Hazards of immobility
Causes of immobility
Any condition in which normal movement is restricted
from a fractured arm in a cast to complete coma
* Devices,
eg. traction for a fracture
* Impairment,
eg. neuromuscular
* Voluntary,
(imposed bed rest, rarely used today)
* Psychiatric
causes
Effects on healthy subjects
Deconditioning - loss of functional capacity secondary
to lack of use
* Decreased
metabolic rate
* Decreased
blood volume and red cell mass
* Increased
urinary secretion of calcium, phosphorus and nitrogenous waste products
* Decreased
muscle mass
* Increased
pulse rate
* Inability
to tolerate positional change
Eg. Recover rates from a shoulder immobolised for
dislocation to return of full range of movements
Days of immobility Days
to full recovery
0 18
7 52
14 121
21 300
Hazards of immobility on the body systems
1. Cardiovascular system
Deep vein thrombosis, (DVT)
Pulmonary embolism, (PE)
Postural hypotension
Increased cardiac workload
2. Respiratory system
Hypostatic pneumonia
3. Muscular skeletal system
Osteoporosis
Muscle wasting and joint stiffness
4. Urinary system
Calculi
Retention
Incontinence
Infection
5. Gastrointestinal system
Constipation
6. Metabolic changes
7. Psychological/psychiatric
Pressure sores
Reduced integrity of the integument
Care deficits
1. Cardiovascular system
Deep vein thrombosis, (DVT)
Blood flow from the limbs back to the heart is aided by
the pumping of calf muscles and the sucking action in the inferior vena cava
produced by breathing.
When someone is inactive in bed limbs are not moving and
respirations are not as deep.
This results in a slowing of blood flow in the lower
limbs.
Compression of the veins in the legs between the bed and
bones slows the blood flow even more and may damage the lining of the vein
leading to the aggregation of platelets which forms a thrombus.
Signs and Symptoms
* Acute
pain
* Swelling
of the affected limb
* A
positive Homan's sign, (pain in the calf from dorsiflexion)
* Raised
temperature and increased pulse
Risk factors
Immobility
Oral contraceptives
Smoking
Personal and family history
Pelvic and leg fractures
Pregnancy
Hypercoagulable states
Prevention of DVT
Leg exercises one hourly during the day - passive
exercised if patient unable to move actively
Do not lie with legs crossed or with a pillow under the
calves
Deep breathing exercises
Change of position regularly
Use a bed cradle to remove the weight of bedclothes from
calves
Use anti-embolic stockings
Prophylactic subcutaneous Heparin may be prescribed
Pulmonary embolism, (PE)
May occur following a DVT if the thrombus in the calf
passes through the venous
circulation, the right side of the heart and then
becomes lodged in the vessels of the
pulmonary circulation.
When a thrombus becomes detached from the vessel wall it
moves freely through the circulation, the clot is then termed an embolus.
Signs and Symptoms
* Chest
pain
* Tachycardia,
tachypnoea
* Dyspnoea
* Cough
with haemoptysis
* Distension
of neck veins
* Shock
and sudden death
Prevention
Dependent largely upon prevention of DVT and/or early
detection of DVT.
Treatment
Anticoagulation, fibrinolytic therapy, embolectomy
Postural hypotension
Due to the decreased effect of gravity the patient
experiences vaso-dilation. When the
patient first sits up or changes from the horizontal to the vertical position,
the resulting change may cause dizziness and nausea.
Prevention
If possible allow the patient to:
* Sleep
sitting up, supported by pillows
* Allow
the patient to become upright as regularly as possible
* Rise
slowly in several stages
Increase in cardiac workload
When lying flat the distribution of circulating blood
changes, 11% of the legs blood supply moves to the thorax --------- venous return is increased -------- work load
of the heart is increased.
Sit up as much as possible
Immobility causes an increase in heart rate, subsequent
exercise will increase the tachycardia.
There is a loss of endurance which may take some weeks
to recover
Prevention
Limit immobile time as much as possible
Gradual progressive rehabilitation
Monitor pulse and blood pressure
2. Respiratory system
Hypostatic pneumonia/chest infections
Occurs when normal bronchial secretions accumulate in
the lungs. Pneumonia is infection and consolidation of the lung tissue
Signs and Symptoms
* Dyspnoea
and Cyanosis
* Increased
temperature and pulse
* Productive
cough
Prevention
Change patient position from side to side 1 - 2 hourly
to allow each lung to expand on
inspiration and allow chest secretions to drain
Encourage deep breathing, coughing and expectorating
Chest physiotherapy.
Avoid cross infection from others
Maintain fluid intake to prevent mucous viscosity
Early detection of infections
3. Muscular skeletal system
Osteoporosis
Demineralisation of bones occurs due to reduced activity
and can cause changes in size, strength, chemistry and appearance of bones.
This usually only becomes problematic in the medium to
longer term, but some increased urinary secretion of calcium begins in the
first week of immobility
Prevention
Stress bones whenever possible, eg occasional standing
if possible
Muscle wasting and joint stiffness
Muscle weakness and atrophy can occur within 3 - 7 days
of bed rest and is most noticeable in the "anti-gravity" muscles used
for standing and walking.
When immobile, the collagen fibres and connective tissue
of the tendons, ligaments and joint capsules become dense and firm ------
fibrosis resulting in the further loss of motion and joint stiffness within a
few days which may take months to reverse.
Contractures
A permanent contraction of a muscle or group of muscles
caused by
shortening and fibrosis of the muscle fibres and leading
to the loss of, or alteration in,
function.
They occur as a result of poor alignment of limbs and
posture in bed. May start after about one week of immobility,
Footdrop
A condition in which the patient is unable to maintain
his foot in the correct
position. It is a
result of gravity and added weight of the bedclothes which pulls the foot down
causing shortening of the calf muscles and tendons.
Prevention
* Support
and position the limb in physiologically normal positions
* Use bed
cradle to lift the weight of bedclothes off limbs.
* Maintain
a full range of joint movements by active or passive exercises.
* Isometric
exercise where possible
Perform each exercise five times each, several times a
day, depending on the patient
condition.
Joints which are inflamed or infected should not be
exercised - refer patient to
physiotherapist.
4. Urinary system
1. Urinary
calculi
2. Urinary
retention
3. Urinary incontinence
4. Urinary infection
Urinary calculi
Calcium is released from bone demineralisation
Due to this and urinary stasis or immobility, the
precipitation of calcium occurs forming calculi or stones.
Signs and Symptoms
* Pain
* Dysuria
* Haematuria
Prevention
Ensure adequate fluid intake of 3000 mls each day.
Urinary retention
The concentration of calcium in the urine decreases the
sensitivity of the bladder
which can lead to retention of urine, a situation which
can be exacerbated by an
inappropriate position in bed when passing urine.
Signs and Symptoms of Urinary Retention
* Pain/discomfort
* Distended
Abdomen (palpable bladder)
Prevention
Ensure fluid intake of 2,000 - 3,000 mls of fluid each
day.
Allow patient up to toilet or commode if at all
possible, to help micturition by the aid
of gravity.
Ensure privacy.
Record fluid balance to assess if bladder is emptied
completely.
Only catheterise as a last resort.
Urinary incontinence
As stated before, urinary calculi and urinary retention
can occur. These may lead to
incontinence by the irritation of the urinary sphincter
by a stone or increased pressure
from urine when the bladder's capacity is reached.
These situations can be compounded by poorly situated
toilets and if the patient has to wait too long for a bed pan or assistance
from a nurse.
Prevention
As for retention, but in addition:
* Allow up
to toilet or commode.
* Provide
plenty of urinals within easy reach.
* Offer
bed pans or toilet facilities at regular intervals.
* Ensure
patient is able to attract the attention of a nurse for assistance if
needed, e.g. buzzer or bell.
Urinary infection
If the bladder is unable to empty completely the
stagnant urine becomes infected, a
fact made worse by ascending bacteria.
Signs and Symptoms
Dysuria
Frequency
Urgency
Raised temperature and pulse
Offensive smelling urine
Prevention
* Ensure
adequate fluid intake - 3000 mls daily
* Ensure
patient empties bladder completely.
5. Gastrointestinal system
Constipation
When mobile the tone of our skeletal muscle helps in the
act of defaecation.
Peristalsis is aided by standing which helps to avoid compression
on internal organs.
Established bowel regimes may be disturbed by
environmental and psychological factors.
Diet may be changed, eg due to fasting or anorexia.
Prevention
* Be aware
of normal bowel habits
* Ensure
privacy - take to the toilet rather than give bedpans
* Allow
normal defaecation position
* High
fibre diet
* Fluids -
3000mls daily
6. Metabolic changes
Decreased basal metabolic rate
7. Psychological/psychiatric
Depression
Boredom
Loss of non verbal communication - frustration,
inability to express emotion
Anger
Anxiety
Altered body image
Grieving
Feelings of helplessness and hopelessness
Care deficits
Inability to move away from noxious stimuli
Inability to defend self
Loss of self-care ability
ADL defects