Complications of Immobilization

Disorder	Pathophysiology	Assessment	Analysis/Nursing Diagnosis	Nursing Care Plan/Implementation	Evaluation/Outcome Criteria
Orthostatic hypotension	A decrease in BP >30/15 caused by failure of vasomotor responses to compensate for change from a recumbent to an upright position	Subjective data: weakness; dizziness Objective data: decreased BP >30/15 measured 2 min after moving from a supine to a sitting or standing position; loss of muscle tone and strength; client may faint	Decreased cardiac output related to orthostatic hypotension Risk for injury related to vertigo Activity intolerance related to dizziness	Prevent trauma resulting from sudden decrease in BP Change position gradually Elastic stockings Leg exercises Dangle before getting up Tilt table Sitting and lying BP Monitor side effects of drugs Health teaching Explain signs and symptoms to client Encourage client to dangle before standing Encourage slow movement from sitting to standing Exercises to maintain muscle tone	Client tolerates increased activity No trauma occurs BP remains within normal limits
Cardiac overload	When the body is recumbent, some of the total blood volume that would be in the legs as a result of gravity is redistributed to other parts of the body, thereby increasing the circulating volume and increasing the workload of the heart; heart rate, which is decreased because blood is prevented from entering the thoracic vessels by pressure from the Valsalva maneuver, increases when normal breathing resumes	Subjective data: fear; apprehension Objective data: Valsalva maneuver (pressure against the closed glottis when breath is held) 10–20 times/hr, when trying to move in bed; tachycardia; decreased exercise tolerance	Risk for injury related to increased workload of heart Activity intolerance related to increased workload of heart Fear related to tachycardia	Prevent injury and further ischemic damage to cardiac tissue by decreasing workload of heart Out of bed in chair when possible Semirecumbent position when in bed; pillows between legs when side-lying Exercises: passive and active ROM, isometric Encourage participation in self-care Turn every 2 hr, dangle Avoid Valsalva, fatigue Minimize constipation Encourage slow, deep breathing when moving in bed Health teaching Exhale while turning; do not hold breath Measures to conserve energy	No complications noted Client tolerates increased activity Heart rate within normal limit
Thrombus formation	Mass of blood constituents formed in the heart or blood vessels due to pooling of blood from lack of activity; increased viscosity related to dehydration or possible external pressure	Subjective data: discomfort over involved vessel Objective data: increased RBC count; venous stasis; hypercoagulability	Altered peripheral tissue perfusion related to obstructed vessel Risk for injury related to emboli	Prevent injury by reducing risk factors and venous stasis Position: change q1–2h Do not gatch bed (causes pressure against leg vessels) Increase fluid intake Monitor coagulation laboratory values Medications: anticoagulation therapy, as prescribed for clients at risk (immobilized, trauma, low pelvic surgery) Ambulate as soon as possible Health teaching How to recognize signs of thrombophlebitis/thromboemboli Leg exercise program to strengthen muscles for improved tone, to prevent pooling of blood in vessels Precautions necessary when on anticoagulation therapy Side effects of anticoagulation therapy (bleeding from gums, body fluids, obvious bleeding)	No thromboemboli Note: If Homans’ sign present (discomfort behind knee on forced dorsiflexion of the foot) see Nursing care for client with thromboemboli, pThe Perioperative Experience, 434
Respiratory congestion related to decreased respiratory movements	Decreased thoracic movement due to: restriction against bed or chair, lack of position change, restrictive clothing or binders/bandages, or abdominal distention	Subjective data: dyspnea; pain Objective data: trauma; immobilization of thorax or abdomen, due to position in bed; inability to cough or deep breathe; abdominal distention	Ineffective breathing pattern related to splinting to reduce pain Ineffective airway clearance related to retained secretions Impaired physical mobility related to trauma	Prevent complications related to respiratory status Maintain a clear airway, assist with ventilation prn Remove or minimize causes of dyspnea Conserve client’s energy (periods of rest and activity—client able to cough more effectively when rested) Incentive spirometry Promote comfort Maintain hydration and nutrition Position: change q2h; out of bed in chair when possible (chest expansion greater when sitting in chair) Health teaching Methods to allay anxieties precipitated by dyspnea Effective breathing and coughing exercises	No respiratory complications or excess secretions noted
Respiratory congestion related to pooled secretions	Inability of cilia to move normal secretions out of bronchial tree due to: ineffective coughing, lack of thoracic expansion, or effects of medications	Subjective data: dyspnea; pain Objective data: dehydration; drugs—anticholinergic, CNS depressants, anesthesia; inadequate coughing; stationary position	Ineffective airway clearance related to pooled secretions Impaired gas exchange related to ineffective coughing	Prevent atelectasis, infection, stasis of air, and secretions in lungs Maintain patent airway; cough; suction; change position See nursing care plan for Respiratory congestion related to decreased respiratory movements (above) Health teaching Effective coughing techniques Importance of adequate hydration	No respiratory complications Client coughs and removes secretions
Oxygen/carbon dioxide imbalance	Imbalance in oxygen and carbon dioxide levels related to pulmonary congestion, ineffective breathing patterns, trauma, or effects of medications	Subjective data: confusion, irritable, restless, dyspnea Objective data: hypoxia, hypercapnia, cyanosis	Impaired gas exchange related to immobilization	Promote improved respirations Change position frequently Increase humidification Monitor side effects of administered medication, especially narcotics, barbiturates See nursing care plan for Respiratory congestion related to decreased respiratory movements (Physiological Integrity)	No respiratory complications Respiratory rate and depth are adequate for maintaining balance of oxygen and carbon dioxide
Malnutrition of adult who is immobilized	Lack of adequate dietary intake to maintain healthy tissue related to lack of food; lack of knowledge about food; problems with ingestion, digestion, or absorption; or psychosocial factors that influence client’s motivation to eat	Subjective data: anorexia, nausea; diet history validating lack of adequate nutritional intake; mental irritability Objective data: Recent weight loss of >10% Decreased: healing ability, GI motility, absorption, secretion of digestive enzymes Appearance: listlessness, muscle weakness; posture—sagging shoulders, sunken chest Anthropometric data (measurement of size, weight, and body proportions): <85% of standard Cardiovascular: tachycardia (>100 beats/min) on minimal exertion; bradycardia at rest Hair: brittle, dry, thin Skin: dry, scaly Lack of financial resources: sociocultural influences Decreased blood values: serum albumin, iron-binding capacity, lymphocyte levels, hematocrit, and hemoglobin	Altered nutrition, less than body requirements, related to decreased appetite Knowledge deficit (learning need) related to nutrition requirements	Improved nutritional intake to maintain basal metabolism requirements and replace losses from catabolism Provide balanced or prescribed diet, soft or ground food if cannot chew or is edentulous Increase fluid intake Attain/maintain normal weight Feed, assist with feeding, or place foods within client’s reach Promote comfort Mouth care; to facilitate mastication of food → improved digestion and absorption Relieve constipation (see nursing care plan for Constipation, Physiological Integrity) Observe for stomatitis, bleeding, changes in skin texture, color Medications: monitor nausea and vomiting side effects of prescribed medications; administer antiemetics as ordered to control nausea and vomiting Ambulate to alleviate flatulence and distention Alleviate pain and discomfort by: distractions, increased social interactions, pleasant environment, back rubs, and administration of prn pain medications, as ordered Health teaching Diet and elimination See Chapter 9. Physiological Integrity: Basic Care and Comfort—Nutrition for foods high in protein and carbohydrate	No complications Client obtains/maintains normal weight No tissue breakdown
Constipation	Waste material in the bowel is too hard to pass easily; or bowel movements are so infrequent that client has discomfort	Subjective data: discomfort, pain, distress, and pressure in the rectum; reported decrease in normal elimination pattern Objective data: immobilization; hard formed stool, possible palpable impaction; decreased bowel sounds; bowel elimination less frequent than usual	Constipation related to decreased water and fiber intake Knowledge deficit (learning need) related to dietary and exercise requirements to prevent constipation	Promote normal pattern of bowel elimination Administer: stool softeners or bulk cathartics as ordered; oil retention, soap suds enemas as ordered Encourage change of position and activity as tolerated Provide high-bulk diet Increase fluid intake Provide for privacy Encourage regular time for evacuation Health teaching Dietary instructions regarding increased fiber Exercise program as tolerated Increase fluids	Client has normal bowel elimination pattern No impactions Increases fluid and fiber in diet
Osteoporosis	Metabolic bone disorder in which there is a generalized loss of bone density due to an imbalance between bone formation and bone resorption; immobilization can cause calcium losses of 200–300 mg/day Risk factors: women, family history; post-menopause, thin and/or small frame, anorexia or bulimia, diet low in calcium; use of corticosteroids and anticonvulsants; inactive lifestyle; cigarette smoking, excessive use of alcohol	Subjective data: backache Objective data: demineralization of bone seen on x-ray; kyphosis; spontaneous fracture of bone (hip, spine, wrist); collapsed vertebrae; loss of height; stooped posture	Pain related to bone fractures or body structural changes	Prevent injury related to decreased bone strength Position: correct body alignment, firm mattress Encourage self-care activities: plan maximum activity allowed by physical condition; muscle exercises against resistance as tolerated Rest/activity pattern: encourage ROM exercise; avoid fatigue Weight-bearing positions, tilt table Diet: high protein, high vitamin D, calcium rich Increase fluids to prevent renal calculi (calcium from bones could cause kidney stones) Health teaching Dietary instructions: foods to include for high-protein, high–vitamin D, high-calcium diet Exercise program Sign and symptoms of renal calculi Avoid smoking, alcohol	No fractures No renal calculi Incorporates dietary improvements in daily menu selection Participates in exercise program on a regular basis Regular bone density tests (1–2 years for ages 40–65+)
Contractures	Abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching; related to lack of active or passive ROM, or improper support and positioning of joints affected by arthritis or injury	Subjective data: pain Objective data: muscles—fixed, shortened, decreased tone; resistance of muscles to stretch; decreased ROM in affected limb	Impaired physical mobility related to muscle weakness and contractures Pain related to injury Self-care deficit related to immobility	Prevent deformities Active or passive ROM Positioning: functional, correct alignment Footboard to prevent footdrop Avoid knee gatch Health teaching Importance of ROM Correct anatomical positions	ROM maintained No deformities noted
Skin breakdown	Presence of risk factors that could lead to skin breakdown, such as: immobility, inadequate nutrition, lack of position changes	Subjective data: fatigue; pain; inability to turn on own Objective data: interruption of skin integrity, especially over: ears, occiput, heels, sacrum, scrotum, elbows, trochanter, ischium, scapula; immobilization; malnutrition	Impaired skin integrity related to lack of frequent position change	Prevent skin breakdown Change position q1–2h and prn, out of bed when possible Protect from infection Increase dietary intake: protein, carbohydrates Increase fluids Assess for/reduce contributing factors known to cause decubitus ulcers: incontinence, stationary position, malnutrition, obesity, sensory deficits, emotional disturbances, paralysis Promote healing Wash gently, pat dry—to avoid skin abrasion Clean, dry, wrinkle-free bed linens and pads Massage skin with lotion that does not contain alcohol (alcohol dries skin) Protect with: wafer barrier, alternating mattress, sheepskin pads, protectors, flotation devices No “doughnuts” or rubber rings (interfere with circulation of tissue within center of ring)	No skin breakdown
Urinary stasis	Immobility leads to inability to completely empty the bladder, which increases risk for urinary tract infection and renal calculi	Subjective data: pain, due to infection or renal calculi Objective data: difficulty in urinating due to position or lack of privacy; infection related to catheter insertion or stasis of urine; hematuria	Altered urinary elimination related to inability to empty bladder	Prevent urinary infections, stasis, and renal calculi Increase activity as allowed Check for distended bladder Increase fluids, I&O Diet: acid-ash to increase acidity, thereby preventing infection Avoid catheterization; use intermittent catheterization instead of Foley whenever possible or Credé’s maneuver to empty bladder (manual exertion of pressure on the bladder to force urine out) Bladder training	No urinary infections or evidence of renal calculi; bladder emptied, no urinary stasis

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Table 6-34