown are Figure 28-12: Supporting joint by holding distal and proximal areas adjacent to joint, and Figure 28-13: Cradling distal portion of extremity.] IADLs, Instrumental activities of daily living; ROM, range of motion. Copyright © 2017, Elsevier Inc. All Rights Reserved.

[Shown is Figure 28-14: A, Stand with feet apart to provide broad base of support. B, Extend one leg and let patient slide against it to the floor. C, Bend knees to lower body as patient slides to floor.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Evaluation Through the patient’s eyes Patient outcomes
It is essential to have the patient’s evaluation of the plan of care Patient outcomes Evaluate effectiveness of specific interventions Evaluate patient’s and family’s understanding of all teaching provided Were the goals met, or is more work required? You must now determine with the patient and others involved with care if the goals or outcomes established with and for the patient have indeed been met; what still needs to be achieved from the patient’s perspective; and the construction of a new plan of care. In other words, how have the patient’s expectations changed and in what ways? From your perspective as the nurse, you are to evaluate outcomes and response to nursing care and compare the patient’s actual outcomes with the outcomes selected during planning such as his or her ability to maintain or improve body alignment, joint mobility, walking, moving, or transferring. When outcomes are not met, consider asking the following questions: Are there ways we can assist you to increase your activity? Which activities are you having trouble completing right now? How do you feel about not being able to dress yourself and make your own meals? Which exercises do you find most helpful? What goals for your activity would you like to set now? Copyright © 2017, Elsevier Inc. All Rights Reserved.

Safety Guidelines for Nursing Skills
Communicate clearly with members of the health care team Assess and incorporate the patient’s priorities of care and preferences Use the best evidence when making decisions about your patient’s care Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with members of the health care team, access and incorporate the patient’s priorities of care and preferences, and use the best evidence when making decisions about your patient’s care. When performing the skills in this chapter, remember the following points to ensure safe, individualized patient-centered care: Determine the amount and type of assistance required for safe positioning, including any transfer equipment and the number of personnel to safely transfer and prevent harm to patient and health care providers. Raise the side rail on the side of the bed opposite of where you are standing to prevent the patient from falling out of bed on that side. Arrange equipment (e.g., intravenous lines, feeding tube, indwelling catheter) so it does not interfere with the positioning process. Evaluate the patient for correct body alignment and pressure risks after repositioning. Copyright © 2017, Elsevier Inc. All Rights Reserved.

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