Chapter 47: Mobility and Immobility

1. Chapter 47: Mobility and Immobility Bonnie M. Wivell, MS, RN, CNS

2. The Nature of Movement Coordination between the musculoskeletal system and the nervous system. Alignment and Balance The positioning of the joints, tendons, ligaments and muscles while standing, sitting, and lying Gravity and Friction Gravity is the force of weight downward Friction is force that opposes movement

3. Physiology and Regulation of Movement Long bones contribute to height Short bones occur in clusters Flat bones provide structural contour Irregular bones make up the vertebral column and some bones of the skull Functions of MSK Protects vital organs Aids in calcium regulation Production and storage of blood

4. Joints • Synostotic = bones joined by bones; no movement; example: skull • Cartilaginous = cartilage unites bony components; allows for growth while providing stability; example: 1st sternocostal joint • Fibrous = ligament or membrane unites two bony surfaces; limited movement; Example: tib/fib • Synovial = A true joint; freely movable; • Pivotal • Ball and socket • Hinge

5. Ligaments/Tendons/Cartilage • Ligaments = white, shin, flexible bands of fibrous tissue binding joints together and connecting bones and cartilages • Tendons = white, glistening, fibrous bands of tissue that connect muscle to bone; strong, flexible • Cartilage = nonvascular, supporting connective tissue

6. Skeletal Muscle • Ability of muscles to contract and relax are the working elements of movement • Muscles are made of fibers that contract when stimulated by an electrochemical impulse that travels from the nerve to the muscle • Muscles associated with posture converge at a common tendon • Lower extremities, Trunk, Neck, Back • Coordination and regulation of different muscle groups depend on muscle tone (normal state of balanced muscle tension) • Muscle tone helps maintain functional positions such as sitting or standing

7. The Nervous System • The motor strip is the major voluntary motor area and is located in the cerebral cortex • A majority of motor fibers descend from the motor strip and cross at the level of the medulla • Motor fibers from right motor strip control voluntary movement on left side of body and motor fibers on left control movement on right side of body • Impulses descend from motor strip to spinal cord • Impulse exits the spinal cord through efferent motor nerves and travels through the nerves

8. The Nervous System Cont’d. • Neurotransmitters or chemicals transfer electric impulses from the nerve to the muscle • Neurotransmitters stimulate the muscles causing movement • Movement is impaired by disorders that alter • Neurotransmitter production • Transfer of impulses from the nerve to the muscle • Activation of muscle activity

9. Pathological Influences on Mobility Postural abnormalities: congenital or acquired postural abnormalities affect the efficiency of the MSK system as well as body alignment, balance, and appearance Can cause pain, impair alignment or mobility Impaired muscle development: patients with muscular dystrophy experience progressive, symmetrical weakness and wasting of skeletal muscle groups, with increasing disability and deformity

10. Pathological Influences on Mobility • Damage to the Central Nervous System: damage to any component of the CNS that regulates voluntary movement results in impaired body alignment, balance, and mobility • Complete transection of the spinal cord results in a bilateral loss of voluntary motor control below the level of trauma • Damage to the cerebellum causes problems with balance and motor impairment is directly related to amount and location of destruction • Trauma to the Musculoskeletal System: direct trauma results in bruises, contusions, sprains, and fractures

11. Mobility and Immobility Mobility refers to a person’s ability to move about freely and immobility refers to the inability to do so The effects of muscular deconditioning associated with lack of physical activity are often apparent in a matter of days Disuse atrophy describes the tendency of cells and tissue to reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting, or local nerve damage

12. The Effects of Immobility • Metabolic changes • Negative nitrogen balance • Calcium resorption (loss) • GI changes • Constipation → Impaction → Mechanical Obstruction • Respiratory changes • Atelectasis → Pneumonia • Cardiovascular changes • Orthostatic hypotension • Increased cardiac workload • Thrombus formation (Virchow’s triad)

13. The Effects of Immobility Cont’d. • Musculoskeletal changes • ↑ protein breakdown → ↓ lean body mass • Osteoporosis • Joint contractures • Foot drop • Changes in urinary elimination • Urinary stasis • Renal calculi • Integumentary changes • Pressure ulcers

14. Older Adults • Immobility can lead to…. • Loss of mobility and functional decline • Weakness, fatigue, and increased risk for falls • Shallow breathing resulting in pneumonia • Inadequate turning/repositioning results in skin breakdown and pressure ulcers • Anorexia and insufficient assistance with eating leads to malnutrition • Multiple interruptions and noise impair sleep, causing fatigue, depression, and confusion.

15. Mobility • ROM = amount of movement at a joint • Active/Passive • See pages 1232 – 1236 • Gait = style of walking • Exercise and activity tolerance: age and illness can affect this • Body Alignment • Standing/Sitting/Lying • Patients with impaired mobility, decreased sensation, impaired circulation, and lack of voluntary muscle control are at risk for damage to the MSK system when lying down

16. Range of Motion

21. Safe Patient Handling Protecting the Patient and Health Care worker Manually lifting and transferring clients contributes to the high incidence of work-related MSK problems and back injury Lift teams/lift equipment Ergonomics training Plan ahead based on patient assessment

26. Assistive Devices for Patient Movement • All devices must be appropriate for patient • Weight limit • Reason for Device • Measured to patient • Canes • Walkers • Wheel chairs • Crutches

27. Gait Belt

28. Wearing a Gait Belt

29. Using a Gait Belt

30. Ambulating With a Walker

32. Metabolic I&O Lab values Height and weight Nutritional intake Respiratory Auscultate lungs CV Pulses/Cap refill Edema/DVT MSK Muscle tone/strength Contractures Integument Breakdown Color changes Elimination I&O Bowel sounds Frequency and consistency of stool Dietary intake Psychosocial Anxiety Depression Sleep deprivation Assessment

33. Plan • Goals and outcomes individualized • Set priorities • Collaborative care: team approach

34. Interventions • Health promotion • Education • Prevention • Early detection • Prevention of work-related MSK injuries • Use of ergonomics • Exercise • Bone health • Screening • Maintain independence with ADLs • Assistive ambulatory devices

35. Interventions Cont’d. • Metabolic • High-protein, high-calorie diet • Vitamin B for skin integrity and wound healing • Vitamin C for replacing protein stores • TPN • Enteral feedings • Respiratory • Turn, cough, and deep breathe (TCDB) • Chest physiotherapy (CPT) • 2000 mL of fluid daily if not contraindicated

36. Interventions Cont’d. • CV • Mobilize ASAP, dangle or sit in chair at minimum • Isometric Exercise • Discourage use of valsalva maneuver • DVT prophylaxis • TEDS – apply properly, remove at least bid • Avoid crossing legs, sitting for prolonged periods of time, wearing constrictive clothing, putting pillows under the knees, and massaging legs • Meds

37. Interventions Cont’d. • MSK • ROM • CPM in orthopedics • Integument • Screen for risk (Braden Scale) • Prevention • Position changes

39. Interventions Cont’d. • Elimination • Adequate hydration • If incontinent, provide frequent skin care • Catheterize prn • Foods high in fiber • Stool softners/cathartics prn • Psychosocial • Schedule care to prevent interruption of sleep • Depression screening (GDS) • Provide stimulation and re-orient prn • Involve clients in own care as much as possible

41. Positioning

45. Semi Fowler’s Position

46. Sim’s or Left Lateral Position

48. Now let’s write a nursing care plan regarding immobility

49. Chapter 48: Skin Integrity and Wound Care

50. Skin • Two layers • Epidermis = has several layers • Stratum corneum = thin, outermost layer • Allows for evaporation of water from skin • Permits absorption of topical meds • Basal layer • Dermis = provides strength, support and protection of underlying muscles, bones, and organs