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Mobility and Immobility

Body mechanics refers to the safe and efficient use of the body during movement and activity. It involves proper body alignment, balance, and coordinated movement. Prolonged immobility can lead to complications like pressure ulcers, bone demineralization, negative nitrogen balance, orthostatic hypotension, increased cardiac workload, contractures, thrombus formation, and stasis of respiratory secretions. Nurses implement measures to prevent these complications through frequent position changes, range of motion exercises, proper nutrition, and encouraging early mobility.

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Body Mechanics  The efficient, coordinated, and safe use of the body to produce motion and maintain balance during activity. Major purpose: facilitate safe and efficient use of appropriate groups of muscles.
3 Basic Elements  Body alignment (posture): geometric arrangement of body parts in relation to each other.  Balance (stability): state of equipoise (equilibrium) in which opposing forces counteract each other.  Coordinated body movement: integrated functioning of the musculoskeletal and nervous system as well as joint mobility. 
Important Concepts  The center of gravity of an object is the center of its mass. In humans, it is at the center of the pelvis about midway between the umbilicus and the symphysis pubis.  The line of gravity is the vertical line passing through the center of gravity.  The base of support is the foundation that provides the object/person’s stability.
Principles of Body Mechanics a. Spread your feet b. Place your feet appropriately in the apart to provide a wide direction in which the base of support movement occurs. c. Keep objects to be d. Push, pull, roll, or slide moved close to the body objects rather than lifting them, whenever possible.
Principles of Body Mechanics e. When pushing or pulling f. Avoid twisting the spine an object, use the body’s by pushing or pulling weight to counteract the objects directly away from weight of the object. or toward the body and squarely facing the direction of movement. g. When lifting objects, distribute the weight between large muscles of the legs and arms.
Other Strategies to Prevent Back Injuries 1. Wear low-heeled shoes that provide good foot support 2. When standing for long periods, occasionally flex one hip and knee and rest your foot on an object if possible 3. Sit with knees slightly higher than hips 4. Exercise regularly, including exercises to strengthen the pelvic, abdominal, and lumbar muscles 5. Sleep on a firm mattress
Poor Body Mechanics
Complications Related to Poor Body Mechanics 1. Muscle fatigue 2. Joint strain 3. Lower back injuries- most common injury among nurses 4. Repetitive motion injuries
Ergonomics
Ergonomics
Ergonomics
Complications of Immobility  1. Pressure Ulcers - “Bed Sore”  A pressure ulcer is a specific tissue injury caused by unrelieved pressure that results in ischemia in and damage to the underlying tissue.  Pressure ulcers occur most commonly over bony prominences.  Risk factors include: 1.immobility 2.malnutrition 3.incontinence 4.compromised peripheral circulation.  The elderly are especially at risk because of a loss of lean body mass and changes in body tissues and peripheral circulation.
Pressure Ulcer Stage 1 redness of intact skin
Pressure Ulcers Stage2 abrasion, crater, or blister; ulcer is shallow
Pressure Ulcers damage to Stage 3 subcutaneous tissue extending down to fascia; deep crater, possibly with drainage
Pressure Ulcers damage to Stage 4 muscle, bone, tendon or joint capsule; small or large surface wound, but with extensive tunneling, and foul smelling discharge.
Nursing Measures to prevent Pressure Sores:  Frequent turning of immobile clients every 2 hours  Instruct patients to do weight shifts (pressure relief) at least every 15-20 minutes when sitting in your wheelchair.  If your injury is at levels C4 and higher you can use a power tilt wheelchair for regular pressure relief.  With an injury at levels C5 or C6 you can usually lean forward or side-to-side for regular pressure relief.  If your levelof injury is C7 and below you can usually perform a wheelchair push-up for regular pressure relief.
Nursing Measures to prevent Pressure Sores:  Provide for good nutrition with diet high in protein, carbohydrates, fluids, vitamin C and zinc  Use alternating-pressure air mattress, flotation pads, elbow and heel pads, sheepskin pads  Do not use “donuts” or rubber rings  Protect from infection
Nursing Measures to prevent Pressure Sores:  Wash skin gently, pat dry to prevent skin abrasion  Use clean, dry, wrinkle-free bed linens and pads  Promote circulation by gently massaging skin with lotion that does not contain alcohol  Remove dead tissue and debris for stages 2-4  Dead tissue in the pressure sore can delay healing and lead to infection. Removing dead tissue is often painful. The client may be given pain-relieving medicine 30 to 60 minutes before these procedures.
Nursing Measures to prevent Pressure Sores:  Procedure  Rinsing (to wash away loose debris).  Wet-to-dry dressings.  Enzyme medications to dissolve dead tissue only.  Special dressings  Complications of pressure sores include localized (i.e. osteomyelitis, cellulitis) and even systemic infection (i.e. sepsis)
Bone Demineralization and Hypercalcemia  Prolonged bedrest  absence of weight-bearing  Osteoporosis  hypercalcemia
Bone Demineralization and Hypercalcemia  Nursing Measures:  Prevent injury related to dec. bone strength  Encourage weight-bearing on long bones, if possible  Correct Body alignment, firm mattress  Encourage self – care, ROM, avoid fatigue  Assume wt. bearing positions (Tilt Table)  Decrease calcium intake, provide balanced diet  Diet: high CHON, Vit.C, Dec. Ca  May be given estrogen, as necessary, and medications like biphosphonates (i.e. alendronate, residronate) to retard demineralization  Encourage fluids, acid ash diet
Negative Nitrogen Balance  Negative nitrogen balance is aggravated by anorexia. It represents depletion of protein stores that are essential for building muscle tissue and for wound healing.  Nursing Measure: Give high protein diet in small, frequent feedings
Orthostatic Hypotension  Orthostatic hypotension is decrease in BP > 20/10 mmHg and it happens when there is decreased ability of the autonomic nervous system to equalize the blood supply when position is changed from recumbent to upright. Another contributing factor is the pooling of blood in the lower extremities due to the decrease in muscle action that causes pressure on the veins and assisting in venous return.  May lead to faintness, weakness, or dizziness in an attempt to stand. The patient is at high risk for injury due to falls.
Orthostatic Hypotension  Nursing Measures:  Increase activity gradually  Encourage ROM and leg exercises  Teach patient to rise from bed slowly and dangle legs before getting up  Elastic stockings  Tilt table  Sitting & lying BP
Increased Cardiac Workload  When the body is recumbent, the total blood volume that would be in the legs due to gravity is redistributed to other parts of the body, increasing the circulating volume and workload of the heart.  With prolonged immobility the sympathetic nervous system takes over resulting to tachycardia
Increased Cardiac Workload  Valsalva maneuver further increases cardiac workload  Nursing Measures: Goal is to prevent injury and further ischemic damage to cardiac tissue by decreasing workload of heart:  Semi-recumbent position when in bed, pillows between legs when side-lying  Passive & Active ROM exercises  Turn every 2 hour, dangle legs  Avoid Valsalva maneuver: use overhead trapeze when moving in be  Encourage slow, deep breathing when moving in bed
Contractures  Contractures are joint abnormalities due to abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching.  Due to lack of active or passive ROM and improper positioning of joints  On assessment: fixed, shortened extremities with pain on manipulation  Leads to difficulties in performing ADL 
Contractures  Nursing Measures:  Promote frequent change in position  Use pillows, trochanter rolls, and foot board to promote proper body alignment  Avoid knee gatch  Perform therapeutic ROM exercises as appropriate  Promote proper body alignment  Position: Functional, correct alignment
Thrombus Formation This is development of clot in a vein due to venous stasis, increased coagulability of blood and damage to the endothelial wall of the vessel DVT present as groin or calf tenderness, pain, warm and edematous extremities. It poses the danger of throwing off an emboli leading to pulmonary infarction
Thrombus Formation  Nursing Measures:  Prevent by leg exercises: flexion and extension of toes for 5 minutes every hour  Ambulate patients as appropriate  Avoid using knee gatch on bed or pillows to support knee flexion  Use anti-thromboembolic stockings  Check for Homan sign
Stasis of Respiratory Secretions  Due to inability of cilia to move normal secretion out of bronchial tree due to ineffective coughing, lack of thoracic expansion or effects of medications  This leads to hypostatic pneumonia (frequent nosocomial infection)
Stasis of Respiratory Secretions  Nursing Measures:  Teach patient the importance of turning, deep breathing, coughing  Teach patient how to use incentive spirometry  Hold the spirometer upright  Teach patient to exhale first and seal the lips tightly around the mouthpiece  Take in a slow, deep breath to elevate the balls or cylinder. Hold the breath initially for 2 seconds and then increasing to 6 seconds.  Repeat the procedure four or five times hourly. Practice increases inspiratory volume, maintains alveolar ventilation and prevents atelectasis.
Postural Drainage  Administer postural drainage  This is drainage by gravity of secretions from various lung segments  Scheduled 2-3 times daily before meals and at bedtime  Before the procedure, patient may be given a bronchodilator medication or nebulization therapy to loosen the secretions  Sequence: positioning, percussion, vibration, and removal of secretions by coughing or suction. Positions are assumed for 10-15 minutes depending on patient’s tolerance  Position for draining middle to lower lung field: head is lower than a chest; patient may be placed in Trendelenburg position  Position for draining upper lung field: sitting position at about 45 degrees  Postural drainage should not be performed on pregnant women; on those with rib or chest injuries; on those with dizziness, fainting, head or neck injuries; on those with pulmonary embolism or abdominal surgery
Postural Drainage Postural Drainage Postural Drainage
Middle and Lower Portions
Postural Drainage •Upper portions of lungs •Sitting position at about a 45 angle Sitting position at about 45 degrees
Postural Drainage When you are in the proper postural drainage position, change your position while following this sequence: 1. Turn side to side 2. Lay on stomach Remain in each position approximately five to 3. Lay on back ten minutes. Use suction or assisted cough before changing position.
Postural Drainage Nursing Management Should not be performed in: Pregnant women Patients with rib or chest injuries Patients with dizziness, fainting, head or neck injuries Patients with pulmonary embolism or abdominal surgery  Increase oral fluid intake to liquefy secretions  Reinforce coughing and deep breathing exercises
Constipation  Constipation is due to stasis of fecal material in the rectum and sympathetic nervous system activity  May present as ribbon-like diarrhea and fecal smearing  Nursing Measures:  Promote ambulation early  encourage high fiber, high fluid diet  Ensure privacy with the use of bedpan or commode  Administer stool softeners as necessary
Urinary Stasis  Immobility leads to inability to completely empty the bladder  Leads to urinary tract infection and renal calculi formation  Nursing Measures:  Have patient void in normal position, if possible  Low calcium diet, increase fluid intake and increase acid ash residue
Sensory Input Depression Changes • Encourage self care that starts • This may lead to confusion and with simple gross activities then disorientation advancing to complex, fine motor movements • Orient patient frequently and • Support patient with positive place clock/ calendar within sight feedback for his efforts and accomplishments • Schedule OT and allow visitors as appropriate
ASSISTIVE DEVICES  Crutches  Height of crutch – measure two to three fingers or 2.5 -5 cm below the axilla  Patient should support weight on the handpiece and not at the axilla: to prevent brachial plexus palsy  Tripod stance: proper standing position with crutches; crutches are placed about 15 cm (6 inches) infront of the feet and out laterally, about 15 cm, creating a wide base  Elbows should be flexed at 20 -30 degrees angle for correct placement of hand grips
Crutch Walking Gaits
Using Crutches: Sitting and Standing  To sit on a chair  Stand with the back of the unaffected leg centered against the chair.  Transfer the crutches to the hand on the affected side and hold the crutches by the hand bars.  The client grasps the arm of the chair with the hand on the unaffected side to support himself.  Lean forward. Flex the hips and knees, and lower into the chair.
 stand up from a chair  Hold the hand grips of both crutches in one hand.  Push off from the chair with the other hand.  Stand and check your balance.
Crutch walking Gaits Note: To go up stairs, advance good leg first followed by crutches and affected leg. To go down stairs, advance crutches with affected leg first, followed by good leg. “Up with the good, down with the bad” “Up bad”
Cane
Cane  Types: straight cane and quad cane  Tips should have concentric rings as shock absorber and to provide optimal stability  Flex elbow 20-30 degrees angle and hold handle  Tip of cane should be 15 cm lateral to the base of the fifth toe  Procedure:  Hold cane on the good side  Advance cane and affected leg  Lean on cane when moving good leg  When going up the stairs, follow “up with the good, down with the bad”
Walker  Lift and move walker forward 8-10 inches  With partial or non-weight bearing, put weight on wrists and arms and step forward with affected leg, supporting self on arms, and follow with good leg  Nurse should stand behind patient, hold onto gait belt at waist as needed for balance
Mobility and Immobility