Chapter II

MOBILITY, EXERCISE, AND BODY

MECHANICS
 LEARNING OUTCOMES
 

At completion of this chapter, the learner should

be able to:
– Demonstrate understanding of the importance of
movement and exercise 
– Assess mobility needs of an individual 
– Make appropriate nursing diagnosis related to
changes in mobility needs of client 
– Develop an individualized nursing care plan that is
based on identified needs 
– Describe different positions used for positioning a
client, its indications and contraindications
– Describe the principles, for transferring and
transporting client 
– Describe the risks and complications associated
with limited mobility or prolonged bed rest
– Identify and manage patients who are at risk of
developing risks or complications associated with
limited mobility or prolonged bed rest 
– Plan preventives measures for clients with risk for
pressure ulcers and other complications
associated with immobility, bed-rest and
inactivity. 
 INTRODUCTION

The body is designed as a dynamic,

moving machine, able to perform a
variety of activities, movements, and
exercises and to maintain a desirable
body posture.
Physical movement has many functions
such as :
 To carry out the normal activities of
daily living; as a source of pleasure.
 ,
Many people undertake physical activities
such as exercise in order to experience
the sense of well-being that is associated
with exercise. Exercise has a positive
effect on metabolism and all systems of
the body, especially the cardiovascular,
musculo-skeletal and respiratory
systems.
 The benefits of exercise

  Muscle tone is improved

 Cardiovascular efficiency and cardiac reserve
are increased 
Oxygenation and pulmonary efficiency are
improved 
 Digestion is enhanced
 The metabolism is improved
 
 ,
Mental alertness is increased 
Work and stress tolerances are increased
 Sleep is improved
Cholesterol levels are decreased, the
amount of fatty tissue in the body is
decreased
Hemoglobin levels are increased 
 ,
Inactivity leads to deterioration of health.
People with limited activity and
movement may develop multiple
complications. The consequences of
inactivity are mainly referred as disuse
syndrome (signs & symptoms that result
from inactivity).
 ,
 Nursing care, such as moving and positioning,
reduce the potential for disuse syndrome.
  Nurses also have potential to develop injuries,
if they fail to use good posture and body
mechanics while providing care. Posture
affects a person’s appearance and ability to
use the musculoskeletal system efficiently
when standing, sitting or lying
 ,
 When a person performs work while is using
a poor posture, muscle spasms (sudden,
forceful, involuntary muscle contractions) and
other problems (back pain) often result.
Therefore, good posture is important both for
nurses and clients
 ASSESSING MOBILITY NEEDS OF A CLIENT
 
,

A general assessment of a patient’s

mobility is essential to:
(1) identify any limitations to movement
or risks for impaired mobility
(2) to fully ascertain the extent to which a
patient will require assistance in carrying
out the activities of daily living.
 ,
Nurse selects Position, transfer and
protective devices according to
whether the client is independent or
requires partial or total assistance.
Assessment includes both
Nursing history and
Physical examination.
 Nursing history

Nursing history aims to determine the

client’s problems through the
interview. The chief complaint is
stated, the specific nature of that
problem, when it began, its
frequency its cause if known and
other information related
 Physical examination

Physical examination involves the

following:
Body alignment
 Gait and Appearance
 Movement of joints
 Capabilities and limitations for
movement
 Muscle mass and strength
 ,
• Activity tolerance
•  
Problems related to immobility
•  
Physical fitness
•  
Review of systems
 
 ,
The nurse should assess the following aspects
when carrying out a general survey of the
patient’s mobility:
  Ask the patient to rise from a lying position to
a sitting position on the edge of the bed or
examination table. Normally the patient should be
able to do this unaided. If the patient is suffering
from muscle weakness, he/ she may push on the
bed, or pull him/herself up by means of the cot sides
or other handy items of furniture.
 
 ,
 Ask the patient to stand up out of chair.
Normally the patient should be able to do this
unaided. If muscles are weak the patient may
push him/ herself up with the hands, or he/
she may lean forward before rising.
  Observe the amount of assistance needed by
the patient to move in bed. Note whether the
patient can turn in bed unaided or not, as well
as sit up in bed. 
 ,
Assess the patient’s gait by asking him/
her to walk a short distance. Note the
following: The steadiness of the gait,
whether the trunk is upright, whether
the feet and legs are lifted normally, or
whether the patient just shuffles along or
whether the steps are appropriate or are
too small.
 NURSING IMPLICATIONS DIAGNOSIS
 

Nursing Diagnoses include (but list not limited)

Impaired physical mobility
Activity intolerance
Risk for activity intolerance
Sedentary lifestyle
Risk for disuse syndrome
 ,
Problems associated with prolonged
immobility
Risk for impaired skin integrity
Risk for infection or Risk for injury
Ineffective airway clearance
Risk for disturbed sleep pattern
 Manifestation Diagnostic
Examples of] Related Characteristics (AMB or AEB)
factors (r/t
Diagnostic label
Activity or decreased strength and endurance

Inability to move purposefully

mpaired Physical

Mobility
Limited range of motion
Pain / Discomfort

Impaired coordination
Cognitive impairment,

Hesitant to attempt movemen

Neuromuscular impairment

Decreased muscle mass, strength,

Musculoskeletal impairment and/or control

Depression

severe anxiety
Activity §
Patient verbalize
intolerence §
Bed rest weakness or fatigue

§
Abnormal physiologic
§
Immobility responses to activity,
for e.g., changes in V/S like
respiration or heart rate
changes
§
Generalized weakness

§
Sedentary lifestyle

§
Imbalance between Discomfort or dyspnea upon
oxygen supply and demand exertion
 §
Inability to wash body or body Patient in poor hygiene
parts conditions

§
Inability to obtain or get to water
source §
Bad smelling

Self-Care deficits §
Activity intolerance §
Bad breaths
Decreased strength and
endurance
 

Pain
 

Impaired transfer ability

MEETING CLIENT’S NEEDS

1. AMBULATION
 Ambulation

 The term ambulation means to walk. Because

immobility/inactivity has a negative effect on most of the
body’s systems and clients must therefore be assisted,
depending on their conditions, to get out from the bed
and to walk as quickly as possible.
  A client can never be allowed to get out of bed and walk
alone for the first time after an illness. The nurse has first
to ascertain his/her condition, and then nurse assists
him/her to get out of bed. In the case of a large, heavy
client, the help from a second person must be sought.
 ,
Certain aids may be used when a client has difficulty
in walking alone. Aids include :
• walking stick,
•  Tripod or quadripod
• Walking frame and Crutches.
The type of aid selected depends on the person’s
condition and the amount of support required.
Ambulation after surgery or illness is an essential
measure to prevent complications.
 2. EXERCISE
 

• If a client is unable to meet his/her own

mobility/activity needs, the nurse will do so for
the client.
This promotes the client’s comfort. Exercise helps
to promote recovery by stimulating the immune
system and increasing the secretion of growth
hormone, which is required for healing and
rebuilding the tissues.
There are 2 types of exercise: active and passive
 Active exercise

 Exercise that is actively carried out by the patient

 In the case of a patient who is not fully mobile,
or who is only able to carry out a limited number
of activities, the nurse should encourage him/her
to do as much for him/herself as is possible
 It may be helpful to refer the patient to the
physiotherapist, who can work out a specific
program of active exercise for the patient.
 Passive exercise

 Exercises are done by a nurse or

physiotherapist where a patient is
unable to carry out the movements,
or is paralyzed or unconscious.
 ,
Movements executed during exercises
involve:
• Hip flexion and extension 
• Hip rotation
• Abduction and adduction of hips
•  Knee extension
•  Flexion, inversion and eversion of ankle
joints
•  Flexion and extension of toes
 ,
Flexion – the movement when two bones forming a
joint are brought closer to each other.
 Extension – is a movement in which the bones at joint
are moved further from each other.
 Abduction – movement of a body part away from the
midline of the body, as when the arm is raised laterally
to shoulder level.
 Adduction – movement of a body part closer to the
midline of the body, as when the arm in abduction is
dropped again.
 ,
Rotation – movement of a bone about its
central axis
 Inversion – turning inwards, e.g. turning the
sole of the foot inwards from the ankle joint.
 Eversion – turning the sole of the foot
outwards from the ankle joint.
 Supination – the palm of the hand is turned
upwards.
 Pronation – the palm of the hand is turned
downwards and therefore faces posterior.
 3. BED REST
Bed rest, or confinement to bed, is prescribed
in a number of conditions in which activity and
strain will hinder recovery. The patient is kept
at rest in order to facilitate healing or to
prevent further damage. Bed rest is prescribed
for conditions like Myocardial infarction,
severe respiratory disease with marked
dyspnea, cerebral aneurysm, some cases of
hypertension, severe flu, … 
 ,
• The patient may be confined to bed
because of an inability to move, because
for example of paralysis, or
unconsciousness. Patients may be placed
at strict bed rest (i.e. not allowed up at
all) or may be allowed up to use the
bathroom and toilet only. 
 4. POSITIONNING CLIENT

• One of the basic procedures that

nursing personnel perform most
frequently is that of changing the
patient's position. Healthy client has
the ability to move and change position
at will, whereas sick person or inactive
client needs assistance from others.
 ,
• Movements maybe limited by
diseases, systemic disorders, injury,
or helplessness. It is often the
responsibility of the practical nurse
to position the patient and change
his position frequently.
 Reasons of changing client's position
 

To promote comfort and relaxation

 To restore body function (Changing
positions improves gastrointestinal
function, improves respiratory
function, allows for greater lung
expansion and relieves pressure on
the diaphragm)
 ,
To prevent deformities – prolonged joints
inactivity and immobility (When one lies
in bed for long periods of time) leads to
contractures, muscle atony and atrophy
stiffness and deformities. Prevention of
deformities will allow the patient to
ambulate when his activity level is
advanced
 ,
To relieve pressure and prevent
bedsore
 To stimulate circulation.
 Treatments, medical indications,
performing physical examination,
range of motion exercises
 Guidelines for positioning of a client

Inactive client’s position should be

changed at least every 2 hours
 The position should be appropriate
to the patient’s general physical
condition and the patient’s specific
medical/ surgical or nursing problem
 ,
  The position should be comfortable
 The limbs should be placed in a
natural and functional position
 Circulation should not be impeded
in any way
 ,
  The limbs and body should be supported
as and where appropriate
 The patient should not have to exert any
effort in order to maintain the position
The patient’s position should be changed
or varied at regular intervals
 ,
• Why the positions of inactive clients are
changed? Inactive clients have the
potential for complications associated to
immobility (pressure ulcers). Position is
also changed to relieve pressure on bony
areas of body and to promote functional
mobility.
 Positioning devices

Many devices are available to help to maintain

good body alignment in bed and prevent
discomfort and pressure. It include:
 Adjustable bed : a kind of bed that can raised
and lowered, allow the position of head and
knees to be changed
 Mattress : firm but flexible enough to permit
good body alignment  
 ,
Bed board : rigid structure placed under
a mattress, to provide additional skeletal
support
Pillows
 Trapeze: triangular piece of metal hung
by a chain over the head of bed
 ,
Nursing assistance is needed for
clients who cannot change from one
position to another independently
and those who need help doing so.
Nurse will help client to move in, to
or from bed and to turn
 Transferring client
 Transfer means to move a client from place
to place. For example, clients are moved from
bed to chair or stretcher and from chair back
to bed.
  Transfer can be active or passive. In active
transfer, client assists or participates actively
whereas in passive transfer, client is unable;
transfer is done totally by others or by
mechanical means
 Types of position

There are several types of positions used

when caring bedridden clients, the
common ones are:
• Supine position
•  Lateral position
•  Prone Position
•  Sims’ or semi prone position
 ,
•  Fowler’s position
•  Trendelenburg
•  Reverse Trendelenburg
• Lithotomy
Each position has the indications (when
can/should be used) and
contraindications (when should not be
used)
 SUPINE POSITION

Supine position is also called dorsal

recumbent position. The client lies on the
back. The head may be supported with one or
two pillows, and pillows may also be placed
under the heels and elbows to provide
support and relieve pressure. A flat soft pillow
may be placed in the small of the back to
provide support.
 Indications:

Supine position is generally preferred for

Comfort, Comfortable position for care
It is indicated for the following:
Clients with Hypotension; to maximize
venous return and cardiac output
 Patients who are on traction; for
problems of neck and back
 
 ,
 Position changing in prevention of bed
sores
 Post-operation, especially after surgical
operation done under spinal anesthesia
 Fracture of the veritable column
 Chest exams
 Contraindications:

Cardiac failure
 Respiratory failure 
Cerebral congestion
 
 Procedure:

Nurse collects data, and prepares him/herself

and the client
  The materials needed include: a pillow, Small
pillow for back, heels and calf, flat soft pillows
for bony areas and positioning aids as
indicated
  Wash your hands
  Approach and identify the patient and explain
the procedure (using simple terms and
pointing out the benefits)
 ,
 Provide privacy throughout the
procedure
 Position the bed.
 Move the patient from a lateral (side)
position to a supine position.
 Align the patient's body in good position
 ,
Support the body parts in good alignment
for comfort:
Place a pillow under the head and
shoulders to prevent strain on neck
muscles and hyperextension and flexion
of the neck.
 Support the small of the back with a
folded bath towel or small pillow. 
 ,
 Put a footboard at the foot of the bed
and place the feet flat against it (at right
angles to the legs) to prevent plantar
flexion ("foot drop").
  Report significant nursing observations
or document in patient file
 Lateral position

Also called side-lying position, the client

lies on side. There is two kinds of
position, left and right lateral position. A
pillow is used to support the head, and a
firm pillow may be placed against the
back to support the patient in the lateral
position. A soft pillow can be placed
between the knees to relieve pressure
 Indications:

Preferred for Comfort, Relaxing

Position (many patients consider it as
a relaxing position)
 Often used as an alternative to the
dorsal position for patients who have
to lie flat
 Position changing in Prevention of
bedsores
 ,
 One-sided pulmonary affection
without dyspnea
 Vomiting
 An operation on the rib cage
 ,
•  Unconscious patients (to facilitate the
drainage of oral and oropharyngeal
secretions)
•  Hemiplegic patients (hemiplegia – paralysis
of whole one side of body)
•  Rectum examination
•  Rectal or perineal treatment
 
 Contraindication:

Severe respiratory problems

 Cardiac failure
Bedsores on side
 Procedure:
Nurse collects data, and prepares
him/herself and the client
 The materials needed include:
pillows, Small pillows, flat soft pillows
for kidneys and Small pillow for the
hip , knees and ankles
 Collect equipment.
 Wash hands.
 ,

Approach and identify the

patient by checking
identification, explain the
procedure and gain patient's
cooperation.
 
Provide for privacy ,
 Turn the patient onto the side
 Align the patient's body in good position:
Ensure the patient is not lying on his/her
arm; Head, neck, and back are in a
straight line; Legs are parallel with knees
slightly flexed, Uppermost arm may be
flexed across patient's abdomen or
supported on his/her body and hip.
 ,
Support the body in good alignment for
comfort
Place a pillow under the patient's head
and neck to prevent muscle strain and
maintain alignment
Put a pillow under the uppermost leg so
that it is supported from the knee to the
foot
 ,
Place another pillow firmly against
the patient's abdomen to support
the back and hips in better
alignment, if necessary
You may want to use a pillow to
support the back or Place a pillow
lengthwise along the back or Tuck
one edge under the side
 ,
You may also want to use a pillow to
support the knee
Place a pillow between the knees
Bend the upper knee to provide stability
Place a pillow between ankles
Report and document significant nursing
observations
 
4. PRONE POSITION
 
The patient lies on his/her abdomen, with
the head to one side. Pillows are placed
under the abdomen and the lower legs
to provide support. The head should be
supported with a soft flat pillow to
maintain good alignment of the neck
 
 Indications:

Comfort, preference, Relaxing Position

 To facilitate the drainage and removal of
secretions from the bases of the lungs
 Prevention of bed sores
 Operation on the spinal column
Injury or operation on the buttocks or on
the back
 Contra-indications:

 Some Surgical interventions

  Bed sores on the anterior part of the
body
 Respiratory and cardiac problems 
 Procedure:

Nurse collects data, and prepares him/herself

and the client
•  The materials needed include: pillows, Small
pillows, Small pillow for head, 2 others for the
legs and toes, A pillow for abdomen region
Collect equipment
•  Wash hands
 ,
• Approach and identify the patient
and explain the procedure
•  Provide for privacy
•  Bring the patient very close to the
bed
•  place a soft pillow on the mattress to
the height of the stomach, and of the
chest
• place a small pillow for the head ,
.
• Turn the patient onto his side and then onto
 

his stomach.
•  place a small pillow under the knee and toes
•  Report / document significant nursing
observations
N.B: If the patient must remain in this position
for a lengthy period. Turn the head in way
that he can see what is entering in the room
and don’t turn therefore at the wall
 4.SEMI-PRONE OR SIM’S POSITION or Recovery position

The position of the patient is between the lateral and

prone position. The patient lies on his/her side with
the legs flexed, the upper legs being flexed more
acutely at both hips and knee so that it lies in front
of the lower leg. The lower arm is placed behind the
patient and the upper arm is placed in front of the
head. The head may be supported on a soft flat
pillow, and pillows are placed under the knee of the
upper leg and under the upper arm for support. 
 indication
• Semi-prone position is indicated for
unconscious patients as drainage from
the mouth and maintenance of the
airway is facilitated, Patients who are
recovering after general anesthesia and
patients who is vomiting. It is also used
to administer enema and for
procedures involving the anal and/or
perineal area
 5. FOWLER’S POSITION OR SEMI-SITTING POSITION

Fowler’s or semi sitting position is bed

position in which the head and trunk are
raised at 45 to 90 degrees
In Semi-Fowler’s or low Fowler’s: the head
and trunk are raised 15-450
In High Fowler’s: the head and trunk are
raised 45-900
 
 Indications

High Fowler’s position

• Preference/Comfort
•  Respiratory and cardiac conditions such as
myocardial infarction, cardiac failure
•  The semi-Fowler’s position is a position in which
optimum cardiac rest combined with optimum
venous return is facilitated to facilitate an
improvement in cardiac output. This position is
thus ideal for patients with cardiac conditions.
 Indication

Respiratory distress and dyspnea

 Pneumonia
 Peritonitis (to get a relaxation of the
muscles)
 All others abdominal affection that
requires a drainage (ascitis,..)
 ,
For taking meal
 After an operation on the chest
 The orthopnea position is used for
patients with severe dyspnea that is
not improved in the
 high Fowler’s position
 Semi-Fowler’s position

Comfort position for old people

 Hemiplegic patient
 Cardio-respiratory failure
Contra- indication
 Patients in coma (or unconscious) or
during general anesthesia
 
 Procedure

• Collect equipment: Pillows, Positioning aids as

indicated.
•  Wash your hands.
•  Approach and identify the patient and explain
the procedure 
• Provide for privacy throughout the procedure. 
• Be sure the patient is in a supine position with
his head near the top of the bed
 ,
• Elevate the head of the bed 
– Elevate 45 to 90 degrees for the high Fowler's
position 
– Elevate 15 to 45 degrees for the semi-Fowler's
position
•  Raise the knee rest of the bed approximately
15 degrees unless contraindicated.
•  Use a footboard to maintain the feet at right
angles to the legs.
 ,
• Use pillows for support as needed (Behind the
shoulders and head to prevent flexion and
hyperextension of the neck, behind the lower
back to prevent posterior convexity of the
lumbar spine region, under the thighs to
prevent hyperextension of the knees.
•  Place the patient in good body alignment)
•  Report/document nursing observations
 6. ORTHOPNEIC POSITION

The orthopnea position is a variation of

high Fowler’s in which the patient sits
upright and slightly forward, with the
head resting on pillows placed on an
overbed table. The position can also be
used with the patient in a chair at the
side of the bed and resting the head on
the bed itself
 ,
• This position facilitates respiration by
allowing maximum lung expansion.
•  Particularly helpful for clients with
problem with exhaling, because they
can press the lower part of the chest
against the edge of the overbed
table.
 6. TRENDELENBURG POSITION
 

• Patient is lying in a decline position

with the feet elevated than the head.
It has the goal to improve brain
blood supply.
 
 ,
Indications: Internal and external
hemorrhage, State of shock, Syncope,
Lower limbs edema to facilitate venous
return
Contra indications: Dyspnea, Ascitis,
Respiratory and Cardiac problems,
Patient underwent epidural anesthesia or
lumbar puncture, cerebral edema and
increased intracranial pressure
 Procedure
Procedure: Raise the lower part of bed
by the blocks about 10 to 20 cm or
bricks The patient is in supine
position, a small pillow under the
head, legs are lengthened
•  Put a pillow between patient’s head
and bed head
 7. LITHOTOMY OR GYNECOLOGIC POSITION

The client lies on her back, the pillow

under the head, the thighs and knees
are flexed with the legs separated.
 ,
Indications:
 Gynecological exam
 Genito-urinary operation
 Delivery
 Urinary catheterization
 Vulvo-vaginal care 
 ,
Procedure
 The patient is lying on the back; the
legs are bent and separated
 The position is released on a
Gynecological table. It can also be
realized in the patient bed.
COMPLICATIONS ASSOCIATED WITH PROLONGED BED REST and
IMMOBILTY

,
 ,
•Physical immobility is referred to the absence of
movement. Immobility affects not only the
relevant aspect or part the body, but the whole
person. The degree to which a person is affected
by immobility depends on the cause of the
immobility, his/her ability to handle stress,
health status and physical fitness before the
illness.
 
 ,
“The term Physical fitness is general
concept used for combined meaning
of good balance, muscle strength
and co-ordination. If a person is fit,
movements are coordinated and
executed with the least amount of
strain. Joints are supple and flexible
and muscle tone is maintained.”
 EFFECT OF BEDREST

Activity, in some form or another, is

essential to health. Prolonged Bed
rest has a number of effects on the
body, which, if not taken into
account and counteracted, may lead
to serious complications, and even to
the death of a patient
 ,
• Oxygen requirements are reduced and
breathing is shallow. As a result, only
certain areas of the lungs are expanded,
usually the apices. The bases of the lungs
and areas that are dependent due to the
recumbent position are not adequately
expanded. This allows secretions to
accumulate and some of the alveoli in
the unexpanded areas may collapse
 ,
• The pumping action of the leg
muscles, which helps to return blood
to heart from the lower extremities,
is decreased, leading to circulatory
stasis.
 ,
• Circulatory stasis also occurs in the lower
abdomen because the movements of the
hip and back that normally assist venous
return from these areas are decreased
• The skin overlying bony prominences in
dependent areas of the body are
subjected to pressure that can only be
relieved by activity and walking about
 ,
• Joints become stiff and painful due to
inactivity
•  Disused muscles become weak and
wasted
• Lack of activity may cause loss of
minerals from bone
•  The bladder may not be properly
emptied due to the awkwardness of
voiding in the recumbent position
 ,
•  Lack of activity may result in
sluggishness of bowel activity
resulting in constipation
•  Inactivity results in a lack of appetite
•  The nurses contribute greatly towards
preventing or alleviating problems
which accompany prolonged bed rest.
 complications on different body systems
 

Effects of Immobility on Musculoskeletal

system
 Disuse osteoporosis: Without stress of
weight bearing activity, bones
demineralize
 Disuse atrophy: when muscles are not
used decrease in size and lose most of
their strength and function
 ,
Contractures: this is a permanent
shortening of muscles. When the muscle
are no longer shorten and lengthen,
contractures form and limited joint
mobility
 Stiffness and pain in the joints: Without
movements, the connective tissues at the
joint permanently immobile (Ankylosis).
Effects of Immobility on Cardiovascular system

 Decreased cardiac reserve

(decreased mobility – imbalance in
the autonomic nervous system –
decreased cardiac reserve –
tachycardia
 Orthostatic (postural) hypotension
  Venous vasodilation and stasis
 ,
Dependent edema from impaired
venous return
 Thrombus formation and
thrombophlebitis: Impaired venous
return to heart – stasis –
hypercoagulability of blood (and
then formation of thrombus (clot) –
injury to vessel 
 Effects of Immobility on Respiratory system

Decreased respiratory movements

 Pooling of respiratory secretions (that is,
Increased secretions collection in lower airway
tracts)
–Increased secretions collection leads to
impaired airway exchange impaired gas
exchange (poor oxygenation and retention
of carbon dioxide in blood) Hypoxemia
–Atelectasis – this is the collapse of a lobe or
of the entire lung  
 ,
• Hypostatic Pneumonia – pooled
secretions provide excellent media
for bacterial growth
•  Pneumonia from static respiratory
secretions is common cause of death
among weakened, and immobile
persons
 Effects of Immobility on Integumentary system are:
 

 Reduced skin turgor

 Skin breakdown: Prolonged pressure
on bony surface cause decrease of
blood supply with deprivation of
oxygen and nutrients. All those lead to
skin breakdown followed by
development of pressure ulcers
(bedsores)
 Pressure ulcers
 Effects of Immobility on Genito-urinary system:
 

The genitourinary system is affected by bed rest

as follow:
Renal calculi: Demineralization of bone
during bed rest releases calcium salts into
the circulation, which are then excreted by
the kidneys. Large quantities of calcium
salts passing through the kidneys may result
in the formation of kidney stones, or renal
calculi.
 ,
Urinary tract infection: Inactivity also
leads to urinary stasis (urinary retention),
with the awkwardness of using a bedpan
or bottle as a contributing factor. This
stagnant urine is a good culture medium
and easily becomes infected. The
development of urinary tract infection
may lead to death due to renal failure, or
to permanent renal impairment
Effects of Immobility on Gastrointestinal tract
(GIT) system

Inactivity reduces the activity of the GIT,

leading to constipation, which is a very
common complication of the prolonged
bed rest. The decrease in bowel motility
results in more water being absorbed
from the bowel, making faeces hard and
small (constipation). Furthermore this
may result in Fecal Impaction.
 ,
• Constipation and fecal impaction are frequent
complications of immobility. Main factors
contributing to these problems are:
•  Lack of activity, which decreases peristalsis
• Lack of privacy
• Inability to sit upright
•  Improper diet
• Inadequate fluid intake
•  Use of some medications, especially
narcotics.
• Bed rest may result in ,a lack of appetite
(Decreased appetite) that may result in the
patient taking in insufficient nutrients and
fluids for recovery. An inadequate food intake
may exacerbate muscle wasting and may
predispose the patient to an infection that
he/she can ill (poorly) afford.
•  In addition to Decreased appetite,
Constipation, and Fecal Impaction, Other GIT
complications are
Stress ulcers.
Psychological effects of prolonged bed-rest

•  Prolonged Bed rest, Immobility and

enforced inactivity can result in boredom,
Anxiety,
 Helplessness, Increased dependency,
decreased competency self-rating, general
dissatisfaction, restlessness, unhappiness,
hopelessness, and depression.
A patient may become anxious about his/
,
her family’s wellbeing if he/she is the
employed person and the period of bed
rest is to be of long duration. This anxiety
may occur even if the patient is not
employed, due to the isolation from the
family experienced while the patient is in
hospital or bedroom. The patient may
also be worried about job security and
the financial implications of
hospitalization.
 ,
• The resulting stress and anxiety may
lead to feeling of decreased self
esteem. Being in hospital also
engenders a feeling of being isolated
and cut off from one’s family and
from the rest of the community.
PREVENTION OF COMPLICATIONS ASSOCIATED of PROLONGED BED REST
 

,
 MUSCULO-SKELETAL SYSTEM

Place limbs in a natural, functional position.

A position of slight flexion is recommended. The
hand should always be positioned in the grip
position. The ankle should be flexed in the
standing position. The hands and the feet may
require splinting to keep them in the
functional position. The limbs should be
adequately supported using pillows.
 ,
ACTIVE/ PASSIVE EXERCISES: A range of motion
exercises should be carried out on all joints at
regular intervals, unless contra-indicated by
injury.
CONTIOUS ASSESSMENT:
  Any stiffness or limited joint movement
should be reported.
  Once contractures have occurred, long-term
physiotherapy will be required to restore
some degree of function at the affected joint.
 ,
Mobilization
Changing position at regular
intervals (at least every 2 hours)
 Promoting balanced diet
 CARDIOVASCULAR SYSTEM:

Prevention of clot formation:

 Mobilization, Active and passive
Exercises: The nurse carries out passive leg
movements at regular intervals. Where
possible the client should be encouraged to
do this for independently.
 Early ambulation and mobilization is
highly desirable. 
 Dehydration must be prevented by
encouraging adequate fluid intake
 ,
Low doses of anticoagulant
medications may be prescribed (by
physician). This reduces the coagulation
of blood and reduces the chances of
clot formation
 CONTINUOUS ASSESSMENT: Early
detection and reporting of any sign of
circulatory complications are important.
 ,
• A deep-vein thrombosis should be
suspected if the patient presents with a
painful, oedematous ankle and calf, which
may be coupled with a slight rise in
temperature
• A positive Homen’s sign, in which flexion of
the ankle causes a sharp pain in the calf, is
also suggestive of a deep-vein thrombosis. 
 ,
Homans' sign is a sign of deep vein
thrombosis (DVT). A positive sign is
present when there is pain in the calf on
dorsiflexion of the patient's foot at the
ankle while the knee is fully extended
The sudden onset of dyspnoea, together
with a sharp, knife-like chest pain,
should make the nurse suspect a
pulmonary embolism.
 ,
N.B. When applying the Homan’s test, a
positive sign doesn’t automatically
conclude a DVT. In fact, a positive
Homan’s sign can be elicited due to
factors such as superficial phlebitis,
Achilles tendonitis, and injury to the
gastric and plantar muscles
•  A negative Homan’s sign, on the other
hand, doesn’t automatically conclude an
absence of DVT.
 ,
• Thrombosis that develops in the thigh
and pelvic veins are often difficult to
detect and patients can often remain
asymptomatic. Keeping this in mind, it
is essential that therapists understand
just how reliable and valid Homan’s
sign is in detection of DVT.
 Management of circulatory complications
 

Anticoagulant therapy is commenced

as prescribed. The patient is kept in
bed until the clot has resolved
Anti-embolism stockings or elastic
bandages are applied: pressure thus
applied at the surface helps to move
the blood back to the heart.
 ,
If thrombophlebitis is present, anti-
inflammatory and anti-phlebitic
ointments are prescribed.
 Elevation of the foot of the bed
assists with venous return and
prevents venous stasis
 ,

• For patients who repeatedly develop

deep-vein thromboses, surgical
procedures such as the insertion of an
umbrella filter in the inferior vena cava
may be carried out, to prevent the
migration of clots to the heart and the
lungs.
 RESPIRATORY SYSTEM:
 

Nurses are responsible for identifying patients

who are most likely to develop pulmonary
complications related to immobility and/or
prolonged bed rest. Those patients include
  Patients with upper respiratory tract
infections
  Patients who have had abdominal surgery
  Patients with chronic lung conditions
  Elderly and debilitated patients
 ,
  Patients who may have inhaled vomitus
  Heavy smokers
  Obese patient
For these patients, Nurses should promote full
lung expansion by:
Changing patient’s position regularly (at least
every 2 hours) in order to expand different
parts of the lungs
 ,
Encouraging deep breathing at regular
intervals
 Encouraging and assisting the patient to
cough up secretions
 Referring the patient for preventive
physiotherapy or respiratory therapist
 ,
Nurse should be alert for any sign or symptom
(“continuous assessment”) of pulmonary
complications and Report immediately to
Primary Care Provider. Some of these signs
comprise: A rise in body temperature, increase
pulse rate and respiration rate, Restlessness,
anxiety, confusion (particularly in the elderly),
dyspnoea, and cough and / or chest pain.
 The management of pulmonary
complications involves:
 Intensive chest physiotherapy to promote lung
expansion and removal of plugged secretions
 Oxygen therapy (administration of oxygen through
masks) as prescribed to ensure adequate oxygenation
 Treatment of infection with an appropriate antibiotic, as
prescribed by the doctor
  Continuous Assessment and monitoring of vital signs for
an improvement and changes in progression. Chest X-
rays can be performed to check for an improvement
 INTEGUMENTARY SYSTEM

Continuous assessment and monitoring

of vital signs
 Changing regularly the position, at least
every 2 hours
 Assess the skin for any sign of skin
breakdown, pressure ulcers – primary
signs include changes in skin coloration,
pain, oedema, abrasion, ...
 ,
  Promote balanced nutrition
 Body hygiene, bed making
 Protection of prominent areas with
small and plain pillows
 Regular mobilization and
passive/active exercises
 GENITO-URINARY SYSTEM
 
Ensure adequate fluid intake – to prevent
urinary stasis. This will also help to
prevent renal calculi by flushing the
kidneys
 Encourage Regular urination
 Change position regularly (at least every
2 hours)
 Regular mobilization 
 ,
 Continuous assessment and monitoring of
Vital signs
  Report any sign and symptom of urinary
complications
  In case there is urinary tract infection, the
treatment consists of prescription of
antibiotics. [The nurse is responsible for
reporting any manifestations of infection].
 GASTRO-INTESTINAL SYSTEM

  The nurse must ensure that the patient

has an adequate fluid intake.
 Monitor Intake and output
The amount of fiber in the patient’s diet
should be increased – Fibers provides
bulk and helps to retain water in the
large bowel, thereby maintaining the
normal consistency of the faeces.
 ,
• Encourage Regular bowel
movements – this prevents stasis of
faecal matter. This is not always easy,
as many patients are embarrassed to
use a bedpan or commode in the
ward. The nurse should provide as
much privacy as possible
 ,
• The above measure can also be used to
manage constipation. The doctor may
prescribe a mild laxative while the patient is
immobile, but this should be discontinued as
soon as possible.
•  If constipation is allowed to become
prolonged, faecal impaction results. The faecal
matter becomes impacted within the bowel,
necessitating manual removal, a painful and
unpleasant procedure for both patient and
nurse
 ,

• Promote adequate nutrition –

balanced diet. A diet high in proteins
and vitamins should be encouraged.
Attractive meals and attention to the
patient’s likes and dislikes may
stimulate appetite.
PREVENTION AND MANAGEMENT OF PSYCHOLOGICAL EFFECTS OF BED-REST

•  Try to interest the patient in his/her

surroundings
•  Place the patient in a bed with a view, or with
patients who will provide pleasant and
congenial (friendly) company
•  Offer books, magazines and newspapers to
read if client can do.
•  Provide Radio or television
 ,
•  Ask an occupational therapist to
organize handwork for the patient if the
patient is interested
•  If necessary, refer to a social worker to
solve family or finance related problems
that are causing anxiety.
•  Active listening to client about his/her
concern
7. MANUAL HANDLING / MOVING PATIENTS
 

,
 ,
Manual handling is defined as “any
transporting or supporting of a load,
including the lifting, putting down,
pushing, pulling, carrying or moving
thereof, by hand or bodily force”.
 It is indicated when a patient cannot move
independently, nurses are involved in the
moving and handling of patients, following
the individual patient assessment.
 Goals

Stimulate blood circulation

 Prevent venous stasis
 Prevent bed sores
 Avoid dangers
 Provide comfort
 ,

Reduce pain
 Maintain the tonicity of the muscles
 Assure a good respiratory, urinary,
gastrointestinal physiological
functioning
 General rules to follow:

 Be aware of indications and

contraindications
 Evaluate patient’s capacity of
moving
 Wash the hands
 Prepare all material
 Observe patient’s reactions
 ,

Prevent any accident

 Hand washing
 Notification of the act
 Proposition of the next mobilization
 PRINCIPLES OF SAFER MANUAL HANDLING
• Relax and move smoothly. Avoid sudden
movements
• Try to vary your tasks (so that different
muscle groups are used in turn)
•  Stay balanced. Keep wide. Stable base –
feet –hip – width apart
•  Wear a uniform that allows unrestricted
movement at shoulder, waist and hip,
with shoes that are ‘non-slip and provide
support’
 ,
• Maintain the natural curves of your
supine. Avoid twisting.
•  If in doubt, seek advice. Do not risk it.
•  Keep close to the load (when safe to do
so).
•  Bend your knees when appropriate, but
avoid over bending.
 ,
• Move your feet to turn, not your body.
Turn feet successively in the direction of
movement (rather than twist at the
waist).
•  When working with others, choose a
leader to plan and give clear, concise
instructions.
• Channel the effort through your legs
when handling.
 ,
• Assess unavoidable handling tasks
and follow/update assessment 
• Remember to look after yourself
with enough rest, suitable exercise
and a healthy diet.
 ,

Procedure – cfr check list (positioning, turning,

transferring and moving a client)
 
BODY MECHANICS AND MANUAL LIFTING
 

,
 ,
Body mechanics means efficient use of
musculoskeletal system. As seen at the
beginning of this unit, Nurses have potential
to develop injuries, if they fail to use good
posture and body mechanics while providing
care. To prevent that, they have to respect and
always use principles of body mechanics and
manual lifting
 Benefits

Increase muscle effectiveness

 Reduces fatigue
 Helps to avoid repetitive strain injuries
(disorders that result from cumulative
trauma of musculoskeletal structures)
 Prevent injuries – lower back pain
 Basic principles
 

To avoid injuries, nurses must use

proper body mechanics when lifting
and positioning a patient. The
posture must maintain anatomical
body alignment
Skills – cfr checklist (Manual Handling
and lifting)
 ,

Good !!!!!!!!