When a client experiences immobility, normally healthy alveoli can collapse and cause decreased lung function. Abduction refers to the movement of a limb away from the bodys midline. The nurse should tilt the bed when this occurs and this can be prevented by keeping the client's head of the bed up at the maximum of less than a 20 degree angle. She got her bachelors of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. WebThe nurse teaches the importance ofNursing measures to prevent integumentary complications include providing adequate nutrition because tissue cannot repair itself Assess for the presence of urinary tract abnormalities related to immobility, such as suprapubic distention or tenderness that can result from urinary retention. The first type of hand device is a cone that slides into the palm of the hand and is kept in place with a soft elastic band. At the current time, automatic sequential compression devices are used in health care facilities and they have virtually replaced the use of compression hose; however, compression stockings continue to be used in other areas including the client's home, for example. They should breathe in slowly and as deeply as possible through the tubing, with the goal of raising the piston to their prescribed level. (Eds.). Compression stockings may be knee length or hip length. Automatic sequential compression devices consist of a pump, a one time single patient use sleeve, and hosing that connects the sleeve to the pump. Therefore, nursing assistants must be diligent in their actions and observations to maintain their clients health and prevent complications. The Applying Prosthetics and Orthotics section in Chapter 8 describes devices such as a foot split to prevent musculoskeletal contracture. Traction forces are classified and categorized as Inline or running traction and balanced traction. Enzymatic chemical debridement can be used on wounds with at least moderate amounts of necrosis and eschar, including pressure ulcers and burns. This technique entails the placing a cupped hand over the lung areas and doing gentle tapping on the area for about one minute while the client is hyper inflating their lungs and holding the breath as long as possible. As teenagers become adults, the nurse provides education about the effects of alcohol and other drugs on balance and safety while driving. Assess for potential signs of atelectasis and pneumonia. Use any of these techniques to place the stocking on the heel, and then check for proper placement of the heel marker before applying the rest of the stocking. Discuss Nursing Interventions That Prevent Clients often have two or more pairs of compression stockings to ensure they dry completely before wearing them again in the morning. Unlike compression hose that exerts continuous pressure on the lower extremities, automatic sequential compression devices deliver intermittent pressure at the ordered pressure and as set on the pump. These open wounds are irrigated with a sterile solution and then packed to keep them open and, over time, they will heal on their own. WebOverview Complications of Immobility Psychologic Cardiovascular Pulmonary Gastrointestinal and renal Musculoskeletal and skin Nursing Points General Psychologic (OpenRN) via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request. Nursing interventions promote a patients mobility and prevent effects of immobility. Joint mobility and range of motion are assessed for the client. 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. There are additional devices that can prevent a clients hand contracture, as well as prevent their fingernails from creating open skin areas in their palm. Members of the nursing care team and other health care professionals like physical therapists must, therefore, promote client mobility and prevent immobility whenever possible. They are commonly used for clients with swelling of their extremities (edema) caused by cardiac conditions that cause fluid retention. Assess muscle strength and coordination, and then assess mobility skills in the following order: mobility in bed, dangling on the bed with supported and unsupported sitting, weight-bearing while transferring from sitting to standing or to a chair, standing and walking with assistance, and walking independently. Some clients are prescribed compression stockings, also referred to as thrombo-embolic-deterrent hose (TED hose). Pressure ulcers are costly both in terms of health care costs and the human costs that the client suffers as the result of a pressure ulcer including, but not limited to, pain, sepsis, cellulitis, and osteomyelitis. See Table 9.4 for potential complications of immobility by body system and additional preventative measures that will keep clients as healthy as possible. Casts must be applied in a smooth manner and they should also be allowed to dry without any external pressure applied to them. Some of the orthopedic devices that nurses apply, maintain and remove include traction devices, splints, braces and casts: Traction, simply defined, is a physical pulling force that exerts pulling on the bodily part. Parents are educated about these developmental milestones during well-child visits. Some of these preventive techniques include: The Braden Scale for Predicting Pressure Ulcers and the Norton Pressure Ulcer Scale are two of the most popular standardized screening tools that are used to screen and assess clients in order to determine if they are at risk for skin breakdown. Note if urinary incontinence is occurring due to the inability of the patient to reach the restroom in time.[1]. nursing fundamentals chapter 16 Flashcards | Quizlet Regular socks or slippers can be placed over the TEDs for warmth if desired. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the lower leg, but can occur anywhere within the cardiovascular system. In addition to traction and splints, many fractures are also casted.