Patient mobility Range of Motion exercises Pressure Area

Patient mobility, Range of Motion exercises, Pressure Area Care Revised and edited March 2012 Michele Archdale References: Tabbner’s Nursing Care 5 E 2009

Why is positioning important? • Good posture achieved when the body is in correct alignment • Prevent contractures: characterized by flexion & fixation & caused by atrophy & shortening of muscle fibers or by loss of normal elasticity of the skin • Prevent injury / Ulcers Pressure Sores – tissues are compressed, decreased blood supply to area, therefore, decreased oxygen to tissue & cells die. • • Stimulate circulation Promote lung expansion Relieve pressure and joint tightness Comfort & pain relief

Moving & Positioning • Mobility – persons ability to move about freely. • Immobility – person unable to move about freely, all body systems at risk for impairment. • It is important to maintain proper body alignment for the patient at all times, this includes when turning or positioning the patient. – Aim – least possible stress on patient’s joints & skin. Maintain body parts in correct alignment so they remain functional and unstressed. – Patients who are immobile need to be repositioned every 2 hrs. (2/24)

Application of proper body mechanics “By applying the nursing process and using the critical thinking approach, the nurse can develop individualized care plans for clients with mobility impairments or risk for immobility. A care plan is designed to improve the client’s functional status, promote self care, maintain psychological well being, and reduce the hazards of immobility. ” (Potter and Perry, 2006)

Moving & Positioning: Nursing Process • Assessment • • Comfort level & alignment while lying down Risk factors - Ability to move, paralysis Level of consciousness Physical ability/motivation Presence of tubes, equipment Wounds Pain • Nursing Diagnosis • Defining characteristics from the assessment – Activity intolerance – Impaired physical mobility – Impaired skin integrity

Nursing Process (cont. ) • Planning • Know expected outcomes – good alignment, increased comfort • Raise bed to comfortable working height • Remove pillows & devices • Obtain extra help if needed • Explain procedure to client • Gather necessary equipment • Multitasking – wash at same time?

Nursing Process (cont. ) • Implementation Offer pain relief as necessary • Consult care plan • Wash hands • Close door/curtain • Put bed in flat position • Move immobile patient up in bed • Realign patient in correct body alignment (pillows etc. ) •

Nursing Process (cont. ) • Evaluation • Assess body alignment, comfort • Ongoing assessment of skin condition • Use of proper body mechanics (nurse)

Tips for positioning the patient • After turning – use aids i. e. pillows, towels, washcloths, blankets, sandbags, footboards etc. • Joints should be slightly flexed b/c prolonged extension creates undue muscle tension & strain • Supine

Types of Positions • • • Supine (dorsal recumbent) Prone (anterior recumbent) Semi-recumbent lateral Sim’s Coma Dorsal Lithotomy Genupectoral (knee-chest) Orthopnoeic; Dorsal Recumbent

A= supine B= prone C= semi recumbent D= lateral E= Sim’s F= Coma G= Dorsal H= lithotomy I= Genupectoral

Orthopnoeic

SUPINE • • • Flat on back, pillow under head Limbs – normal alignment Pillow if needed to maintain normal position of feet Relaxation of abdo muscles Relieves tension on abdo area Several hours after lumbar puncture to facilitate normal circulation of CSF; helps to prevent severe headache Low or flat pillow (prevents neck flexion) Trochanter role (supports hip joint prevents external rotation) Hand roll – used if hands are paralyzed (thumb & fingers flexed around it) High top sneakers, foot board, sandbags (support feet with toes pointing upward. Prolonged plantar flexion leads to foot drop (permanent plantar flexion & inability to dorsiflex)

• Disadvantages: – Restriction of chest expansion – complications – Difficulty toileting – retention – Loss of independence – depression – Increased work of heart – lying flat increased venous return (preload) – Pressure necrosis of skin • Occipital- may be assessed. • Sacral – pressure sores • Heels – a special & serious risk in diabetic pts – Postoperative backache • Use of a lumbar support may be beneficial

Prone – anterior recumbent • Head supported on small pillow • Lies on abdo- pillow to ensure natural curve of the spine & relieves pressure on breasts • Pillow may be placed under ankles or toes extended over mattress • Comfortable positioning of arms

• Use support to protect pressure points, toes and feet as done in this picture.

• To relieve pressure on posterior surface of the body – promote healing & relieve pain e. g. burn, ulcer. • Provision of access to posterior surface of body. • Promote drainage from respiratory tract – elevation of foot end of bed?

• Disadvantages • • Restriction of chest expansion – complications Loss of independence – depression Difficulty with ADL’s – eating drinking toileting etc. Counter indicated with spinal cord problems.

Prone Position 2 • Airway, airway!!! • Pressure points – Ladies’ breasts – Men’s genitailia

Semi-recumbent • Lies on back • Three – four pillows supporting head, neck and shoulders • No specific indications – may be comfort only related.

LATERAL • Lies on side head supported with a pillow. • Arms in front of the body – supported with pillows. • Legs flexed or extended. • Pillows along the back and or between knees. • Even if paralyzed on one side a patient can be placed on that side. Take care not to pull on the affected extremity.

• Left lateral – examination / treatment invoving rectum. • Lumbar puncture – spine flexed. • Unconscious client – promotes maintenance of clear airway. • Prevents oral secretions entering trachea.

• Pressure problems – The skin below the iliac crest is at risk – The underlying deltoid can suffer ‘crush syndrome’ – The underlying sciatic nerve is at risk in emaciated pts – Axillary support is essential to protect the underlying brachial plexus

Sims Position • Not used frequently. • Can be used for vaginal examination – perhaps less embarrassing. • Upper leg drawn towards chest, buttocks towards edge of bed. • Lower arm placed behind client. • Upper arm in front. • Pressure points are different from other positions, i. e. supine, thereby preserving skin integrity.

Coma • Basically Sim’s position but without a pillow under the head. • Correct positioning of head essential for clear airway – pillow may impede breathing. • Temporary position during unconsciousness – e. g fainting. • Prevents tongue / oral secretions from obstructing trachea.

• Disadvantages – prolonged use – Restriction of chest expansion – complications – Postural deformities – contractures – Prolonged pressure on arm & shoulder placed behind client– damage to brachial plexus.

Dorsal • • Lies on back – knees flexed and apart. Soles of feet flat on bed. Head supported by a pillow. Indications: – Insertion of urinary catheter. – Vaginal examination – Enema / rectal suppositories if unable to assume left lateral position.

• Variation to dorsal – lithotomy – Gynaecological exam – Birthing • Disadvantages – Embarrassing – Nervous system complication • Straight leg sling system may cause nerve problems – Compartment syndrome - This can result from undue pressure on the calf muscles – Increased intra-abdominal pressure enhances the possibility of gastric regurgitation

Genupectoral • Knee – chest, client kneeling • Indications: – Specific examination of lower colon to facilitate insertion of instruments. – Management of specific obstetric emergencies. • Disadvantages: – Uncomfortable – Embarrassing – Difficult to maintain – Could result in dizziness, fainting and falling.

Sitting positions

– There are three variations of a sitting position: • The semi-upright, or semi-Fowler's, position, in which the client sits at an angle of about 30 degrees, supported by pillows, which are placed against the backrest of the bed • The upright, or Fowler's, position, in which the client is in a full sitting position, with pillows placed to support the upper body • The orthopnoeic position, in which, from an upright position, the individual leans onto an over-bed table

– A particular one of these sitting positions may be indicated: • After abdominal or thoracic surgery. Less tension is exerted on an abdominal wound, therefore comfort is promoted. Drainage by gravity from body cavities is facilitated (e. g. when there has been a drainage tube inserted after surgery) • To facilitate breathing and reduce dyspnoea. Because the diaphragm is able to flatten, maximal chest expansion is promoted and the risk of lung congestion is decreased. Leaning forward, as in the orthopnoeic position, helps to increase lung capacity and therefore alleviate distressed breathing • To facilitate independence, as a sitting position enables the client to see and participate in ward activities. The activities of daily living (e. g. eating and drinking or using toilet utensils) are also facilitated in this position. – The disadvantages of a sitting position include: • Difficulty maintaining the position, which may become tiring or uncomfortable • Difficulty in sleeping • Prolonged pressure on the buttocks and sacral area, which increases the risk of decubitus ulcers • Difficulty maintaining a comfortable body temperature: in cold weather it may be hard to bring the bedclothes up to the shoulders, while in hot weather the client may experience discomfort from the number of pillows required to maintain a sitting position.

Other positions - Trendelenberg

• In the Trendelenburg position the body is laid flat on the back with the feet higher than the head by 15 -30 degrees, in contrast to the reverse Trendelenburg position, where the body is tilted in the opposite direction. • This is a standard position used in abdominal and gynaecological surgery. It allows better access to the pelvic organs as gravity pulls the intestines away from the pelvis.

Clients in Bed • Evaluate Comfort After Positioning for Alignment • Check for tubes, equipment, bed creases • Reposition 2 hrly • Use Repositioning for effective ROM • Use Supportive Devises for Positioning

Patient mobility Encourage independence at all times Assess client Physio input? Attitudes play a part – socio-economic status, upbringing Provide information & support Functional decline associated with disuse. Being fit makes it easier to perform daily activities & improves recovery after illness. • Prevalence of obesity – current trends 1 in 3 obese • Obesity – leads to severe health problems • Nurses role in education and encouragement. • •

Types of Range of Motion • Nurses may need to assist and encourage ROM exercise when activity is limited. – Active Range Of Motion – Passive Range Of Motion – Active Assistive Range of Motion (We assist patient) • ROM is the extent of movement that a joint is normally capable of.

ROM Goals • To keep patient in the best physical shape possible. • To increase joint mobility. • To increase circulation to the affected part.

Assessing Joint Mobility • The ROM is appropriate to each joint.

Precautions with ROM – Infection or inflammation around a joint. – Pain – Osteoporosis – Arthritis

Limitations Swelling, tenderness & pain are among factors that limit ROM.

Passive ROM • The patient is unable to move independently and someone else manipulates body parts.

Active-Assistive ROM • The nurse provides minimal support as the patient moves through ROM.

Active ROM • The patient moves independently through a full ROM for each joint.

Hip ROM • Hip ROM includes flexion, extension and lateral & external rotation • Adduction & Abduction

Hand Movements (ROM) • ROM in wrist includes flexion, extension. • ROM in hands include abduction, adduction, flexion, extension, opposition and circumduction of the thumb.

Restraints • Device used to immobilize a client or an extremity • A temporary means to control behavior • Restraints are used to: • Prevent falls & wandering • Protect from self-injury (pulling out tubes) • Prevent violence toward others • Restraints deprive a fundamental right to control your own body. • While restraint-free care is ideal, there are times that restraints become necessary to protect the patient & others from harm. • Highly agitated, violent individual – Physical/Chemical restraints • Intubated patient – pulling out endotracheal tube • Suicide patient - ? Chemical restraints

Goals of Restraint Use • To avoid the use of restraints whenever possible. • Encourage alternatives • Family member to sit with patient • Geri chair vs. bed • Consider restraints as a temporary measure – decrease likelihood of injury from restraint use. • Remove restraints as soon as the patient is no longer at risk for injury. • Trial periods of removal of restraint.

Use of Restraints Review organisational policy. Use only when absolutely necessary. Least restrictive measure. Attending physician is responsible for the assessment, ordering & continuation of restraint. • Can be instituted on your nursing judgment – must have a doctors order ASAP. • Continued use of restraints must be reviewed daily by the RN & documented on the health record. Will require 1/24 monitoring / restraint chart. – Always explain what you do & why, to reduce anxiety & promote cooperation. • •

Complications assoc. with restraints • Hazards of immobility • Pressure sores, pneumonia, constipation, incontinence, contractures, decreased mobility, decreased muscle strength, increased dependence • Altered thought processes • Humiliation, fear, anger & decreased self-esteem • Strangulation • Compromised circulation • Lacerations, bruising, impaired skin integrity • Must release restraint every 1 - 2 hours for assessment & ROM

Physical Restraints – device that limits a clients ability to move • Side rails – stop patient from rolling out, but does not stop them from climbing out – side rail down when working on that side. • Jackets & Belts – patient who is confused & climbing over rails may need a jacket or belt to restrain them to bed. Sleeveless with cross over ties, allows relative freedom in bed. • Arm & Leg – Undesirable, limits patients movement, injury to wrist/ankle from friction rubbing against skin – use extra padding. Restrain in a slightly flexed position, if too tight could impair circulation. Never tie to a bed rail.

Suggestions to promote restraint minimisation Reducing risk of wandering • Bed, chair or wrist alarms • Exit door alarm • Electronic movement sensors • Planned night-time activities for those who wander at night • Daytime recreational and social activities • Activity areas at the end of each corridor Reduce incidence of agitation and aggression • Easy access to safe outdoor areas • Structural design of units modified to enhance visibility of residents • Rocker and recliner chairs • Outlets for industrious or anxious behaviour; for example, physical, occupational and recreational therapies • Soothing music • Diversions such as television or radio (adapted from Joanna Briggs Institute 2002 b) (Funnell, Rita. Tabbner's Nursing Care, 5 th Edition. Elsevier Australia, 12/1/2008. p. 373). <vbk: 978 -0 -7295 -3857 -2#outline(26. 7. 2)>

Forms of restraint, in order of restrictiveness • • • Restricting body extremities; for example, securing hands, wrists or ankles to the arms or legs of a chair or to bed rails, using body restraining vests Restricting body movements by other means; for example, safety belts or vests Restricting movement in the environment by secluding a client in a dedicated seclusion room. Restricting movement in the environment by restriction within a ward or unit Restricting activities of daily living; for example, selection of preferred foods, television programs, social activities or choice of visitors or people to meet or socialise with Denial of purposeful or meaningful activities, such as access to preferred leisure or work pursuits Restricting choice of treatment; for example, in some cases people with mental health, intellectual or cognitive impairment are given treatment not of their choosing that is mandated by the legal system (courts) Restricting access to personal belongings; for example, use of own money Restricting the expression of personal feelings or views; for example, censoring expressions of emotion (expressions of anger or frustration may be controlled and vocabulary normally used may be censored, e. g. swearing). This form of restriction and control is more common in mental health nursing than in other areas (adapted from Olsen 1998)

Supporting Documentation • Rationale for the use of restraints, including a statement describing the behavior of the patient. • Previous unsuccessful measures or the reason alternatives are not feasible. • Decision to restrain with the type of restraint selected and date & time of application. • Observations regarding the placement of the restraint, its condition and the patient’s condition, including the frequency of observation (not just at the end of your shift) • Assessment of the need for ongoing application of restraint. • Care of the patient which may include re-positioning, toileting, mobilization and/or skin care