Exam 4 - Immobility.docx - Med Surg – MOBILITY EXAM 4...

Med Surg – MOBILITY EXAM 4
Assessment of Immobility
 Hx of injury, progression of symptoms
 THE SIX P’s
1. Pain
2. Paresthesia
3. Pallor
4. Paralysis
5. Pulselessness
6. Poikilothermic
System Specific Assessments
 Musculoskeletal
 Mentation
 Oxygenation
 Bone Demineralization
 Intake
 Lack or decrease in Cardio Output
 Elimination
Priority Interventions for Immobile Patients
 Alignment
 Cough and Deep Breathe
 Transfer out of Bed
 Increase Fluids = 2000 – 3000 per day (NO KIDNEY DISEASE OR HF)
 Devices for Immobilization
 Exercise in Bed
Complications if we do not Intervene
 Thrombus formation (risk)
 Elimination (fluid and electrolyte imbalance)
 Risk for atelectasis
 Reduced cardiac output
 Integumentary compromise
 Bone loss
 Loss of muscle endurance
 Emotional status changes
HOW DO WE PREVENT COMPLICATIONS?????
 Move the clients within their ability
o Assist to ambulate, sit, turn, ROM
 O
2
xygenate
o O
2
Sat, RR, Cough/Deep breathe, Incentive Spirometry

 Vital Signs
o Evaluate trends for signs of altered oxygenation and intervene
 Eliminate Pain
o If they are in pain they will not move or cough/deep breathe
TRAUMATIC INJURIES
SPRAINS/STRAINS
■ Sprain = injury to ligaments surrounding joint, usually through stretching/twisting
– 1
st
, 2
nd
, 3
rd
degree , Painful , Avulsion fracture
■ Strain = excessive stretching of muscle, fascial sheath or tendon
– Most common in large muscle groups
Manifestations of BOTH
 Pain, edema, contusion, reduced function
What do we do?? RICE
 Rest
 Ice
 Compression
 Elevation
FRACTURES
 Comminuted: shattered into pieces
 Compression: bone is crushed
 Impacted: ends of jammed together
 Spiral: bone twists and have jagged breaks
 Greenstick: incomplete break
 Transverse: complete break to right angle of long axis of bone
Assessment Findings
 Localized pain, decreased function, inability to bear weight/use, guard against movement, may
or may not have deformity
 IMMOBILIZE IF SUSPECTED FRACTURE
Priority Interventions