1. Discuss nursing interventions that prevent complications of immobility.

Prevention Complications of Immobility Promote adequate elimination  Hydration  Toilet/Bedside commode whenever possible  Fiber supplements  Stool softeners  PRN laxatives Prevent pressure ulcers  Pressure reduction  Pressure relief  Repositioning every 2 hr  Teach shift weight every 15 minutes  Pull sheet to prevent shear  Overbed trapeze  Perineal hygiene Individualized exercise program  Progressive  Active Range of Motion exercises  Passive Range of Motion exercises  CPM ± (continuous passive motion) machine Prevent deformity  Positioning  Trochanter roll: prevents external rotation  Hand rolls: hand in functional position  Hand-wrist splints  Foot boards  High ±top-sneakers

2. Identify head- to- toe nursing assessments that indicate complications of immobility. Nursing Diagnosis: Impaired Physical Mobility Limitation of physical mobility

Risks related to:  Bed rest  Restriction of movement related to devices (ie: casts, traction)  Voluntary restriction (ie: fear of falling)  Pain or deformity  Muscular deconditioning Nursing Assessment: Musculoskeletal Effects of Immobility 

Muscular Deconditioning  Lack of physical activity  Bed rest = 3% muscle strength/day  Disuse atrophy ± pathological reduction in normal size of muscle fibers Assessment  muscle strength, ROM  ability to perform ADLs  Ability to walk, gait  Activity tolerance  Risk for falls Joint contracture  Fixation joint  Disuse, atrophy, shortening muscle fibers  Joint non-functional position Impaired Calcium metabolism ± loss of calcium from bone  Disuse osteoporosis  Pathologic fractures Assessment  Body alignment  Joint position  Joint mobility  Pain (joint, bone)  Functional use of joint  Gait  Falls    

crackles. cognition. air hunger) o Assess Pulse Oximetry Integumentary o Pressure ulcers caused by prolonged ischemia to tissue o Skin shear injury Assessment o Inspect skin o Look for non-blanching erythemia over boney prominences Cardiovascular o Increase cardiac workload  Decrease cardiac output o Orthostatic hypotension  Drop 20 mm/hg systolic  Drop 10 mm/hg diastolic Assessment o Fatigue o Edema o Auscultate lungs: crackles o Orthostatic BP Cardiovascular  Risk thrombus formation Loss integrity vessel wall (injury) Abnormality blood flow (slowed blood flow in LE r/t bedrest) Alteration blood constituents (ie: change in clotting factors or increased platelet activity)  Assessment o Pulses o Edema: compare legs . wheezes o Oxygenation: mucous membranes. nail beds.Nursing Assessment: Systemic Effects of Immobility Respiratory o Atelectasis (collapse of alveoli) o Hypostatic pneumonia (inflammation lung r/t stasis of secretions) Assessment o Lung sounds: clear. respiratory effort (use accessory muscle.

bowel sounds. abnormal tympany. frequency. somatic complaints. UTI (urgency. changes in metabolism of CHO. assess urine for concentration. fats. constipation. odor. slowing peristalsis. incontinence. size o Lab studies: Albumin. Pre-albumin Psychological/Social Depression  Sleep-wake disturbances  Impaired coping  Change self concept Older Adults  Effects of immobility accelerated!  Functional decline  Delirium Assessment o Affect. protein o Negative nitrogen balance  More nitrogen excreted than ingested(food)  Weight loss  Decrease muscle mass  Weakness Assessment o Weight o Calorie count o Muscle strength. negativity o Ability to get to sleep and stay asleep. tenderness. eating. daytime sleeping .o o o o Homan¶s sign: calf pain on dorsiflexion Pain Erythema Warmth GI: decreased appetite. fecal impaction (diarrhea caused by stool obstruction) GU: incomplete bladder emptying (loss help of gravity when supine)  Urinary stasis  Increases risk kidney stones  UTI Assessment  Abdomen: distention. verbalizations of despair. bowel pattern  GU: I & O. dysuria) Nutrition: deficiency in calories and protein (R/T decreased appetite) o Decrease in metabolic rate.

o Cognition: abrupt change in cognition o Ability perform ADLs Complications of a fracture: y y y infection Compartment syndrome Venus thromboembolism .

y y y y y y y y y Fat embolism syndrome Muscle atrophy Contracture Footdrop Pain Muscle spasms Pressure ulcers Open fractures and soft tissue injuries have o incidence Osteomyelitis State the symptoms of fat embolism. Fat Embolism Syndrome (FES) y Characterized by the presence of fat globules in tissues and organs after a traumatic skeletal injury y Tissues most often affected:  Lungs y Brain y Heart y Kidneys y Skin Fractures that most often cause FES: y Long bones y Ribs y Tibia y Pelvis Clinical Manifestations y Usually occur 24 to 48 hours after injury y Interstitial pneumonitis y Produce symptoms of ARDS y Clinical Manifestations .

y Symptoms of ARDS: o Chest pain o Tachypnea o Cyanosis o q PaO2 o Dyspnea o Apprehension o Tachycardia y y y Rapid and acute course Feeling of impending disaster Client may become comatose in a short time Collaborative Care y Treatment directed at prevention y Careful immobilization of a long bone fracture y Most important preventative factor y Symptom management y Fluid resuscitation y Oxygen y Reposition as little as possible State the symptoms of pulmonary embolism State the symptoms of compartment syndrome. burns. knee or leg surgery y Exertional ± intensive exercise y Crush injuries Two basic etiologies create compartment syndrome: y Decreased compartment size o Restrictive dressings o Splints o Casts y Increased compartment content . y Causes capillary perfusion to be reduced below a level necessary for tissue viability y Acute ± fractures. Compartment Syndrome y elevatedintracompartmental pressure within a confined myofascial compartment y compromises the neurovascular function of tissues within that space.

Musculoskeletal Injuries y Sprains .o Bleeding o Edema Clinical Manifestations Six Ps: ‡ Paresthesia ‡ Pain ‡ Pressure ‡ Pallor ‡ Paralysis ‡ Pulselessness Client may present with one or all of the six Ps! Absence of peripheral pulse Ominous late sign MyoglobinuriaDark reddish-brown urine Collaborative Care y Prompt. accurate diagnosis is critical y Early recognition is the key y Do not apply ice or elevate above heart level y Remove/loosen the bandage and bivalve the cast y Traction weight reduction y Surgical decompression (fasciotomy) Complications of Fractures Venous Thrombosis y Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture. especially hip fracture y Precipitating factors: o Venous stasis caused by incorrectly applied casts or traction o Local pressure on a vein o Immobility State interventions for the client with a sprain/ sprain.

ice. elevation)  Mild analgesics Musculoskeletal Injuries y Dislocations ± complete separation articular surfaces of a joint y Subluxation ± partial separation y Nursing Assessment y Joint asymmetry y Pain y Tenderness y Loss of function y Edema y Nursing Preventions y Medical emergency y Pain control y Joint protection y Gradual increase ROM (support joint) Desrcibe Fractures: What is a fracture y A disruption or break in the continuity of the structure of bone y Traumatic injuries account for the majority of fractures Fracture Location .y y y y Injury to ligaments Wrenching and twisting Classified according to amount of ligament fibers torn Strains y Excessive stretch of a muscle and tendon Musculoskeletal Injuries y Nursing Assessment of Strains and Sprains y Pain y Edema y Decrease in function y Bruising y Nursing Preventions o Primary o Secondary  RICE (rest. compression.

and alignment of the bone fragments Stable fractures y Occur when a piece of the periosteum is intact across the fracture y External or internal fixation has rendered the fragments stationary Unstable fractures y Grossly displaced y Site of poor fixation y Immediate localized pain y Muscle spasms y Guarding Function Inability to bear weight or use affected part Edema and swelling Deformity (but not all fractures!) Ecchymosis Crepitation q q y y y y Nursing Assessment after an injury Emergency o ABCs y Bleeding y Vital signs y Level of consciousness . position.What is a fracture? What is a fracture? What is a fracture? Stress Fracture y tiny cracks in a bone y occur during high-impact repetitive activity y most common in the weight-bearing bones of lower leg and foot y osteoporosis Fractures y Closed (simple) y Open (compound) Classified by appearance.

alignment y Muscle strength y Joint crepitation Limb below injury y Pulses y Paresthesias y Change in sensation y Capillary refill y Temperature Fracture Healing ‡ ‡ ‡ ‡ ‡ ‡ y y y y y y y Fracture hematoma Granulation tissue Callus formation Ossification Consolidation Remodeling Reduction Anatomic realignment of bone fragments Immobilization Maintain alignment Restoration of normal function Closed reduction Nonsurgical .y Pain Pulses Site of injury Lacerations y Skin color and temp y Ecchymosis y Hematoma y Edema y Loss of function.

screws. rods. plates.y Manual realignment Open reduction y Surgical procedure y Placement of wire. pins. nails y Application of a pulling force to an injured part of the body while countertraction pulls in the opposite direction Collaborative Care Fracture Reduction/Immobilization y Traction y Skin traction (short-term) y Skeletal traction (longer periods) Purpose of traction: y Prevent or reduce muscle spasm y Immobilization y Reduction y Treat a pathologic condition y Neck ± degenerative disc disease y Back ± muscle spasms Collaborative Care Fracture Immobilization y Casts y Immobilization after closed reduction Collaborative Care Fracture Immobilization .

pale. equal. absent) .y y y y Short arm cast Long arm cast Long leg cast Short leg cast Collaborative Care Fracture Immobilization y Body jacket cast y Hip spica cast Collaborative Care Fracture Immobilization y External fixation y Metallic device composed of pins that are inserted into the bone and attached to external rods y ³skeletal traction´ Collaborative Care Fracture Immobilization y Internal fixation y Pins. strong. plates. cold) y Capillary refill (3 second rule!) y Peripheral pulses (present. cyanotic) y Temperature (hot. by Doppler. cool. warm. intramedullary rods. and screws y Surgically inserted at the time of realignment Collaborative Care Drug Therapy y Pain managment y Muscle relaxant y Analgesics y Tetanus-diphtheria toxoid or immunoglobulin y Bone-penetrating antibiotic y Cephalosporin Nursing Management Nursing Assessment y Brief history of the accident y Mechanism of injury y Collaborative care (reduction/immobilization) Nursing Assessment after fracture reduction and immobilization Neuro-vascular assessment y Color (pink.

tingling y decreased.y Edema Nursing Assessment after fracture reduction and immobilization Neuro-vascular assessment y Sensation y numbness.  Motor function Hand ± abduction/adduction fingers. hypersensation. supination/pronation hand Leg ± dorsiflexion and plantar flexion Equal strenght  Pain Location Quality Intensity 1-10 Nursing Diagnoses Fracture reduction and immobilization y Risk for peripheral neuro-vascular dysfunction y Acute pain y Risk for infection y Risk for impaired skin integrity y Impaired physical mobility y Ineffective therapeutic regimen management Facture reduction and immobilization Planning y Physiologic healing with no associated complications y Pain relief y Achieve maximal rehabilitation potential Facture reduction and immobilization Primary Preventions y Fall prevention y Use of seat belts y Stretching before exercising y Participate in moderate exercise .

Fracture reduction and immobilization Secondary Preventions y Preoperative management y Inform of immobilization device and expected activity limitations y Skin preparation y Postoperative management y Monitor vital signs y Frequent neurovascular assessments y Carefully monitored mobility y Pain management y Hydration y High fiber diet Facture reduction and immobilization Secondary Preventions Skin Traction  Neurovascular assessment  Use trapeze for repositioning  Ensure proper functioning of tractioning equipment  Body alignment  Weights hang freely  Skin care and repositioning to prevent pressure ulcers y Skeletal Traction Pin site care  Pin should be immobile  Assess for infection  Removal of exudate Facture reduction and immobilzation Secondary Preventions y Cast care  Frequent neurovascular assessments  Teach patient signs of complications  Increased pain .

Edema Discoloration of digits Burning/tingling under cast Odor ³sores´ under cast  Elevation of extremity above level of the heart  Exercise joints above and below the cast Facture reduction and immobilization Secondary Preventions y Spiritual Variable y Psychosocial Variable y Management of ADLs y Social support systems y Change in family constellation ± change in role expectations y Financial y Evaluate presence of posttraumatic stress disorder      Facture reduction and immobilization Secondary Preventions y Ambulation y Usually started in mobility training when able to sit in bed and dangle feet over the side y Weight bearing: None. Total y Assistive devices o Cane o Walker o Crutches Fracture reduction and immobilization Evaluation y Normal neurovascular examination y Tolerable or no pain y No evidence of infection y No evidence of skin breakdown y Crutches correctly used y Minimal loss of muscle mass of affected extremity Identify assessment findings for a broken hip Fractures: Hip Fracture y More common in older adults The Older Adult with Hip Fracture y Physiological Variable . Partial.

Stressors y Type of fracture y Type of surgery y Postoperative concerns  DVT  PE  Infection  Weight-bearing/ambulation  Nutrition  Pain The Older Adult with Hip Fracture Developmental Variable o Sexual activity o Neurocognitive complications Psychological Variable Stressors o Delerium o Depression o Agitation/aggression Sociocultural Variable o Social support systems o Managing ADL¶s Spiritual Variable Stressors o Search for meaning o Community/religious support systems Fractures: Hip Fracture y Clinical Manifestations o External rotation o Muscle spasm o Shortening of affected extremity o Pain .

y o Tenderness Collaborative Care o ORIF (open reduction. bleeding y y y Neurovascular assessment Proper joint alignment o Abductor pillow Hip precautions o Avoid flexion > 90  Use raised toilet seat o No adduction  No leg crossing o No internal rotation ³Hip Precautions´ Older Adult with Hip Fracture y Hip prosthesis dislocation y Increased pain at surgical site. immobilization y Acute groin pain y Abnormal external or internal rotation y Inability to move leg . internal fixation)  Femoral head replaced with prosthesis  Plate/screws/ pins/intramedullary rod Nursing Assessment y Hip Fracture   Lateral rotation leg One leg shorter Fractures: Hip Fracture Post-Operative Preventions y Vital signs y I&O y Cough & Deep breathing y Incentive spirometry y Pain management y Prophylactic anticoagulation  LMWH  Heparin (SQ)  Coumadin y Incisional care  Assess for infection. swelling.

y ³popping´ sensation Older Adult with Hip Fracture y Nursing Diagnosis y Acute pain y Impaired physical mobility y Impaired skin integrity y Risk or impaired urinary elimination y Risk for ineffective coping y Risk for disturbed thought processes y Risk for ineffective health maintenance y Collaborative Diagnosis y Hemorrhage y Infection y Peripheral neurovascular dysfunction y DVT y Pulmonary complications y Pressure ulcer y Joint dislocation Describe care of client after knee replacement: y A compression dressing may be used to immobilize the knee in extension immediately after the operation y Great emphasis is placed on postoperative physical therapy y Isometric quadriceps begins the first day after surgery y Progresses to straight leg raises and gentle rom to increase muscle strength .

State interventions for the client with osteoporosis: y Preventions focus on adequate calcium supply y exercise .

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