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N41A CareofImmobilizedClient

The document discusses care of immobilized clients. It covers conditions that can cause immobility like cardiovascular, neurological and musculoskeletal issues. Immobility puts clients at risk for complications like blood clots, skin breakdown, pneumonia and more. Nursing goals are to promote mobility and function while preventing disabilities. Interventions include assessing mobility, identifying contributing factors, promoting optimal function, and preventing complications through positioning, skin care, exercise and more.

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Soma Al-mutairi
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71 views15 pages

N41A CareofImmobilizedClient

The document discusses care of immobilized clients. It covers conditions that can cause immobility like cardiovascular, neurological and musculoskeletal issues. Immobility puts clients at risk for complications like blood clots, skin breakdown, pneumonia and more. Nursing goals are to promote mobility and function while preventing disabilities. Interventions include assessing mobility, identifying contributing factors, promoting optimal function, and preventing complications through positioning, skin care, exercise and more.

Uploaded by

Soma Al-mutairi
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPSX, PDF, TXT or read online on Scribd
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Care of Immobilized Client

Conditions Causing Immobility


Cardiovascular conditions Neurological conditions Musculoskeletal Conditions Respiratory Conditions Other conditions

Risk and Effects of Immobility


Muscle wasting/atrophy/contractures/muscular weakness Clot formation Skin Breakdown

Risk of discomfort and complications related to immobility


( constipation, renal calculi, pneumonia) Reduced respiratory effort/lung capacity Impaired clients recovery Postural hypotension Disorientation

Nursing Diagnosis of the Immobilized Client


Nursing Diagnosis - Analysis of Data

Immobility a state in which the individual experiences a limitation of ability for independent physical movement

Related Factors
Intolerance to activity/decreased strength and endurance Pain/discomfort Neuromuscular/musculoskeletal impairment Depression/severe anxiety

Restrictive therapies/safety precautions


( bedrest, limb immobilization)

Goals for Immobilized Client


Promote optimum function Prevention of disability and deformities Increased Mobility Increased circulation Increased systemic function

Nursing Interventions for the Immobilized Clients


1. Asses functional mobility: Assess degree of immobility Note movement when patient is unaware of observation Note emotional/behavioral responses to problems of immobility Note presence of complications related to immobility

Nursing Interventions for the Immobilized Clients


2. Identify causative contributing factors Determine diagnosis that contributes to immobility Note situations such as surgery, fractures, amputation, tubings, that restrict movement Assess degree of pain

Note decrease motor agility related to age

Nursing Interventions for the Immobilized Clients


3. Promote return to optimal level of function and prevent complications Position patient for optimum comfort Monitor circulation Instruct use of side rails,trapeze Support affected body parts Provide well balanced diet Monitor elimination patterns Active/passive ROM Provide skin care Encourage deep breathing exercises

Nursing Interventions for the Immobilized Clients


4. Promote wellness Encourage involvement of family Assist patient to learn safety measures Identify need of adjunctive devices Consult PT/OT as indicated

Nursing Care for Decubitus Ulcers


Pressure- relieving beds and mattresses Stages of ulcer development Body positioning Universal precautions Topical medications Dressings Special considerations for the elderly

Stages of Pressure Sore


Stage I
Nonblanchable erythema of intact skin heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration or hardness may be indicators.

Stage III

Full-thickness loss of the skin and necrosis of subcutaneous tissue.

Stage IV
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g, tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.

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