Nursing Care Plan Chapter 27 PDF

Many conditions, such as strokes, fractures, surgery, and neuromuscular disorders, require bed rest for the patient to heal and recover. These periods of bed rest may result in immobilization (prevention or restriction of normal body movement) of the patient. Problems caused by immobilization includ...

Many conditions, such as strokes, fractures, surgery, and neuromuscular disorders, require bed rest for the patient to heal and recover. These periods of bed rest may result in immobilization (prevention or restriction of normal body movement) of the patient. Problems caused by immobilization include pressure injuries, pneumonia, loss of bone mass, and permanent loss of function in the immobilized part. Many supportive or corrective measures necessary for treatment, such as traction (exertion of a pulling force), casts, or braces, also restrict mobility and may cause the same types of problems (Fig. 39.1). Good nursing care is critical in preventing complications for immobilized patients. Systemic Effect of Immobilization Decrease in muscle strength and coordination, generalized weakness, stiff joints, constipation, and abdominal distention begin within a few days of immobility. Table 39.1 presents the more severe problems that may occur when lack of activity occurs for a longer period. Pressure injuries are a frequent consequence of immobility and are presented in Chapter 19. One of the major concerns when a patient's movement is restricted is the development of respiratory complications. Physical activity causes people to breathe more deeply, expanding their lungs and encouraging clearing of secretions. Without adequate physical activity, these secretions can collect in the lower airways, leading to congestion and ultimately to respiratory illness, particularly hypostatic pneumonia (pneumonia caused by stasis of secretions due to inactivity) or hospital-acquired pneumonia. Range-of-motion (ROM) exercises (Chapter 18), frequent turning, and use of deep breathing exercises can help prevent pneumonia and increase general oxygenation. Patients experiencing pain may be reluctant to move and breathe deeply; therefore pain control is essential. However, medications used to control pain may cause sleepiness and further reduce the patient's desire to move about. Opioid analgesics, such as codeine, may depress respirations and further inhibit respiratory clearing (Chapter 31). Measures to promote respiratory function must be included in the plan of care for the immobile patient. Circulation is also affected by immobilization. Normal movement assists in venous return by compression of the muscles against the venous walls when the muscles are in motion. Healthy, firm muscles provide general support for the venous walls. This is important throughout the body but especially in the legs, where the force of blood flow is reduced because of the distance from the heart. Various conditions (such as a fracture, trauma, or debilitating illness) and treatments (such as casts, traction, or bed rest) can impair circulation and predispose the patient to pressure injury and permanent loss of function. For these reasons, you must monitor the general circulatory status of the patient and blood flow to the affected body areas on a regular basis. Increasing fluids to at least 3000 mL/day, encouraging adequate nutritional intake, and increasing dietary fiber help prevent gastrointestinal system complications. The fluid increase also helps prevent urinary complications. Stool softeners and laxatives are ordered as needed for constipation. Lifespan Considerations Older Adult Advanced age compromises the respiratory and circulatory systems, which can lead to even greater risk for complications from immobility. Inactivity tends to cause anorexia. Interventions for adequate nutritional care should be added to the plan of care for the immobile older adult. Frequent small feedings and bedtime nourishments may be needed. Having their favorite foods brought in by family and friends also can be helpful. Performing active or passive ROM exercises to maintain joint mobility and muscle integrity is the standard of practice for bed rest care. Encouraging active movement of the unaffected extremities throughout the day assists in maintaining muscle tone. When the patient is on extended periods of bed rest, isometric exercises (exercises performed against resistance) may be beneficial. Turning the patient every 2 hours, keeping the skin clean and dry, providing smooth and clean linens, and using pressure relief devices help prevent pressure injuries. Perform a skin assessment at least every 8 hours and more frequently for the patient at high risk for skin breakdown. Table 39.1 Effects and Problems of Immobility Body Part or System Effect of Immobility Problem or Complication Cardiovascular system Venous stasis Increased cardiac workload Blood pressure alterations Thrombus formation Thrombophlebitis Pulmonary embolus Orthostatic hypotension Increased pulse rate Respiratory system Stasis of secretions Decreased elastic recoil Decreased vital capacity Hypostatic pneumonia Bacterial pneumonia Atelectasis Decreased gas exchange Gastrointestinal tract Anorexia Metabolic change to catabolism and negative nitrogen balance Decreased peristalsis Weight loss Protein deficiency Abdominal distention Constipation Musculoskeletal system Decreased muscle mass and muscle tension Shortening of muscle Loss of calcium from bone matrix Decrease in bone weight Fibrosis of connective tissue Atrophy Weakness Joint contracture Osteoporosis Bone pain Urinary system Stasis of urine Urinary tract infection Kidney stones Precipitation of calcium salts Urinary frequency Dysuria Skin Decreased circulation from pressure Ischemia and necrosis of tissue Skin breakdown Pressure injuries Brain/psychological Decreased mental activity Decreased sensory input Decreased socialization Decreased independence Disorientation Confusion Boredom Anxiety Depression Loneliness QSEN Considerations: Teamwork and Collaboration Teamwork Value The Perspectives and Expertise of All Health Team Members The systemic effects of immobility can be managed by using multiple health care team members. Respiratory therapists; physical therapists; unlicensed assistive personnel; wound, ostomy, and continence nurses (WOCNs); and dietary personnel are all vital members of the patient's health care team. Psychosocial Effects of Immobilization Immobilized patients may experience a variety of emotional responses. For example, they may be afraid that they will not be able to return to work and support themselves and those who depend on them. They may fear abandonment by those they love if they cannot function as they did before. Patients who are facing permanent loss, or their significant others, may need professional counseling or support groups. Provide support, use therapeutic techniques of communication that focus on listening, and allow the patient to verbalize concerns. When signs of fear and stress are observed, take time to listen and refer these patients to social services as appropriate. QSEN Considerations: Teamwork and Collaboration Collaborative Care Appreciate the Importance of Intra-Professional and Interprofessional Collaboration Patients with prolonged immobility or permanent loss may need professional help in dealing with depression. Collaborate with appropriate health care providers to address the psychosocial effects of immobilization and your patient's emotional needs. Another frequent problem for the alert immobile patient is boredom. Not all patients like television or enjoy reading, and even those who do will become bored with nothing else to do. Chat with patients about things that interest them while providing care. Some patients may want a diversion through using a laptop, tablet, or smartphone or may want to do something creative, such as crocheting or crafts. Encourage family and friends to space visits so that the patient avoids long periods of loneliness. Family members can also help by contacting friends and relatives and asking them to send notes and cards on a regular basis. Cards, texts, phone calls, emails, and personal visits increase the patient's sense of value to others and feelings of self-worth. Positive feelings are known to play an important role in the healing process. For the immobile patient being cared for at home, it may be helpful to move the bed into the living room or family room to reduce social isolation. This also may save many steps for those providing care, especially if bedrooms are on separate floors. Visits by home health aides and friends or respite caregivers can provide a chance for the caregiver to get out of the house and do errands or spend some time at leisure. Remember that the nonalert or comatose patient also needs emotional support. Always assume that patients can hear and understand, even when they cannot respond or when they respond inappropriately. Talk to the patient in a kind and caring voice. Explain what is being done before and during procedures and apologize for any unavoidable pain the care may be causing. Talk to the patient about what is going on in the world. If cards or letters arrive, read them to the patient. Patients who have recovered from unconscious states have been known to describe in great detail things that happened while they were unconscious and have expressed thanks to those staff members who continued to treat them as valuable human beings. Lifespan Considerations Older Adult Following a stroke, hip fracture, or other condition that causes immobility, older adults may worry about becoming a burden to their families. This feeling may be so strong that they feel as if it would be better if they died, and they become depressed. Encouragement and praise from the staff, kindness and patience when they attempt self-care or learn a new task, frequent family visits, and expressions of hope for recovery can help reestablish their sense of self-worth. Consultation with social services may lead to solutions for financial concerns. Types of Immobilization Splints A splint is a device that protects an injured body part by immobilizing or limiting its movement. A splint may be used as a first aid measure before a cast or traction is applied to an injured part, or it may be used instead of a cast. Box 39.1 presents the guidelines for applying a splint. Several types of commercial splints are available: molded splints, immobilizers, inflatable splints, cervical collars, and traction splints (Fig. 39.2). First aid splints are fashioned from materials at hand and require only some rigid material, padding, and something to secure the splint in place. Inflatable splints help control bleeding, as well as immobilize the injured part. The splint should be inflated until fingertips can indent the device only 1½ inches (3.8 cm). Immobilizers are made of cloth and foam with Velcro straps. They are often used on an injured knee to prevent movement while an injury heals or during activity to prevent further injury. Molded splints keep the body part in a functional position to prevent contracture and maintain functional ability. These are used for chronic disorders. Traction splints are applied and hooked to traction ropes, pulleys, and weights to maintain pull on a fracture. Box 39.1 Applying a First Aid Splint to an Extremity When a serious injury or fracture occurs in the home or outdoor setting, it is advisable to render first aid by splinting the injured part. To apply a splint to an extremity: Handle the injured part gently and do not change its position in any way. This decreases the chance of nerve injury and further bleeding. Cover any open wounds with material as clean as can be found to help prevent infection. Use a rigid splinting material to immobilize the injured part. Flat boards, broom handles, rolled up newspaper, or similar materials are appropriate. The splint should be long enough to span the joint above and below the injury. Pad bony prominences with soft material to prevent pressure wounds. Secure the splint with wide bands of material to stabilize the injured limb within the splint. Elevate the injured part to decrease edema and swelling. Check circulation distal to the injury and loosen the splint ties if tissue becomes pale, cold, or blue. Keep the person warm and seek transport to a medical facility. Traction Traction is the application of a pulling force, and it is used to maintain parts of the body in extension and alignment. It is used to realign bone ends following fracture and to relieve pain and nerve impairment caused by compression or muscle spasm. There are three types of traction: manual, skin, and skeletal. The amount of traction is determined by the pull exerted by weights at the end of the traction ropes. The amount of weight must be ordered by the primary care provider and often changes over the course of treatment. Initially the muscles tend to be tight and may go into spasm. A heavier weight is required to overcome the muscular pull and allow the body to resume a normal alignment. As time goes on, the muscles tire and relax; the amount of weight is then reduced. The care provider will leave orders concerning if and how much the head of the bed may be raised. The head of the bed should be no higher than 20 degrees (unless ordered) to keep the patient from sliding down in bed and to keep the weights hanging free. A slight Trendelenburg position may be ordered to keep the patient from slipping down in the bed. Tape a sign to the head of the bed indicating any restrictions related to bed positioning. The weights should swing freely without touching the bed or floor. The ropes must move freely through the pulleys to prevent injury to the patient and alteration in the effects of the traction. Principles to be followed for traction are listed in Table 39.2. Table 39.2 Principles of Traction With Nursing Interventions Principle Nursing Intervention Ropes and weights must be free of friction. Keep ropes free of entanglement in the linens. Maintain the correct line of pull. Keep the patient centered in the bed with the body in good alignment. Weight and pull of the traction must be continuous and as ordered by the primary care provider. Remove or add weights only by medical order. Do not interrupt the pull of traction to provide care. Sufficient countertraction must be maintained. Keep the patient from sliding down in the bed when in leg or back traction. Keep the patient in sidearm traction in the center of the bed. The patient in traction should have an over-the-bed frame (rectangular frame to which traction equipment may be attached) with a trapeze bar (overhead bar that patient can grab) attached to the bed (see Fig. 18.9A). The trapeze bar can be grasped by the patient to assist in repositioning. Teach the patient how to tell when body alignment is correct in the bed so that as they become more active, they can place their body in correct alignment to maintain the traction. Manual Traction In this form of treatment, the hands are used to aid in the realignment of fractured bones. This method should be used only on stable, clean fractures or dislocations. It is typically performed by the physician prior to placing the affected extremity into a splint or cast. Skin Traction In patients with hip fractures, recent studies have shown that skin traction has the same effect on pain relief as placing a pillow under the affected extremity. However, skin traction does offer short-term pain relief from muscle spasms due to muscles and tendons pulling the extremity into a shortened position. QSEN Considerations: Evidence-Based Practice Decreased Use of Skin Traction Nurses must differentiate clinical opinion from research and evidence summaries. Recent studies of patients with hip fractures showed that those who used position splints experienced less pain; fewer complications, such as skin damage, pressure injuries, and plaster allergies; and increased satisfaction with treatment and care compared to those who used skin traction (Tosun, Aslan, & Tunay, 2018). In skin traction a Velcro boot (Buck traction), belt, halter, or sling (bandage for supporting a part) is applied snugly to the skin, and the traction is attached to the appliance (Fig. 39.3). Skin traction has the advantage of being noninvasive, its main purpose being to decrease muscle spasm that accompanies fractures. Damage from skin traction includes blisters, rashes from irritation by adhesives, and skin tears and tissue injuries from the shearing effects of the lateral pull across the skin surface. The amount of weight that can be applied is limited to a maximum of 10 to 15 pounds. Skin traction should not be used if the fracture requires 15 pounds (6.7 kg) or more of tractive weight. Skin traction is generally not used with older adults because of their fragile skin. Check the skin frequently for any indications of injury; report any problems or skin pain immediately to the primary care provider or traction technician. Safety Alert Safety With Immobilization Whenever a patient is in an immobilization device, be sure to check for adequacy of circulation in the affected extremity by assessing skin temperature and color, capillary refill when appropriate, and sensation. Skeletal Traction Although external fixation is used more frequently for fractures today, skeletal traction is occasionally used for some injuries. Skeletal traction requires the surgical placement of pins, tongs, screws, or wires that are anchored to or through the bone and therefore pierce the skin. Traction is thus applied directly to the bone, which can support more weight than the skin. As much as 30 pounds (14 kg) of tractive force can be used for this type of traction. An orthopedic technician may set up traction. The licensed practical nurse/licensed vocational nurse (LPN/LVN) is responsible for maintaining the correct weight and alignment of the traction and for maintaining a balance between traction pull and countertraction force (the weight pulling against the weight of the traction). Countertraction is provided by the weight of the patient and the position of the bed. Skin care around the openings for the pins, tongs, or wires is performed according to the medical order. Sterile technique is used when performing pin care (Box 39.2). After the sites are healed, they may be left open to the air. Clear fluid drainage is expected initially. Follow the medical order and the policies of the facility, and report immediately any indication of infection at the wound or pin sites. Circulation checks are performed every hour for the first 24 hours and every 4 hours thereafter. Always follow the primary care provider's orders for cleansing or antiseptic solution and use or nonuse of antimicrobial ointment. Using sterile swabs, cleanse closest to the pin in a circular motion. Use one swab for each circle. Work your way out in succeeding circles until 1½ inch from the pin. Apply antimicrobial ointment with a sterile swab, if ordered. Dress with sterile gauze, if ordered. Secure ends of wires with cork. Monitor for infection, assessing for increased pain, redness, edema, tenderness, or purulent drainage. Think Critically What interventions would you use to prevent skin breakdown on the back and buttocks of the patient in traction? Casts Patients may be placed directly into a cast (a stiff plaster of Paris, fiberglass, or polyester dressing used to immobilize) following a fracture or a variety of orthopedic procedures, or a cast may be applied after a period in traction. The skin is cleansed and inspected; any wounds are treated before a cast is applied. A layer of stockinette is applied first, followed by a thin layer of cotton or synthetic padding and then the cast material. Most casts are made of fiberglass, polyester resin, or thermoplastic material. Plaster of Paris casts are often applied to a lower extremity because they will withstand weight-bearing better than the synthetics. Heat may be felt as the casting material is applied, especially with plaster of Paris. Plaster casts can take from a few hours to a couple of days to dry and be fully hardened. Casts made of synthetic material dry rather quickly (7 to 20 minutes) and may be hardened enough to be durable within 30 minutes. It is critical to protect the cast from uneven pressure during the drying period because the shape or position can be inadvertently changed. When handling the cast during the drying period, use the palm and flat parts of the fingers rather than the fingertips. Dents in the cast can lead to circulatory impairment and pressure injuries, and changes in alignment can alter the position of the healing parts or impede circulation. Swelling of the tissues is common during the first days after a cast is applied, and if left uncontrolled, this can impair the circulation and cause a pressure injury. A casted extremity should be elevated on pillows. If not padded sufficiently, the edges of the cast may rub or push against bony areas, causing pain and injury. The stockinette may be folded over the outside cast edge and taped to protect from chafing, or the cast edge may be "petaled" with waterproof tape. Changing position may relieve discomfort; adding extra padding beneath the edge of the cast may help. If the cast becomes too tight, it may be bivalved (cut in half lengthwise) to relieve the pressure on the tissues. If there is a wound under the cast that needs observation, a window may be cut in the cast over the wound area. When edema has decreased, the cast is secured with outside bandaging or by more casting material. Sometimes after edema subsides, the cast is too loose and must be replaced. Hip spica casts can be particularly challenging for both the patient and the caregiver. Hip spica casts encase a portion of the trunk and part or all of both legs (Fig. 39.4). A spreader bar is placed between the legs to maintain the desired angle at the hip and incorporated into the cast. Do not use the spreader bar as a handle for lifting and turning the patient. It may be dislodged, ruining the cast and causing pain and possible injury to the patient. Grasp the cast over the leg to assist in turning. Because of their size and thickness, hip spica casts often take longer to dry. Frequent turning is necessary, including prone positioning to ensure complete and uniform drying. Clinical Cues A hair dryer set on low may be used to assist in drying the plaster of Paris cast. Just be sure to uniformly dry all areas of the cast and lightly touch the cast frequently to make certain that it is not becoming so hot that it will burn the patient's skin. Toileting can be difficult for the patient with a hip spica cast. Ingenuity is needed to protect the cast from soiling. Using disposable plastic wrap around the perineal opening is one method of protection. Maintaining skin integrity of an incontinent patient in a spica cast is a great challenge for the orthopedic nurse. Most patients can go home soon after cast placement. If the cast is not yet dry before discharge, instruct the patient and family or caregiver in the proper care of the cast to ensure uniform drying. When elevating a wet cast with pillows, use cloth-covered pillows because plastic-covered pillows hamper drying. Show the patient and family how to check the cast edges for rough spots or crumbling, how to use pillows to elevate the extremity and prevent swelling, and how to pad the rough edges using tape or moleskin (thick, durable form of adhesive material). Assess cast condition every 8 hours, checking for cracks, crumbling, or rough edges. A damaged cast may need to be replaced. Safety Alert Precautions When the Patient Has a Cast Caution patients not to place a foreign object under the cast (e.g., wire hanger or stick to scratch an itch). Blowing cool air under the cast with a can of electronic air cleaner may help decrease itching. Discomfort sometimes can be relieved by directing the air of a hair dryer set on "cool" into the cast. Cast Comfort spray is a commercial product that delivers a soothing layer of talc under the cast. A major concern for patients with casts is bathing. Plaster casts must be kept dry, or they can disintegrate. Even fiberglass casts are a problem if they become thoroughly wet. The outside material tolerates water, but the padding inside tends to stay wet, causing irritation to the skin. Small casts, such as those that immobilize the forearm or lower leg, often can be covered with a large plastic bag taped in place to allow the patient to shower. However, larger casts usually require that the patient take sponge baths until the cast is removed. When a child is sent home with a cast, it is important to stress the dangers of placing small items inside the cast. These can cause pressure necrosis and infection. Casts are removed using an oscillating saw. The saw is noisy and may frighten the patient. The saw does not cut down to the skin, and the patient needs reassurance about this. After separating the cast material, scissors are used to cut through the stockinette and padding, and the cast is removed. Clinical Cues Prior to cast removal, inform the patient that the skin underneath will be dry and dirty in appearance, with an unpleasant odor. Washing with warm soapy water, rinsing, and applying cream or lotion removes dead skin cells and helps the skin return to normal. Applying vitamin E or other recommended ointment over the healed incisions also may improve appearance. External Fixators An external fixator is a metal device, such as a pin, screw, or tong that is inserted into or through one or more bones to stabilize fragments of a fracture while it heals (Fig. 39.5). The metal inserts are attached to a metal frame. This type of immobilization allows the patient to be more active during healing while maintaining immobilization of the fractured area. The pins, screws, or tongs and the frame should be checked for stability every 4 hours. The insertion of the metal device through the skin provides a break in skin integrity that requires regular pin care to prevent infection, which is a common complication of external fixators (see Box 39.2). Pin care is included in Skill 39.2 later in this chapter. Devices Used to Prevent Problems of Immobility Specialty Beds On occasion, illness or injury may result in long-term or permanent immobility. The potential complications from permanent immobility can worsen a patient's condition and may require additional interventions. Kinetic (moving) and air fluidized beds can be used to help decrease the incidence of these complications. Because their use is very expensive, thorough ongoing documentation of the need for this type of bed is essential. Air Fluidized Beds Air fluidized beds contain tiny silicone beads within the bed under a flexible, air permeable filter sheet (Fig. 39.6). Warmed air passes through the small particles, setting them into motion so that they act as a fluid that suspends the patient free from contact with any stationary, hard surface. The flotation or buoyancy of the patient on the air fluidized beads prevents pressure occlusion of blood vessels and shearing of tissues against the mattress during movement, unlike conventional mattresses. The loose filter sheet reduces friction, and the warm air protects the skin from damage by wetness. Air fluidized therapy is effective in the prevention of pressure injury and helps reduce generalized body pain common among bedridden patients. The indications for use include those patients with full thickness or multiple pressure injuries, fresh grafts, or flap repairs of injuries and immobile patients whose general condition puts them at high risk for skin breakdown. Air fluidized therapy is not recommended for patients with unstable spines or ambulatory patients. To maximize the beneficial effects of the therapy, the unit should be in the fluidized mode at all times. Exceptions would be during patient transfer in and out of the bed or during nursing procedures for which the patient needs to be in one stable position for the intervention. Low Air Loss Beds Low air loss support is achieved by distributing air through multiple cushions connected in a series. The cushions are calibrated to provide maximum pressure relief for the individual patient. Shear and friction are reduced or eliminated because the cushions "give" with the patient during movement or rest. A low airflow through the cushion controls moisture on the skin. Segments of cushions may be deflated for patient care. The head of the bed can be raised. This bed is contraindicated for the patient with an unstable spine. Continuous Lateral Rotation Beds Lateral rotation therapy beds, such as the RotoRest bed, are believed to decrease the incidence of lung collapse and hospital-acquired pneumonia, facilitate normal urine flow, and reduce the risk for deep vein thrombosis and pulmonary embolism by encouraging venous flow. This intervention may have a significant positive effect on various body systems of the critically ill patient and improve the overall patient outcome. Skin breakdown is reduced by the pressure reduction foam and gel pack surface. The patient is secured in position on the bed by multiple cushion wedges (Fig. 39.7). The bed turns in an arc up to 80 degrees and can be set to pause on either side for up to 30 minutes. The rotation is stopped and the wedge cushions removed as needed for bathing, procedures, or toileting. There is a built-in scale to allow patient weighing. FIG. 39.6 Clinitron Elexis air fluidized therapy unit.  Copyright 2011 Hill-Rom Service, Inc., reprinted with permission. All rights reserved. The degree and rate of movement are programmed to meet the individual patient's requirements. The constant side-to-side movement prevents the accumulation of respiratory secretions and promotes respiratory clearing. Other lateral rotation beds are combined with low air loss technology to provide relief of tissue pressure. Think Critically What types of problems, if any, do you think you might encounter when caring for a patient in a kinetic or air fluidized bed? Pressure Relief Devices There are a variety of accessories that aid in the reduction of skin trauma from pressure for patients in standard hospital beds. These include foam and gel pads, sheepskin pads, and heel and elbow protectors. Pulsating air pads and water mattresses lie on top of the regular mattress, providing additional pressure relief (Figs. 39.8 and 39.9). FIG. 39.7 RotoRest Delta kinetic therapy bed.  RotoRest Delta Advanced Kinetic Therapy System, Courtesy KCI Licensing, Inc. FIG. 39.8 Alternating air mattress pad.  Courtesy Medline Industries Inc., Mundelein, IL. FIG. 39.9 Heel protector helps prevent skin breakdown.  Copyright AliMed. Continuous Passive Motion Machine After orthopedic surgery to replace a joint, continuous passive motion (CPM) is often ordered to restore joint function. A purpose of the machine is to exercise the extremity and joint, thus preventing contracture, muscle atrophy, venous stasis, and thrombus formation. The dressing to the extremity must be intact before attaching the patient's extremity to the device. Once in place, the CPM machine extends and flexes the extremity to prescribed angles for a specific period. The machine operates continuously for as long as it is switched on. Follow Steps 39.1 to initiate therapy. As the degree of joint motion is tolerated, the settings are altered to increase the mobility of the joint (Fig. 39.10). Clinical Cues Assess pain level and medicate with ordered analgesia before initiating treatment with this machine. Closely monitor for need for more analgesia throughout exercise. The use of the machine is initially quite painful. Pain is controlled best when it is treated before it becomes severe. Therapeutic Exercise Physical therapy is often ordered for the patient who is immobilized for an extended period. The primary care provider indicates what the problems are for the patient, and the therapist performs an evaluation and then designs an exercise program to help the patient and to prevent further musculoskeletal problems from occurring. Full ROM exercises should be performed either actively or passively several times a day (Chapter 18). To prevent joint injury while performing passive ROM exercises, support the limb to be exercised above and below the joint. When the physical therapist is not available, the nurse assists the patient to perform these exercises. A family member or significant other can also be shown how to assist the patient with exercise. Application of the Nursing Process/Clinical Judgment Model Assessment (Data Collection) Recognize Cues: When performing head-to-toe assessment of the immobilized patient, be alert to indicators of circulatory impairment such as reddened areas, pale or blue skin, coldness, or diminished or absent pulses. Look for signs of respiratory impairment such as shallow breathing, rapid or depressed respiratory rate, cough, abnormal lung sounds, use of accessory muscles, retractions or grunting, generalized paleness, duskiness, or cyanosis. In addition to regular assessment, you should determine which activities of daily living (ADLs) the immobilized patient can perform and which ones require assistance. Incorporate any assistance needs into the nursing care plan. Continually assess for pain and discomfort. Perform a neurovascular assessment for any patient with a cast or traction device (Box 39.3). Assess for cultural beliefs and customs that should be considered in planning care. When the patient is in traction, assess the pulleys and ropes for proper function and free movement. Ensure that the weights are hanging free and the correct amount of weight is applied. Assess the pin, the wire, or the tong insertion sites for indications of infection. For the patient in a cast, observe and document any foul or musty odor from the cast. Other indicators of infection are an elevated temperature, purulent drainage, and/or an elevated white blood cell (WBC) count or increased complaints of pain. Check all assistive devices and equipment for structural problems prior to use. Assess the assistive device for correct length or height in relation to the patient's height and posture. Evaluate the patient's ability to use the device correctly and determine whether the device provides adequate stability for your patient's safety. Check the foot of the crutch or cane for an intact rubber tip or the walker for properly functioning wheels if they are present (Fig. 39.11). Steps 39.1 Use of a Continuous Passive Motion Machine The most common use of a continuous passive motion (CPM) machine is for the knee following knee replacement surgery. The nurse is responsible for making certain that the machine is attached properly and that the settings are what the surgeon ordered. Review and carry out the Standard Steps in Appendix A. Action (Rationale) 1\. Check the surgeon's order for flexion and extension limits, speed, duration, and extremity involved. (Provides data for setting up machine.) 2\. Place machine on the bed on the affected side. Place directly on sheet-covered mattress. (Provides a stable surface. No extra mattress pad should be under the machine.) 3\. Connect the control box to the CPM machine and set the limits of flexion, extension, and speed control. (Prepares machine for function.) 4\. Let machine run through one complete cycle, then stop the machine at the end of extension. (Ensures that the CPM machine is working properly.) 5\. Ensure that dressing to wound or incision is intact before attaching extremity to machine. Center the extremity on machine with sheepskin beneath the extremity and adjust the machine to fit the patient. Align patient's joint with the machine joint and strap the extremity in place. (Prepares machine to work on the joint properly. Avoids pressure on the extremity and protects skin. Intact dressing prevents rubbing directly against wound or incision.) 6\. Start the machine. When it reaches full flexion, stop the machine and check the degree of flexion. (Ensures that machine is not flexing the joint more than desired, preventing complications.) 7\. Set the cycle rate, start the machine, and observe for two full cycles. (Ensures that machine is functioning correctly. Cycle rate is usually between 2 and 10 cycles per minute.) 8\. Raise side rail at the foot of the bed to keep CPM machine in place. Keep bed flat with head raised only 20 degrees if necessary. (Ensures that machine can function as ordered and patient's body will remain in alignment.) 9\. Assess patient's comfort level. (CPM therapy initially may be painful. Patient should be medicated regularly as ordered for pain. Good pain control allows patient to tolerate increases in speed and flexion.) 10\. Assess the operative site for bleeding and evaluate alignment of extremity and placement of straps every 2 to 4 hours. (Prevents complications and promotes patient's adherence with therapy.) 11\. Assess skin condition over bony prominences and provide skin care every 2 hours. (Helps prevent pressure injuries from occurring.) FIG. 39.10 Continuous passive motion machine for the knee joint.  From DeWit, S. C. \[2017\]. Medical-surgical nursing \[3rd ed.\]. St. Louis, MO: Mosby. Data Analysis/Problem Identification Analyze Cues and Prioritize Hypotheses: Common problem statements for patients with immobility are as follows: Altered mobility related to hemiparesis or hemiplegia (one-sided weakness or one-sided paralysis, respectively) Altered mobility related to fractured extremity in traction or a cast Box 39.3 Neurovascular Assessment Neurovascular assessment is performed for every patient who has experienced a fracture, whether treated with a cast or traction. It should be performed every hour for the first 24 hours, then after the cast is dry, every 4 to 8 hours. Check agency protocol for specific time schedule. This is easily remembered by using the 5 Ps: Pain: Inquire about the degree, location, nature, and frequency of pain, noting any increase in intensity or change in type of pain. Pallor: Inspect the skin distal to the injury, noting color. Compare to other extremity. Palpate skin temperature with dorsum (back) of the hand; compare with opposite extremity or site. Check the capillary refill of the affected extremity. Normal capillary refill is less than or equal to 3 seconds, or within 5 seconds in the older adult. Paralysis: Have patient move the area distal to the injury or move it passively. There should be no discomfort. Parasthesia: Inquire about feelings of numbness or tingling (paresthesia). Check sensation with a paper clip and compare bilaterally. Sensation should be the same. Pulselessness: Palpate pulses distal to the injury. Compare bilaterally if possible. FIG. 39.11 Assess the gait of the patient learning to use a walker. Altered peripheral tissue perfusion (circulation of blood through tissue) related to decreased circulation in the lower extremities Altered skin integrity related to skin disruption Acute pain related to tissue or bone injury or muscle spasm Alteration in airway clearance related to inactivity and bed rest Potential for disuse syndrome Potential for impaired neurologic function related to fracture and cast application Problem statements related to the psychosocial needs of the immobile person are as follows: Potential for social isolation related to immobility Altered body image related to brace or cast Boredom related to immobility and bed rest Decreased self-esteem related to inability to perform usual roles Planning Generate Solutions: Planning care for the immobile patient requires careful consideration of the time needed to assist the patient with various aspects of ADLs, the time needed for treatments, and the time to be spent providing diversional activity and socialization. Expected outcomes for some of the above problem statements might be that the patient will: Demonstrate the ability to cope with physical mobility limitations as evidenced by resumption of as many self-care activities as possible within 10 days. Remain free of pressure-related injuries. Have pain controlled with medication and alternative techniques. Maintain good respiratory status as evidenced by effective airway clearing and clear breath sounds bilaterally. Not experience contracture or muscle atrophy from immobilization. Show no evidence of peripheral neurologic impairment from swelling and/or cast application. Maintain regular contact with significant others, participating in available activities. Maintain interest in events occurring in the outside world. Maintain self-esteem by positive self-statements and voluntary participation in self-care and attention to grooming. Implementation Take Action: Appropriate interventions related to the identified problem statements include regular turning and positioning, use of pressure relief devices, coughing and deep breathing exercises, ROM exercises, assisted ambulation, and visitation or activities addressing the psychosocial needs of the immobile patient. Nursing Care Plan 39.1 presents interventions for a specific patient. When caring for a patient in a fresh plaster cast, elevate the cast on pillows if possible. Performing this action places a soft, yielding surface against the plaster that is less likely to alter the shape of the cast. Elevating the extremity reduces the likelihood of swelling. Turn the patient hourly so that the cast rests on a different area of its surface and will dry evenly. Skill 39.1 presents the points of care for the patient with a cast. For the patient going home with a cast in place, review cast care and assessment of problems with the patient and caregiver. Patient Education Fracture and Cast Care To promote healing of your fracture and care for your cast: Keep the casted limb elevated above heart level whenever possible to prevent swelling. Call the primary care provider if your fingers or toes become numb, tingle, turn blue, or are cold to the touch. Call the primary care provider if you develop a fever, have unusual pain in the casted extremity, or notice a bad odor coming from the cast. These could be signs of infection. Regularly perform the exercises your care provider or physical therapist has taught you. These will help you retain your muscle strength while the bone heals. If the cast becomes loose or slides, call the primary care provider because it probably needs changing. Do not get a plaster cast wet. Check with your care provider about bathing or swimming if you have a synthetic cast. Do not insert any object inside the cast to relieve an itch. Doing so may damage the skin and result in an infection. Do not bear weight on the cast unless your primary care provider has advised you to do so. Care of the patient in traction is time consuming because the patient's mobility is severely limited. Skill 39.2 presents the points of care for the patient in traction. Nursing Care Plan 39.1 Care of the Patient Immobilized by a Stroke ADLs, Activities of daily living; bid, twice daily; IV, intravenous; PTT, partial thromboplastin time; q, every; ROM, range-of-motion; tid, three times daily. Scenario Millie Palmer, age 76, is admitted after suffering an apparent stroke. She has left sided hemiparesis and poor bladder control. She is confused and somewhat groggy. A computed tomography (CT) scan of the brain shows that the problem is from a thrombosis (clot), and she is being started on heparin to prevent further thrombi from forming. Problem Statement Altered mobility related to weakness of left extremities. Supporting Assessment Data Objective: Weakness of left arm and left leg; stroke. Goals/Expected Outcomes Nursing Interventions Selected Rationales Evaluation Patient will maintain muscle tone in all muscles. Repositioning q 2 hr. Repositioning prevents pressure ulcers and provides comfort for joints. Is muscle tone being maintained? Some tone to muscle. Patient will maintain joint mobility in all joints. Passive ROM to left extremities tid. Passive ROM will help maintain muscle function and joint mobility. ROM performed.. Active ROM to other joints bid. Encourage to perform ADLs as possible. Active ROM will preserve muscle tone and joint function. Actively moving other extremities and joints. Assess for muscle spasm each shift. Muscle spasm may occur with hemiparesis and can be painful. Progressing toward expected outcomes. Continue plan. Problem Statement Potential for altered skin integrity related to decreased mobility and incontinence. Supporting Assessment Data Objective: Left sided weakness, confusion; incontinent of urine. Goals/Expected Outcomes Nursing Interventions Selected Rationales Evaluation Skin will remain intact. Assess skin each shift and when turning, with special attention to pressure points. Frequent inspection of skin reveals reddened areas before pressure injuries form. Is skin intact? Skin remains intact; area of redness over right ankle; heel protector applied to protect ankle. Use cushioning devices under pressure points as needed. Cushioning reduces pressure over bony prominences. Offer bedpan q2h. Opportunity to void q2h helps prevent incontinence. Check absorbent undergarment frequently and change quickly when wet; clean and dry the skin. Reposition q2h. Moisture contributes to skin breakdown. Keeping skin clean and dry prevents breakdown. Repositioning prevents pressure injuries and provides comfort for joints. Meeting expected outcomes. Continue plan. Problem Statement Potential for impaired neurologic function related to cerebral thrombus. Supporting Assessment Data Objective: Cerebral thrombus visualized on CT scan. Goals/Expected Outcomes Nursing Interventions Selected Rationales Evaluation Neurologic deficits will not increase. Neurologic assessment and vital signs q2h. Assessment will reveal deteriorating condition in a timely fashion. Are there neurologic deficits? Left sided weakness present. Monitor heparin IV administration. Heparin IV will help prevent formation of further thrombi. No change in neurologic status. Monitor PTT for therapeutic response to heparin. PTT levels will demonstrate whether heparin dose is sufficient. Progressing toward outcomes. Continue plan. Problem Statement Incontinence related to stroke. Supporting Assessment Data Objective: Left sided weakness, confusion; incontinent of urine. Goals/Expected Outcomes Nursing Interventions Selected Rationales Evaluation Patient will regain continence. Institute bladder training program in 2 days. Bladder training regimen can reinstitute urinary continence in many stroke patients. Is patient continent? Not completely; some intermittent uncontrolled voiding. Offer bedpan q2h. Opportunity to void q2h helps prevent incontinence. Voids in bedpan after meals. Obtain order for bedside commode. With hemiparesis it is easier to transfer to the bedside commode than walk to the bathroom to void. Check absorbent undergarment frequently; change when wet. Progressing toward outcomes. Continue plan. Applying Clinical Judgment 1\. How might incontinence affect this patient psychologically? 2\. If Mrs. Palmer says that she is too tired to do the exercises and all she feels like doing is sleeping, how would you respond? Skill 39.1 Cast Care               Casts may be applied to almost any area of the body. The larger and thicker the cast, the longer it takes to dry fully. Hip spica and full body casts may take 1 to 2 days to dry completely. Synthetic material casts dry much more quickly than plaster casts. Supplies Tape or moleskin Pen for marking drainage Lamb's wool for padding Review and carry out the Standard Steps in Appendix A. Action (Rationale) Assessment (Data Collection) 1\. Examine cast for any dents. Handle the cast gently with the flats of the fingers and the palms, not the fingertips. (Dents may cause compression on underlying tissues. Fingertip pressure more easily dents the cast because pressure is on a small area rather than spread over a broader surface.) 2\. Examine cast for any areas where blood may have seeped through. Circle any such areas in ink and write the date and time on the cast. (Bloodstains seeping through the cast are a common occurrence when  surgery has preceded the application of a cast. Marking provides a way to judge further bleeding.) 3\. Assess cast for rough edges and excessive tightness by running a finger along all cast edges and under the edges next to the skin. Inspect the skin for pressure injuries at the cast edges and note areas of warmth, redness, or swelling. (A finger should slip easily under the edge of cast. Checking helps discover problem areas.) Planning 4\. Plan to reassess a new cast every hour for the first 24 hours and every 4 to 8 hours thereafter or per agency policy. (Swelling may occur in the period after injury or surgery and may cause pressure on nerves and vessels.) Implementation 5\. Pad any rough edges by petaling with 1½- to 2-inch pieces of tape or moleskin. Place lamb's wool beneath cast to pad under rough spots. (Rough spots will cause skin chafing, abrasion, and breakdown.) Step 5 6\. Notify the orthopedic technician or primary care provider if any area of cast is too tight. (Cast may need to be cut to relieve pressure.) 7\. Elevate the casted extremity so that the hand or foot is at or above heart level. (Aids in reducing or preventing swelling.) 8\. For patients in large casts (e.g., hip spica, body), place the bed in a slight Trendelenburg position for the first day or two to help prevent swelling, unless contraindicated by patient's condition or medical orders. (Patients in large casts may experience swelling in the legs, thighs, perineum, buttocks, and lower abdomen during the first few days. Placing bed at an approximate 10-degree angle in Trendelenburg position will help prevent this swelling.) 9\. Turn the patient at intervals so that all cast surfaces are exposed to the air to facilitate even drying and prevent skin pressure injuries. When cast is still wet, turn patient hourly. As cast dries, every 2 hours is sufficient unless patient is uncomfortable. Get adequate help when turning patient to prevent injury. Use pillows to prop the patient at different angles as cast dries. (Air exposure allows moisture to evaporate.) 10\. Instruct patient not to use sharp, pointed, or rigid items to scratch under the cast. (Skin under the cast often itches. Using such items to scratch can injure skin. If itching is severe, ask for an order for medication to control it.) 11\. Be alert to any odor at the edges of the cast to assess for infection under the cast. (Skin injuries may become infected or necrotic and cause a foul or musty odor.) Evaluation 12\. Evaluate the cast by inspecting for crumbling or cracks. Ask yourself: Is there any discomfort under the cast? Is the cast rubbing the skin anywhere? Are the edges smooth? Is the cast drying evenly? Is swelling in the tissues subsiding? Is any odor present? (Answers to these questions tell whether the interventions are successful in meeting the expected outcomes.) Documentation 13\. Document assessment findings and interventions. (Verifies that assessment has been performed and interventions carried out.) Documentation Example Received from recovery room alert and stable. Fresh plaster cast encases right leg from mid-thigh to mid-toes. Toes pink, warm, move well; sensation present; capillary refill less than 2 seconds. Edge of cast easily admits fingertip. Leg elevated on pillows. Rates pain as 3 out of 10. Advised to request pain medication if pain increases. (Nurse's electronic signature) Special Considerations Provide full instructions for cast care for the patient discharged home with a cast. Instruct to use a hair dryer only on the "cool" setting to help dry the cast or relieve itching. Demonstrate how to wrap a cast in plastic for showering, if appropriate. Demonstrate how to handle the extremity when repositioning, supporting the joints. Critical Thinking Questions 1\. What would you do if you notice that the edge of the cast is crumbling? 2\. What would you tell a patient with a long leg cast who keeps slipping a ruler inside the cast to scratch the skin? Skill 39.2 Care of the Patient in Traction               Skin traction is mostly used to decrease muscle spasms after a fracture or back muscle injury. Skin traction may be used on small children with a lower extremity fracture. Supplies Clean gloves (if needed) Review and carry out the Standard Steps in Appendix A. Action (Rationale) Assessment (Data Collection) 1\. Check the medical order for desired amount of weight for traction. (Ensures that the correct amount of weight is applied.) 2\. Assess boot, wrap, and traction appliance. Check that ropes and pulleys are working smoothly and weights are hanging free. (Surface of appliance should be smooth and free of wrinkles or gaps to prevent pressure injury to skin. Appliance should not be rubbing on any skin surface. Traction will not function properly if ropes are hung up in pulleys or weights are resting on floor or bed.) Step 2 3\. Assess the skin, distal circulation, and sensation. (Detects signs of complications.) Planning 4\. Plan times into work schedule to perform assessments, treatments, and activities of daily living (ADLs). (Care for the immobile patient in traction takes more time.) Implementation 5\. Realign the patient in the bed as needed to maintain optimal traction pull. (A direct straight line is needed for traction to be completely effective. Patients need to be pulled up in bed periodically.) Evaluation 6\. Evaluate for signs of complications. Ask yourself: Is there any sign of irritation where the patient's skin meets the apparatus? Does the patient have a fever? Does the patient complain of pain? Is traction apparatus functioning correctly? (Answers to these questions reveal whether interventions are successful.) Documentation 7\. Document interventions performed; note any abnormal assessments with actions taken. (Verifies performance of traction care, amount of weight applied, and assessment findings.) Documentation Example Slight irritation and erythema on medial aspect of left leg where traction boot meets skin, lateral aspect is clean and without signs or symptoms of infection. Cleansed both aspects of leg with normal saline and dried with 4 × 4 gauze; thin layer of lamb's wool padding inserted between medial aspect of left leg and traction boot. (Nurse's electronic signature) Special Considerations It is important to evaluate and medicate the patient in traction for pain, especially in the first few days when muscle spasm occurs. Teach family and significant others that they must not tamper with the traction device, ropes, or weights. A trapeze bar attached to the over-the-bed frame is very helpful so that the patient may assist in repositioning; it also provides opportunity for exercise of the upper extremities. Critical Thinking Questions 1\. What would you say to a nurse who is helping a patient move up in the bed if the nurse lifts the weights attached to the leg traction? 2\. What activities might be good for a patient who is confined to bed in traction to combat boredom? Box 39.4 Guidelines for Applying an Elastic or Roller Bandage Elevate the limb and support it while applying the bandage. Face the patient and wrap the bandage from the distal to the proximal area. Apply even pressure by exerting equal tension throughout the wrapping of the bandage. Overlap turns of the bandage equally. Smooth the bandage, removing wrinkles, as you wrap it. Secure the end of the bandage with self-adherent portion of the bandage, a safety pin, or tape. (Do not use metal clips, as they may come loose and land in the bed, causing injury to the patient.) Check the color and sensation of the part distal and proximal to the bandage when finished and at frequent intervals thereafter. Remove the bandage for bathing of the body part; assess the skin for irritation or breaks; rewrap the bandage at least twice a day. Bandages Used to Support, Apply Pressure, or Immobilize Elasticized bandages are applied to immobilize a joint or to apply pressure to reduce swelling. They also may be used to provide support to a wound and hold dressings in place. Elastic bandages are made in rolls of varying widths; the heavy stretch material conforms to the body part and provides support (Box 39.4). Steps 39.2 show the technique for application of an elastic bandage. The same technique is used for gauze roller bandages. Different bandaging techniques are applied depending on the part to be bandaged. Circular turn Circular turns are used to anchor the bandage and to terminate the wrap. This turn is useful for bandaging the proximal aspect of the finger or wrist. Simply hold the free end of the rolled material in one hand and wrap it about the area, bringing it back to the starting point (Fig. 39.12A). Spiral turn This turn is used to bandage parts of the body that are uniform in circumference, such as the upper arm or upper leg. The spiral turn partly overlaps the previous turn. The amount of overlap varies from one-half to three-fourths of the width of the bandage (see Fig. 39.12B). Spiral reverse turn Spiral reverse turns are used to bandage body parts that are not uniform in circumference, such as the lower leg or forearm. After securing the bandage with circular turns, bring the bandage upward at a 30-degree angle. Place the thumb of the free hand on the upper edge of the bandage to hold it in place while it is reversed on itself. Unroll the bandage approximately 6 inches (15 cm) and turn the hand so that the bandage falls over itself. Continue the bandage around the extremity, overlapping each previous turn by two-thirds the width of the bandage. Make each turn at the same position on the extremity so that the turns of the bandage are all aligned (see Fig. 39.12C). Take care not to apply undue pressure over a major blood vessel. Figure-of-eight turn Figure-of-eight turns are used to bandage and stabilize an elbow, knee, or ankle or to immobilize and hold a fractured clavicle in position. Anchor the bandage with two circular turns. Bring the bandage above the joint, around it, and then below it, making a figure-of-eight. Continue bandaging above and below the joint, overlapping the previous turn by one-third to two-thirds the width of the bandage (see Fig. 39.12D). Secure the bandage above the joint with two circular turns and fasten it. Steps 39.2 Applying an Elastic Bandage The type and size of the bandage used will depend on the area to be bandaged and the purpose of the bandage. The primary care provider may order a specific type of bandage. Review and carry out the Standard Steps in Appendix A. Action (Rationale) 1\. Wash and dry area to be bandaged. (Helps prevent infection by removing microorganisms.) 2\. Elevate extremity to be bandaged; ask an assistant to help if necessary. (Elevation encourages venous return and helps prevent swelling. It is easier to wrap the bandage properly if someone else supports extremity.) 3\. Stand in front of patient and unroll the end of the bandage slightly; anchor it in place with the thumb of the nondominant hand on the anterior part of extremity to be bandaged. (Secures bandage while wrapping is occurring.) 4\. Make two initial circular turns to anchor the bandage in place. (Securing the bandage end prevents it from becoming loose.) 5\. Use a circular, spiral, spiral reverse, figure-of-eight, recurrent turn, or thumb spica bandaging technique, as appropriate for the area to be bandaged. (The body part to be bandaged will indicate which style of bandaging is best.) 6\. Apply bandage smoothly and evenly with light to moderate tension. (Smoothness helps prevent pressure areas; adequate tension is necessary for bandage to stay in place.) 7\. Secure the end of the bandage with self-adherent portion of bandage, tape, or a safety pin. (Bandage must be secured to remain in place. Do not use metal clips, as they may come loose and land in the bed, causing injury to the patient.) 8\. Assess bandage for fit and circulation distal and proximal to area bandaged. (A bandage applied too tightly will impede circulation; a loose bandage will fall off.) Recurrent turn This turn is used to cover distal parts of the body, such as the end of a finger, the skull, or the stump left by amputation. Anchor the bandage by two circular turns. Then fold it back on itself and bring it centrally over the distal end to be covered. Hold it in place with the other hand; bring the bandage back over the end to the right of the center bandage but overlapping it by two-thirds the width of the bandage. Then bring the bandage back on the left side, overlapping the first turn by two-thirds the width of the bandage. Continue alternating bandaging right and left until the area is well covered. Terminate the bandage with two circular turns and secure the end appropriately (see Fig. 39.12E). Thumb spica This is a variation of the figure-of-eight bandage used to support the thumb in neutral position following a sprain or other injury. The technique also can be used to bandage the hip or shoulder. For the thumb, secure the bandage with two circular turns around the wrist. Bring the bandage down to the distal aspect of the thumb and encircle the thumb. If possible, leave the tip of the thumb exposed. Take the bandage back up and around the wrist and then back down and around the thumb, overlapping the previous turn by two-thirds the width of the bandage. Repeat the above steps, working up the thumb and hand until the thumb is covered (see Fig. 39.12F). Immobilizing and Supporting With a Sling A sling may be used to support and immobilize an injured wrist, elbow, or shoulder. The sling holds the extremity in an elevated position to avoid edema of the hand and to minimize pain, discomfort, and fatigue. A commercially made arm sling can be placed about the arm and the straps adjusted about the neck. If this type of support is not available, a triangular bandage sling may be used to support the injured upper extremity (Fig. 39.13; Steps 39.3). Using a Mechanical Lift to Transfer the Immobile Patient Lifts can be used to move immobile patients from the bed to a stretcher (gurney), a chair, or a wheelchair and back again. Mechanical lifts consist of a sturdy metal frame with a wide base of support from which a canvas sling is suspended. The lift is on wheels and, when empty, can be moved easily by one person. A hydraulic pump device allows one person to lift the weight of the patient, but it takes two people to use a mechanical lift safely---one to raise and move the lift and one to guide the patient into the chair or onto the bed or stretcher. Such lifts are also used to place patients into a tub or whirlpool bath for bathing or hydrotherapy (massage or debridement by moving water). FIG. 39.12 Applying an elastic bandage. (A) Starting a bandage with circular turns. (B) Bandaging with spiral turns. (C) Bandaging with spiral reverse turns. (D) Bandaging a joint with figure-of-eight turns. (E) Recurrent turn bandaging. (F) Thumb spica bandaging. FIG. 39.13 A triangular bandage sling. Never leave a patient requiring the use of a lift unattended while in the lift, in the tub, or in the whirlpool bath. When using a lift, explain to the patient exactly what is being performed. Many patients feel somewhat frightened being lifted off the bed or out of a chair by a mechanical device and may need reassurance. However, the proper use of a mechanical lift allows the nurse to move weak or helpless patients safely while avoiding self-injury (Skill 39.3). Before placing a patient on the sling, be sure that the skin is clean and dry. Protect the sling as needed with a sheet or bath blanket. If soiled, wash the sling with a disinfectant solution before using it again. FIG. 39.14 Nurse assisting patient ambulate with walking sling. Assisting With Aids to Mobilization Although the use of ambulatory aids is often taught by a physical therapist or kinesiologist, it is important for you to know the proper techniques so that you can reinforce patient education. Some rehabilitation units have a walking sling that is suspended from the ceiling and supports the unstable patient when ambulating (Fig. 39.14). Whenever a patient is using an assistive device for mobility, it is important to keep floors clear of clutter and pathways well lit. Place the assistive device within easy reach of the patient when not in use. In the home, assess the main pathways the patient will be using and ask for assistance in removing any hazards. Steps 39.3 Applying a Triangular Bandage Sling When a commercial arm support is not available, use a triangular bandage to form a sling. This will support the upper extremity. Review and carry out the Standard Steps in Appendix A. Action (Rationale) 1\. Place one end of the triangle over the shoulder on the uninjured side. (Positions the sling properly.) 2\. Position the point of the triangle toward the elbow. Ask the patient to bend the injured arm horizontally across the body, with the thumb toward the body. Place the bandage under the arm flat against the chest. (Forms the sling support.) 3\. Bring the other end over the injured arm and shoulder while the patient keeps the elbow bent at right angles across lower chest. The hand should be about 4 inches higher than the elbow. (Finishes forming the sling support. Elevating the hand prevents the fingers from swelling.) 4\. Tie the two ends at one side of the neck in a square knot. (Secures the sling; the knot at the side prevents discomfort when the patient lies down and decreases pull on the back of the neck when the arm is in the sling.) 5\. Fold the point of the triangle neatly over the elbow toward the front, and secure with a safety pin. (Keeps the elbow and sling from slipping back and forth.) 6\. Check the circulation in the fingers, comparing color of the nail beds and temperature of the hand with the other hand. (Fingers should be pink and warm; cold or bluish fingers indicate impaired circulation.) Skill 39.3 Transferring With a Mechanical Lift               Mechanical lifts allow immobile patients to be moved safely between two points some distance apart. A lift also may be used to elevate helpless patients while the bed is changed under them. Supplies Mechanical lift with sling Bath blanket or sheet Chair, wheelchair, stretcher, or clean tub (to receive patient) Review and carry out the Standard Steps in Appendix A. Action (Rationale) Assessment (Data Collection) 1\. Determine that lift is functioning correctly and that sling is clean. (Promotes smooth, safe use of the lift.) 2\. Assess patient's readiness to be transferred. Explain to patient exactly what will be performed. (Patient will experience less anxiety if prepared for the procedure.) Planning 3\. Obtain the assistance of a second person. (Two people are needed to safely transfer a patient using a lift.) Implementation 4\. Position the chair, wheelchair, or stretcher correctly, clearing away any obstructions; set brakes if applicable. (A clear floor is needed to maneuver the lift. Setting brakes prevents the chair or stretcher from moving while transferring the patient.) 5\. Raise the far side rail, adjust bed to working height, and lock wheels. (Bed adjustment allows proper use of body mechanics and decreases risk of injury to patient and nurse. Locked wheels prevent bed from moving while transferring.) 6\. Roll the patient onto the side. Instruct patient to hold onto the side rail if possible. Place the sling on the bed positioned from back of the head or the shoulders to mid-thigh; roll patient onto the sling. Assist or have the patient roll to other side so that the sling can be safely unrolled. Assist or have the patient lie supine on the sling. (Supports entire trunk and positions patient in sling for transfer and allows for correct position of sling before attempting to activate the lift.) 7\. Position the lift: Widen the stance of the base of the lift and lock it into place. Position the base under the bed so that hooks for the sling are over the patient and in line with the hook openings on the sling. (Correct positioning prevents lift from tipping during transfer. Allows for easy attachment of hooks to the sling). 8\. Lower the sling hooks in a controlled manner and attach to the sling. Be certain that hooks will not press into patient's skin when sling is elevated. (Controlling the hooks prevents them from striking the patient. Checking hook location prevents pressure damage to patient's skin). 9\. Ask the patient to fold the arms over the chest; support patient's head. (Head must be supported if sling is not long enough to do so. One person supports the patient's head and guides the sling as the other operates the lift.) Step 9 10\. Using the lift mechanism, elevate the patient in the sling until it clears the bed by several inches. (Allows unimpeded transfer of the patient to chair or stretcher.) Step 10 11\. Roll the lift away from the bed while the second helper safely guides the patient over the chair or stretcher. (Keeps patient secure and safe. Positions sling for the transfer.) 12\. Use the pressure release valve to lower the patient slowly into the chair or onto the stretcher while the helper guides the patient's body. Lower only enough to allow unhooking the sling. (Safely transfers the patient.) 13\. Unhook the sling, elevate the lift, and roll it away from the patient. (Prevents hook assembly from striking the patient.) 14\. Position the patient in good alignment. Smooth the sling or remove it. (Ensures that patient is correctly and safely transferred and made comfortable.) 15\. Cover patient with a blanket or sheet; place call light and needed items within reach. Secure patient in the chair with a security vest or on the stretcher as appropriate. (Promotes safety and comfort for the patient.) 16\. Monitor at least every 15 minutes for sitting tolerance if the patient is in chair. (If patient is unable to use a call light, place chair where it is visible to a nurse at all times, such as in the hallway near the nurse's station.) 17\. With the help of an assistant, return the patient to bed using the lift and following the same steps in reverse order. (An assistant helps prevent injury to the patient.) Evaluation 18\. Ask yourself: Was the patient transferred smoothly and without injury? Was the patient excessively frightened? Did the lift work correctly? (Answers to these questions provide data to evaluate effectiveness of interventions.) Documentation 19\. Document the procedure, noting the use of an assistant. Include the patient's tolerance of the procedure. (Notes transfer of patient and tolerance of procedure.) Documentation Example Smooth transfer from bed to wheelchair using mechanical lift and an assistant. Seatbelt in place; chair positioned next to nurse's station. (Nurse's electronic signature) Up in chair × 30 min. Returned patient to bed with assistance and placed into position of comfort, call light within reach. Patient stated "it felt good to be out of the bed" and rated pain as 2 out of 10. (Nurse's electronic signature) Special Considerations Allow patient to see how the lift works before attempting transfer of patient if at all possible. In home situation, instruct caregivers thoroughly in use of lift and provide a demonstration of the equipment. Critical Thinking Questions 1\. How would you handle the situation if your patient, who is to be transferred from the bed to a chair with a lift for the first time, is very frightened of this procedure? 2\. Why do you think it is essential that the sling for the lift be attached exactly according to the directions that come with it? Walkers A walker is frequently the first mechanical aid used when training an individual to walk following a loss of function or surgical procedure such as a hip or knee replacement. It is particularly helpful for patients who are weak or tend to lose their balance because it offers a broad base of support. Walkers are rectangular tubular metal frames that are at least waist high and are open on one side. Most walkers have four rubber-capped tips that rest on the floor, although some have wheels on the front. There are handgrips on the side crossbars. Walkers are adjustable in height. The height is correct if the person's elbow is bent at a 15- to 30-degree angle while standing upright and grasping the handgrips. To use a walker, the individual must have the use of both hands and arms and at least one leg. However, generalized weakness still may allow the patient to use a walker effectively. Crutches Depending on the person and the need for assistance with ambulation, the use of crutches may follow the use of a walker or be the first aid to ambulation (Fig. 39.15). Although there are various styles of crutches, three basic types are most commonly seen. These are axillary, Lofstrand, and Canadian crutches. Lofstrand and Canadian crutches are shorter and are designed for patients who will need crutches permanently for mobility. Axillary crutches are commonly used for short-term needs. They are adjustable to a variety of heights and are relatively easy to use. They do present one real danger: resting the body's weight on the axillary bar puts pressure on vital nerves and can occlude blood vessels in the axilla, causing temporary or permanent damage, including paralysis. For this reason it is critical that crutches be adjusted to the proper height and the patient be instructed to avoid resting the body's weight on the axillary bar. Crutches need to adjust both in overall length and from the axillary bar to the handgrip. Measure with the patient standing or supine. If standing, be certain that the patient's shoes are on the feet. For standing measurement, position the crutches with tips at a point 4 to 6 inches (10 to 15 cm) to the side and 4 to 6 inches in front of the patient's feet. The pads should be ½ to 2 inches (1.3 to 5 cm) below the axilla. For supine measurement, position the tips 6 inches (15 cm) lateral to the patient's heel. The pad should be three or four fingerbreadths under the axilla. Adjust handgrips for both measurements so that the elbow is flexed 15 or 20 degrees when the palms of the hands are resting on the handgrips. When walking, the patient will need to straighten the elbow and the wrist during weight-bearing. This should allow the axilla to pass freely over the axillary bar during forward movement (Box 39.5). Patient Education Common Crutch Gaits Gait Description Pattern Four-point gait Sequence: 1\. Advance left crutch. 2\. Advance right foot. 3\. Advance right crutch. 4\. Advance left foot. Three-point gait Sequence: 1\. Advance both crutches forward with the affected leg and shift weight to crutches. 2\. Advance unaffected leg and shift weight onto it. Advantages: Allows the affected leg to be partially or completely free of weight-bearing. Requirements: Full weight-bearing on one leg, balance, and upper body strength. Two-point gait Sequence: 1\. Advance left crutch and right foot. 2\. Advance right crutch and left foot. Advantages: Faster version of the four-point gait, more normal walking pattern (arms and legs moving in opposition). Requirements: Partial weight-bearing on both legs, balance. Swing-through gait Sequence: 1\. Move both crutches forward. 2\. Move both legs forward, beyond, or even with crutches. Or may keep weight on good foot and move other foot forward and then move good foot forward. Patient Education Special Maneuvers on Crutches Maneuver Description Walking upstairs 1\. Stand at foot of stairs with weight on good leg and crutch. 2\. Put weight on the crutch handles and lift the good leg up onto the first step of the stairs. 3\. Put weight on the good leg and lift other leg and the crutches up to that step. 4\. Repeat for each stair step. Walking downstairs 1\. Stand at top of stairs with weight on good leg and crutches. 2\. Shift weight completely onto the good leg and put the crutches down on the next step. 3\. Put weight on the crutch handles and transfer injured leg down on the step with the crutches. 4\. Bring good leg down to that step. 5\. Repeat for each stair step. Sitting down 1\. Crutch walk to the chair. 2\. Turn around slowly so that back is to the chair and the backs of the legs touch the seat of the chair. 3\. Transfer both crutches to the side with the injured leg and grasp both handgrips with the one hand. 4\. As weight is supported on the crutches and good leg, reach back with free hand and grasp the arm of the chair. 5\. Lower slowly onto the chair seat, using the support of both the crutches and the chair. 6\. Sit back in the chair and elevate the leg, but not to an angle greater than 90 degrees at the hip. 7\. Keep the knee slightly flexed when elevated because too much extension can decrease the circulation. 8\. To get up, bring both crutches along the side of the injured leg and grasp the handgrip firmly. Make sure that the crutch tips are firmly on the floor. Place the other hand on the arm of the chair and push up. 9\. After becoming upright, transfer one crutch to the other hand for walking. FIG. 39.15 A patient receiving the beginning of instruction in crutch walking. Canes The most commonly used canes are the standard (one-point) and the quad (four-point) canes (Fig. 39.16). An advantage of a quad cane is that it will stand up by itself (Box 39.6). Wheelchairs Wheelchairs are used for patients who are not able to ambulate either independently or with aids, such as crutches or a walker. Many paraplegics (those without use of the legs), quadriplegics (those without use of both arms and legs), amputees, and individuals with severe hemiparesis or respiratory problems are dependent on wheelchairs for movement from place to place. Patients who are wheelchair dependent over an extended period need chairs that are made specifically to their body measurements. When a patient brings a wheelchair to the hospital, see that it is clearly labeled with the owner's name, and never borrow it for someone else. Box 39.5 Guidelines to Be Considered When Teaching Crutch Walking The head is held up, and the eyes look ahead, as in normal walking. The crutches are placed slightly ahead of the patient's feet and to the outside of each foot. The hands, not the axillae, are used to support the body's weight. The back should be kept straight, and the patient should bend at the hips. The crutches and affected foot or leg should be moved forward together (at the same time), except when using a swinging gait. A smooth, easy rhythm should be achieved in shifting the weight from the crutches to the unaffected (good) leg and then to the crutches again. The crutches should be of the proper length and equipped with heavy rubber suction tips to prevent slipping. The gait used will depend on the weight-bearing status of the lower extremities and the patient's abilities. When moving someone into or out of a wheelchair, always set the brakes. Be sure that the person's feet are correctly placed on the footrests and that clothing or lap robes are tucked safely away from the wheels. Shoes, slippers, or bed socks will protect the feet from direct contact with the footrests. To prevent accidents, keep patients in wheelchairs well away from stairwells, elevators, and doorways if left to sit stationary. Always lock the brakes when the chair is not in motion. FIG. 39.16 A regular cane (right) provides support, whereas a quad cane (left) provides support and stability because of its broad base. Braces, splints, and prostheses for stabilization Braces and splints are used to strengthen and support areas of the body affected by weakness or paralysis, such as the legs or back. They also may be used after surgery or trauma to immobilize a part while it heals. Braces and splints are generally made of plastic or metal pieces with padding and straps for attachment. A leg brace may be combined with a shoe. A back brace has metal staves sewn into the fabric; the fabric may be elasticized to provide more support. A wrist splint is a padded device with an inner metal frame. It is often used to relieve or prevent carpal tunnel syndrome that sometimes occurs with repetitive hand movements and to immobilize a sprained wrist. A prosthesis (artificial substitute for a body part) is used to replace a body part that is missing, either from birth or following amputation. It is specially fashioned to fit the patient and assist with lost function. It takes considerable time for a patient to adjust to the use of a prosthesis. All braces, splints, and prostheses have the potential to irritate and injure the tissues and must be monitored closely. The skin should be evaluated carefully during the initial assessment and then reassessed regularly throughout the hospital stay or at home. Any problems must be both noted in the medical record and reported promptly to the primary care provider. Handle prosthetic devices carefully, as they are made for the specific individual, are expensive, and take many weeks to obtain. Label all devices with the patient's name and do not allow them out of the room unless they are in place on the patient. Box 39.6 Guidelines for Using a Cane Instruction for walking with a cane includes ensuring that: The cane has an intact rubber tip. The patient uses the cane on the unaffected side unless directed by the therapist or primary care provider to use it on the other side for balance reasons. The patient does not lean on or bear full weight on the affected leg. The caregiver walks beside the patient on the affected side to provide support in case the patient begins to fall. The handgrip is at hip level and the person's elbow is bent at a 15- to 30-degree angle when placing weight on the cane. The cane's tip is 6 to 10 inches (15 to 25 cm) to the side and 6 inches (15 cm) in front of the near foot. The patient looks straight ahead while walking. Rehabilitation As patients recover from immobilization or from serious illness that restricts usual activity, an exercise prescription may be written to improve muscle tone, joint flexibility, and/or cardiovascular fitness. Parameters for exercise are determined by a target heart rate during activity that is based on age and condition. In a healthy person the target heart rate for aerobic activity is a minimum of 60% of the age-predicted maximum heart rate (subtract the current age from 220 and multiply by the percentage). The ideal training target is 80% of the age-predicted maximum heart rate (American Heart Association, 2016). Patients who have had a joint immobilized are often sent to an outpatient physical therapy facility for an individual exercise program to regain maximum strength and mobility of the joint and extremity. Evaluation Evaluation is performed daily by considering whether the specific expected outcomes have been met. Does the skin remain healthy, or are there signs of breakdown? Evaluate the breath sounds; note any developing cough or signs of dyspnea. Observe the patient's emotional status, including the attitude toward therapy or visitors. Is the patient alert and active in social interactions or withdrawn, hostile, or depressed? If nursing interventions are not achieving the expected outcomes, the care plan needs to be revised. Evaluation statements indicating that some of the expected outcomes stated earlier are being met might be as follows: Performing sponge bath, mouth care, and grooming tasks except for left foot. Skin is clean, dry, and without redness or abrasion. Respirations normal with clear breath sounds bilaterally. Demonstrating pleasant interactions with family, friends, and staff. Patient is knitting and working on crossword puzzles daily. Watching television news show several times a day and discussing events with visitors. Asking if a haircut is possible and wants to wear own clothes. Checking social media and sending emails and texts to friends, family, and co-workers. Documentation Each member of the health care team must maintain a written record of the treatments provided and its effects. Documentation should include any changes in skin integrity, respiratory status, or signs of peripheral circulatory changes. Many assessment aspects can be recorded on an activity or assessment flow sheet. For proper reimbursement, it is vital to document data that indicate a continuing need for use of equipment and ambulation aids. Get Ready for the Next Generation NCLEX® Examination! Key Points It is essential to include measures to prevent the complications of immobility in the nursing care plan. Pay particular attention to respiratory and circulatory function. Active or passive exercise is extremely important for the immobilized patient. There are special beds and a variety of pressure relief devices available to prevent pressure injuries and other complications of immobility. Frequent visitors and inclusion of the patient in family life are important to prevent social isolation. The older adult is at higher risk for the complications of immobility and may suffer more psychosocial problems. Splints are used for immobilization of an injury or for stabilization of an area with paralysis or weakness. Traction is used to treat muscle spasm and fractures. To be effective, the body must be aligned correctly, ropes and pulleys must not be impeded, and weights must hang free. Skin traction is applied with a Velcro boot, adhesive strips, slings, or wraps; it is noninvasive but can be damaging or irritating to the skin. External fixators may be used to stabilize a fracture, rather than using a cast, so that the patient can be more active during healing. Casts are applied to immobilize a particular body part to allow bone healing. They must be handled gently while drying. Inspect casts every shift for cracks, crumbling, pressure problems, and signs of infection beneath them. If they become too tight, they may be bivalved. The CPM machine is used to exercise the joint after joint replacement surgery. Assessment of neurovascular status, of function of an immobilizing device, and of body systems for complications is performed on each shift. Problem statements are related to altered mobility, altered tissue perfusion, the risk of complications, and psychosocial problems. Elastic bandages are applied to immobilize a joint or to reduce swelling. Perform neurovascular assessment while they are in place. To transfer a patient safely with a mechanical lift, two people should perform the procedure. Always follow the facility's policy. Never leave a patient alone while suspended in the sling of the lift. Aids to mobilization include walkers, crutches, canes, wheelchairs, braces, and prostheses. For walkers and canes, the patient's arms should have the elbows placed at a 15- to 30-degree angle when the hands are gripping the device. There should be at least two fingerbreadths of space between the top of the crutch and the axilla when the patient's hands are gripping the crutches. Crutches, canes, and walkers should have rubber tips on the feet of the device. Wheelchairs are placed in locked position when transferring patients in or out of them and whenever the patient is placed in a stationary position. Braces and prostheses must be handled gently and kept with the patient. Tissue under the device should be assessed before application and when the device is removed. Evaluation data are collected to determine whether expected outcomes of nursing care plans have been met. Documentation is vital for proper reimbursement for equipment and specialty beds.