They are commonly used for clients with swelling of their extremities (edema) caused by cardiac conditions that cause fluid retention. The nurse should monitor these clients to insure that they are performing these active range of motion exercises in the correct manner and to the greatest possible extent of movement for all of the joints of the body. Simply defined, full range of motion is defined as the maximum movement of a joint specific to that joint. Conditions such as osteoarthritis, orthostatic hypotension, inner ear dysfunction, osteoporosis resulting in hip fractures, stroke, and Parkinsons disease are among the most common causes of immobility in old age. When implementing interventions to promote mobility, in addition to reviewing the current orders regarding assistance and weight-bearing, assess the patients current status. The advantages of this kind of wound debridement include its effectiveness, its ease in terms of performing it, its relative safety, and lack of pain for the client. The stages of wound healing are the homeostasis phase, the inflammation phase which is also referred to as the exudate and lag phase, the proliferative and granulation phase, and the maturation phase. The muscles, joints and bones are adversely affected by immobility. This page titled 13.3: Applying the Nursing Process is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Ernstmeyer & Christman (Eds.) These stages are: The treatment of pressure ulcers is complex and it often includes a combination of treatments and therapies. The nurse determines whether or not the client's expected outcomes were accomplished after preventive measures were implemented to prevent the complications associated with immobility. The prevention of the complications associated with immobility include early out of bed activity as soon as possible after surgery and complication related See Figure 9.6[7] for an image of locating the heel marker. Many of these costly complications of immobility can, and should be, prevented whenever possible. A joint should never be forced to achieve full ROM if there is resistance. Therefore, nursing assistants must be diligent in their actions and observations to maintain their clients health and prevent complications. For example, a bicep curl during weight lifting demonstrates both flexion and extension. We also acknowledge previous National Science Foundation support under grant numbers 1246120, 1525057, and 1413739. At each stage of growth and development, the nurse assesses a patients mobility and provides appropriate education. The homeostasis phase is marked with vasoconstriction, platelet formation, thrombin formation and the formation of a fibrin mesh for healing; the inflammation phase is characterized with the signs and symptoms of inflammation including edema, swelling, pain, in addition to the beginning of debris removal to prevent infection through the process of phagocytosis; the proliferative and granulation phase is marked with the fibroblastic production of collagen and granulation tissue; and, lastly, the maturation phase of wound healing is characterized with the still fragile skin after the wound healing process that can last up to two years after a wound. The joints are affected with stiffness, pain, impaired range of motion and contractures including foot drop which is a plantar flexion contracture. The depth of a wound is measured using a sterile cotton applicator which is then compared to the disposable rule for an accurate measurement. RegisteredNursing.org does not guarantee the accuracy or results of any of this information. Automatic sequential compression devices consist of a pump, a one time single patient use sleeve, and hosing that connects the sleeve to the pump. Compression stockings require a physicians order and should be applied in the morning and taken off at night. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Associations task force on competency and education for the nursing team members. As previously discussed skin integrity can be maintained and skin breakdown can be prevented with a number of different interventions such as turning and repositioning the client at least every two hours, special pressure relieving mattresses, and the avoidance of all pressure, friction and shearing. Automatic sequential compression devices can have sleeves to accommodate for pressure on the legs as well as the foot. Like automatic sequential compression, compression stockings are fitted for the specific client after measuring the client's legs and checking the doctor's order for the amount of pressure that these stockings should exert on the client's leg. For example, some compression stockings may seem like slightly tight socks, whereas other stockings for clients with severe edema are custom-made to fit very tightly and may have a zipper for ease of application. Monitor 24-hour trend of intake and output, as well as for symptoms of dysuria, urgency, or frequency. Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, Some of these joint disorders can be prevented with frequent and proper positioning of the client in correct bodily alignment, the provision of range of motion exercises to all joints several times a day, and the use of devices like a hand roll and a bed board to prevent contractures of the hands and feet, respectively. Do not send them to the laundry or put them on a heater to dry because this can cause shrinking and ruin the hose. Accessibility StatementFor more information contact us atinfo@libretexts.org. See Figure 9.9[10] for images of both types of applications of the toe opening of the stocking. Some splints, like an inflatable arm splint, a Downey splint and a Sager splint, are temporarily placed on clients by paramedics in the field prior to their arrival at the emergency department of a hospital. Nursing interventions promote a patients mobility and prevent effects of immobility. Secondary intention healing, also referred to as healing by second intention, is done for contaminated wounds in order to prevent infections, to prevent the formation of abscesses and to promote healing from the bottom up to the outer surface of the skin so that any potential infection is not closed in at the bottom of the wound. The eschar is gently crosshatched with a scalpel so that the introduced enzymes can penetrate all layers of it. See Figure 9.5[6] for an image comparing both lengths. The nurse or respiratory therapist initially teaches the client how to use the incentive spirometer but encouraging and observing clients complete this action every hour is commonly delegated to a nursing assistant. See Table 9.4 for potential complications of immobility by body system and additional preventative measures that will keep clients as healthy as possible. An avulsion fracture occurs when a fragment of the fractured bone is pulled off the bone at its tendon or ligamentous attachment. Patients able to perform full joint movement on their own and without the assistance of another should be encouraged to do so several times a day to promote circulatory functioning and also to maintain full joint mobility. Preventive measures and the treatments of these skin integrity disorders will be discussed below in the section entitled "Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown". Some of the expected client outcomes relating to immobility and mobility can include specific goals such as: The interventions for immobility according to system that can be adversely affected with immobility, in addition to the constant monitoring of the client, assessments and reassessments for these hazards, include: Clients are encouraged to cough, deep breathe, use an incentive spirometer, and perform inspiratory respiratory exercises, and the nurse, or the certified respiratory therapist, will also perform postural drainage, percussion, and vibration to correct and prevent the collection of respiratory secretions in the client's airway which can result from immobility and some respiratory diseases and disorders. Balanced traction utilizes the weight of the client's bodily part, rather than externally placed weights, to exert the traction force to the body. Perform active range of motion to all joints two times a day, Safely transfer from the bed to the chair with assistance, Demonstrate proper deep breathing and coughing, Ambulate 30 feet three times a day with a walker and the assistance of another, Increase their level of exercise and physical activity, Demonstrate the proper use of their assistive device while ambulating, Maintain their skin integrity and not have any signs of skin breakdown, Maintain adequate respiratory functioning. Monitor for signs of vertigo and orthostatic hypotension and assist the patient to a sitting or lying position if they occur. For example when the length of the sound is 4 cm and the width of the wound is 3 cm and the depth of the wound is 1 cm, the wound dimension is 12 cm because 4 x 3 x 1 = 12 cm. However, as the client sits or stands upright during the day, blood tends to pool in the lower legs. Nurses maintain skin integrity and prevent skin breakdown in a number of different ways. The circulatory system is jeopardized by immobility; some of these respiratory complications and risks include venous stasis, venous dilation, decreased blood pressure, edema, embolus formation, thrombophlebitis and orthostatic hypotension which is a risk factor that is often associated with client falls. Assess for the presence of urinary tract abnormalities related to immobility, such as suprapubic distention or tenderness that can result from urinary retention. When the pulling traction force is greater than the counter traction force of the client's body, the client will slide to the source of the traction. The client should be reminded and encourage to take at least 10 breaths using the incentive spirometer at least every 2 hours while they are awake. An example of segmenting ADLs would be assisting a person to bathe in bed as independently as possible, letting them rest after bathing, and then returning later to assist them with dressing and grooming to get them ready for the day.

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