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

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, crackles, wheezes
o Oxygenation: mucous membranes, nail beds, cognition, respiratory effort (use accessory
 muscle, 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
o Homan’s sign: calf pain on dorsiflexion
o Pain
o Erythema
o Warmth

GI: decreased appetite, slowing peristalsis, constipation, 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, bowel sounds, tenderness, abnormal tympany, bowel pattern
 GU: I & O, assess urine for concentration, odor, incontinence, UTI (urgency,
frequency, dysuria)

Nutrition: deficiency in calories and protein (R/T decreased appetite)

o Decrease in metabolic rate, changes in metabolism of CHO, fats, 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, 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, eating, somatic complaints, verbalizations of despair, negativity
o Ability to get to sleep and stay asleep, daytime sleeping
o Cognition: abrupt change in cognition
o Ability perform ADLs
Complications of a fracture:
 infection
 Compartment syndrome
 Venus thromboembolism
 Fat embolism syndrome
 Muscle atrophy
 Contracture
 Footdrop
 Pain
 Muscle spasms
 Pressure ulcers
 Open fractures and soft tissue injuries have  incidence
 Osteomyelitis

State the symptoms of fat embolism.

Fat Embolism Syndrome (FES)

 Characterized by the presence of fat globules in tissues and organs after a traumatic
skeletal injury
 Tissues most often affected:
 Lungs
 Brain
 Heart
 Kidneys
 Skin

Fractures that most often cause FES:

 Long bones
 Ribs
 Tibia
 Pelvis

Clinical Manifestations
 Usually occur 24 to 48 hours after injury
 Interstitial pneumonitis
 Produce symptoms of ARDS

 Clinical Manifestations
 Symptoms of ARDS:
o Chest pain
o Tachypnea
o Cyanosis
o  PaO2
o Dyspnea
o Apprehension
 o Tachycardia

 Rapid and acute course

 Feeling of impending disaster
 Client may become comatose in a short time

Collaborative Care
 Treatment directed at prevention
 Careful immobilization of a long bone fracture
 Most important preventative factor
 Symptom management
 Fluid resuscitation
 Oxygen
 Reposition as little as possible

State the symptoms of pulmonary embolism

State the symptoms of compartment syndrome.
Compartment Syndrome
 elevated intracompartmental pressure within a confined myofascial compartment
 compromises the neurovascular function of tissues within that space.
 Causes capillary perfusion to be reduced below a level necessary for tissue viability
 Acute – fractures, burns, knee or leg surgery
 Exertional – intensive exercise
 Crush injuries

Two basic etiologies create compartment syndrome:

 Decreased compartment size
o Restrictive dressings
o Splints
o Casts
 Increased compartment content
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

Myoglobinuria Dark reddish-brown urine

Collaborative Care
 Prompt, accurate diagnosis is critical
 Early recognition is the key
 Do not apply ice or elevate above heart level
 Remove/loosen the bandage and bivalve the cast
 Traction weight reduction
 Surgical decompression (fasciotomy)

Complications of Fractures
Venous Thrombosis
 Veins of the lower extremities and pelvis are highly susceptible to thrombus formation
after fracture, especially hip fracture
 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.

Musculoskeletal Injuries
 Sprains
 Injury to ligaments
 Wrenching and twisting
 Classified according to amount of ligament fibers torn
 Strains
 Excessive stretch of a muscle and tendon

Musculoskeletal Injuries
 Nursing Assessment of Strains and Sprains
  Pain
 Edema
 Decrease in function
 Bruising
 Nursing Preventions
o Primary
o Secondary
 RICE (rest, ice, compression, elevation)
 Mild analgesics
Musculoskeletal Injuries
 Dislocations – complete separation articular surfaces of a joint
 Subluxation – partial separation
 Nursing Assessment
 Joint asymmetry
 Pain
 Tenderness
 Loss of function
 Edema
 Nursing Preventions
 Medical emergency
 Pain control
 Joint protection
 Gradual increase ROM (support joint)

Desrcibe Fractures:

What is a fracture
 A disruption or break in the continuity of the structure of bone
 Traumatic injuries account for the majority of fractures
Fracture Location
What is a fracture?
What is a fracture?
What is a fracture?
Stress Fracture
 tiny cracks in a bone
 occur during high-impact repetitive activity
 most common in the weight-bearing bones of lower leg and foot
 osteoporosis
Fractures
 Closed (simple)
 Open (compound)

Classified by appearance, position, and alignment of the bone fragments

Stable fractures
 Occur when a piece of the periosteum is intact across the fracture
 External or internal fixation has rendered the fragments stationary

Unstable fractures
 Grossly displaced
 Site of poor fixation

 Immediate localized pain

 Muscle spasms
 Guarding
 Function
 Inability to bear weight or use affected part

 Edema and swelling

 Deformity (but not all fractures!)
 Ecchymosis
 Crepitation

Nursing Assessment after an injury

Emergency
o ABCs
 Bleeding
 Vital signs
 Level of consciousness
 Pulses
Pain

Site of injury
Lacerations
 Skin color and temp
 Ecchymosis
 Hematoma
 Edema
  Loss of function, alignment
 Muscle strength
 Joint crepitation

Limb below injury

 Pulses
 Paresthesias
 Change in sensation
 Capillary refill
 Temperature

Fracture Healing

• 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
 Manual realignment
 Open reduction
 Surgical procedure
 Placement of wire, screws, plates, pins, rods, nails

Application of a pulling force to an injured part of the body while countertraction

pulls in the
opposite direction
Collaborative Care
Fracture Reduction/Immobilization
 Traction
 Skin traction (short-term)
 Skeletal traction (longer periods)

Purpose of traction:
 Prevent or reduce muscle spasm
 Immobilization
 Reduction
 Treat a pathologic condition
 Neck – degenerative disc disease
 Back – muscle spasms

Collaborative Care
Fracture Immobilization
 Casts
 Immobilization after closed reduction
Collaborative Care
Fracture Immobilization
 Short arm cast
 Long arm cast

 Long leg cast

 Short leg cast

Collaborative Care
Fracture Immobilization
 Body jacket cast
 Hip spica cast
Collaborative Care
Fracture Immobilization
 External fixation
 Metallic device composed of pins that are inserted into the bone and attached to
external rods
 “skeletal traction”
Collaborative Care
Fracture Immobilization
 Internal fixation
 Pins, plates, intramedullary rods, and screws
 Surgically inserted at the time of realignment

Collaborative Care
Drug Therapy
 Pain managment
 Muscle relaxant
 Analgesics
 Tetanus-diphtheria toxoid or immunoglobulin
 Bone-penetrating antibiotic
 Cephalosporin

Nursing Management
Nursing Assessment
 Brief history of the accident
 Mechanism of injury
 Collaborative care (reduction/immobilization)

Nursing Assessment after fracture reduction and immobilization

Neuro-vascular assessment
 Color (pink, pale, cyanotic)
 Temperature (hot, warm, cool, cold)
 Capillary refill (3 second rule!)
 Peripheral pulses (present, equal, strong, by Doppler, absent)
 Edema
Nursing Assessment after fracture reduction and immobilization
Neuro-vascular assessment
 Sensation
 numbness, tingling
 decreased, hypersensation,

 Motor function
 Hand – abduction/adduction fingers, supination/pronation hand
 Leg – dorsiflexion and plantar flexion
 Equal strenght
 Pain
 Location
  Quality
 Intensity
 1-10

Nursing Diagnoses
Fracture reduction and immobilization
 Risk for peripheral neuro-vascular dysfunction
 Acute pain
 Risk for infection
 Risk for impaired skin integrity
 Impaired physical mobility
 Ineffective therapeutic regimen management

Facture reduction and immobilization

Planning
 Physiologic healing with no associated complications
 Pain relief
 Achieve maximal rehabilitation potential

Facture reduction and immobilization

Primary Preventions
 Fall prevention
 Use of seat belts
 Stretching before exercising
 Participate in moderate exercise

Fracture reduction and immobilization Secondary Preventions

 Preoperative management
 Inform of immobilization device and expected activity limitations
 Skin preparation
 Postoperative management
 Monitor vital signs
 Frequent neurovascular assessments
 Carefully monitored mobility
 Pain management
 Hydration
 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
Skeletal Traction
 Pin site care
 Pin should be immobile
 Assess for infection
 Removal of exudate

Facture reduction and immobilzation

Secondary Preventions
 Cast care
 Frequent neurovascular assessments
 Teach patient signs of complications
 Increased pain
 Edema
 Discoloration of digits
 Burning/tingling under cast
 Odor
 “sores” under cast
 Elevation of extremity above level of the heart
 Exercise joints above and below the cast

Facture reduction and immobilization

Secondary Preventions
 Spiritual Variable
 Psychosocial Variable
 Management of ADLs
  Social support systems
 Change in family constellation – change in role expectations
 Financial
 Evaluate presence of posttraumatic stress disorder

Facture reduction and immobilization

Secondary Preventions
 Ambulation
 Usually started in mobility training when able to sit in bed and dangle feet over the side
 Weight bearing: None, Partial, Total
 Assistive devices
o Cane
o Walker
o Crutches

Fracture reduction and immobilization

Evaluation
 Normal neurovascular examination
 Tolerable or no pain
 No evidence of infection
 No evidence of skin breakdown
 Crutches correctly used
 Minimal loss of muscle mass of affected extremity
Identify assessment findings for a broken hip
Fractures: Hip Fracture
 More common in older adults

The Older Adult with Hip Fracture

 Physiological Variable
Stressors
 Type of fracture
 Type of surgery

 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

 Clinical Manifestations
o External rotation
o Muscle spasm
o Shortening of affected extremity
o Pain
o Tenderness
 Collaborative Care
o ORIF (open reduction, internal fixation)
 Femoral head replaced with prosthesis
 Plate/screws/ pins/intramedullary rod

Nursing Assessment
 Hip Fracture
 Lateral rotation leg
 One leg shorter
Fractures: Hip Fracture
Post-Operative Preventions
 Vital signs
 I&O
 Cough & Deep breathing
 Incentive spirometry
 Pain management
 Prophylactic anticoagulation
 LMWH
 Heparin (SQ)
 Coumadin
 Incisional care
 Assess for infection, bleeding

 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

“Hip Precautions”
Older Adult with Hip Fracture
 Hip prosthesis dislocation
 Increased pain at surgical site, swelling, immobilization
 Acute groin pain
 Abnormal external or internal rotation
 Inability to move leg
 “popping” sensation

Older Adult with Hip Fracture

 Nursing Diagnosis
 Acute pain
 Impaired physical mobility
 Impaired skin integrity
 Risk or impaired urinary elimination
 Risk for ineffective coping
 Risk for disturbed thought processes
 Risk for ineffective health maintenance
 Collaborative Diagnosis
 Hemorrhage
 Infection
 Peripheral neurovascular dysfunction
 DVT
 Pulmonary complications
 Pressure ulcer
 Joint dislocation

Describe care of client after knee replacement:

 A compression dressing may be used to immobilize the knee in extension immediately
after the operation
 Great emphasis is placed on postoperative physical therapy
 Isometric quadriceps begins the first day after surgery
 Progresses to straight leg raises and gentle rom to increase muscle strength

State interventions for the client with osteoporosis:

 Preventions focus on adequate calcium supply
 exercise