Complications of Immobilization


Disorder

Pathophysiology

Assessment

Analysis/Nursing Diagnosis

Nursing Care Plan/Implementation

Evaluation/Outcome Criteria

Orthostatic hypotension

A decrease in BP>30/15 caused by failure of vasomotor responses to compensate for change from a recumbent to an upright position

 

 

Subjective data:weakness;dizziness

Objective data: decreased BP>30/15 measured 2 minutes. after moving from a supine to a sitting or standing position; loss of muscle tone and strength;patient may faint

 

 

Decreased cardiac output related to orthostatic hypotension

Risk for injury related to vertigo

Activity intolerance related to dizziness

 Prevent trauma resulting from sudden decrease in BP
  1. Change position gradually
  2. Elastic stockings
  3. Leg exercises
  4. Dangle before getting up
  5. Tilt table
  6. Sitting and lying BP
  7. Monitor side effects of drugs
Health teaching
  1. Explains signs and symptoms to patient
  2. Encourage patient to dangle before standing
  3. Encourage slow movement from sitting to standing
  4. Exercises to maintain muscle tone

Patient tolerates increased activity

No trauma occurs

BP remains within normal limits
Cardiac overload When the body is recumbent, some of the total blood volume that would be in the legs as a result of gravity is redistributed to other parts of the body, thereby increasing the circulating volume and increasing the workload of the heart; heart rate, which is decreased because blood is prevented from entering the thoracic vessels by pressure from the Valsalva maneuver, increases when normal breathing resumes

Subjective data: fear, apprehension

Objective data: Valsalva maneuver (pressure against the closed glottis when breath is held) 10-20 times/hour, when trying to move in bed; tachycardia; decreased exercise tolerance

Risk for injury related to increased workload of heart

Activity intolerance related to increased workload of heart

Fear related to tachycardia

Prevent injury and further ischemic damage to cardiac tissue by decreasing work load of heart

  1. Out of bed in chair when possible
  2. Semi-recumbent position when in bed; pillows between legs when side-lying
  3. Exercises: passive and active ROM, isometric
  4. Encourage participation in self-care
  5. Turn every 2 hours., dangle
  6. Avoid Valsalva, fatigue
  7. Minimize constipation
  8. Encourage slow, deep breathing when moving in bed

Health teaching

  1. Exhale while turning; do not hold breath
  2. Measures to conserve energy

No complications noted

Patient tolerates increased activity

Heart rate within normal limit
Thrombus formation

Mass of blood constituents formed in the heart or blood vessels due to pooling of blood from lack of activity; increased viscosity related to dehydration or possible external pressure

Subjective data: discomfort over involved vessel

Objective data: increased RBC; venous stasis; hypercoagulability

Altered peripheral tissue perfusion related to obstructed vessel

Risk for injury related to emboli

Prevent injury by reducing risk factors and venous stasis

  1. Position: change ql-2h
  2. Do not gatch bed (causes pressure against leg vessels)
  3. Increase fluid intake
  4. Monitor coagulation lab values
  5. Medications: anticoagulation therapy, as
    prescribed for patients at risk (immobilized,
    trauma, low pelvic surgery)
  6. Ambulate as soon as possible

Health teaching

  1. How to recognize signs of thrombophlebitis/thromboemboli
  2. Leg exercise program to strengthen muscles for improved tone, to prevent pooling of blood in vessels
  3. Precautions necessary when on anticoagulation therapy
  4. Side effects of anticoagulation therapy (bleeding form gums, body fluids, obvious bleeding)

No thrombo emboli

Note: If Homans’ sign present (discomfort behind knee on forced dorsiflexion of the foot).

 

 
Respiratory congestion related to decreased respiratory movements Decreased thoracic movement due to restriction against bed or chair, lack of position change, restrictive dothing or binders/bandages or abdominal distention

Subjective data: dyspnea; pain

Objective data: trauma; immobilization of thorax or abdomen, due to position in bed; inability to cough or deep breathe; abdominal distention

Ineffective breathing pattern related to splinting to reduce pain

Ineffective airway clearance related to retained secretions

Impaired physical mobility related to trauma

Prevent complications related to respiratory status

  1. Maintain a clear airway, assist with ventilation prn
  2. Remove or minimize causes of dyspnea
  3. Conserve patients energy (periods of rest and activity-patient able to cough more effectively when rested)
  4. Incentive spirometry

Promote comfort

  1. Maintain hydration and nutrition
  2. Position: change q2h; out of bed in chair when possible (chest expansion greater when sitting in chair)

Health teaching

  1. Methods to allay anxieties precipitated by dyspnea
  2. Effective breathing and coughing exercises
 No respiratory complications or excess secretions noted
Respiratory congestion related to pooled secretions Inability of cilia to move normal secretions out of bronchial tree due to ineffective coughing, lack of thoracic expansion, or effects of medications

Subjective data: dyspnea; pain

Objective data: dehydration; drugsanticholinergic, CNS depressants, anesthesia; inadequate coughing; stationary position

Ineffective airway clearance related to pooled secretions

Impaired gas exchange related to ineffective coughing

Prevent atelectasis, infection, stasis of air and secretions in lungs

  1. Maintain patent airway; cough; suction; change position

Health teaching

  1. Effective coughing techniques
  2. Importance of adequate hydration

No respiratory complications.

Patient coughs and removes secretions
Oxygen-carbon dioxide im- balance Imbalance in oxygen and carbon dioxide levels related to pulmonary congestion, ineffective breathing patterns, trauma, or effects of medications

Subjective data: confusion, irritable, restless, dyspnea

Objective data: hypoxia, hypercapnia, cyanosis

Impaired gas exchange related to immobilization

Promote improved respirations

  1. Change position frequently
  2. Increase humidification
  3. Monitor side effects of administered medication, especially narcotics, barbiturates

No respiratory complications

Respiratory rate and depth are adequate for maintaining balance of oxygen and carbon dioxide
Malnutrition of immobilized adult Lack of adequate dietary intake to maintain healthy tissue related to lack of food; lack of knowledge about food; problems with ingestion, digestion, or absorption; or psychosocial factors that influence patients motivation to eat

Subjective data: anorexia, nausea; diet history validating lack of adequate nutritional intake; mental irritability Objective data:

  1. Recent weight loss of >10%
  2. Decreased: healing ability, GI motility, absorption, secretion of digestive enzymes
  3. Appearance: listlessness, muscle weakness; posture - sagging shoulders, sunken chest
  4. Anthropometric data (measurement of size, weight, and body proportions): <85% of standard
  5. Cardiovascular: tachycardia (>100 beats/min) on minimal exertion; bradycardia at rest
  6. Hair: brittle, dry, thin
  7. Skin: dry, scaly
  8. Lack of financial resources: sociocultural influences
  9. Decreased blood values: serum albumin, iron-binding capacity, lymphocyte levels, hematocrit and hemoglobin

Altered nutrition, less than body requirements, related to decreased appetite

Knowledge deficit related to nutrition requirements

Improved nutritional intake to maintain basal
metabolism requirements and replace losses
from catabolism

  1. Provide balanced or prescribed diet, soft or
    ground food if cannot chew or is edentulous
  2. Increase fluid intake
  3. Attain/maintain normal weight
  4. Feed, assist with feeding, or place foods
    within patient's reach

Promote comfort

  1. Mouth care: to facilitate mastication of food —» improved digestion and absorption
  2. Relieve constipation
  3. Observe for stomatitis, bleeding, changes in skin texture, color
  4. Medications: monitor nausea and vomiting side effects of prescribed medications; administer antiemetics as ordered to control nausea and vomiting
  5. Ambulate to alleviate flatulence and distention
  6. Alleviate pain and discomfort by distractions, increased social interactions, pleasant environment, backrubs, and administration of pm pain medications, as ordered

Health teaching

  1. Diet and elimination

No complications

Patient obtains/maintains normal weight

No tissue breakdown
Constipation Waste material in the bowel is too hard to pass easily; or bowel movements arc so infrequent that patient has discomfort

Subjective data: discomfort, pain, distress, and pressure in the rectum; reported decrease in normal elimination pattern

Objective data: immobilization; hard-formed stool, possible palpable impaction; decreased bowel sounds; bowel elimination less frequent than usual

Constipation related to decreased water and fiber intake

Knowledge deficit related to dietary and exercise requirements to prevent constipation

Promote normal pattern of bowel elimination

  1. Administer: stool softeners or bulk cathartics as ordered; oil retention, soap suds enemas as ordered
  2. Encourage change of position and activity as tolerated
  3. Provide high-bulk diet
  4. Increase fluid intake
  5. Provide for privacy
  6. Encourage regular time for evacuation

Health teaching

  1. Dietary instructions regarding increased fiber
  2. Exercise program as tolerated
  3. Increase fluids

Patient has normal bowel elimination pattern

No impactions

Increases fluid and fiber in diet
Osteoporosis

Metabolic bone disorder in which there is a generalized loss of bone density due to an imbalance between formation and bone resorption; immobilization can cause calcium losses of 200-300 mg/day

Risk factors: women, family history; post-menopause, thin and/or small frame, anorexia or bulimia, diet low in calcium; use of corticosteroids and anticonvulsants; inactive lifestyle; cigarette smoking, excessive use of alcohol

Subjective data: backache

Objective data: demineralization of bone seen on
x-ray; kyphosis; spontaneous fracture of bone (hip, spine, wrist); collapsed vertebrae; loss of height; stooped posture

Pain related to bone fractures or body structural changes

Prevent injury related to decreased bone strenght

  1. Position: correct body alignment, firm mattress
  2. Encourage self-care activities: plan maximum activity allowed by physical condition; muscle exercises against resistance as tolerated
  3. Rest/activity pattern: encourage ROM exercise; avoid fatigue
  4. Weight-bearing positions, tilt table
  5. Diet high protein, high vitamin D, calcium rich
  6. Increase fluids to prevent renal calculi (calcium from bones could cause kidney
    stones)

Health teaching

  1. Dietary instructions: foods to include for
    high-protein, high-vitamin D, high-calcium
    diet
  2. Exercise program
  3. Signs and symptoms of renal calculi
  4. Avoid smoking, alcohol

No fractures

No renal calculi

Incorporates dietary improvements in daily menu selection

Participates in exercise program on a regular basis

Regular bone density tests (1-2 years for ages 40-65+)
Contractures Abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching; related to lack of active or passive ROM, or improper support and positioning of joints affected by arthritis or injury

Subjective data: pain

Objective data: muscles - fixed, shortened, decreased tone; resistance of muscles to stretch; decreased ROM in affected
limb

Impaired physical mobility related to muscle weakness and contractures

Pain related to injury

Self-care deficit related to immobility

Prevent deformities

  1. Active or passive ROM
  2. Positioning: functional, correct alignment
  3. Footboard to prevent footdrop
  4. Avoid knee gatch

Health teaching

  1. Importance of ROM exercises
  2. Correct anatomical positions

ROM maintained

No deformities noted
Skin breakdown Presence of risk factors that could lead to skin breakdown, such as immobility, inadequate nutrition, lack of position changes

Subjective data: fatigue: pain; inability to turn on own

Objective data: interruption of skin integrity, especially over ears, occiput, heels, sacrum, scrotum, elbows, trochanter, ischium, scapula; immobilization; malnutrition

 Impaired skin integrity related lack of frequent position change

Prevent skin breakdown

  1. Change position ql-2h and pm, out of bed when possible
  2. Protect from infection
  3. Increase dietary intake: protein, carbohydrates
  4. Increase fluids Assess for/reduce contributing factors known to cause decubitus ulcers: incontinence, stationary position, malnutrition, obesity, sensory deficits, emotional disturbances, paralysis

Promote healing

  1. Wash gently, pat dry - to avoid skin abrasion
  2. Clean, dry, wrinkle-free bed linens and pads
  3. Massage skin with lotion that does not con- tain alcohol (alcohol dries skin)
  4. Protect with wafer barrier, alternating mattress, sheepskin pads, protectors, flotation devices
  5. No "doughnuts” or rubber rings (interfere with circulation of tissue within center of ring)
 No skin breakdown
Urinary stasis

Immobility leads to inability to completely empty the bladder, which increases risk for urinary tract infection and renal calculi

Subjective data: pain, due to infection or renal calculi

Objective data: difficulty in urinating due to position or lack of privacy, infection related to catheter insertion or stasis of urine; hematuria

Altered urinary elimination related to inability to empty bladder

Prevent urinary infections, stasis, and renal calculi

  1. Increase activity as allowed
  2. Check for distended bladder
  3. Increase fluids, l&O
  4. Diet: acid ash to increase acidity, thereby preventing infection
  5. Avoid catheterization; use intermittent catheterization instead of Foley whenever possible or Credé maneuver to empty bladder (manual exertion of pressure on the bladder to force urine out)
  6. Bladder training
 No urinary infections or evidence of renal calculi; bladder emptied, no urinary stasis