Do not send them to the laundry or put them on a heater to dry because this can cause shrinking and ruin the hose. The skin underneath skin traction must be inspected on a regular and ongoing basis to prevent some of the possible complications associated with this type of traction including blistering, skin breakdown, compartment syndrome, circulatory impairment, neurological impairment, and areas of necrosis. Corn starch is NOT used. A joint should never be forced to achieve full ROM if there is resistance. Refer to the Objective and Subjective Signs of Pain subsection in Chapter 6.3 to review observations to make and report. Legal. Wound discharge, which is also referred to as wound exudate, is assessed and described as the lack of any drainage or the presence of some drainage which be described in terms of color, amount and characteristics. The primary purposes of splinting for limb fractures are to protect soft tissue from further damage, to reduce the client's pain, to reduce the possibility of a fat embolism, and to minimize painful muscular spasms. Some of its disadvantages, however, include the fact that autolytic debridement is not as rapid as a surgical debridement in terms of its effectiveness and the fact that anerobic microbes may thrive under the dressing that is used for this type of debridement. The stockings have a square marker around the heel to guide correct placement on the heel. An oblique fracture is one that occurs at an angle across the fractured bone. Decreased lung function can reduce a persons stamina and their ability to perform activities, referred to as activity intolerance. See the steps for providing ROM for the shoulder and hip joints in the ROM Exercises for the Shoulder and ROM Exercises for the Hip and Knee Skills Checklists later in this chapter. For example, an area of skin breakdown can be described as on the posterior of the arm just inferior to the elbow or over the sacrum and coccyx. For example, the client may be encouraged to bend their knees and then exert pressure on their heels as they are being moved up in bed. For example, clients who undergo knee replacement surgery may be prescribed a passive range of motion machine that continuously flexes and extends the patients knee while they are lying in bed. Mechanical debridement is often the preferred form of treatment for pressure ulcers that only have a moderate amount of necrotic tissue that has to be removed. WebNursing interventions While many interventions depend on the underlying cause of the patients immobility, the nursing interventions in this article will focus on aspects of A depressed fracture occurs when bone fragments of the fractured bone is pushed in beyond the surrounding skin. 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. 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.) Encourage or perform active or passive range of motion exercises as prescribed by the physical therapist. See Figure 9.7[8] for a demonstration of these techniques. Compression stockings require a physicians order and should be applied in the morning and taken off at night. These efforts are even more intense and comprehensive when the client has one or more risk factors associated with impaired skin integrity, as discussed previously in this section. The client is placed in the same positions that are used for postural drainage, as discussed immediately above. The lateral position is a side lying position with the upper most knee bent and often maintained in that position with a pillow; the Fowler's position is a sitting position with the head of the bed up and elevated; the dorsal recumbent position and supine position are lying on the back with or without a pillow for the head; the prone position is lying on the stomach; and the Sim's position is a semi prone position. Splints are also used the immobilization of the spine, to support a weakened area of articulation such as a knee from damage and to support it after a knee replacement, for example. Some of the disadvantages of mechanical debridement include the fact that it nonselective and, as such can damage healthy tissue, it can cause pain, it is more subject to an infection than other forms of debridement, and it is more time consuming on the part of the person performing this procedure, when compared to other methods of debridement. Report completion of the activity to the nurse who documents frequency and effectiveness of this intervention.[5]. See Figure 9.3[3] for an image of a passive motion machine. [3], There are several nursing diagnoses related to mobility. 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. There are three types of ROM exercises: passive, active, and active assist. Gait is a function of a number of different things including balance, coordination, muscular strength, and joint mobility. For example, hip abduction is the movement of the leg away from the midline of the body. 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. (OpenRN) via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request. Coordination can be adversely affected with a neurological disorder of the cerebellum, cerebral cortex and basal ganglia; muscular strength can be impaired with things like muscular atrophy, spasticity, nutritional deficits, paresis, flaccidity and other causes; and joint mobility can be impaired disuse, arthritis and other disorders of the bone. The fabric should be completely over the toes, or completely at the base of the toes, to prevent skin breakdown or blockage of circulation to the toes. 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. Pressure ulcers are also referred to as stasis ulcers, trophic ulcers, and ischemic ulcers; they can result from the mechanic forces of pressure, friction and shearing, all of which can, and should, be prevented. A greenstick fracture occurs when only one side of the bone is fractured. In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of mobility and immobility in order to: The hazards or complications of immobility, such as skin breakdown, pressure ulcers, contractures, muscular weakness, muscular atrophy, disuse osteoporosis, renal calculi, urinary stasis, urinary retention, urinary incontinence, urinary tract infections, atelectasis, pneumonia, decreased respiratory vital capacity, venous stasis, venous insufficiency, orthostatic hypotension, decreased cardiac reserve, edema, emboli, thrombophlebitis, constipation and the loss of calcium from the bones, are highly costly in terms of health care dollars and in terms of client suffering. Segmenting ADLs refers to breaking up tasks to accommodate the clients activity intolerance. Some clients are prescribed compression stockings, also referred to as thrombo-embolic-deterrent hose (TED hose). Skeletal fractures are classified and described in several ways, many of which are not mutually exclusive. 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. A comminuted fracture is one that splinters the fractured bone into small fragments as a result of a traumatic force. For instance, if the shoulder is being exercised, the nursing assistant places their hands underneath the elbow and wrist to support them. Some nursing diagnoses related to immobility can include: Mobility is defined as the "ability to move freely, easily, rhythmically, and purposefully in the environment. Traction, when ordered, should be continuous and not interrupted. A transverse fracture is one that occurs straight across the fractured bone. Enzymatic chemical debridement can be used on wounds with at least moderate amounts of necrosis and eschar, including pressure ulcers and burns. 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. 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. The quantity or amount of drainage can be described as minimal, moderate or excessive and copious when a wound drain is not being used to measure drainage precisely. When blood is not moving much due to client inactivity, it can coagulate (i.e, form a clot). When applying stockings, proper placement on the heel is important. Legal. 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. Wound drainage is also described in terms of its color and characteristics. An example of primary intention healing is the suturing of an abdominal surgical wound after an appendectomy or the suturing of a traumatic laceration with Steri Strips or sutures when this traumatic wound is free of any contamination and infection. Manual traction, which is applied with the hands, is done to properly align a bone after a fracture so that a cast can be applied to the bone while it is in correct anatomical alignment. If the clot breaks free, it can travel to the lungs and become fatal. While the client is in an upright semi-Fowler's position or sitting in the chair, the client is instructed to put the mouth piece tightly into their mouth and to take the deepest possible diaphragmatic breath while observing the ball rise to the level of their goal. An avulsion fracture occurs when a fragment of the fractured bone is pulled off the bone at its tendon or ligamentous attachment. The enzymes introduced for this type of debridement are maintained within a moist environment so that they can destroy cellular debris, slough and eschar. Joint mobility and range of motion are assessed for the client. These stages are: The treatment of pressure ulcers is complex and it often includes a combination of treatments and therapies. Some of these complications of immobility can be prevented with respiratory hygiene measures such as deep breathing, coughing, postural drainage, The correct application of antiembolism stockings entails the application of these stockings while the client is lying in bed and before rising. Monitor for signs of vertigo and orthostatic hypotension and assist the patient to a sitting or lying position if they occur. RYB stands for the colors of red, yellow and black. The amount of pressure the hose applies to the legs is prescribed. At times a tilt table can be used to prevent this damage by placing the client in a position of weight bearing to avoid these complications. They should never touch the floor or any other surface such as a part of the bed because this will interfere with the traction's ordered weight. (Eds.). They should be applied upon awakening because edema is usually at its lowest point after lying in bed overnight. The best way for nursing assistants to prevent DVT is to assist clients to ambulate or otherwise complete as much activity as they can tolerate. Determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer ). Immobility can adversely affect all physiological bodily systems. Skeletal traction is applied directly to an affected bone with a continuous traction force and with the use of a surgically inserted Steinman pin that is placed into the distal end of the affected bone. Assess for the presence of urinary tract abnormalities related to immobility, such as suprapubic distention or tenderness that can result from urinary retention. 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. Assess the cardiovascular system, including blood pressure, heart sounds, apical and peripheral pulses, and capillary refill time. Parents are educated about these developmental milestones during well-child visits. Postural drainage is done by the nurse or the certified respiratory therapist. Insure that the counter traction force is less than the pulling traction force. People must be able to move to protect themselves from trauma and to meet their basic needs. 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. In addition to anti embolism stockings and sequential compression devices, as previously discussed, active or passive range of motion, positioning and mobilization are also measures that promote circulation. The client should attempt to hold their breath for as long as possible (at least five seconds) and then exhale and rest for a few seconds.