07.02 Complications of Immobility

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Overview

  1. Complications of Immobility
    1. Psychologic
    2. Cardiovascular
    3. Pulmonary
    4. Gastrointestinal and renal
    5. Musculoskeletal and skin

Nursing Points

General

  1. Psychologic
    1. Frustration
    2. Anxiety and depression
    3. Delirium
      1. Increases length of stay
      2. Decreases compliance
  2. Cardiovascular
    1. Coagulopathies
      1. Blood pooling
      2. Increased risk of deep vein thrombosis
        1. Increased risk of pulmonary embolism
    2. Edema
    3. Changes in blood pressure
      1. Orthostatic hypotension
  3. Pulmonary
    1. Decreased gas exchange
      1. Due to decreased thoracic expansion
      2. Increased risk of pneumonia
    2. Weakened cough
      1. Inability to clear secretions
  4. Renal and gastrointestinal
    1. Urinary
      1. Urinary stasis
        1. Increased risk of UTI
      2. Risk of urinary incontinence
        1. Due to positioning
    2. Gastrointestinal
      1. Risk of aspiration
      2. Malnutrition
      3. Difficulty with bowel movements
        1. Mobility increases peristalsis
  5. Musculoskeletal & skin
    1. Musculoskeletal
      1. Atrophy
      2. Foot drop
      3. Decreased strength
    2. Skin
      1. Pressure and poor oxygenation
        1. Skin breakdown
      2. Friction and shearing
        1. Increases abrasions, skin injuries
          1. Infections
          2. Pain

Assessment

  1. Psychologic
    1. Complete neurologic assessments as ordered
    2. Observe for changes in mentation or alertness
    3. Observe for signs of delirium or withdrawn affect
  2. Cardiovascular
    1. Observe for changes in blood pressure, and orthostatic hypotension
    2. Assess for new leg pain or difficulty breathing
  3. Pulmonary
    1. Assess lung sounds for adventitious sounds
    2. Watch for any changes in cough, secretions or sputum
    3. Like cardiovascular, watch for changes in breathing
      1. Breathing difficulty and a feeling of “impending doom” could be pulmonary embolism
  4. Renal and gastrointestinal
    1. Complete ins and outs to verify fluid and nutrition status
    2. Ensure regularity of bowel movements
  5. Musculoskeletal and skin
    1. Assess range of motion and strengths daily
    2. Check over bony prominences for skin breakdown

Therapeutic Management

  1. Promoting mobility
    1. Increases strength, cardiovascular functioning, respiratory strength
  2. Turn patient or assist in turning patient to reduce skin breakdown
  3. Use orthotics to prevent foot drop
  4. Work with physical therapy and occupational therapy to assess and promote mobility
  5. Work with registered dieticians to promote optimal nutrition

Nursing Concepts

  1. Patient-Centered Care
  2. Safety
  3. Mobility
  4. Health Promotion

Patient Education

  1. Encourage patient to participate in their own care by promoting education
  2. Educate patient on different types of mobility exercises
  3. Reinforce teachings from other disciplines such as PT & OT, speech therapy and respiratory therapy

Reference Links

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Video Transcript

In today’s lesson, we’re going to focus on complications of immobility.

We have a lot of ground to cover, but these complications aren’t all encompassing. We’ve picked out the most common ones and the ones you’ll most likely see when taking care of your patients.

I’m really going to focus this lesson pretty much system by system, so let’s go.

From a psychological standpoint, if a patient isn’t getting out of bed and participating in their own care, they can get quickly frustrated that they aren’t healing. That’s where you come in and really need to reinforce and encourage them in participating. That frustration can often lead to anxiety and depression, and if not addressed quickly, can make things worse

Another big one that we need to pay attention to is delirium. If you aren’t keeping your patients on their right sleep cycles and getting them up and moving during the day, delirium can set in. This makes your patients confused and noncompliant (and sometimes combative), increases hospital stays, increases mortality, and ultimately keeps them from getting better. There’s a great resource attached to this lesson about decreasing delirium.

Now let’s take a look at how the heart and vessels are affected by immobility.

Even though your patient’s heart is pumping, there’s blood throughout the body that’s pooling. Don’t forget from A&P that we need muscle contraction to keep fluid moving, and when the muscles aren’t moving, the blood stops and pools. And when it pools, it can create blood clots which can complicate your patient’s condition. That leads to the possibility of them getting a deep venous thrombosis (DVT) or having that guy dislodge and create a pulmonary embolism, which can be fatal.

Remember, that when we walk, our leg muscles contract to move fluid through our lymph system just like blood. When they’re not moving because the patient is immobile, you’ll get edema. And if that fluid isn’t in the blood vessels, you can have blood pressure issues like orthostatic hypotension, where your patient’s blood pressure will drop because they stand up, and its related to their position. So you need to work to get your patient moving, doing range of motion exercises, or using your preventative measures (like heparin, or SCDs or Ted hoses). This helps to move that fluid where it needs to go.

And since we just talked about the heart, we can’t forget about the lungs.

When your patient is immobile, laying in bed, they really can’t get oxygen like they need to. Their lungs can’t fill up like they need to and that prevents them from getting the oxygen they need. The other thing that happens from a pulmonary standpoint is that they really can’t engage their diaphragm like they need to, and their cough gets weakened. That keeps them from clearing their secretions and can lead to pneumonia.

So what can you do? GET YOUR PATIENT OUT OF BED! Sit them up, make sure their position is optimal and if they can’t move, make sure they’re using an incentive spirometer (the little breathing device). They use it to build up their lung capacity. I usually tell patients to use it 10 times per hour, so during commercials when they’re watching TV. Encourage them to work with their respiratory therapists, too.

Now you might not think that the kidneys and the GI tract become affected by immobility, but they really are and here’s how and why.

When your patient is standing up, urine pools at the bottom of the bladder, and then empties when the patient urinates. But when they’re immobile, the urine pools at the back of the bladder, where there isn’t an exit. If they have a foley, they have to wait for their bladder to fill up to a certain level to empty. So why does this matter? Oh, well because warm, dark environments are great breeding grounds for bacteria. And because the urine isn’t moving, patients can get urinary tract infections.

The other thing that happens when a foley is inserted is that the urinary bladder can’t close completely, and if affects complete closure of the urinary sphincter, which weakens it. This can cause urinary incontinence. And if your patient is leaking urine, then you can get skin breakdown from that.

With the GI tract, patient’s caloric needs get totally messed up. They run the risk for aspiration because immobility slows down GI peristalsis. This slowing of the GI tract creates a risk for aspiration and also difficulty with bowel movements. By getting your patient up, you help to reduce these risks.

Now, we can’t forget about muscles and skin.

Atrophy is a huge problem with immobility. If your patient isn’t moving, they’re not triggering muscle response and it weakens the muscle. So at the point they start to feel better, they may just not have the strength to get up and move. Some studies estimate a 10% muscle mass loss per week for immobile patients. Also, the atrophy in the lower legs can cause something called foot drop. Because the lower leg muscles aren’t engaged and working, the foot will actually drop forward. This will definitely make walking more difficult.

SKIN, SKIN, SKIN! I can’t emphasize this one enough. If you have an immobile patient, you HAVE to realize that the skin will be impaired. Because the poor oxygenation and poor blood flow that’s happening in the heart and lungs, the tissue doesn’t get the oxygen and perfusion it needs, and becomes weakened, especially with heat and pressure. This can cause pressure ulcers. The other thing that happens is that your patient, especially your older patients, can have skin tearing or shearing due to the friction. So, you need to check your patient’s skin every time you turn, every time you assess them, and you really need to be checking up on them if they are already at major risk of skin issues because of disease or age.

For this lesson, our nursing concepts focus on safety and patient-centered care, as well as mobility…because you should MOBILIZE YOUR PATIENTS!

So let’s recap.

Remember, immobility affects every system, and sometimes more than just one.

For your patients that can’t get up, be sure to use your preventative measures like heparin, SCDs and Ted hoses to reduce the risk of blood clots and edema.

A patient’s nutrition status is really important when they’re immobile. They need all the proper nutrition to minimize atrophy and key in nutrition.

I can’t emphasize this enough because skin problems lead to all sorts of issues. Check your patient’s skin every time you turn them and every time you interact with them.

The single best thing you can do for immobile patients is to move them. Get them up when you can, minimize any complications by using preventative measures, and keep them on a good sleep cycle.

That’s our lesson on the complications of immobility. Make sure you check out all the resources attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing!!

Read more

  • Question 1 of 10

A nurse is assisting a bedridden client with moving up in bed and repositioning. Which of the following interventions would most likely prevent friction against this client’s skin while transferring? Select all that apply.

  • Question 2 of 10

A nurse is caring for a client who had knee surgery and is morbidly obese. The client has difficulties with mobility and needs two-person assistance when getting out of bed. Which of the following best describes appropriately education about preventing skin breakdown?

  • Question 3 of 10

An immobile client is at risk of aspiration because of difficulty with chewing and swallowing food. Which of the following nursing interventions is most appropriate?

  • Question 4 of 10

A 45-year-old client has been diagnosed with amyotrophic lateral sclerosis (ALS) and is unable to get out of bed. Which of the following nursing interventions are appropriate to prevent complications of immobility in this client? Select all that apply.

  • Question 5 of 10

Which of the following is an example of a cardiovascular complication associated with immobility?

  • Question 6 of 10

A bedridden client requires cradle boots bilaterally to prevent foot drop while in bed. Which of the following describes how to apply cradle boots? Select all that apply.

  • Question 7 of 10

A nurse is caring for a client who has developed a pressure ulcer after a period of immobility. The nurse assesses the wound and notes that there is an area under the skin that extends in one direction away from the wound bed and creates an opening to a different layer of skin. Which best describes this phenomenon?

  • Question 8 of 10

A nurse is using the Banner Mobility Assessment Tool (BMAT) to determine a client’s level of mobility while in the long-term care center. Which of the following is an element of assessment during this portion of the exam? Select all that apply.

  • Question 9 of 10

A client has suffered a bruise on the elbow from being assisted in bed for repositioning. Which best describes how the nurse can prevent this injury from becoming a point of skin breakdown?

  • Question 10 of 10

Prior to back surgery, the provider has ordered a complete blood count for a client. Which best describes the purpose of performing this test before surgery?

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