Week 3 Reading Text - Fundamentals of Nursing (PDF)

Website http://evolve.elsevier.com/Canada/Potter/fundamentals/ Case Study Kate (preferred pronouns: she/her) is a 36-year-old individual who has multiple sclerosis and was admitted to the neurology unit 3 days ago for exacerbation of symptoms. She came to the emergency department with a chief conce...

Website http://evolve.elsevier.com/Canada/Potter/fundamentals/ Case Study Kate (preferred pronouns: she/her) is a 36-year-old individual who has multiple sclerosis and was admitted to the neurology unit 3 days ago for exacerbation of symptoms. She came to the emergency department with a chief concern of weakness, difficulty balancing, and extreme pain, with loss of muscle function in her legs. Kate was diagnosed with multiple sclerosis 3 years ago. She is married and has two children, ages 7 years and 4 years. Prior to admission, she adhered closely to her medication regimen and continued her very active lifestyle, enjoying outdoor activities with her family. Since hospital admission 3 days ago, Kate’s muscle function in her lower extremities has deteriorated significantly and she is unable to leave her bed and cannot walk. Think about this case study as you read this chapter. There are review questions at the end of the chapter that relate to the case study. Mobility refers to the ability to move easily and independently. To maintain optimal mobility, musculoskeletal and nervous system function must be intact. Illnesses, surgery, injuries, pain, and aging can temporarily or permanently impair mobility. Nurses must assess for hazards created by immobility and know how to care for patients who are immobile in order to prevent complications. This care includes positioning patients to maintain optimal body alignment and safely moving patients when they cannot do so independently. Integration of evidence-informed practice related to mobility is essential for providing comprehensive nursing care. Scientific Knowledge Base Nature of Movement Movement is a complex process that requires coordination between the musculoskeletal and nervous system. As a nurse, you will assess how a patient’s physical and psychological condition affects body movement. Body mechanics are the coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing activities of daily living (ADLs). Knowing how patients initiate movement and understanding your own movements requires a basic understanding of body mechanics. Lifting techniques historically used in nursing practice can cause debilitating injuries to nurses and other health care providers (Lee et al., 2021). In Canada, government legislation and employer policies require nurses to use evidence-informed guidelines regarding body alignment, balance, gravity, and friction when implementing nursing interventions such as positioning patients, assessing a patient’s risk for falls, and selecting the safest way to move or transfer patients (Alberta Health Services, 2021; Shaw et al., 2021) (see Chapter 37). Alignment and Balance The terms body alignment and posture are analogous and refer to the positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Collectively, joints, tendons, and ligaments are stabilizing and supporting structures of the musculoskeletal system. Joints are structures, or articulations, that connect two or more adjacent parts of the skeleton to facilitate movement. Ligaments are bands of tough, fibrous tissue that surround joints and connect bone to bone to reinforce joint stability to limit extreme movement of joints. Tendons are bands of fibrous connective tissue that attach muscle to bone. Being in correct body alignment means that the individual’s centre of gravity is stable. Correct body alignment reduces strain on musculoskeletal structures, minimizes the risk of injuries and falls, aids in maintaining adequate muscle tone, and contributes to balance. Balance is enhanced with correct body posture and when the body’s centre of gravity is kept low within a wide base of support (see Chapter 37). Balance is required for maintaining a static position (e.g., sitting), moving (e.g., walking), and performing ADLs. Disease, injury, pain, physical development (e.g., age), life changes (e.g., pregnancy), medications (e.g., in which dizziness or drowsiness is an adverse effect), and deconditioning (as a result of prolonged immobility) can compromise the ability to remain balanced. Impaired balance is a major threat to mobility and physical safety and contributes to a fear of falling and self-imposed activity restrictions (see Chapter 37). Gravity and Friction Weight is the force exerted on a body by gravity. The force of weight is always directed downward, which is why an unbalanced object falls. Unsteady patients fall when their centre of gravity becomes unbalanced; the gravitational pull of their weight moves outside their base of support. Friction is a force that occurs in a direction opposing movement. The greater the surface area of the object to be moved, the greater the friction. A larger object produces greater resistance to movement. The force exerted against the skin while the skin remains stationary and the bony structures move is called shear. An example of shear is when the head of a hospital bed is elevated beyond 60 degrees and gravity pulls a patient so that the bony skeleton moves toward the foot of the bed while the skin remains against the sheets. The blood vessels in the underlying tissue are stretched and damaged, resulting in impeded blood flow to the deep tissues. Ultimately, pressure injuries often develop within the undermined tissue; the surface tissue appears less affected. To reduce friction when a patient is unable to assist in moving up in bed, nurses use ergonomic assistive devices such as friction-reducing transfer sheets and full-body slings (Schoenfisch et al., 2019). Full-body slings are used to mechanically lift a patient off the surface of a bed, thereby preventing friction, tearing, or shearing of the patient’s skin and protecting the nurse and other staff from injury. Whenever possible, nurses should use some of the patient’s strength when lifting, transferring, or moving the patient. The procedure should be explained to the patient and the patient told when and what body parts to move. The result should be a synchronized movement in which the patient can participate and in which friction is decreased. A patient’s participation in self-care may promote their sense of accomplishment. Pathological Influences on Mobility Pathological conditions affect mobility, including congenital and acquired impairments, degenerative and episodic conditions, and disease processes. Although a complete description of each is beyond the scope of this chapter, four categories of pathological influences are presented here: postural abnormalities, impaired muscle development, central nervous system damage, and direct trauma to the musculoskeletal system. Postural Abnormalities Congenital or acquired postural abnormalities affect the efficiency of the musculoskeletal system, as well as body alignment, balance, and appearance. During assessment, the nurse observes body alignment and range of motion (ROM; see Chapter 37). Postural abnormalities can cause pain, impair alignment or mobility, or both. Knowledge about the characteristics, causes, and treatment of common postural abnormalities (Table 46.1) is necessary for moving, transferring, and positioning a patient. Some postural abnormalities may limit ROM. Nurses intervene to maintain a patient’s maximum ROM in unaffected joints and then often collaborate with physiotherapists to design interventions to strengthen affected muscles and joints, improve the patient’s posture, and adequately use affected and unaffected muscle groups. Referral to or collaboration with a physiotherapist and occupational therapist may enhance nursing interventions for a patient with a postural abnormality. Impaired Muscle Development Injury and disease can lead to numerous alterations in musculoskeletal function. For example, the muscular dystrophies are a group of familial disorders that cause degeneration of skeletal muscle fibres. Patients with muscular dystrophies experience progressive, symmetrical weakness and wasting of skeletal muscle groups, with increasing disability and deformity (McCance & Huether, 2019). Damage to the Central Nervous System Damage to any component of the central nervous system that regulates voluntary movement results in impaired body mobility. Trauma from a head injury, ischemia from a stroke or cerebrovascular accident (CVA), hemorrhage, tumour, or bacterial infection such as meningitis can damage the cerebellum or the motor region in the cerebral cortex. Damage to the cerebellum causes problems with balance, and motor impairment is directly related to the amount of destruction of the motor region. For example, a person with a right-sided cerebral hemorrhage with necrosis has destruction of the right motor strip that results in left-sided hemiplegia (muscle paralysis) or hemiparesis (muscle weakness). Trauma to the spinal cord also impairs mobility. For example, a complete transection of the spinal cord results in a bilateral loss of voluntary motor control below the level of the trauma, because motor fibres are cut. Injury above the first thoracic vertebra results in quadriplegia (also known as tetraplegia) (four-limb paralysis), and injury below that level results in paraplegia (two-limb paralysis). TABLE 46.1 Postural Abnormalities Possible Abnormality Description Cause Treatments∗ Torticollis Inclining of head to the Congenital or Surgery, heat, affected side, in which the acquired condition support, or sternocleidomastoid immobilization, muscle is contracted depending on cause and severity, gentle range of motion Lordosis Exaggeration of anterior Congenital Spine-stretching convex curve of lumbar condition exercises (based on spine Temporary cause) condition (e.g., pregnancy) Kyphosis Increased convexity in Congenital Spine-stretching curvature of thoracic condition exercises, sleeping spine Rickets, without pillows, osteoporosis use of bed board, Tuberculosis bracing, spinal of the spine fusion (based on Gerontological cause and severity) changes Kypholordosis Combination of kyphosis Congenital Similar to and lordosis condition methods used in kyphosis or lordosis (based on cause) Immobilization and surgery (based on cause and severity) Scoliosis Lateral “S”- or “C”- Sometimes a Approximately half shaped curvature of consequence of of children with spinal column with numerous scoliosis require vertebral rotation, congenital, surgery. unequal heights of hips connective Nonsurgical and shoulders tissue, and treatment is with neuromuscular braces and disorders exercises. Poliomyelitis Spastic  paralysis Unequal leg length Kyphoscoliosis Abnormal Congenital Immobilization anteroposterior and condition and surgery (based lateral curvature of spine Poliomyelitis on cause and Cor pulmonale severity) Congenital hip Hip instability with Congenital Maintenance dysplasia limited abduction of hips condition (more of continuous and, occasionally, common with abduction of adduction contractures breech deliveries) the thigh so (head of femur does not that head of articulate with femur presses acetabulum because of into centre of abnormal shallowness of acetabulum acetabulum) Abduction splints, casting, surgery Knock-knee Legs curved inward so Congenital Knee braces, (genu that knees come together condition surgery if not valgum) as person walks Rickets corrected by growth Bowlegs (genu One or both legs bent Congenital Slowing rate of varum) outward at knee, which is condition curving if not normal until 2 to 3 years Rickets corrected by of age growth With rickets, increase of vitamin D, calcium, and phosphorus intake to normal ranges Clubfoot 95%: medial Congenital Casts, splints such deviation and plantar condition as Denis–Browne flexion of foot splint, and surgery (equinovarus) (based on degree 5%: lateral deviation and rigidity of and dorsiflexion deformity) (calcaneovalgus) Footdrop Inability to dorsiflex and Congenital None (cannot evert foot because of condition be corrected) peroneal nerve damage Trauma Prevention Improper through position of physiotherapy  patient who is Bracing with immobilized ankle–foot orthotic Pigeon-toes Internal rotation of Congenital Growth, wearing (metatarsus forefoot or entire foot, condition reversed shoes, adductus or common in infants, often Habit casting, bracing metatarsus accompanied by varus) developmental dysplasia of the hip ∗ Severity of the condition and its cause will dictate treatment, which must be individualized. Based on McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Mosby. Direct Trauma to the Musculoskeletal System Direct trauma to the musculoskeletal system can result in bruises, contusions, sprains, and fractures. A fracture is a disruption of bone tissue continuity. Fractures most commonly result from direct external trauma but can also occur as a consequence of some deformity of the bone (e.g., pathological fractures, or bone fractures that result from disease rather than injury, such as osteoporosis, Paget’s disease, metastatic cancer, or osteogenesis imperfecta). Young children are usually able to form new bone more easily than adults and, as a result, have few complications after a fracture. Treatment often includes positioning the fractured bone in proper alignment and immobilizing it to promote healing and restore function. Even this temporary immobilization can result in some muscle atrophy (loss of muscle tissue), loss of tone, and joint stiffness. After the fracture has healed, physiotherapy may be required to regain functional losses. Nursing Knowledge Base Mobility–Immobility Fully understanding mobility requires more than an overview of the physiology and regulation of movement by the musculoskeletal and nervous systems. Nurses must also know how to apply these scientific principles in the clinical setting in order to determine the safest way to move patients and understand the effect of immobility on a patient’s physiological, psychological, and developmental health status. Factors Influencing Mobility–Immobility To determine how to move patients safely, nurses need to assess a patient’s ability to move. As stated earlier, mobility refers to a person’s ability to move about freely. Immobility refers to the inability to move about freely. Mobility and immobility are best understood as the end points of a continuum, with many degrees of partial mobility in between. Some patients move back and forth on this continuum, but for other patients, immobility is absolute and continues indefinitely. The terms bed rest and impaired physical mobility are frequently used when discussing patients on the mobility–immobility continuum. Bed rest is an intervention that restricts patients to bed for therapeutic reasons. Although not common, health care providers may prescribe this intervention. The general objectives of bed rest are as follows: To reduce physical activity and the oxygen needs of the body To reduce pain, including postoperative pain, and the need for large doses of analgesics To promote safety for patients recovering from the effects of anaesthetics or who are sedated To allow patients who are ill or debilitated to rest To allow patients who are exhausted the opportunity for uninterrupted rest The duration of bed rest depends on the illness or injury and the patient’s prior state of health. The effects of muscular deconditioning associated with lack of physical activity are often apparent within days. The individual of average weight and height without a chronic illness on bed rest loses muscle strength from baseline levels at a rate of 3% a day. Deconditioning can occur to any individual regardless of age. Immobility is also associated with cardiovascular, skeletal, and other organ changes. The term disease atrophy describes the tendency of cells and tissue to reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting of a body part, or local nerve damage (McCance & Huether, 2019). Impaired physical mobility is defined by the North American Nursing Diagnosis Association as a state in which the individual experiences or is at risk of experiencing limitation of physical movement (Ackley et al., 2020). Periods of immobility due to disability or injury or prolonged bed rest can cause major physiological, psychological, and social effects. These effects can be gradual or immediate and vary from patient to patient. The greater the extent and the longer the duration of immobility, the more pronounced are the consequences. The patient with complete mobility restrictions is continually at risk for side effects of immobility. When possible, it is imperative that patients, especially older persons, have limited bed rest and that their activity is more than movement from bed to chair. Loss of walking independence increases hospital stays, need for rehabilitation services, or long-term care placement. In addition, the deconditioning related to reduced walking increases the risk for patient falls (Xu et al., 2018). Systemic Effects of Immobility Exercise has positive outcomes for all major systems of the body (see Chapter 37). When there is an alteration in mobility, each body system is at risk for impairment. The severity of the impairment depends on the patient’s overall health, degree and length of immobility, and age. For example, persons with chronic illness develop pronounced effects of immobility. Metabolic Changes Changes in mobility alter endocrine metabolism, calcium resorption, and functioning of the gastrointestinal system. The endocrine system, made up of hormone-secreting glands, maintains and regulates the following: (1) response to stress and injury; (2) growth and development; (3) reproduction; (4) homeostasis; and (5) energy production, use, and storage. When injury or stress occurs, the endocrine system triggers a series of responses aimed at maintaining blood pressure and preserving life. The endocrine system is important in maintaining homeostasis. Tissues and cells live in an internal environment that the endocrine system helps regulate through maintenance of sodium, potassium, water, and acid–base balance. The endocrine system also helps regulate energy metabolism. Thyroid hormone increases the basal metabolic rate (BMR), and energy becomes available to cells through the integrated action of gastrointestinal and pancreatic hormones (McCance & Huether, 2019). Immobility disrupts normal metabolic functioning, decreasing the metabolic rate. This decrease in BMR alters the metabolism of carbohydrates, fats, and proteins; causes fluid, electrolyte, and calcium imbalances; and produces gastrointestinal disturbances, such as decreased appetite and slowing of peristalsis. However, in response to hypermetabolic processes (i.e., infection, fever, wound healing), patients who are immobilized may have an increased BMR because of increased cellular oxygen requirements (McCance & Huether, 2019). A deficiency in calories and protein is characteristic of patients with a decreased appetite secondary to immobility. The body is constantly synthesizing proteins and breaking them down into amino acids to form other proteins. When the patient is immobile, the body excretes more nitrogen (the end product of amino acid breakdown) than protein ingested, resulting in negative nitrogen balance. Weight loss, decreased muscle mass, and weakness result from tissue catabolism (tissue breakdown) (McCance & Huether, 2019). Another metabolic change associated with immobility is calcium resorption (loss) from bones. Immobility causes the release of calcium into circulation. Normally, the kidneys can excrete the excess calcium. However, if the kidneys are unable to respond appropriately, hypercalcemia results. Pathological fractures occur if calcium resorption continues as a patient remains on bed rest or continues to be immobile (McCance & Huether, 2019). Impaired gastrointestinal functioning can result from decreased mobility. Difficulty in passing stools (constipation) is a common symptom, although pseudodiarrhea may result from a fecal impaction (accumulation of hardened feces). This finding is not normal diarrhea, but rather liquid stool passing around the area of impaction. Left untreated, fecal impaction can result in a mechanical bowel obstruction that may partially or completely occlude the intestinal lumen, blocking normal propulsion of liquid and gas. The resulting fluid in the intestine produces distension and increases intraluminal pressure. Over time, intestinal function becomes depressed, dehydration occurs, absorption ceases, and fluid and electrolyte disturbances worsen. Respiratory Changes Regular aerobic exercise is known to enhance respiratory functioning. In contrast, lack of movement and exercise places patients at higher risk for respiratory complications. Patients who are immobile are at a high risk of developing pulmonary complications such as atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Both conditions decrease oxygenation, prolong recovery, and add to the patient’s discomfort (Lewis et al., 2023). In atelectasis, secretions block a bronchiole or a bronchus, and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. The site of the blockage determines the severity of atelectasis. A lung lobe or even a whole lung may collapse. At some point in the development of these complications, there is a proportional decline in the patient’s ability to cough productively. Ultimately, the distribution of mucus in the bronchi increases, particularly when the patient is in the supine, prone, or lateral position. Mucus accumulates in the dependent regions of the airways. Hypostatic pneumonia frequently results because mucus is an excellent medium for bacterial growth. Cardiovascular Changes Immobilization also affects the cardiovascular system, frequently resulting in orthostatic hypotension, increased cardiac workload, and thrombus formation. Orthostatic hypotension is a drop of blood pressure greater than 20 mm Hg in systolic blood pressure and of 10 mm Hg in diastolic blood pressure. Symptoms include dizziness, light-headedness, nausea, tachycardia, pallor, or fainting when the patient changes from a lying or sitting position to a standing position (Ball et al., 2019). In the immobilized patient, decreased circulating fluid volume, pooling of blood in the lower extremities, and decreased autonomic response occur. These responses are especially evident in older persons. As the workload of the heart increases, its oxygen consumption does as well. Therefore, the heart works harder and less efficiently during periods of prolonged rest. As immobilization increases, cardiac output falls, further decreasing cardiac efficiency and increasing workload. Patients who are immobile are also at risk for thrombus formation. A thrombus is an accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery, sometimes occluding the lumen of the vessel (Figure 46.1). Three factors contribute to venous thrombus formation: (1) loss of integrity of the vessel wall (e.g., injury during surgical procedures), (2) alterations in blood flow (e.g., slow blood flow in calf veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity). These three factors are sometimes referred to as Virchow’s triad (McCance & Huether, 2019). A dislodged venous thrombus, called an embolus, may travel through the circulatory system to the lungs and impair circulation and oxygenation. Venous emboli that travel to the lungs are called pulmonary emboli and may be life-threatening. More than 90% of all pulmonary emboli begin in the legs or pelvis (Copstead-Kirkhorn & Banasik, 2018). As a nurse, you will practice in numerous situations where deep vein thrombosis must be prevented, especially during perioperative care. Musculoskeletal Changes Immobility affects the musculoskeletal system by causing temporary or permanent impairment that may lead to permanent disability. Muscle effects resulting from restricted mobility include loss of endurance, strength, and muscle mass, as well as decreased stability and balance. Skeletal effects of immobility include impaired calcium metabolism and impaired joint mobility. Muscle effects Because of protein breakdown, a patient loses lean body mass when immobile. Reduced muscle mass makes it difficult for patients to sustain activity. If immobility continues and the patient does not exercise, there is further loss of muscle mass.  FIGURE 46.1 Thrombus formation in a vessel. Prolonged immobility often leads to disuse atrophy, the reduction in normal size of muscle fibres after prolonged bed rest, trauma, casting, or local nerve damage. Loss of endurance, decreased muscle mass and strength, and joint instability (see “Skeletal Effects” in next section) put patients at risk for falls. Skeletal effects Immobilization causes two skeletal changes: impaired calcium metabolism and joint abnormalities. Because immobilization results in bone resorption, the bone tissue is less dense and disuse osteoporosis results, putting the patient at risk for pathological fractures. Bone resorption also causes calcium to be released in the blood, resulting in hypercalcemia. Osteoporosis (or porous bone) is a disease characterized by loss of bone mass and deterioration of bone tissue that can lead to increased risk of fractures. Osteoporosis is a major health concern in Canada. Eighty percent of fractures in women over 50 are related to osteoporosis. Fragility fractures are responsible for increased mortality and morbidity in older persons (Brown et al., 2021). Although primary osteoporosis is different in origin from the osteoporosis that results from immobility, nurses must recognize that immobilized patients are at high risk for accelerated bone loss if they have primary osteoporosis. Interventions for preventing disability in immobilized patients with primary osteoporosis include early patient evaluation, and consultation with and referral to health care providers, dietitians, occupational therapists, and physiotherapists. Patient teaching should focus on limiting the severity of the disease through diet and activity (Box 46.1). Immobility can also lead to joint contractures. A joint contracture is an abnormal and possibly permanent condition characterized by fixation of a joint. Flexor muscles for joints are stronger than extensor muscles and therefore contribute to the formation of contractures. Disuse, atrophy, and shortening of the muscle fibres cause joint contraction. When a contracture occurs, the joint cannot obtain full ROM. Contractures may leave a joint or joints in a nonfunctional position (Figure 46.2) and can be permanent. Interventions to prevent development of contractures in patients who are immobile are essential for nurses and health care providers to carry out. Footdrop is the inability to dorsiflex and evert the foot because of peroneal nerve damage. It is a common and debilitating contracture (Figures 46.3 and 46.4) that causes the foot to be permanently fixed in plantar flexion. Ambulation becomes difficult because the patient cannot dorsiflex the foot and is unable to lift their toes off the ground. Footdrop can be associated with a variety of etiologies, including prolonged bed rest, peroneal nerve damage, peripheral neuropathy, and CVAs (strokes). FIGURE 46.2 A contracture of the joints in the fingers. From Sorrentino, S. A., & Wilk, M. J.. Mosby’s Canadian textbook for the support worker [4th ed.]. Mosby. B OX 4 6. 1 Patient Teac hing Patients With Osteoporosis Objective Patient will identify strategies to prevent or limit the severity of osteoporosis. Teaching Strategies Assess the patient’s current state of knowledge about osteoporosis, including the disease processes and self-care, to determine whether information needs to be reinforced or introduced. Provide the patient (and caregiver, if present) with information about common risk factors (e.g., smoking, caffeine, alcohol). Assess learner readiness to engage in change of lifestyle behaviours and adapt teaching to individual patients. Provide patient and caregiver with dietary education, including current recommended dietary allowances for calcium and vitamin D, and review foods high  in calcium and vitamin D. To identify how patients access supplements and recommended foods, integrate questions in order to assess social determinants of health, to explore potential barriers such as income, physical environments, social supports, and access to health services (Orsted et al., 2017). Explore patient’s cultural preferences or beliefs regarding use of supplements and eating recommended foods. Collaborate with the interprofessional team to address the patient’s challenges to accessing supplements and recommended foods, as necessary. Provide the patient and caregiver with activity education, including appropriate types of weight-bearing exercises as recommended by the health care provider or physiotherapist to prevent injury or fractures. Provide the patient and caregiver with information about safety, fall prevention, and strategies to create a safe home environment. Collaborate with the interprofessional team to determine if home assessment is required, as well as support for assistive devices or home modifications. Teach the patient and caregiver how to self-administer prescribed medications. Engage the patient and caregiver in return demonstrations to assess their understanding and determine if home supports are required. Evaluation Patient and caregiver openly discuss lifestyle and risk factors and identify supports they can access if they are ready to change risk behaviours. Patient and caregiver identify foods high in calcium and vitamin D. If access is a barrier for patients, strategies to facilitate access can include collaborating with social workers to identify sources of financial support and working with patients to identify community resources, such as food distribution programs and community kitchen programs. Patient and caregiver demonstrate appropriate weight-bearing exercises. Patient and caregiver identify safety strategies to prevent falls. Patient and caregiver demonstrate appropriate knowledge about medications. Patient and caregiver express positive but realistic feedback regarding the effects of disease. Urinary Elimination Changes Immobility also alters a patient’s urinary elimination. In the upright position, gravitational force facilities flow of urine out of the renal pelvis and into the ureters and bladder. When the patient is recumbent or flat, the kidneys and the ureters are in a level position. Urine formed by the kidney must enter the bladder unaided by gravity. Peristaltic contractions of the ureters are insufficient to overcome gravity. Consequently, the renal pelvis may fill before urine enters the ureters. This condition, called urinary stasis, increases the risk of urinary tract infection and renal calculi (see Chapter 44). Renal calculi are calcium stones that lodge in the renal pelvis and pass through the ureters. Patients who are immobile are at risk for calculi because of both urinary stasis and altered calcium metabolism leading to hypercalcemia. FIGURE 46.3 Footdrop. The ankle is fixed in plantar flexion.Normally, the ankle is able to flex (dotted line), which eases walking. As the period of immobility continues, oral fluid intake can decrease, and this increases the risk for dehydration. As a result, urinary output may decline around the fifth or sixth day after immobilization and the urine is often highly concentrated. Concentrated urine increases the risk for calculi formation and infection. Patients who are immobile may have limited access to bathing equipment and be unable to perform adequate perineal hygiene, leading to increased risk for urinary tract contamination by Escherichia coli bacteria. FIGURE 46.4 Patient with bilateral footdrop. Patients who are immobile may be unable to use the bathroom or a bedside commode. Voiding on a bedpan or using a urinal does not provide the usual sensory stimulation to void and does not allow gravity to act on the bladder sphincter. Consequently, patients may be unable to void or completely empty their bladder. This situation leads to residual urine in the bladder, which increases the risk for infection. Complete urinary retention requires catheterization. Both intermittent catheterization and in-dwelling catheters increase the risk of developing urinary tract infection. Integumentary Changes Immobility is a major risk factor for developing pressure injuries. Preventing a pressure injury is much less expensive for health care facilities and causes patients less distress than treating one; therefore, preventative nursing interventions are imperative (Norton et al., 2017). A pressure injury is localized damage to the skin, underlying soft tissue, or both as a result of prolonged ischemia (decreased blood supply in the tissues). The injury can present as intact skin or an open ulcer (pressure injury) and may be painful. A pressure injury is characterized initially by inflammation and usually forms over a bony prominence. Ischemia develops when the pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin. Adequate blood flow is necessary to supply oxygen and nutrients for tissue metabolism and the elimination of metabolic wastes. Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation. People who are conscious have voluntary muscle control and normal perception of pressure to perceive decreased circulation to tissue. They change positions regularly to increase circulation to tissue, thus preventing formation of pressure injuries. To avoid the development of pressure injuries in individuals with impaired sensation or mobility, they may require assistance to regularly reposition themselves. Areas of skin covering bony prominences (i.e., scapulae, elbows, coccyx, heels) are most at risk for skin breakdown. Nurses must be aware of these areas and assist patients with frequent position changes, whether patients are lying down or sitting. Safety Alert Implement a comprehensive skin care program to prevent skin breakdown in all patients, from newborns to older persons. Effective skin care programs include accurate and consistent assessment and documentation as well as interventions to protect the skin (e.g., turning the patient every 2 hours and using mechanical devices such as lifts when you need to move the patient to reduce friction and shear [Norton et al., 2017]). Psychosocial Effects of Immobility Immobilization can contribute to decreased social interaction, social isolation, sensory deprivation, loss of independence, and role changes (Boscart et al., 2023; Norton et al., 2017). These, in turn, may lead to emotional reactions, behavioural responses, sensory alterations, and changes in coping. Every patient responds to immobility differently. Immobility may lead to depression in some patients because of changes in role, self- concept, and other factors. Depression is an affective disorder characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion to reality. Depression can result from worrying about present and future levels of health, finances, and family needs. Because immobilization removes the patient from a daily routine, individuals may worry about disability. Worrying can quickly increase the patient’s depression, leading to withdrawal. By assessing behavioural changes throughout a patient’s restricted mobility, nurses are better equipped to identify changes in self-concept, recognize early signs of depression, develop nursing interventions, and collaborate with the interprofessional team to ensure that proper supports are provided for the patient. Developmental Changes Immobility often leads to developmental changes in very young children and in older persons. The immobilized young or middle-aged adult who has been healthy may experience few, if any, developmental changes. However, exceptions exist, and patients must be fully assessed for developmental implications. Infants, Toddlers, and Preschoolers The newborn’s spine is flexed and lacks the anteroposterior curves of the adult. As the baby grows, musculoskeletal development permits support of weight for standing and walking. Posture is awkward because the head and upper trunk are carried forward. Because body weight is not evenly distributed along a line of gravity, posture is off balance, and falls occur often. When the infant, toddler, or preschooler is immobilized, it is usually because of trauma or the need to correct a congenital skeletal abnormality. Prolonged immobilization can delay the child’s gross motor skills, intellectual development, musculoskeletal development, or a combination of these growth areas. Nurses caring for immobilized children should plan activities that provide physical and psychosocial stimuli. Frequent skin assessment of pediatric patients who are immobilized is essential. In acute care settings, equipment-related factors can contribute to development of pressure injuries. A comprehensive assessment should include pressure injury risk assessment and head-to-toe skin assessment, with close attention to areas under splints, braces, traction devices, and tracheostomies (Norton et al., 2017). Adolescents The adolescence stage is usually initiated by a tremendous growth spurt (see Chapter 24). Growth is frequently uneven. Prolonged immobilization may alter adolescent growth patterns. When the activity level is reduced because of trauma, illness, or surgery, the adolescent may lag behind peers in gaining independence. Social isolation and self-concept are concerns for this age group when immobilization occurs. Adults An adult who has correct posture and body alignment feels good, looks good, and generally appears self-confident. The healthy adult also has the necessary musculoskeletal development and coordination to carry out ADLs. When periods of prolonged immobility occur, however, all physiological systems are at risk. In addition, the role of the adult may change with regard to the family or social structure. The adult may lose their identity and self-concept associated with a job. Older Persons A progressive loss of total bone mass (strength), muscle strength, and aerobic capacity occurs in older persons. Some of the possible causes of this loss are decreased physical activity, hormonal changes, and bone resorption. Older persons may walk more slowly, take smaller steps, and appear less coordinated. Adverse effects of prescribed medications can include altering of a sense of balance or changes in blood pressure, which increase older persons’ risks for falls and injuries (see Chapter 25). The outcomes of a fall include possible injury, hospitalization, loss of independence, and psychological effects. B OX 4 6. 2 F unc tional Dec line in Hospitalized Immobile Older Persons For many older persons, admission to the hospital often results in functional decline despite the treatment for which they were admitted. Some older persons have difficulties with mobility and can quickly regress to a dependent state. Rapid intervention of an interprofessional health care team is required to maintain the patient’s functional capacity. Usual aging is associated with decreased muscle strength and aerobic capacity, which becomes exacerbated if a patient’s nutritional state is poor. A nutritional assessment needs to be included in the plan of care for the older person experiencing immobility. Anorexia and insufficient assistance with eating food lead to malnutrition, which contributes to the known challenges associated with immobility. Improved nutrition increases the patient’s ability to perform physical reconditioning exercises. There is a direct relationship between the success of older persons’ rehabilitation and their nutritional status. Adapted from Boscart, V., McCleary, L., Taucar, L.S., et al. (2023). Ebersole & Hess’ gerontological nursing and healthy aging in Canada (3rd ed.). Elsevier Inc. Older persons may experience functional-status changes secondary to hospitalization and altered mobility status (Box 46.2). Immobilization of older persons increases their physical dependence on others and accelerates functional losses (Fazio et al., 2020). Immobilization of some older persons results from a degenerative disease, neurological trauma, or chronic illness. In others, immobilization can occur suddenly, such as after a stroke. When providing nursing care for an older person, nurses should develop a care plan that encourages the patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility and functionality. Nurses may inadvertently contribute to a patient’s immobility by providing unnecessary help with activities such as bathing and transferring. Critical Thinking Critical thinking requires nurses to synthesize knowledge, experience, patient data, and professional standards. Each of these sources must be integrated into the nurse’s diagnosis and care plan for the patient with impaired mobility (Figure 46.5). Over the past decade, most health care facilities in Canada have established standards of practice related to moving and transferring patients, as well as the prevention of falls and pressure sores.  Nursing Process Nurses must apply the nursing process and use a critical thinking approach to develop individualized care plans for patients with mobility impairments or risk for immobility. The aim of the care plan is to improve the patient’s functional status, promote self-care, maintain psychological well-being, and reduce the hazards of immobility. FIGURE 46.5 Critical thinking model for mobility assessment. Assessment Nursing assessment with a focus on mobility and immobility must incorporate the following: 1. A patient’s normal mobility status 2. The effects of diseases or conditions on mobility 3. The patient’s risk for mobility alterations as a result of treatments During assessment, nurses critically analyze findings and collaborate with patients and the interprofessional team to ensure that patient-centred clinical decisions are made. Patient Expectations Usually, the nurse will assess a patient’s degree of mobility and immobility during the health history interview and physical examination. The nurse must include the patient as a partner in designing the plan of care and assess how the patient perceives any limitations in mobility. Has the patient had a disability for an extended period of time, or is the patient well adapted to the use of an assist device or even a wheelchair? Is the limitation in mobility sudden and unexpected, causing the patient to be fearful or full of questions? Nurses must have respect for the patient’s preferences, values, and needs during assessment and when designing a plan of care (Ackley et al., 2020). Mobility Assessment of patient mobility focuses on ROM, gait, exercise and activity tolerance, and body alignment. When unsure of the patient’s abilities, the nurse begins assessment of mobility with the patient in the most supportive position and moves to higher levels of mobility according to the patient’s tolerance. Generally, the nurse starts assessing movement while the patient is lying, then proceeds to assessing sitting positions in bed, transfers to chair, and, finally, gait. This sequence of assessment helps to protect the patient’s safety. Range of Motion Range of motion (ROM) is the maximum amount of movement available at a joint in one of the four planes of the body: medial, sagittal, frontal, or transverse. The medial plane is a line through the axis of the body, separating the body into equal halves, a left side and a right side. The sagittal plane is any plane parallel to the medial plane. The frontal plane passes through the body from side to side and divides the body into front and back. The transverse plane is a horizontal line that divides the body into upper and lower portions. The anatomical position is used as a reference when describing the parts of the body as they relate to each other (Figure 46.6). Ligaments, muscles, and the nature of the joint control joint mobility in each of the planes. Joint movements are described using the following terms and examples provided in Table 46.2: Flexion and extension: Flexion is decreasing the angle between two adjoining bones (bending of the joint); extension is increasing the angle between two adjoining bones (extending the joint). FIGURE 46.6 Planes of the body. TABLE 46.2 Range-of-Motion Exercises Range Body Part Type of Joint Type of Movement (Degrees) Neck, Pivotal Flexion: Bring chin to 45 cervical rest on chest. spine  Extension: Return 45 head to erect position. Hyperextension: 10 Bend head back as far as possible. Lateral flexion: Tilt 40–45 head as far as possible toward each shoulder. Rotation: Turn head as 180 far as possible along transverse plane to look to each side. Shoulder Ball and socket Flexion: Raise arm 180 from side position forward to position above the head. Extension: Return arm 180 to position at side of the body. Hyperextension: Move 45–60 arm behind body, keeping elbow straight. Body Type of Range Primary Type of Joint Part Movement (Degrees) Muscles Abduction: 180 Deltoid, Raise arm to supraspinatus side to position above head with palm away from head. Adduction: 320 Pectoralis major Lower arm sideways and across body as far as possible. Internal 90 Pectoralis major, rotation: With latissimus dorsi, elbow flexed, teres major, rotate shoulder subscapularis by moving arm until thumb is turned inward and toward back. External 90 Infraspinatus, rotation: With teres major, elbow flexed, deltoid move arm until thumb is upward and lateral to head. Circumduction: 360 Deltoid, Move arm in full coracobrachialis, circle. latissimus dorsi, (Circumduction teres major is a combination of all movements of the ball-and- socket joint.) Elbow Hinge Flexion: Bend 150 Biceps brachii, elbow so that brachialis, lower arm brachioradialis moves toward its shoulder  joint and the hand is level with the shoulder. Extension: 150 Triceps brachii Straighten elbow by lowering hand. Forearm Pivotal Supination: 70–90 Supinator, Turn lower arm biceps brachii and hand so that the palm is up. Pronation: 70–90 Pronator teres, Turn pronator lower arm quadratus so that the palm is down. Table Continued Body Range Primary Type of Joint Type of Movement Part (Degrees) Muscles Wrist Condyloid Flexion: Move palm 80–90 Flexor carpi toward inner aspect of ulnaris, forearm. flexor carpi radialis Extension: Move 80–90 Extensor fingers and carpi hand posterior radialis to midline. brevis, extensor carpi radialis longus, extensor carpi ulnaris Hyperextension: 80–90 Extensor Bring dorsal carpi surface of hand radialis  back as far as brevis, possible. extensor carpi radialis longus, extensor carpi ulnaris Abduction (radial Up to 30 Flexor carpi deviation): Place hand radialis, with palm up and extensor extend wrist laterally carpi toward the thumb. radialis brevis, extensor carpi radialis longus Adduction (ulnar 30–50 Flexor carpi deviation): ulnaris, Place hand with extensor palm up and carpi ulnaris extend wrist medially toward the fifth finger. Fingers Condyloid hinge Flexion: Make a fist. 90 Lumbricals, interosseous volaris, interosseous dorsalis Extension: Straighten 90 Extensor fingers. digiti quinti proprius, extensor digitorum communis, extensor indicis proprius Hyperextension: Bend 30–60 Extensor fingers back as far as digitorum possible. Abduction: Spread 30 Interosseous fingers apart. dorsalis  Adduction: Bring 30 Interosseous fingers together. volaris Thumb Saddle Flexion: Move thumb 90 Flexor across palmar surface pollicis of hand. brevis Extension: Move 90 Extensor thumb straight pollicis away from longus, hand. extensor pollicis brevis Abduction: Extend 30 Abductor thumb laterally pollicis (usually done brevis when placing fingers in abduction and adduction). Adduction: Move 30 Adductor thumb back pollicis toward hand. obliquus, adductor pollicis transversus Opposition: Touch Opponeus thumb to each pollicis, finger of the opponeus same hand. digiti minimi Table Continued Body Type of Range Primary Type of Joint Part Movement (Degrees) Muscles Hip Ball and socket Flexion: Move leg 90–120 Psoas major, forward and up. iliacus, sartorius Extension: 90–120 Gluteus maximus, Move leg semitendinosus, semimembranosus  back beside other leg. Hyperextension: 30–50 Gluteus maximus, Move leg behind semitendinosus, the body. semimembranosus Abduction: Move 30–50 Gluteus medius, leg laterally away gluteus minimus from the body. Adduction: 30–50 Adductor longus, Move leg adductor brevis, back adductor magnus toward medial position and beyond, if possible. Internal rotation: 90 Gluteus medius, Turn foot and leg gluteus minimus, toward other leg. tensor fasciae latae External 90 Obturatorius rotation: internus, Turn foot obturatorius and leg externus away from other leg. Circumduction: Psoas major, Move leg in a gluteus maximus, circle. gluteus medius, adductor magnus Knee Hinge Flexion: Bring 120–130 Biceps femoris, heel back toward semitendinosus,  back of thigh. semimembranosus, sartorius Extension: 120–130 Rectus femoris, Return leg vastus lateralis, to the floor. vastus medialis, vastus intermedius Ankle Hinge Dorsiflexion: 20–30 Tibialis anterior Move foot so that toes are pointed upward. Plantar 45–50 Gastrocnemius, flexion: soleus Move foot so that toes are pointed downward. Table Continued Body Type of Range Type of Joint Primary Muscles Part Movement (Degrees) Foot Gliding Inversion: Turn 10 or less Tibialis anterior, sole of foot tibialis posterior medially. Eversion: 10 or less Peroneus longus, Turn sole peroneus brevis of foot laterally. Toes Condyloid Flexion: Curl 30–60 Flexor digitorum, toes downward. lumbricalis pedis, flexor hallucis brevis Extension: 30–60 Extensor digitorum Straighten longus, extensor toes. digitorum brevis, extensor hallucis longus Abduction: 15 or less Abductor hallucis, Spread toes interosseous dorsalis apart.  Adduction: 15 or less Adductor hallucis, Bring toes interosseous together. plantaris Adduction: 15 or less Adductor hallucis, Bring toes interosseous together. plantaris Hyperextension: This is movement of a body part beyond its normal resting extended position. Dorsiflexion and plantar flexion: Dorsiflexion is the flexion of the ankle moving toes and foot upward; plantar flexion of the ankle is bending of the toes and foot downward. Abduction and adduction: Abduction is movement of an extremity away from the midline of the body; adduction is movement of an extremity toward the midline of the body. Eversion and inversion: Eversion is the turning of a body part away from the midline; inversion is the turning of a body part toward the midline. Pronation and supination: Pronation is movement of a body part so that the front or ventral surface faces downward; supination is movement of a body part so that the front or ventral surface faces upward. Internal and external rotation: Internal rotation is rotation of the joint inward; external rotation is rotation of the joint outward. Circumduction: This is the circular movement of a limb in a cone-shaped manner (e.g., shoulder). Assessment of ROM is important as a baseline measure to determine a patient’s mobility status and to later compare and evaluate whether loss in joint mobility has occurred as a result of clinical changes or treatments. ROM assessment includes examining the patient for stiffness, swelling, pain, limited movement, and unequal movement. Patients with restricted mobility require ROM exercises to reduce the hazards of immobility, such as contractures. Limited ROM often indicates inflammation such as arthritis, fluid in the joint, or altered nerve supply. Increased mobility (beyond normal ROM) of a joint sometimes indicates connective tissue disorders, ligament tears, or possible joint fractures. ROM exercises may be active (the patient is able to move all joints through their ROM unassisted), passive (the patient is unable to move independently, and the nurse moves each joint through its ROM), or somewhere in between (see Table 46.2). To assess the type of ROM exercise a patient can perform, the nurse must first review the medical plan of care to determine whether active ROM exercises are appropriate. Then, the patient’s ability to engage in active ROM exercise is assessed. Passive ROM exercises are prescribed for patients who are unable to move because of paralysis, sedation, or generalized weakness. Passive ROM exercises improve joint mobility, prevent contractures, and help prepare the patient for ongoing rehabilitation exercises (Smith et al., 2016). With a patient who is weak, the nurse may provide support while the patient performs most of the movement, or the patient may be able to move some joints actively while the nurse passively moves others (Box 46.3). The nurse’s assessment will help to determine the patient’s need for assistance, teaching, or reinforcement. In general, exercises should be as active as health and mobility allow. Assessment data from patients with limited joint movements vary on the basis of the area affected. Gait The term gait is used to describe a particular manner or style of walking. It is a coordinated action that requires the integration of sensory function, muscle strength, proprioception, balance, and a properly functioning central nervous system (vestibular system and cerebellum). The gait cycle begins with the heel strike of one leg and continues to the heel strike of the other leg. Assessing a patient’s gait helps nurses to draw conclusions about balance, posture, safety, and ability to walk without assistance, all of which affect the risk of falling. Here are a few ways to assess a patient’s gait: 1. Observe the patent entering the room, and note speed, stride, and balance. 2. Ask the patient to walk across the room, turn, and come back. 3. Ask the patient to walk heel-to-toe in a straight line. This may be difficult for older patients, even in the absence of disease, so stay at the patient’s side during the walk. Exercise and Activity Tolerance Exercise is physical activity for conditioning the body, improving health, and maintaining fitness. It can be used as therapy to correct a deformity or to restore the overall body to a maximal state of health. When a person exercises, physiological changes occur in body systems (see Chapter 37). Nurses assess a patient’s exercise history by asking what exercise the patient normally engages in and the amount of exercise performed daily and weekly. For example, if a patient walks, what distance does the person typically walk, and how often? If a patient does not exercise regularly, the nurse will want to focus on their activity tolerance. B OX 4 6. 3 How to Perform Passive Range-of-M otion E xerc ises 1. Perform hand hygiene. 2. Identify the patient using two unique identifiers (e.g., chart, wrist band). 3. Explain the procedure and its purpose to the patient. Provide additional information, as needed. 4. Assess the patient’s health status, including pain, to determine the patient’s activity tolerance and need for analgesia. 5. Assist the patient into a comfortable position in a bed or chair. 6. Perform range-of-motion exercises, working from head to toe: a. Head and neck: flexion, extension, rotation, lateral flexion b. Shoulder: flexion, extension, abduction, adduction, internal rotation, external rotation c. Elbow: flexion, extension, supination, pronation d. Wrist: flexion, extension, adduction, abduction, rotation e. Hand, fingers, and thumb: flexion, extension, adduction, abduction, opposition, circumduction of thumb f. Hip: flexion, extension, abduction, adduction, internal rotation, external rotation∗ g. Knee: flexion, extension h. Ankle: plantar flexion, dorsiflexion, inversion, eversion i. Feet and toes: flexion, extension ∗ Contraindicated in patients who have undergone total hip arthroplasty. Adapted from Smith, N., Caple, C., & Pravikoff, D. (2016). Range-of-motion exercises, passive. CINAHL Nursing Guide, EBSCO Publishing. Nursing practice and skill-CEU. CINAHL AN: T703878. Activity tolerance is the type and amount of exercise or work that a person is able to perform without undue exertion or possible injury. Assessment of a patient’s activity tolerance is necessary when planning activities for the patient, such as walking, ROM exercises, or ADLs. Activity tolerance assessment includes data from physiological, emotional, and developmental domains (see Chapter 37). After a prolonged period of inactivity, the nurse should monitor the patient for symptoms such as dyspnea, fatigue, or chest pain. If these symptoms develop, the nurse must assess for a change in vital signs (heart rate and blood pressure). A weak or debilitated patient is unable to sustain even slight changes in activity because of the increased demand for energy. Simple tasks such as eating or moving in bed often result in extreme fatigue. When the patient experiences decreased activity tolerance, the nurse must assess the time needed by the patient to recover. Decreasing recovery time indicates improved activity tolerance. People who are depressed, worried, or anxious are frequently unable to tolerate exercise. Patients who are depressed tend to withdraw from activity rather than participate in it. Patients who worry or are anxious expend a great amount of mental energy and often report feeling fatigued. Because of this, they may experience physical and emotional exhaustion. Developmental changes also affect activity tolerance. As the infant enters the toddler stage, the activity level increases and the need for sleep declines. The child entering preschool or primary grades expends mental energy in learning and may require more rest after school or before strenuous play. The adolescent going through puberty may require more rest because much of the body’s energy is expended for growth and hormone changes (see Chapter 24). Pregnancy causes fluctuations in energy tolerance, especially during the first and third trimesters. Hormonal changes and fetal development use body energy, and expectant mothers may be unable or unmotivated to carry out physical activities. During the last trimester, fetal development consumes a great deal of the mother’s energy, and the size and location of the fetus may limit the mother’s ability to take a deep breath, resulting in less oxygen being available for physical activities. Activity changes continue through adulthood and are primarily related to employment and lifestyle choices. As the person grows older, activity tolerance changes. Muscle mass is reduced, posture changes, and bone composition changes. Changes in the cardiopulmonary system, such as decreased maximum heart rate and decreased lung compliance, affect the intensity of exercise. With progressing age, some older persons still exercise but do so at a reduced intensity. The more inactive a patient becomes, the more pronounced these activity changes are. Body Alignment Nursing assessment of body alignment is done with the patient lying, sitting, or standing. Objectives of body alignment assessment include the following: Determining normal physiological changes in body alignment resulting from growth and development for each individual patient Identifying deviations in body alignment caused by incorrect posture Providing opportunities for patients to observe their posture Identifying learning needs of patients for maintaining correct body alignment Identifying trauma, muscle damage, or nerve dysfunction Obtaining information about other factors contributing to poor alignment, such as fatigue, malnutrition, and psychological issues The first step in assessing body alignment is to put the patient at ease so that the person does not assume an unnatural or rigid position. When assessing the body alignment of a patient who is immobilized or unconscious, pillows and positioning supports should be removed from the bed and the patient placed in the supine position. Standing When the patient is standing, the nurse assesses the following for correct body alignment: The head is erect and midline. When observed posteriorly, the shoulders and hips are straight and parallel. When observed posteriorly, the vertebral column is straight. When observed laterally, the head is erect and the spinal curves are aligned in a reversed “S” pattern. The cervical vertebrae are anteriorly convex, the thoracic vertebrae are posteriorly convex, and the lumbar vertebrae are anteriorly convex. When observed laterally, the abdomen is comfortably tucked in and the knees and ankles are slightly flexed. The person appears comfortable and does not seem conscious of the flexion of knees or ankles. Arms hang comfortably at the sides. Feet are placed slightly apart to achieve a base of support, and the toes are pointed forward. When observed posteriorly, the centre of gravity is in the midline, and the line of gravity is from the middle of the forehead to a midpoint between the feet. Laterally, the line of gravity runs vertically from the middle of the skull to the posterior third of the foot (Figure 46.7). Sitting Characteristics of correct alignment of the sitting patient include the following (Figure 46.8): The head is erect, and the neck and vertebral column are in straight alignment. FIGURE 46.7 Correct body alignment when standing. FIGURE 46.8 Correct body alignment when sitting.The patient’s feet are flat on the floor, the calves do not touch the chair, and the back is straight and against the back of the chair. From Sorrentino, S. A., & Wilk, M. J.. Mosby’s Canadian  textbook for the support worker [4th ed]. Mosby. Body weight is evenly distributed on the buttocks and thighs. Thighs are parallel and in a horizontal plane. Both feet are supported on the floor or on wheelchair footrests. With patients of short stature, a footstool can be used to ensure ankles are comfortably flexed. A 2.5- to 5-cm space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee. This space ensures that no pressure is on the popliteal artery or nerve to decrease circulation or impair nerve function. The patient’s forearms are supported on the armrest, in their lap, or on a table in front of the chair. Assessing alignment when the patient is sitting is important if the patient has muscle weakness, muscle paralysis, or nerve damage. Diminished sensation impairs the patient’s ability to perceive pressure or decreased circulation. Proper alignment while sitting reduces the risk of musculoskeletal system damage. Lying People who are conscious have voluntary muscle control and normal perception of pressure. Because their ROM, sensation, and circulation are within normal limits, they change positions when they perceive muscle strain and decreased circulation when lying down. Assessment of body alignment for a patient who is immobilized or bedridden is done with the patient in the lateral position. All positioning supports should be removed from the bed except for the pillow under the head, and the body is supported with an adequate mattress (Figure 46.9). This position allows for full view of the spine and back and provides other baseline body alignment data, such as whether the patient can remain positioned without aid. The vertebrae should be aligned, and the position should not cause discomfort. Patients with impaired mobility (e.g., traction or arthritis), decreased sensation (e.g., hemiparesis following a CVA), impaired circulation (e.g., diabetes), or lack of voluntary muscle control (e.g., spinal cord injury) are at risk for damage when lying down.  FIGURE 46.9 Lateral lying position for assessment of body alignment. Immobility Physiological Assessment Assessment of the patient for physiological hazards of immobility is done while performing a head-to-toe physical assessment (see Chapter 33). Additionally, the examiner should assess relationships between the patient’s immobility and psychosocial health, developmental stage, and the social determinants of health (Orsted et al., 2017). Physiological hazards of immobility that may be identified during a nursing assessment are summarized below and in Table 46.3. Metabolic system When assessing metabolic functioning, nurses use anthropometric measurements (measures of height, weight, and skin fold thickness) to evaluate muscle atrophy. In addition, the nurse may need to analyze intake and output records to determine whether intake equals output or if a fluid imbalance exists (see Chapter 41). Dehydration and edema can increase the rate of skin breakdown in a patient who is immobilized. Monitoring laboratory data such as electrolytes, serum protein (albumin and total protein) levels, and blood urea nitrogen can help in determining metabolic functioning. Assessment of wound healing and monitoring of food intake and elimination patterns will help to identify altered gastrointestinal functioning and determine if there are potential metabolic concerns. If a patient who is immobile has a wound, the rate of healing indicates how well nutrients are being delivered to tissues. Normal progression of healing indicates that metabolic needs of injured tissues are being met. Anorexia occurs commonly in patients who are immobilized. The patient’s food intake should be assessed before the meal tray is removed to determine the amount eaten. The patient’s dietary patterns and food preferences are assessed at the onset of immobilization, to help prevent nutritional imbalances. Respiratory system A respiratory assessment is performed at least every 2 hours for patients with restricted activity. The nurse needs to inspect chest wall movements during the full inspiratory– expiratory cycle. If a patient has an atelectatic area, chest movement may be asymmetrical. The entire lung region should be auscultated to identify diminished breath sounds, crackles, or wheezes. Auscultation is focused on the dependent lung fields because pulmonary secretions tend to collect in lower regions. The nurse needs to perform a complete respiratory assessment to identify the presence of secretions and to determine nursing interventions necessary for optimal respiratory function. Cardiovascular system Cardiovascular assessment of the patient who is immobile includes blood pressure monitoring, evaluation of apical and peripheral pulses, and observation for signs of venous stasis (e.g., edema and poor wound healing). All patients should have their vital signs monitored during the first few attempts at sitting or standing. TABLE 46.3 Physiological Hazards of Immobility System Assessment Techniques Abnormal Findings Metabolic Inspection Delayed wound healing, abnormal laboratory data Inspection Muscle atrophy Anthropometric Decreased amount of measurements (mid- subcutaneous fat upper arm circumference, triceps skinfold measurement) Inspection, palpation Generalized edema Respiratory Inspection Asymmetrical chest wall movement, dyspnea, increased respiratory rate Auscultation Crackles, wheezes, decreased air entry Cardiovascular Auscultation Orthostatic hypotension Auscultation, palpation Increased heart rate, third heart sound, weak peripheral pulses Inspection, palpation Dependent edema in feet and legs (if seated) and in sacrum (if lying)  Musculoskeletal Inspection, palpation Decreased range of motion, erythema, asymmetrical diameter in calf or thigh Inspection, palpation Joint contracture Inspection Activity intolerance, muscle atrophy, joint contracture Elimination Inspection Decreased urine output, cloudy or concentrated urine, decreased frequency of bowel movements Palpation Distended bladder and abdomen Auscultation Decreased bowel sounds Skin Inspection, palpation Impaired skin integrity When monitoring orthostatic blood pressure, the nurse must move the patient gradually during position changes from supine to sitting or standing and assess for dizziness. First, with the patient in a supine position, the nurse obtains baseline blood pressure and pulse measurements. Next, the nurse assists the patient to a position sitting at the side of the bed. The patient should remain sitting for 3 minutes before the blood pressure and pulse are taken. The nurse should not leave the patient and continually monitor the patient for dizziness or lightheadedness. If the patient has no dizziness or drop in blood pressure (≥20 mm Hg systolic or 10 mm Hg diastolic), the nurse assists the patient to a standing position and retakes the blood pressure and pulse immediately and again after 3 minutes of standing. The patient should be monitored for dizziness throughout this procedure. The longer the period of immobility, the greater the risk of hypotension when the patient stands (McCance & Huether, 2019). Frequent and peripheral pulse assessment are performed on patients who are immobile. Recumbent positions increase cardiac workload and result in an increased pulse rate. In some patients, particularly older persons, the heart may not tolerate the increased workload and cardiac failure may develop. A third heart sound, heard at the apex with the bell of the stethoscope, can be an early indication of heart failure. Monitoring of peripheral pulses helps the nurse to evaluate the heart’s ability to pump blood. Absence of a peripheral pulse in the lower extremities should be documented and reported immediately to the patient’s health care provider, especially if the pulse was present previously. Edema may develop in patients who have had injury or whose heart is unable to handle the increased workload of bed rest. Because edema moves to dependent body regions, assessment of the patient who is immobile includes inspection of the sacrum, legs, and feet. If the heart is unable to tolerate the increased workload, peripheral body regions, such as the hands, feet, nose, and earlobes, will be colder than central body regions. The nurse assesses for other sources of edema beyond heart failure and immobility. Renal impairment and certain medications, such as steroids, can cause edema. Deep vein thrombosis (DVT) is a hazard of restricted mobility. To assess for a DVT, the patient’s elastic stockings or sequential compression devices (SCDs) are removed every 8 hours (or according to employer policy) and the calves observed for redness, warmth, and tenderness. Homans’ sign, or calf pain on dorsiflexion of the foot, is contraindicated in patients when a DVT is suspected, as vigorous dorsiflexion may dislodge the thrombus. Daily measurement of bilateral calf circumference is an assessment for DVT. The nurse marks a point on each calf 10 cm from the mid-patella. The circumference is measured each day, using the mark for placement of the tape measure. Unilateral increases in calf diameter can be an early indication of thrombosis. Because DVTs can also occur in the thigh, daily thigh measurements should be taken if the patient is prone to thrombosis. In many patients, DVTs can be prevented by doing active exercise and wearing compression devices, in conjunction with prescribed anticoagulant treatment. If a patient has a DVT, an embolus can dislodge and travel through the circulatory system to the lung, causing a pulmonary embolism (PE). The signs and symptoms of PE vary depending on the size of the embolus and, hence, the extent of occlusion of the pulmonary vasculature. A massive PE can cause sudden and profound shock, including hypotension, tachycardia, tachypnea, hypoxia, and chest pain. Individuals can die within hours if the PE is not identified and treated quickly (McCance & Huether, 2019). Musculoskeletal system Nurses need to assess patients who are immobile for musculoskeletal abnormalities, such as decreased muscle tone and strength, loss of muscle mass, reduced ROM, and contractures. Anthropometric measurements (weight, body mass index [BMI], skin fold measurements) may indicate loss of muscle mass. During assessment of ROM, the nurse can palpate muscle tone by asking the patient to relax and then passively moving each limb at several joints while palpating for resistance or rigidity. Muscle strength is assessed by having the patient assume a stable position and then performing manoeuvres to assess strength of the major muscle groups (see Chapter 37). Assessment of ROM is important as a baseline to compare later measurements and evaluate whether a loss in joint mobility has occurred. ROM can be measured with a goniometer. Disuse osteoporosis cannot be identified by physical assessment. However, patients on prolonged bed rest, postmenopausal women, patients taking steroids, and people with increased serum and urine calcium levels have a greater risk for bone demineralization. The nurse should consider the risk of disuse osteoporosis when planning nursing interventions. Although some falls result in injury, others occur because of pathological fractures secondary to osteoporosis. Patients who are at risk for osteoporosis should have their diet assessed for calcium intake. Integumentary system Early identification of high-risk patients and of their risk factors can help prevent pressure injuries. The patient’s skin must be continually assessed for breakdown and colour changes. The nurse needs to know a patient’s normal skin colouring in order to assess for colour changes, in both light- and dark-skinned patients (Jarvis, 2019). Using the Braden Scale Assessment (see Table 47.2), the nurse can identify patients at high risk for impaired skin integrity or early skin changes (Orsted et al., 2017). The skin should be observed often during routine care (e.g., when the patient is turned, during hygiene measures, and when providing for elimination needs). Skin assessment should occur every 2 hours (Norton et al., 2017) and is based on patients’ mobility, hydration, and physiological status. Prompt identification of skin changes facilitates early intervention. Elimination system To determine the effects of immobility on elimination, the patient’s total intake and output is assessed each shift and every 24 hours. The amounts should be compared over time to determine that the patient is receiving the correct amount and type of fluids orally or parenterally (see Chapter 41). Inadequate intake and output or fluid and electrolyte imbalances increase the risk for renal system impairment, ranging from recurrent infections to kidney failure. Dehydration also increases the risk for skin breakdown, thrombus formation, respiratory infections, and constipation. Immobility impairs gastrointestinal peristalsis. Assessment of bowel elimination includes an analysis of a patient’s dietary choices and fluid intake, review of medications, monitoring of the frequency and consistency of bowel movements, and an abdominal examination (Jarvis, 2019). With accurate assessment, the nurse can intervene before constipation and fecal impaction occur. Psychosocial Assessment Many alterations in psychological, sociocultural, cognitive, and developmental functioning are related to immobility. Nursing care must focus on all of these dimensions. Often the focus of immobility is on the early visible physical manifestations, such as skin impairment, but the psychosocial and developmental aspects of immobility should not be overlooked. Abrupt changes in cognition may have a physiological cause, such as surgery, a medication reaction, a PE, or an acute infection. For example, confusion is a primary symptom of compromised older persons with an acute urinary tract infection or fever. Identifying confusion is an important component of the nurse’s assessment. Acute confusion in older persons is not normal and should be thoroughly examined (Boscart et al., 2023; Registered Nurses’ Association of Ontario [RNAO], 2016). Common reactions to immobilization are boredom, feelings of isolation, depression, and anger. The patient’s history should be explored to identify mental health concerns, risk for social isolation, support systems, and resources. Families are a key resource for providing information about behaviour changes. The nurse should listen to family members if they report emotional changes. Examples of change that may indicate psychosocial concerns are a cooperative patient who becomes less cooperative, or an independent patient who asks for more help than is necessary. The nurse should investigate reasons for such alterations. Identifying how the patient usually copes with loss is vital (see Chapter 26). A change in mobility status, whether permanent or not, may cause a grief reaction. Because psychosocial changes usually occur gradually, it is important to observe the patient’s behaviour on a daily basis. If behavioural changes occur, the cause or causes should be determined and the changes evaluated as short or long term. Identifying the cause helps the nurse to design appropriate nursing interventions. For example, a fear of falling often limits the bariatric or older person’s mobility; fear may be related to past experiences of falling and not being able to get up (Van Seben et al., 2019). Interventions include encouraging the patient to lean forward before standing, rather than standing straight up, and teaching the patient how to get up and down from the floor, with assistance if needed. Unexplained changes in the sleep–wake cycle should be identified and corrected. Nurses can prevent or minimize most stimuli that interrupt the sleep–wake cycle (e.g., nursing activities, a noisy environment, or discomfort). However, the effects of some medications such as analgesics, sleeping pills, or cardiovascular medications can also cause sleep disturbances (see Chapter 42). Developmental Assessment Nurses need to include a developmental assessment of patients who are immobilized, to ensure that the patients’ holistic needs are met. When caring for a young child, the nurse needs to determine whether the child can meet expected developmental tasks. The child’s development may regress or be slowed because of immobilization. After identifying a child’s developmental needs, the nurse should design nursing interventions that maintain expected development and provide physical and psychological stimuli. The nurse should also assure the parents that developmental delays are usually temporary (see Chapter 23). Immobilization of a family member changes the family’s functioning. The family’s response to this change may lead to problems, stress, and anxieties. When children see parents who are immobile, they may have difficulty understanding what is occurring and with coping. Immobility can have a significant effect on the older person’s levels of health, independence, and functional status. Nursing assessment enables the nurse to determine the older person’s ability to meet needs independently and to adapt to developmental changes such as declining physical functioning and altered family and peer relationships. A decline in developmental functioning needs prompt investigation to determine why the change occurred and what can be done to return the patient to an optimal level of functioning as soon as possible. Activities that reduce immobility and promote participation in ADLs are vital to preventing functional decline (Cohen et al., 2019). Assessment should also include the patient’s home, community, and social determinants of health to identify factors that are risks to the patient’s mobility and safety (see Chapter 38). Patient Expectations. It is important to explore patient expectations by asking patients to explain what they know about their mobility status, what questions they and their families have, and how the immobility is affecting their goals. Nurses must work collaboratively with patients, their families, and the interprofessional team to establish realistic, achievable, and measurable goals to facilitate optimal health for patients who are affected by immobility. Nursing Diagnosis A patient who is partially or completely immobilized may have one or more nursing diagnoses. Two diagnoses most directly related to mobility problems are impaired physical mobility and risk for disuse syndrome. The diagnosis of impaired physical mobility is used for the patient who has some limitation but is not completely immobile. The diagnosis of risk for disuse syndrome should be considered for the patient who is immobile and at risk for multisystem pathophysiology because of inactivity. The list of potential diagnoses is extensive, because immobility affects multiple body systems: Activity intolerance Ineffective airway clearance Ineffective breathing pattern Ineffective individual coping Risk for disuse syndrome Risk for fluid volume deficit Impaired gas exchange Risk for infection Risk for injury BOX 4 6. 4 Researc h Highlight