Basic Care and Comfort / 03
Make sure to:
Picture the following example: a patient has undergone shoulder surgery and is now home on their first day after being discharged. They want to go back to their normal life, but they find that even the simpler tasks are now hard to do. They experience complicated feelings because they now need to wait for others to help them out or face the embarrassment of others witnessing their struggle to do things themselves. They wonder if they will be able to move like they used to and are worried about how long that might take.
Mobility is vital for an individual's well-being and quality of life, allowing them to perform daily activities such as going to work, attending school, participating in leisure activities, and engaging in physical exercise. The total or partial loss of mobility significantly impacts an individual’s development, leading to dependence on medical devices or assistance from others. Nurses must be able to identify alterations in mobility and investigate the underlying causes in order to aid in their recovery, maintenance, rehabilitation, or adaptation to these changes.
External factors affecting movement include aspects such as environmental temperature, patient height, and weight. For instance, the skin is influenced by external factors like temperature, light, humidity, and environmental pollution. Internal factors that can affect either movement or skin condition encompass the patient's age, sex, hereditary traits, overall health, nutritional status, existing pathologies, accidental injuries, and medication usage.
2.1 Assessment of Mobility and Skin
Movement Assessment
Movement assessment involves observing the range of motion in the joints, as well as evaluating the patients'/clients' strength, skill, and cardiovascular endurance.
There are different moments when the nurse can evaluate the patient’s/client’s movement. Some examples would be:
When describing movement, it is important to provide the context of the patient’s/client’s position while carrying it out. The most common natural body postures are:
Skin Assessment
Skin assessment involves observing appearance, color, turgor, edema, wounds or ulcers, and infections.
Wounds
While assessing the skin, another aspect that the nurse should be able to properly describe are the noticeable wounds that the patient/client could present.
Wounds are considered as any damage to the tissues, and can be classified as follows:
While attending to patients or clients with wounds, understanding the different types of wound healing provides nurses with a framework for knowing how care should be administered. The types of wound healing are as follows:
A particular type of skin wound prevalent among patients with mobility challenges is the pressure ulcer. Due to immobility and continuous friction in their resting postures, there is diminished blood circulation, leading to tissue detachment. This leads to breaks in the skin layers and the risk of infections is increased.
To assess the risk of developing ulcers, clinicians commonly utilize the Braden Scale. In this scale, each item is scored from 1 to 4, as shown in the table that follows.
Table 1
Braden Scale for Predicting Pressure Sore Risk
Retrieved from Kennerly et al. (2022). Nursing Assessment of Pressure Injury Risk with the Braden Scale Validated against Sensor-Based Measurement of Movement. Healthcare, 10(11). https://doi.org/10.3390/healthcare10112330
Based on their appearance and extent, pressure ulcers can be categorized into various stages, as shown in the table below:
Table 2
Ulcer Classification
Retrieved from Aboud, A., & Manna, B. (2023). Wound Pressure Injury Management. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532897/
2.2 Identification of immobility complications
Immobility has a significant impact on various body systems. Understanding the unique characteristics of these systems and how their alterations are interconnected provides nurses with the knowledge required to deliver specific care to their patient/client.
Musculoskeletal System
Due to a lack of movement, bones experience calcium loss, increasing the risk of fractures and subsequent falls. Joints become stiff, resulting in a reduced range of motion, and may also show signs of inflammation. Muscles weaken and are prone to atrophy.
Integumentary System
Pressure on weight-bearing areas of the body —such as the scapulae, sacrum, ischium, and heels— interrupts blood flow. This leads to symptoms like redness, irritation, poor skin turgor, edema, and pain, along with a loss of skin integrity. These conditions can evolve into more severe complications like ulcers, osteomyelitis, necrotizing fasciitis, gas gangrene, or septicemia.
Circulatory System
Prolonged immobility leads to a loss of muscle tone, which in turn affects the tone of blood vessels. This can result in dilated vessels, causing both resting hypotension and orthostatic hypotension, thereby increasing the patient's/client’s risk of falls. Slow blood flow heightens the risk for varicose veins, thrombophlebitis, and emboli. Moreover, the leakage of intravascular fluid into the extravascular space can cause edema, potentially progressing to cellulitis, ulcers, and necrosis. To compensate for stasis, the heart works harder, often leading to late-stage ventricular hypertrophy and other complications related to preload and afterload imbalances.
Respiratory System
Fluid leakage from the intravascular space into the lung's interstitial space can result in respiratory distress, coughing, increased secretions, and heightened risk of infection, including conditions like atelectasis and pneumonia.
Gastrointestinal System
Gastrointestinal movements decrease in force and frequency, so constipation and compaction may appear.
Urinary System
Urine stagnation promotes the formation of stones as solutes settle. This static condition also fosters bacterial and viral replication, increasing the likelihood of infection. Delayed bladder emptying can further contribute to urinary incontinence.
Metabolic System
The metabolic rate diminishes, potentially leading to weight gain. Furthermore, constipation may contribute to anorexia and inadequate nutrient intake.
Psychological Alterations
Emotional well-being significantly influences an individual's quality of life. Long-term or even permanent loss of mobility could engender depression. The feelings of dependency, coupled with the absence of a robust support network, could exacerbate this condition.
2.3 Care Interventions to Promote and Assist Patient/Client Safety, Mobility, Circulation, and Skin Integrity
As part of the comprehensive care provided by nurses, there exists a suite of interventions designed to identify, manage, and mitigate the afflictions discussed, along with their potential complications.
General Nursing Interventions that should be routinely applied include:
Interventions to Promote Mobility include:
Some Interventions to Promote Circulation are:
The Interventions to Promote Skin Integrity include:
Some therapeutic positions are:
When pressure ulcers have been developed, the need for debridement might arise. Various types of debridement exist, each with its own specific technique tailored to the nature of the wound. These types include:
2.4 Management of Assistive Devices for Mobility and Immobility
Medical Devices to Manage Mobility and Immobility Issues
Due to immobility, patients/clients may require specialized medical devices to facilitate their daily activities. Below are the most frequently employed:
Walking Stick. The cane should be used on the affected side, keeping the elbow at an angle between 25 to 30 degrees. The cane should be positioned 15 cm from the side of the foot. When advancing, extend the cane 30 cm forward and then step.
Walker. Position the walker comfortably in front of the patient. Instruct the patient/client to advance the walker approximately 15 cm with each step.
Crutches. Place the crutches 15 cm beside and ahead of the foot. When stepping, the crutch on the affected side should lead. The hands should bear the body weight via the crutch handles, with the elbow angled at 25 to 30 degrees.
Gait Belt. This belt serves as a handle, easing the process of moving the patient.
Slider Boards. Utilized to slide patients from one position to another, these boards reduce surface friction.
Sit-to-Stand Lifts. These facilitate the patient's transition from sitting to standing positions.
Mechanical Lift. Particularly useful for patients who are either fully immobile or overweight, this device helps in relocating them.
Splints. Employed to immobilize limbs in cases of fractures or sprains. Ensure there is finger-width space between the splint and the skin and monitor blood circulation in the nail bed as previously described. For arm splints, elevation can minimize swelling.
Medical Traction Equipment. A system of weights and pulleys designed to provide spacing or alignment for bones or joints.
Braces. Used to provide support and alignment for various body parts, common types include neck, back, and elbow braces.
Medical Devices to Promote Circulation
Compression Socks. These firm, reinforced socks are designed to prevent blood stagnation and edema. The degree of compression should be gradually adjusted to assess patient/client tolerance.
Intermittent Pneumatic Compression (IPC). This system consists of air cuffs wrapped around the legs to apply pressure, thereby preventing edema and stimulating circulation.
Blood Circulation Machine for Arms or Legs. These devices employ repetitive movements to stimulate blood circulation in the extremities.
Medical Devices to Manage Skin Integrity
Pillows and Wedges. Utilized for body alignment and pressure distribution, these aids help vary body positions to disperse weight at different pressure points.
Chair Cushions. Especially useful for wheelchair users who are prone to bedsores, these cushions alleviate body weight pressure on the ischium and mitigate the risk of ulcers.
Mattresses Toppers. Also known as bed covers or Egg Crate covers, these provide an extra layer for skin care (Mansouri, 2023).
Soft Mattresses. Recommended for minimizing skin pressure, these mattresses are more effective than their orthopedic counterparts for this purpose.
Air Mattress. Serving as a pressure-relief mechanism, these mattresses are designed to reduce the body weight's impact on pressure points.
Alternating Pressure Mattresses. These advanced mattresses are engineered to periodically shift the distribution of body weight, offering an additional level of pressure relief.
Recalling the initial example of the patient who underwent shoulder surgery, it is now evident that his temporary state of immobility can induce emotional distress and impact both his quality of life and overall health. At the same time, learners should understand that this condition can be holistically managed. It can be evaluated, monitored, and most importantly, mitigated through proper intervention. A skilled nurse can implement any of the interventions discussed in this unit to provide the necessary comfort and expedite the healing process for underlying conditions. Meticulous attention to detail in detecting and treating any skin lesions is also a vital component of exceptional nursing care, one that facilitates quicker recovery, rehabilitation, and functional maintenance. Involving the family to establish a robust support network will undoubtedly yield significant benefits in patient care.
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