Chapter 6 Rest and Exercise - Shandong University
Chapter 8 Rest and Exercise
Rest and exercise are basic human needs. Proper rest and exercise are of great importance to both people with physical fitness and people with illness, which can relieve tiredness and pain and promote comfort and recovery. Nurses should assist clients with rest and exercise properly, which demands that nurses should master the purposes, conditions and measures of rest and exercise, and find out and resolve problem existing in rest and exercise process of clients as well.
Section 1 Rest
Rest is important to one’s physical and mental health, which can make clients relax, refresh and relieve mental stress. Without rest and sleep, the ability to concentrate, make judgments, and participate in daily activities decreases while irritability increases, even immunity declines and trigger diseases. When a person becomes ill, increased rest and sleep are often required for normal recovery. However, the nature and implications of an illness may prevent the client from gaining adequate rest and sleep. Hospitalized clients must face the problem of inadequate rest and sleep as a result of the routines heath care personnel follow. Unpredictable scheduling and the hectic-paced environment of a hospital make it difficult for clients to sleep.
To help a client gain needed rest and sleep, a nurse must understand the nature of sleep, the factors influencing it, and each client’s unique sleep habits. Each client requires an individualized approach. A nurse’s interventions can be effective for short- and long-term sleep disturbances.
Rest
A person at rest feels mentally relaxed, free from anxiety, and physically calm. Rest is a state of decreased mental and physical activity that leaves a person feeling refreshed, rejuvenated, and ready to resume the activities of the day.
Benefits of Rest
Rest is crucial to maintain physical and mental health, which can promote clients to recovery from diseases. To be specific, the benefits are as follows:
Rest can relieve tiredness and stress
Rest can maintain the normality of physiological regulation.
Rest can promote development of body.
Rest can decrease exhaustion of energy.
Rest can promote protein synthesized and tissues rehabilitated.
Conditions of Thorough Rest
Each person has personal habits for gaining rest such as reading a book, practicing a relaxation exercise, or taking a long walk. Physical inactivity such as bed rest does not always imply a state of rest because such a client may have emotional worries that prevent complete relaxation.
The rest and sleep habits of clients entering a health care facility can easily be changed by illness or disturbances within the health care environment. Illness may have already caused a sleep disturbance. The nurse plays an important role in understanding the causes of sleep disturbances and helping clients to learn the value of rest and ways to promote it at home or in the health care environment. Conditions that promote proper rest include the following:
1.Physical comfort
a. Eliminating sources of physical irritation
Keeping sheets dry and smooth
Providing frequent mouth care
b. Controlling sources of pain
Providing analgesics before pain becomes severe
c. Providing warmth
Controlling room temperature
Offering extra blankets
d. Maintaining hygiene
Keeping the skin clean and dry
Providing dry clothing
e. Maintaining proper anatomical alignment or positioning
Turning frequently
Supporting painful extremities
2. Freedom from worry
a. Making decisions
Asking a neighbor to pick up medications from a pharmacy
Choosing not to attend a social event
b. Participating in personal health care
Following a daily exercise routine
c. Gaining an understanding of health problems and their implications
Attending a support group
d. Practicing restful activities regularly
Reading a book nightly
3. Comfortable environment
a. Removing environmental distractions
Closing room doors
b. Providing adequate ventilation
c. Knowing the environment is safe
Installing dead bolt locks and an outdoor lighting system for the home
4. Sufficient sleep
a. Obtaining average hours of sleep needed to avoid fatigue
Going to bed at a regular hour
b. Following good sleep hygiene habits
Avoiding intake of caffeine before bedtime
Sleep
Sleep is a recurrent, altered state of consciousness that occurs for sustained periods, restoring a person’s energy and well-being. Fordham (1998) defines sleeping in two ways: first as a discrete state of reduced responsiveness to external stimuli, from which a person can be aroused; second as a continuous cyclical change in level of consciousness. These definitions help explain why people occasionally have problems with the state of sleep or with the scheduling of sleep, and sometimes with both (Hodgson, 1991).
Physiology of Sleep
Sleep is a set of complex physiological processes resulting from the interaction of many different neurochemical systems within the brain and associated with changes in the peripheral nervous, endocrine, cardiovascular, respiratory, and muscular systems. Each sequence can be identified by specific behaviors, physiological responses, and patterns of brain activity. Sleep is a cyclical phenomenon.
Sleep regulation
A single cause for sleep has not been discovered. The control of sleep is not confined to one localized part of the brain (Hodgson, 1991). Instead many different neurochemical systems interact within the brain to regulate sleep. Areas of the brain believed to influence sleep control are the reticular activating system (RAS) located in the upper brainstem and the bulbar synchronizing region (BSR) in the pons and medical forebrain. These systems are believed to work together, alternately activating and suppressing the brain’s higher centers to control sleep.
The RAS is believed to contain special cells that maintain alertness and wakefulness. The RAS receives visual sensory input and auditory, pain, and tactile stimuli. Activity from the cerebral cortex (e.g., emotions) also stimulates the RAS. Biddle and Oaster (1990) suggest that wakefulness results from neurons in the RAS releasing neurotransmitters such as norepinephrine, dopamine, and GABA (gamma-aminobutyric acid). Biddle and Oaster (1990) write that sleep is a complex intertwining of the central nervous system, its neurotransmitters, and a person’s behavior.
Sleep may be produced by the release of serotonin from specialized cells in the BSR. Whether a person stays awake or falls asleep depends on a balance of impulses received from the cerebral cortex (e.g., thoughts), peripheral sensory receptors (e.g., sound or light) and the limbic system (emotions).
As a person begins to fall asleep and relax, stimuli to the RAS decline. If the room is generally dark and quiet, activation of the RAS further declines. At some point the BSR takes over, causing a person to fall asleep.
Stages of Sleep
Sleep involves two phases: nonrapid eye movement (NREM) and rapid eye movement (REM) sleep (see box on p.722). During NREM a sleeper progresses thorough four stages during a typical sleep cycle. These stages do not occur once but cycle back and forth several times during the course of sleep (Hodgson, 1991). At the end of each NREM phase, REM sleep typically occurs. Various factors interfere with the sleep stages. The nurse learns to choose therapies that foster sleep or attempts to eliminate factors that can disrupt sleep.
Sleep Cycle
The normal adult sleep pattern begins with a presleep period during which the person is aware only of a gradually developing drowsiness. Presleep usually lasts 10 to 30 minutes, but if a person has trouble falling asleep, it may last more than 1 hour.
Following presleep, the first 90 minutes or so of human sleep is characterized by NREM, with a person moving progressively through four stages into a deep sleep. As a sleeper progresses through NREM sleep, the quality of sleep becomes increasingly deep. Light sleep is characteristic of stages 1 and 2, and a person is easily arousable. Stages 3 and 4 involve a deeper sleep. After reaching stage 4, the sleep pattern reverses back from stage 4 to 3 to 2, ending with a period of REM sleep. During REM the sleeper is very difficult to arouse.
With each full sleep cycle, stages 3 and 4 shorten, and the period of REM lengthens. REM sleep may last 30 to 60minutes during the last sleep cycle. If a person awakens from sleep during any stage, sleep begins again at stage 1. Consistent interruption in the sleep cycle can ultimately lead to sleep deprivation.
Not all people progress consistently through the sleep stages. The amount of time spent in each stage also varies. The number of sleep cycles depends on the total amount of time a person sleeps.
Table 6-1 Sleep Cycle Stages
|Stages |Characteristic |
|Stage1: NREM |The lightest level of sleep |
| |Lasts a few minutes |
| |Physiological activity decreases, vital signs fall gradually and metabolism begins to slow down |
| |People easily aroused by sensory stimuli such as noise |
| |If person awakes, feels as though daydreaming has occurred |
| |Reduction in autonomic activities (e.g., heart rate) |
| |Period of sound sleep |
|Stage2: NREM |Relaxation progresses |
| |Arousal is still easy |
| |Lasts 10 to 20 minutes |
| |Body functions still slowing |
| |Initial stages of deep sleep |
|Stage3: NREM |Sleeper difficult to arouse and rarely moves |
| |Muscles completely relaxed |
| |Vital signs decline but remain regular |
| |Lasts 15 to 30 minutes |
| |Hormonal response includes secretion of growth hormone |
| |Deepest stage of sleep |
|Stage4: NREM |Very difficult to arouse sleeper |
| |If sleep loss has occurred, sleeper will spend most of night in this stage |
| |Restores and rests the body |
| |Vital signs significantly lower than during waking hours |
| |Possible sleepwalking and enuresis |
| |Hormonal response continues |
| |Stage of vivid, full-color dreaming (less vivid dreaming may occur in other stages) |
|REM Sleep |First occurs approximately 90 minutes after sleep has begun, thereafter occurs at end of each NREM |
| |cycle |
| |Typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and |
| |increased or fluctuating blood pressure. |
| |Loss of skeletal muscle tone |
| |Responsible for mental restoration |
| |Stage in which sleeper is most difficult to arouse |
| |Duration increasing with each cycle and averaging 20 minutes |
Figure 6-1 The stages of the adult sleep cycle
Awakeness
NREM Stage 1 NREM Stage2 NREM Stage3 NREM Stage4
REM
NREM Stage2 NREM Stage3
Normal Sleep Requirements and Patterns
Sleep duration and quality vary among age-groups. One person may function well with 4 hours of sleep, whereas another requires 10 hours.
Neonates
The neonates average 16 hours of sleep daily with a range of 10 to 23 hours. Each sleep cycle lasts generally 40 to minutes. And after one to two cycles, they wake up. For the first week they sleep nearly all the time. Approximately 50% of this sleep is REM sleep, which is important for the development of the higher brain centers. So, it is essential for the neonates.
Infants
In contrast with newborns whose sleep and wakefulness alternate throughout the whole day and night, by 3 to 4 months of age the infant usually develop nighttime pattern of sleep. Infant may take several naps daily but usually sleeps an average of 8 to 10 hours during the night. Breast-fed infants usually sleep less, with frequent waking, than a bottle-fed infant. An infant between 1 month and 1 year of age sleeps an average of 14 hours daily with REM sleep predominating (30%).
Toddlers
By age 2, children usually sleep through the night and take daily naps. Total sleep averages 12 hours daily. Daily naps are common but cease at 3 years.
Preschoolers
Child averages 12 hours of sleep nightly and rarely takes naps. Preschooler has difficulty relaxing or quieting down after an active day. A preschooler has problems with bedtime fears, waking during the night, or nightmares. Bedtime rituals help parents to get active preschoolers to bed.
School-age children
Amount of sleep required varies by state of activity and level of health. Naps are usually not required. Older children may resist sleeping because of an unawareness of fatigue or a need to be independent. 90-minute adult sleep cycle is in place. Child will be tired the following day if allowed to stay up later than usual.
Adolescents
Adolescent averages 8 to 9 hours of sleep nightly. Because of staying up late, an adolescent often sleeps late in the mornings. Rapid physical growth and an active life-style can cause fatigue.
Young adults
Adult requires rest and sleep but busy life-style may interrupt sleep pattern. Young adults average 6 to 81/2hours of sleep nightly. Stress often leads to use of medications, but their long-term use disrupts sleep patterns and causes other health problems.
Middle adults
Total time spent sleeping at night begins to decline with the amount of stage 4 NREM sleep falling. Sleep disturbances are common and generally caused by anxiety, depression, or certain physical ailments. Women with menopausal symptoms may experience insomnia.
Older adults
The total amount of sleep does not change as age increases, but this is due to an increase in time asleep during daily naps. The need for increased rest occurs earlier than the need for increased sleep. Duration of nighttime sleep declines with shortening of REM sleep and a decrease in stage 3 and 4 NREM sleep. Older adults awaken more during the night and often take more time to fall asleep. Changes in the CNS, sensory impairment, and chronic illnesses influence an older adult’s sleep pattern.
Factors Affecting Sleep
Sleep is not always easy to attain. Factors that promote sleep in one person may hinder sleep in another. Physiological and psychological factors may alter the quality and quantity of sleep.
Age
See sleep requirements of different age-groups.
Physiological factors: Circadian Rhythms
Each person’s life is a series of cyclical rhythms influencing and regulating physiological function and behavioral responses. The most familiar rhythm is the 24-hour, day-night cycle known as the diurnal or circadian rhythm. The fluctuation and predictability of body temperature, heart rate, hormone and electrolyte secretions, and mood depend on the circadian cycle. Another rhythm is woman’s menstrual cycle, an infradian rhythm (loner than 24 hours). Biological cycles lasting less than 24 hours are called ultradian rhythms.
Circadian rhythms, including daily sleep-wake cycles, are most affected by light and temperature; other stimuli such as social and occupational habits can also be influential. All people have biological clocks that synchronize their sleep cycle. People have different preferred sleep times and function best at different times of the day. Hospitals or extended-care facilities often fail to adapt care to an individual’s preference for sleep. If a person’s sleep-wake cycle is altered significantly, poor quality sleep results. Reversals of the sleep-wake cycle can signal serious illness.
The biological rhythm of sleep frequently becomes synchronized with other bodily functions such as body temperature. When a person’s sleep-wake cycle changes (e.g., by rotating job shifts), numerous physiological functions may also change.
Physical illness
Pain or physical discomfort results in difficulty falling or staying asleep. Chronic pain may have a circadian rhythm of increasing intensity at night, thus disrupting sleep. Illness may force clients to sleep in positions to which they are unaccustomed. Respiratory diseases interfere with the rhythm of breathing or influence the position a person must assume to breath easily. Both factors can disturb sleep. Clients with heart disease are often afraid to go to sleep at night. Hypertension causes early morning awakening and fatigue. Nocturia and “restless leg syndrome” disrupt sleep, causing clients to awaken during the night and often result in difficulty resuming sleep. Conditions that increase intracranial pressure or later central nervous system physiology alter sleep patterns and can cause excessive day-time sleeping.
Environment
Environment factors influence the ability to fall and remain asleep. Significant factors include ventilation, lighting, type of bed, sound level, and the presence or absence of a bed partner. In hospitals, unfamiliar noises and higher noise levels such as that created by wall suction, opening packages, ringing alarms, and flushing toilets can cause sleep deprivation. Intensive care units are sources for high noise levels.
Drugs and substances
Various drugs and substances affect the pattern and quality of sleep. Older adults often take several drugs, the combined effects of which disrupt sleep. L-Tryptophan, a protein found in foods such as milk, cheese, and meats, may help induce sleep.
Table 6-2 Drugs and their effects on sleep
|Drugs |Effects on sleep |
|Hypnotics |Interfere with reaching deeper sleep stages |
| |Provide only temporary (1 week) increases in quantity of sleep |
| |Eventually cause “hangover” during the day: excess drowsiness, confusion, |
| |decreased energy |
| |May worsen sleep apnea in older adults |
| |Decrease stages 2, 4, and REM sleep |
|Valium |Decrease awakenings |
| |Cause nocturia |
|Diuretics |Suppress REM sleep |
|Antidepressants and Stimulants |Reduce total sleep |
| |Speeds onset of sleep |
|Alcohol |Disrupts REM sleep |
| |Awakens person during the night and causes difficulty in returning to sleep |
| |Prevents person from falling asleep |
| |May cause person to awaken during night |
|Caffeine |Cause nightmares |
| |Cause insomnia |
|Beta-Adrenergic Blockers |Cause awakening from sleep |
| |Cause nightmares |
| |Suppress REM sleep |
|Digoxin |If discontinued quickly, can increase risk of cardiac dysrythmias because of |
|Narcotics |“rebound REM” periods |
| |Cause increased awakenings and drowsiness |
Stress
Stress resulting from personal problems or situational crises causes tension and may cause a person to try too hard to fall asleep, to awaken frequently, or to oversleep. Stress causes release of corticosteroids and adrenalin, which leads to catabolism and sleeplessness. Clients with advanced cancer or chronic illness often are afraid to sleep in case they might die. Older clients experience losses such as retirement or death of death of a loved one. Thus older adults can suffer delays in falling asleep, earlier REM sleep, frequent awakening, increased total bed time, and feeling of sleeping poorly.
Food and caloric intake
Good eating habits is important for proper heath and sleep. If people eat a large, heavy, and spicy meal at night, they may indigest and have poor sleep. Consuming caffeine and alcohol in the evening may lead to insomnia. It is an important strategy to improve sleep that people reduce or avoid these substances drastically. Food allergies may cause insomnia. In infants, a milk allergy may cause nighttime waking and crying or colic. Corn, wheat, nuts, chocolates, eggs, seafood, red and yellow food dyes, and yeast are other foods that often cause an insomnia-producing allergy among both children and adults. If the particular food causing the difficulty has been eliminated from the diet, people can restore normal sleep after 2 weeks.
Weight loss or gain also influence sleep patterns. When people gain weight, sleep periods become longer with fewer interruptions. On the other hand, weight loss can lead to short and fragmented sleep.
Life-style
Daily routines such as working rotating shifts influence sleep patterns. Only after several weeks of working a night shift does a person’s biological clock adjust. Performing unaccustomed heavy work, late-night social activities, and changing evening mealtimes are activities that can disrupt sleep.
Exercise and fatigue
Exercise and fatigue in moderation usually facilitate restful sleep, but excess fatigue from exhausting or stressful work can make falling asleep difficult. Exercise 2 hours before bedtime allows the body to cool down and promotes relaxation.
Sleep Disorders
Sleep disorders are conditions that repeatedly disrupt a person’s pattern of sleep. They are common among clients. Research shows that most adults have significant sleep debts from cumulative sleep losses. The best way to diagnose sleep disorders is by a nighttime polysomnogram, which uses electrodes to measure a sleeping client’s electrical brain waves (EEG), extraocular eye movements (EOG), and chin and facial muscle movements (EMG).
Insomnia
Insomnia is a symptom wherein a person has chronic difficulty falling asleep (initial insomnia), difficulty remaining asleep (intermittent insomnia), or inability to resume sleep after awakening (terminal insomnia). The client with insomnia complains of insufficient quantity and quality of sleep but usually sleeps more than he or she realizes. Insomnia can cause daytime sleepiness, fatigue, depression, and anxiety, and it may signal an underlying physical or psychological disorder.
Insomnia may be temporary as a result of situational crises (e.g, jet lag or illness) or may continue for years. It can develop at any age. Insomnia may recur, but between episodes the client is able to sleep well. A temporary case of insomnia, however, can lead to a chronic problem.
Insomnia is most commonly associated with poor sleep habits. If the condition continues, the fear of not being able to sleep can cause wakefulness. Because there are many causes of insomnia, management involves several approaches. First, it is important to treat underlying emotional or medical problems. Treatment is usually symptomatic, including improved sleep hygiene measures, biofeedback, and relaxation techniques. In drug dependence insomnia the client is unable to fall asleep because of excessive use of hypnotics. A gradual withdrawal of the drug should help.
Narcolepsy
Narcolepsy is a chronic, incurable dysfunction of REM sleep processes and of mechanisms regulating sleeping and waking states. During the day a person experiences excessive sleepiness. A person may suddenly feel an overwhelming wave of sleepiness and fall asleep, even in unusual situations such as while having a conversation. REM sleep can occur within 15 minutes of falling asleep. These attacks may occur 2 to 6 times a day and last for more than 30 minutes. Cataplexy is a symptom of narcolepsy involving a brief sudden loss of muscle control occurring during intense emotions such as anger, sadness, or laughter. This symptom may result in a client falling or collapsing. A client with narcolepsy may also have hallucinations just when falling asleep. The client may not know the difference between a dream and reality. Sleep paralysis, or the feeling of being unable to move or talk just before waking or falling asleep, is another symptom. Studies show a genetic link for narcolepsy.
The greatest problem with narcolepsy is falling asleep at inappropriate times. Attacks are most likely to occur in sedentary, unstimulating situations, such as watching television or driving. Persons suffering narcolepsy often have driving accidents. Unless a client and family understand the disorder, a sleep attack can easily be mistaken for laziness, lack of interest in activities, or drunkenness. A client with narcolepsy frequently experience psychosocial consequences that may affect interpersonal relations, vocation and educational endeavors, and marital and family relationships.
Combination drug therapy may help to control the symptoms of narcolepsy. Sleep attacks are treated with central nervous system stimulants such as Ritalin (methylphenidate) and Cylert (pemoline), which increase alertness and wakefulness and diminish the sense of fatigue. Brief daytime naps no longer than 20 minutes help reduce narcoleptic attacks. Factors that increase a narcoleptic’s drowsiness (e.g, liquor or exhausting activities) should be avoided. Following a regular exercise program, practicing deep breathing, eating light meals high in protein, taking vitamins and chewing gum, are other helpful management methods. Alcohol, heavy meals, exhausting activities, long-distance driving, long periods of sitting, and hot stuffy rooms increase a narcoleptic client’s drowsiness and they should be avoided.
Sleep Apnea
Sleep apnea is the cessation of breathing for a time during sleep. Apnea is the cessation of airflow through the nose and mouth for at least 10 seconds, resulting in a reduction in oxygen level of a person’s blood. A serious decline in arterial oxygen levels can create risks for cardiac dysrhythmias, right heart failure, angina, stroke, and hypertension. The most frequent time of naturally occurring death is between 4AM and 6AM, and some researchers believe sleep apneas are a cause. There are three types: central, obstructive, and mixed.
The most common form, obstructive sleep apnea, occurs when muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes blocked and nasal airflow stops. The person still tries to breathe because chest and abdominal movement continue. During apnea, each successive diaphragmatic movement becomes stronger until the obstruction is relieved. Structural abnormalities such as a deviated septum or enlarged tonsils can result in obstructive apnea. However, most clients with sleep apnea have anatomically normal airways.
Central apnea involves defects in the brain’s respiratory center. The impulse to breathe temporarily fails, and nasal airflow and chest wall movement cease. The condition is seen in clients with brain stem injury, muscular dystrophy, and encephalities. No treatment exists for central sleep apnea. Mixed sleep apnea involves a combination of decreased ventilatory drive and upper airway obstruction.
A person with sleep apnea typically snores. Obstruction of the upper airway may last as long as 30 to 60 seconds. The client rarely awakens. The client is also deprived of deep sleep periods. Complaints of daytime sleepiness, sleep attacks, fatigue, morning headaches, and decreased aex drive are common. Treatment includes therapy for underlying cardiac or respiratory complications and emotional problems. Sleep hygiene and weight-loss therapy can also help. One of the most effective therapies is use of a nasal continuous positive airway pressure (CPAP) device at night. CPAP requires a client to wear a mask over the nose. Room air is delivered through the mask at a high pressure, which keeps the airway open. In case of severe obstructive apnea, surgical removal of portions of the pharynx and palate may be attempted.
Sleep deprivation
Although not a true sleep disorder, sleep deprivation is a problem for many clients. It involves a decrease in the amount, quality, and consistency of sleep. When sleep becomes interrupted or fragmented, changes in the normal sequence of sleep stages occur, and cycles cannot be completed. Over time, cumulative sleep deprivation occurs in persons who receive “usual ” hours of sleep. Thus a person with insomnia may develop sleep deprivation. Sleep deprivation is a common problem for those who care for loved ones with advanced diseases at home. A care giver can experience serious sleep deprivation, as a result of circadian rhythms being disrupted over the long term.
A client’s response to sleep deprivation is highly variable. Clients may experience physiological symptoms such as hand tremors, decreased reflexes, showed response time, reduced word memory, and decreased reasoning and judgment. Other physiological effects include fall in body temperature, slight changes in cardiovascular and respiratory function, slight hormonal changes, and changes in control of eye movements and musculature. Psychological symptoms include mood swings, disorientation, irritability, decreased motivation, fatigue, sleepiness, hyperactivity and agitation. The severity of symptoms is often related to the duration of sleep deprivation. Causes may include illness, sleep disorders, emotional stress, aging, medications, environmental disturbances, and changes in sleep patterns. The most effective treatment for sleep deprivation is to eliminate or correct factors that disrupt the sleep pattern.
Other sleep disorders
Sleep problems common in children include some somnambulism (sleep walking), night terrors, nightmares, nocturnal enuresis (bedwetting), and bruxism (tooth grinding). When adults have these problems, it may indicate more serious disorders. Specific treatment for these disorders varies. However, in all cases, it is important to support clients and maintain their safety. For example, sleepwalkers are unaware of surroundings and are slow to react. Thus the risk of falls is great. A nurse should not startle sleepwalkers but instead gently awaken them and lead them to bed.
Characteristics of sleep in hospitalized clients
The nature and implications of an illness may prevent the client from gaining adequate rest and sleep. Hospitalized clients must face the problem of inadequate rest and sleep as a result of the routines heath care personnel follow. Unpredictable scheduling and the hectic-paced environment of a hospital make it difficult for clients to sleep. To be specific, changes of sleep pattern involve the following aspects.
Changes of sleep rhythm
Desynchronization of circadian rhythms
Changes of sleep quality
Sleep deprivation
Sleep assessment
The client is the best resource for a sleep assessment. The client can report the extent to which a sleep problem represents a change from normal. Parents are often the best source of information about children’s sleep problems.
Description of sleeping problems
When a client reports a sleep problem or shows behaviors suggesting a problem, the nursing history must be detailed. Open-ended questions help a client to describe a problem more fully. A general description of a problem followed by more focused questions usually reveal specific characteristics used in planning care. To begin, the nurse needs to understand the type of sleep disturbance and the nature of the problem. The following questions will ensure a complete assessment:
1.Nature of the problem---Tell me what type of problem you have sleeping. Tell me why you think your sleep is inadequate.
2.Signs and symptoms---Describe for me how easy it is to fall asleep. Tell me about the times when you awaken during the night. Tell me what your wife has said about your snoring. Are you tired or irritable during the day? Do you fall asleep at inopportune times? Describe how often you take naps during the day.
3.Onset and duration---Tell me about the time when you first noticed a problem with sleeping. How long has the problem lasted?
4.Severity---Describe how long it usually takes to fall asleep. How often during the week do you have trouble falling asleep? Tell me how many hours of sleep you got this week; compare that to normal.
5.Predisposing factor---Tell me what you do just before going to bed. Have you recently had problems at work or at home?
6.Effect on client—-Tell me how the loss of sleep has affected you? Ask a spouse, friend, or parent: what changes in behavior have you noticed since your spouse developed a sleep problem?
Normal sleep pattern
The nurse must gain an understanding of a client’s normal sleep pattern compared with the current reported sleep pattern. To determine a client’s sleep pattern, the nurse asks the following questions:
1.What time do you usually go to sleep?
2.How quickly do you fall asleep?
3.What is the average number of hours you sleep during the night?
4.How many times do you awaken at night?
5.When do you typically awaken in the morning?
6.Do you rise once you awaken or do you stay in bed?
Findings from the assessment are compared with the norm for the client’s age. The nurse begins to assess for identifiable patterns such as insomnia. It is important to recognize that hospitalized clients usually need or want more sleep as a result of illness, or they may require less sleep because they are less active. These changes can disrupt sleep patterns and lead to more serious problems.
Implementation
Health promotion
The ability to gain adequate rest and sleep is affected by many factors. In community health and home settings nurses help clients develop behaviors conductive to rest and relaxation, which may include suggesting them to change the environment or certain lifestyle habits. To develop good sleep habits at home, clients and their bed partners should learn ways to promote sleep and to avoid conditions that interfere with sleep. Parents can also learn good sleep habits to enforce with their children. Improved sleep habits will be reflected in how a person feels during work and play.
Clients benefit most from instructions that can easily be applied in their daily lives. Information about good sleep hygiene, the pratices that promote a sound, uninterrupted sleep cycle, should apply to the client’s personal routines. For example, a suggestion to exercise regularly, a few hours before bedtime, should be given to clients who return home in enough ime to do so. In contrast, suggestions for controlling noise may do little for the client who lives near a busy airport. The nurse must know the cient’s routines and preferences for sleep therapis to be effective. Suggestions for relaxing bedtime activities should include activities the client enjoys.
Environmental controls
All clients require a sleeping environment with a comfortable room temperature and ventilation, minimal noise, a comfortable bed, and proper lighting. The best room temperature is 18℃ to 22℃ in winter and about 25℃ in summer. Individuals also prefer different type of covers.
Distracting noise needs to be eliminated to make the bedroom as quiet as possible. If there are several family members, it may require the cooperation of them to reduce noise. But sometimes, the clients may be used to sleeping with familiar inside noises.
A bed and mattress should be safe, comfortable and wide enough. The height of pillows must appropriate. For some clients, the position of the bed in the room may also make a difference.
Clients vary in regard to the preferring amount of light at night. For infants and older adults, they sleep best in softly lit room. Additionally, this also reduces the chance of confusion and prevents falls enroute to the bathroom for older adults.
Promoting bedtime routines
Bedtime rituals relax clients in preparation for sleep. Newborns and infants sleep through so much of the day that a specific ritual is hardly necessary. However, quieting activities such as holding them snugly in blankets, singing or talking softly, and gentle rocking, will help infants fall asleep.
A bedtime ritual such as the same hour of bedtime or a quiet activity used consistently helps young children avoid attempts to delay sleeping. Toddlers and preschoolers may be too excited and full of energy to sleep. Parents should ignore attention-seeking behaviors and instead reinforce patterns of preparing for bedtime. Reading stories or sitting on the nurse’s lap while listening to music, are routines that can be associated with preparing for bed. Quiet activities such as coloring and reading work well for school-ages. A child should never be put to bed as punishment.
Adults should learn to follow normal bedtime routines as closely as possible. Physical exercise at least 2 hours before bedtime can promote sleep. Reading, watching television, or listening to music may also help. A client should not try to finish office work or resolve family problems before bedtime. It is usually best to associate the bedroom only with sleep. Working toward a consistent time for sleep and voiding before retiring helps most clients gain a healthy sleep pattern and strengthens the rhythm of the sleep-wake cycle.
In a hospital or health care facility, part of the bedtime ritual is assuring clients of their safety and well-being. A client should know that a nurse is available at all times. A call light should be placed within reach so the client may obtain assistance when needed.
Establishing periods of rest and sleep
In a hospital or extended-care setting it is hard to give clients the time needed for rest and sleep. However, the nurse schedules care activities to avoid awakening clients for nonessential tasks. The nurse can help by scheduling assessments, treatments, procedures, and routines for times when clients are awake. For example, if a client has been physically stable, the nurse may decide to avoid checking vital signs. Unless maintaining a drug’s therapeutic blood level is essential, drugs should be given during waking hours. When a client’s condition demands more frequent monitoring, the nurse can combine activities (such as dressing changes, specimen collection, and IV assessment) to allow for extended rest periods. If the nurse plans to check the client or the room equipment, it helps to make sure the path to the bed is uncluttered so that tables and chairs will not be bumped.. It may also be necessary to limit the number of visitors. Although important to a client’s well-being, visitors may stay much too long and prevent a client from gaining needed rest.
In an intensive care environment the nurse uses monitors to check a client’s condition. To make sure monitors are valid, the nurse checks blood pressure using both cuff and monitor readings to acquire a baseline. The nurse can then track trends without awakening a client for vital sign assessment.
In the home, it may help to encourage clients to stay physically active during the day so they are more likely to sleep at night. Increasing daytime activity lessens problems with falling asleep. It is common for older adults to nap during the day.
Stress reduction
Emotional stress interferes with sleep. The inability to sleep can make clients irritable and tense. Forcing sleep may lead to insomnia and bedtime may become associated with inability to relax. A client who has difficulty falling asleep may find it helpful to get up and pursue a relaxing activity rather than stay in bed and think about sleep. Relaxation exercises can be useful in extending a person’s sleep period. Slow, deep breathing for 1 to 2 minutes induces calm. Rhythmic contraction and relaxation of muscles reduces tension and prepares the body for rest. Guided imagery, praying, and yoga may also promote sleep.
In health care settings nurses should take time to sit and talk with clients unable to sleep. This helps in determining factors keeping clients awake. Explaining procedures or answering questions may give clients needed peace of mind. If a sedative is indicated, the nurse confers with the physician to be sure the lowest dosage is used initially. Older adults can be vulnerable to the side effects of sedatives, hypnotics, or analgesics because the drugs are metabolized slowly.
For clients with chronic sleep problems such as sleep apnea and narcolepsy, it is important for nurses to assist clients and families in developing appropriate coping strategies. Uncomfortable social situations such as negative labeling of clients with narcolepsy may affect work or school success. The nurse can suggest ways for clients to improve study habits, facilitate employment choices, and achieve productivity. These may include stimulating environments, job choices in areas where there is less monotony, and employer or teacher education about the disorder. The nurse must also help clients find ways to retain their family relationships. The symptoms and treatment of sleep disorders may disrupt family unit. Marital counseling and child care referrals can prove helpful.
Children often have bedtime fears, awaken during the night, or have nightmares. After nightmares, parents should enter children’s rooms immediately and talk to them briefly about fears to calm them down. Children are comforted but left in their own beds. Their fears should not be used as excuses to delay bedtime.
Nutritional therapy
Some clients enjoy bedtime snacks, whereas others cannot sleep after eating. A perfect light snack includes a dairy product such as warm cocoa that contains L-tryptophan and a small serving of fruit or crackers. A full meal before bedtime can often cause gastrointestinal upset and interfere with the ability to fall asleep. Generally, clients should avoid spicy foods just before bedtime.
Clients with sleep apnea may benefit from a weight loss diet. The condition is more common in obese clients. The mechanism by which weight reduction improves the syndrome is unknown. It is known that small degrees of weight loss improve a client’s oxygenation and reduce daytime somnolence.
The ingestion of alcohol or stimulants such as caffeine before bedtime can affect the client’s sleep cycle. Caffeine impairs the ability to fall asleep and can cause cardiac dysrhythmias. Alcohol interrupts sleep cycles and reduces the amount of deep sleep. Caffeine drinks and alcohol act as diuretics and may cause a client to awaken in the night to void.
Administering sleep medications
Sleep medications can help a client if used short term. However, their long-term use can disrupt sleep and lead to more serious problems. Benzodiazepines, including flurazepam (Dalmane), temazepam (Restoril), triazolam (Halcion) and alprazolam (Xanax) are relatively safe. They do not cause general CNS depression like other sedatives or hypnotics do. The benzodiazepines create muscle relaxation, antianxiety, and hypnotic effects. The antianxiety effects usually occur at safe, nontoxic doses. The benzodiazepines are generally not available to children under 12 to 18 years of age, depending on the specific drug.
Pregnant clients should avoid benzodiazepines because of their association with the risk of congenital problems. Nursing mothers should not take the drugs because they are excreted in breast milk. Older adults should use caution in taking benzodiazepines.
One group of clients particularly at risk when taking sedatives are those with sleep apnea. These clients suffer sleep deprivation and may try anything for a night’s sleep. Sedatives and hypnotics can decrease ventilatory drive and worsen the apnea.
Clients benefit from knowing the risks of nonprescription sleeping medications, especially the long-term effects of sleep disruption. Behavioral therapy can often cure sleep problems more safely. Regular use of any sleep medication can lead to tolerance, withdrawal, and eventual rebound insomnia. Routine medical monitoring of any sleeping medication is important.
A client who takes sleep medications should know about risks and possible side effects. Nurses should caution clients against taking benzodiazepines with alcoholic beverages, opioid analgesics, or monoamine oxidase inhibitors (MAO) and tricyclic antidepressants to avoid CNS depression. Clients should learn to not take more than the prescribed dose if a drug seems less effective.
Promoting comfort
People fall asleep only after feeling comfortable and relaxed. Even minor irritants may cause wakefulness.
Newborns and infants should be put to bed in dry diapers and soft cotton nightclothes. Children and adults need loose-fitting nightwear and dry, unwrinkled bed linens. The nurse should remove any moist, wrinkled sheets or equipment that a client may lie on.
A client’s sense of comfort is also improved by personal hygiene at bedtime, such as dental and denture care, a warm bath or shower, and an opportunity for the bed-restricted client to wash the face and hands. At home, a client whose sleep is disturbed by the bed partner may need to temporarily sleep in another room.
When a sleep disorder results from a painful illness, the nurse should encourage the administration of analgesics at least 1/2 hour before bedtime. Application of dry or moist heat to a painful area may help to reduce inflammation or muscle tension and promote relaxation. Proper positioning also can be useful in eliminating stress on painful body parts, whereas a gentle backrub can ease muscle tension and aches. Measures designed to alleviate the client’s pain can promote restful sleep.
Controlling physical disturbance
The nurse can help clients control the symptoms of physical illness that disrupt sleep. For example, a client with respiratory problems should sleep with two pillows in a semisitting position in bed or sleep in a recliner chair to ease breathing. A client with a hiatal hernia also needs special care. After meals the client may have a burning sensation as a result of gastric reflux. To prevent sleep problems, the client should eat a small meal several hours before bedtime and sleep in a semisitting position.
Clients will not sleep if they are in pain or suffer from other recurrent symptoms. Symptom-relieving medications such as analgesics and antiemetics should be given so the drug’s peak action takes effect at bedtime. Analgesia can be provided during the night with use of controlled-release morphine. Often a client’s pain worsens at night because of fear, anxiety, and lack of distraction. The nurse can spend time offering information to alleviate the client’s fears before bedtime.
Section 2 Mobility and Exercise
Mobility is a person’s ability to move about freely, which is essential to the client. Mobility serves many purposes including expressing emotion, self-defense, attaining basic needs, completing activities of daily living, and performing recreational activities. In addition, mobility assists in maintaining the body’s normal physiological activities. Mobility facilitates pulmonary functioning and increases peripheral blood flow. Regular exercise contributes to healthy functioning of each part of body system. Mobility also influences self-esteem and body image. For most people, self-esteem depends on a sense of independence and a feeling of usefulness or being needed. At the same time, it also helps relieve stress and relax physically and mentally. To maintain normal physical mobility, the nervous, muscular, and skeletal systems of the body must be intact and functioning.
Types of Exercise
The best program of physical activity includes a combination of exercises that produce different physiological and psychological benefits. Exercises can be classified according to muscle contraction and body movement.
Muscle contraction Exercise may be categorized according to the type of muscle contraction involved as being isotonic, isometric or isokinetic.
Isotonic (dynamic) exercise involves muscle shortening and active movement. Examples of isotonic exercises are walking, swimming, dancing, jogging, bicycling, and moving arms and legs with light resistance. Isotonic exercise increases muscle tone, mass, and strength, improves joint mobility, increases cardiopulmonary function, increases circulation, and increases osteoblastic activity. During isotonic exercise, both heart rate and cardiac output were quickened to increase blood flow to all parts of the body. Little or no change on blood pressure occurs.
Isometric (static) exercises are those in which there is a change in muscle tension but there is no movement in muscle length and no muscle or joint movement. Examples of isometric exercises are quadriceps set exercises and contraction of the gluteal. This form of exercises is ideal for clients who are unable to tolerate an increase in activity. Isometric exercises are easily accomplished by an immobilized client in bed. The benefits of this exercise are increased muscle mass, tone, and strength, thus decreasing the potential for muscle wasting; increased circulation to the involved body parts; and increased osteoblastic activity. Isometric exercises produce a moderate increase in heart rate and cardiac output, but no appreciable in blood flow to other part of the body.
Isokinetic (resistive) exercises involve muscle contraction or tension against resistance, thus they can be either isotonic or isometric. During isokinetic exercises, the person moves or tenses against resistance. Special machines or devices provide the resistance to movement. These exercises are used in physical conditions and are often done to build up certain muscle groups. For example, the pectorals may be increased in size and strength by lifting weights.
Body movements
Exercise activities may also be categorized according to the type of body movement involved and the health benefits they produce.
Aerobic exercise
Sustained (often rhythmbic) muscle movements that increase blood flow, heart rate, and metabolic demand for oxygen over time, promoting cardiovascular conditioning. Activities that may be aerobic are swimming, walking, jogging, aerobic dance, bicycling, jumping rope, and racquetball.
Stretching exercises
Movements that allow muscles and joints to be stretched gently through their full range of motion increase flexibility. Specific warm-up and cool-down exercises, hatha yoga, and some forms of dance are examples. Benefits include increased range of joint movements, improved circulation and posture, and relaxation.
Strength and endurance exercise
A variety of muscle-building programs fall into this category. Weight training, calisthenics, and specific isometric exercises can build both strength and endurance, increasing the power of the musculoskeletal system and generally improving the whole body. They may or may not have aerobic benefit.
Movement and activities of daily living
Housecleaning, running after a playful toddler, and climbing stairs instead of riding in elevators, all have an effect on health. Increased fitness does not require a gym.
Changes in the client’s mobility may result from many types of health problems. Clients with certain illnesses or injuries become immobilized but return to mobility with rehabilitation. Other clients may experience a sudden or gradual shift from mobility to long-term or permanent immobility. Some clients are immobilized for therapeutic reasons; their ambulation may be restricted or they may be placed on bed rest.
Factors Affecting Body Alignment and Immobility
Clients who are partially and completely immobile usually have a motor or sensory impairment in a region of the body or a therapeutic restriction (e.g., a casted extremity). A partial loss of mobility may be temporary (e.g., the result of a fracture) or permanent (e.g., the result of paralysis). In some cases the restriction of mobility benefits the client’s recovery, as with a casted extremity. Immobility may be the result of either physical inactivity or physical restriction of movement. Physical inactivity such as bed rest causes a reduction in body movement. Physical inactivity may occur as a response to severe pain or as a result of sensory changes reducing the physical stimulus to move. It may also be a result of cognitive-emotional changes such as depression, or as result of a treatment such as prescribed bed rest. Physical restriction or limitation of movement, such as by cast, traction, or restraints, results in an imposed reduction of movement. Both inactivity and restricted movement may cause changes in body position and posture that result in a loss of the body’s ability to adapt to such changes. The degree of the client’s immobility depends on the interaction of the conditions present.
Bed rest is an intervention in which the client is restricted to bed for therapeutic reasons. Bed rest has different meanings among nurses, physicians, and other health care professionals. The general objectives of bed rest include the following:
1. Reducing physical activity and the oxygen needs of the body
2. Allowing ill or debilitated clients to rest and regain strength
3. Preventing further injury to traumatized structures (e.g., spinal and vertebral injury)
Bed rest has physiological and psychological benefits only if the client finds it restful and if the client can freely move and change positions. Clients resistant to bed rest may actually expend more energy in fighting it than they would if allowed to move to from bed to chair.
Clients with a wide variety of conditions are placed on bed rest. The box below lists conditions often requiring bed rest. The duration of bed rest depends on the illness or injury and the client’s prior state of health.
Effects of Immobility on Major Body Systems
Immobility occurs when a client is unable to independently move or change positions. The effects of immobility are systemic and functional. No body system is immune to the effects of immobility. Research has shown that healthy people exposed to periods of immobility or prolonged bed rest suffer physiological and psychological effects. These effects can be gradual or immediate. The greater the extent and the longer the duration of immobility, the more pronounced the consequences. The Table 6-3 lists the effects of immobilization in all dimensions.
Table 6-3 the effects of immobilization in all dimensions.
|Effects of immobilization in all dimensions | |
|Physiological effects |Integument |
| |Pressure ulcer formation |
|Metabolic system |Urinary system |
|Decreased basal metabolic rate (BMR) |Renal calculi |
|Altered carbohydrate, fat, and protein metabolism |Decreased urinary output |
|Fluid and electrolyte imbalances |Urinary stasis |
|Increased bone resorption |Urinary tract infection |
|Gastrointestinal disturbances | |
|Respiratory system |Psychosocial effects |
|Decreased hemoglobin levels |Depression |
|Reduced lung expansion |Behavioral changes |
|Respiratory muscle weakness |Altered sleep-wake cycles |
|Stasis of secretions |Decreased coping abilities |
|Cardiovascular system |Increased isolation |
|Orthostatic hypotension |Sensory deprivation |
|Increased cardiac workload | |
|Thrombus formation |Developmental effects |
|Musculoskeletal system |Decreased progression through developmental tasks |
|Loss of endurance |Increased dependence |
|Decreased muscle mass | |
|Atrophy | |
|Decreased stability | |
|Joint contractures | |
|Disuse osteoporosis | |
Physiological effects
Each body system is at risk for impairments resulting from immoility. The severity of the impairment depends on the clent’s age, overall health, and the degree of immobility. Frail older adult clients with chronic illnesses develop pronounced effects of immobility more quickly than younger clients. For an older adult client who has had a stroke, immobility-related problems can occur within a few days.
Metabolic changes
Immobility disrupts normal metabolic functioning, including problems with the metabolic rate and the metabolism of carbohydrates, fats, and proteins. It can also cause fluid and electrolyte imbalances, problems with bone metabolism, and gastrointestinal disturbance.
Metabolic Rate
Decreased mobility results in a decrease in the basal metabolic rate (BMR). The client’s BMR falls in response to the decreased energy requirement of body cells, which is directly related to cellular oxygen demands. However, fever or wound healing may increase the BMR because these conditions increase celluar oxygen requirements.
Metabolism of carbohydrates, fats, and proteins
As bed rest continues, pancreatic activity decreases, as does the body’s ability to tolerate glucose. Insulin production is not enough to lower serum glucose levels. These effects can be seen in as little as 3 days but can reverse 7 days after resuming activity.
As proteins are metabolized, nitrogen is produced as an end product. Nitrogen balance provides a reliable indicator of protein use by the body. A negative nitrogen balance exists when the excretion of nitrogen from the breakdown of protein exceeds intake. During periods of immobility, urinary excretion of nitrogen rises, increasing the risk of a negative nitrogen balance. The urinary excretion of nitrogen increases about day 5 or 6 of immobilization.
Decreased mobility results in changes in fat stores. The percentage of body fat increases because of the loss of lean body mass.
Fluid and electrolyte imbalances
Because the client is in a recumbent position, major shifts in blood volume occur. An immediate diuretic response occurs during the first day of bed rest, and the client loses an additional average of 600 ml per day. Urinary excretion of calcium, chloride, and sodium also increases.
Bone metabolism
The classic research on healthy , immobilized young men by Deitrick et al. (1948) demonstrated an increased excretion of calcium in the urine during bed rest. Later research showed the probable source of this calcium is bone resorption. Normally the kidneys are able to excrete excess calcium. However, if the kidneys are unable to respond appropriately, hypercalcemia results. Because of the hypercalcemia, an increase in fecal and renal excretion of calcium also occurs.
Gastrointestinal changes
Although impairments in gastrointestinal functioning vary in clients, the symptoms are related to decreased mobility. Constipation is common. Diarrhea, when it occurs, is frequently the result of a fecal impaction. The nurse must be aware this is not normal diarrhea but rather liquid stool passing around the area of impaction. Left untreated, this 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 stasis in the intestine produces distension and increases intraluminal pressure. Finally, intestinal function becomes depressed, dehydration occurs, and absorption ceases. Thus fluid and electrolyte disturbances worsen.
Respiratory changes
When a client assumes a recumbent position, the lungs shift position a full 90 degrees. Shifts in lung position and body fluids, along with the pressure of the abdominal contents pushing against the diaphragm, cause a change in lung volume. Respiratory problems occuring with immobility are caused by decreased hemoglobin, decreased lung expansion, generalized muscle weakness, and stasis of secretions.
Because of the diuretic response to bed rest, hypovolemia may result, causing transient elevations in hematocrit values on or about the eighth day of immobilization. Red blood cell mss and hemoglobin levels decline. Hemoglobin transports oxygenated blood to the tissues, and when the oxygen carrying capacity is reduced, there is a reduction in oxygen delivery to the tissue. Initially the body tries to adapt by increasing the heart rate, but this is a short-term adaptive response and ultimately increases cardiac workload.
Immobilization decreases lung expansion. Changes in the client’s position alter the distribution of ventilation and blood flow through the lung. As a result, the dependent lung is less effectively oxygenated. The exception to this principle occurs when the client has underlying lung disease. In addition, research has documented that all lung volumes are reduced during immobilization.
Limited physical activity and metabolic changes result in weakened and decreased respiratory muscles. Thus the work of breathing increases, causing a proportional decline in the client’s ability to cough productively. Ultimately the distribution of mucus in the bronchi increases, particularly when the client is in the supine, prone, or lateral positions. Mucus accumulates in the dependent regions of the bronchial tube, and because mucus is an excellent medium for bacterial growth, hypostatic bronchopneumonia may result.
With decreased lung expansion and weakened respiratory muscles, secretions stagnate or pool in the dependent lung regions. In addition, cilia become unable to move the secretions from the respiratory tract. Thus the potential increases for pneumonia and atelectasis. Atelectasis is a collapse of the alveoli that prevents the normal exchanges of oxygen and carbon dioxide.
Cardiovascular changes
The cardiovascular system is also affected by immobilization. The three major changes are orthostatic hypotension, increased cardiac workload, and thrombus formation.
Orthostatic hypotension occurs in the client on bed rest, but it also occurs in clients with prolonged immobility in the sitting position. Orthostatic hypotension is a drop of 15mmHg or more in blood pressure when the client rises from a lying or sitting position to a standing position. In the immobilized client, there is decreased circulating fluid volume, pooling of blood in the lower extremities, and decreased automatic response. These result in decreased venous return, central venous pressure , stroke volume, and a drop in systolic blood pressure when the client stands .
Increased cardiac workload is demonstrated by rate changes. Prolonged bed rest increases the resting heart rate 4 to 15 beats per minute. When the immobilized client is asked to do physical activity such as with range of motion (ROM) exercises or activities of daily living, this increased rate is more pronounced. As the workload of the heart increases, so does its oxygen consumption. The heart therefore works harder and less efficiently during prolonged rest. As immobilization increases, cardiac output falls, further decreasing cardiac efficiency and increasing the workload. In an earlier classic study, Coe (1954) noted that cardiac workload is increased almost 20% when the client is lying down.
Immobile clients are at risk for thrombus formation. A thrombus is an accumulation of palates, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery, sometimes occluding the lumen of the vessel. Thrombi form for many reasons. Because of hypovolemia, the hematocrit level is increased, and the circulating is more viscous. After 8 days of bed rest, more procoagulants are found, and thromboplastin time shortens. In addition, the weight of the legs on the bed compresses the blood vessels of the calves, causing stasis and injury to vessel linings. Another problem in the venous system is the loss of the pumping action of the skeletal muscles. Normally, muscles aid venous return by squeezing blood through the legs back to the heart. However, this mechanism is reduced when the client is on bed rest or has a cast on a leg.
Venous thrombi put the client at risk for pulmonary emboli, a life-threatening complication. Pulmonary emboli, a life-threatening complication. Pulmonary emboli are clots that have moved in venous system and block a portion of the pulmonary artery system and thus disrupt blood flow to the lungs. Immobilized surgical and older adult clients are at high risk for developing pulmonary emboli.
Musculoskeletal changes
The effects of immobility on the musculoskeletal system can include permanent impairment of mobility. Restricted mobility affects the client’s muscles by loss of strength and endurance, decreased muscle mass, and decreased stability.
Muscle strength is lost when muscles are inactive. The rate of loss will vary with the degree of immobility but may be as high as 5% per day. These effects can be devastating to clients who are marginally functioning at home in the tasks of daily living. Hoenig and Rubenstein (1991) noted that a 10% loss in function in some older adult clients may mean the loss of independence in their activities of daily living.
Reduced endurance results from changes in muscle strength and altered cardiovascular functioning. Because of the increased cardiac workload, muscle endurance is decreased due to the reduced ability of the cardiopulmonary system to meet the oxygen needs of the tissue. In addition, because of the metabolic changes, the client loses lean body mass, which is composed partially of muscle. Therefore, the reduced muscle mass is unable to sustain activity without fatigue.
Muscle mass decreases from metabolic causes and disuse. As immobility continues and the muscle are not exercised, muscle mass continues to decrease. Muscle atrophy resulting from immobility can be observed and measured. The muscle atrophies, and the size of the muscle decreases. The extensor muscles in the legs appear to be the most affected, lending support to the theory that the normal stresses of gravity are important in maintaining function, development, and therefore mobility.
Decreased stability is the result of loss of endurance, decreased muscle mass, and joint abnormalities. Therefore clients are unable to move steadily, and their risk for falling increases.
Immobilization causes two skeletal changes. A joint contracture is an abnormal and usually permanent condition of a joint, characterized by flexion and fixation and caused by disuse, atrophy, and shortening of muscle fibers. When a contracture occurs, the joint cannot maintain its full range of joint motion. Contracture usually leaves the joint in a nonfunctional position. Footdrop contracture results in the foot being permanently fixed in plantar flexion. Ambulation is difficult with the foot in this position.
The second skeletal change is disuse osteoporosis, the result of impaired calcium metabolism. Because immobilization results in bone resorption, bone tissue is less dense, osteoporosis results, and the client is at risk for pathological fractures. The link between disuse osteoporosis and immobility is twofold. Immobilization and non-weight-bearing activities increase the rate of bone resorption. Bone resorption also causes calcium to be released in the blood. If the kidneys cannot fully excrete this increased calcium, hypercalcemia results.
Integument changes
The effect of immobility on the skin is compounded by impaired metabolism, the loss of lean body mass, and negative nitrogen balance. Any break in the skin’s integrity is difficult to heal in the immobilized client. Older adult clients with paralysis have a greater risk for developing pressure ulcers.
A pressure ulcer, or decubitus ulcer, is an inflammation in the skin as a result of prolonged ischemia in tissues. Usually the ulcer 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.
Normally, tissue metabolism depends on the body’s receipt of oxygen and nutrients from the blood supply and the elimination of metabolic wastes. Any factor that interferes with this process affects the cellular metabolism and, as a result, the function or life of the cell. Pressure affects cellular metabolism by decreasing or obliterating tissue circulation.
When s client lies in bed or sits in a chair, the weight of the body is on bony prominences. The longer the pressure is applied, the longer the period of ischemia and therefore the greater the risk of skin breakdown.
Urinary elimination changes
Urinary elimination is altered by immobility. Urine flows out of the renal pelvis and into the ureter and bladder because of the gravitational forces when the client is upright. When the client is recumbent, the kidneys and ureters move toward a more level plane, and urine formed by the kidney must enter the bladder against gravity. Because the peristaltic contractions of ureters are insufficient to overcome gravity, the renal pelvis may fill before urine enters the ureters. This condition, called urinary stasis, increases the client’s risk of urinary stasis, increases the client’s risk of urinary tract infection and renal calculi.
Renal calculi are calcium stones that lodge in the renal pelvis and pass through the ureters. Immobilized clients are at risk for calcium stones because of altered bone metabolism and the resulting hypercalcemia.
During the initial period of immobility, urine volume is increased secondary to fluid shifts and a natural diuresis. As immobility continues, fluid intake diminishes, and other causes such as fever increase the risk of dehydration. Because of these factors, urinary output declines on or about day 5 or 6. The urine then produced is usually highly concentrated.
This concentrated urine increases the risk for calculi formation and infection. Poor perineal care after bowel movements, particularly in women, increases the risk of urinary tract contamination by Escherichia coli. Another cause of urinary tract infections is indweeling urinary catheters, which provide pathways for pathogens to ascend into the urinary tract.
Immobility also increases the risk of incontinence. Barriers such as side rails, distant bathrooms, and lack of staff to help with toileting make incontinence a problem particularly for the older adult client.
Psychosocial effects
Immobilization may lead to emotional, intellectual, sensory, and sociocultural responses. However, the older adult may be more susceptible to these changes. As a result, the nurse may observe them earlier. The most common emotional changes are depression, behavioral changes, and impaired coping.
The immobilized client can become depressed 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 client from a daily routine, he or she has more time to worry about disability. Worries can quickly increase the client’s depression, causing withdrawal. Assessing behavioral changes throughout restricted mobility helps the nurse to identify changes in self-concept, recognize early signs of depression, and develop nursing interventions.
Behavioral changes resulting from immobilization vary widely, depending on the client. Common behavioral changes include hostility, belligerence, giddiness, withdrawal, confusion, and anxiety. Early in the nursing process the nurse should interview the client’s family and friends about normal behavioral patterns to gain baseline data. If unexpected behaviors are observed later, the nurse can intervene to reduce the effects of immobilization on the client’s behavioral patterns.
The immobilized client requires constant nursing care. Because of physiological hazards, the client cannot be allowed to sleep for 8 hours without a change of position or other nursing care. Disruption of normal sleep patterns can further cause behavioral changes. Nursing interventions should be used to ensure the client receives sufficient sleep. The client who is on bed rest and is able to change position during sleep does not require continuous physical nursing care directed at reducing the hazards of immobility. Unless other treatment activities are required during the night, the care plane for the physiologically stable client on bed rest can provide for uninterrupted sleep.
Long-term immobility or bed rest can affect usual coping patterns. Such a client may withdraw and become passive. The passive client allows nurses to provide care and is not interested in increasing independence or involvement in care. Early in the care of an immobilized client the nurse should assess the client’s normal coping mechanisms. The nurse then design a nursing care plane that will allow the client to continue to use these coping abilities or will help him or her develop new ones.
Developmental effects
More developmental changes tend to be associated with immobility in the very young and in the older adult. The immobilized young or middle-aged adult may experience few, if any, developmental changes. However, there are exceptions to this guideline, and clients must be fully assesses for developmental implications. One exception might be a mother who has complications at childbirth and as a result cannot interact with the newborn as expected. 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 motor skill and intellectual development. Nurses caring for immobilized children should plan activities that provide physical and psychosocial stimuli. Other activities focus on the specific effects of immobilization.
Immobilization of older adult clients increases their physical dependence on others and accelerates functional losses in physiological systems. Immobilization of an older adult client usually results from a degenerative disease, neurological trauma, or a chronic illness. For some clients, immobilization occurs gradually and progressively, whereas for others—especially those who have had a stroke—immobilization is sudden. When providing nursing care for an older adult client, the nurse should develop a care plan that encourages the client to perform as many self-care activities as possible, thereby maintaining the highest level of mobility.
Assessment Mobility of Client
The assessment includes the client’s present mobility and the potential effects of immobility.
Mobility Assessment of the client’s mobility focuses on range of joint motion, muscle strength, activity tolerance, gait, and posture. Observation during activities of daily living enables the nurse to estimate the client’s fatigability, muscle strength, and ROM. These assessment data assist the nurse in developing a care plan.
Finally, observing posture and gait helps the nurse to determine the type of assistance the client may require to change positions or to transfer from bed to chair. This information helps the nurse to assess the client’s overall level of mobility and coordination.
Individual information of clients
Individual information includes the age, sex, educational background, occupation of clients, which have some effect on mobility.
Respiratory and cardiovascular function
A respiratory assessment should be performed every 2 hours for acutely ill clients with restricted activity patterns. The nurses should inspect chest wall movements during the full inspiratory-exspiratory cycle. The nurse should auscultate the entire lung region to identify regionos of diminished breath sounds, crackles, or wheezes. Auscultation should focus on the dependent lung field, because pulmonary secretions tend to move to these lower regions. If a client has an atelectatic area, breath sounds may be asymmetrical. A complete respiratory assessment identifies the presence of secretions and can be used to determine nursing interventions necessary to maintain optimal respiratory function.
The cardiovascular assessment of immobilized client includes monitoring blood pressure, evaluating apical and peripheral pulses, observing the venous system. Because of the risk for orthostatic hypotension, blood pressure should be measured, particularly when changing from lying to a sitting or standing position. In this way the client’s ability to tolerate postural changes can be assessed.
The nurse also needs to assess the apical and peripheral pulses. Recumbency increases the cardiac workload and results in an increased pulse rate. In some clients, particularly the older adult, the heart may not be able to tolerate the increased workload, and a form of cardiac failure may develop. Monitoring the client’s peripheral pulses allows the nurse to evaluate the heart’s ability to pump the blood throughout the body. The absence of a peripheral pulse, particularly one that was previously present, should be documented and reported immediately.
Edema may indicate the heart’s inability to handle the increased workload. Because fluid moves to dependent body regions, assessment of the immobilized client should include the sacrum, legs, and feet. If the heart is unable to tolerate the increased cardiac workload, the peripheral body regions such as the hands, feet, nose, and earlobes will be colder than the central body regions.
Finally, the nurse assesses the venous system because deep vein thrombosis is a hazard of restricted mobility. A dislodged thrombus, called an embolus, may travel through the circulatory system to the lungs and impair that organ’s circulation. Emboli to the lungs (pulmonary emboli) pose a threat to the client’s life.
To assess for a deep vein thrombosis, the nurse should remove the client’s elastic stockings once every 8 hours and observe the calves for redness, warmth, and tenderness. The nurse should ask the client about calf pain. The nurse may also ask the client to dorsiflex the foot and assess for the presence of calf pain. Calf pain on dorsiflexion (positive Homan’s sign) may indicate deep vein thrombosis. In addition, calf circumference should be measured daily in clients at high risk for developing thrombi. To do this, the nurse marks a point on each of the client’s calves 10 cm from the midpatella. The circuference is measured each day using the mark as a reference point for placing the tape measure. One-sided increases in calf diameter can be an early indication of thrombosis. Because deep vein thrombosis can also occur in the thigh, thigh circumference measurements should be taken daily.
Musculoskeletal system
The major musculoskeletal abnormalities identified during assessment include decreased muscle strength, loss of muscle tone and mass, and contractures. Anthropometric measurements provide clues to muscle mass loss. Muscle strength and tone may be measured during ROM assessment. Disuse osteoporosis cannot be identified by physical assessment. However, postmenopausal women and clients with increased serum and urine calcium levels are at greater risk for bone demineralization. Clients who have joint pain (such as in the hip) or who complain of back pain may have an unrecognized fracture caused by disuse osteoporosis.
Muscle strength varies greatly from one individual to another and within the same individual, and is affected by muscle use. Muscle strength is measured by asking the client to move actively against gravity and resistance. Impaired muscle strength or weakness is termed paresis. Absence of strength secondary to nervous impairment is paralysis. Muscle strength is graded as following:
0: 0% of normal strength; complete paralysis
1: 10% of normal strength; no movement, contraction of muscle is palpable or visible
2: 25% of normal strength; full muscle movements against gravity, with support
3: 50% of normal strength; normal full movement against gravity
4: 75% of normal strength; normal full movement against gravity and against minimal resistance
5: 100% of normal strength; normal full movement against gravity and against full resistance
Joint structure and function
The nurse uses inspection and palpation to examine joints and the surrounding tissue, and assess their range of active motion or passive motion. Range of motion (ROM) is the complete extent of movement of which a joint is normally capable. The following joints may be given special attention: neck, shoulder, elbow, wrist, hip, knee, and ankle. When measuring ROM of a joint, ask the client to move selected body parts as shown in table 6-3. As indicated, a device that measures the angle of the joint in degrees. Assessment of ROM should not be unduly fatiduing, and the joint movements need to be performed smoothly, slowly, and rhythmically. Uneven, jerky movement and forcing can injure the joint and its surrounding muscles and ligaments. When assessing joint mobility, the nurse should note the following: any limitation in the normal range of motion or any unusual increase in the mobility of a joint; any swelling in or around the joint; tenderness in or around the joint; increased temperature over the joint; redness of the overlying skin; crepitation (palpable or audible cracking or grating sensation produced by joint motion); deformities such as bony enlargement, subluxation, or contracture; and symmetry of involvement.
Physical mobility
Physical mobility is measured by observing the client’s daily activities, which include walking, dressing, toilet and so on. Gordon delineates five levels that can be used after the diagnostic label:
Level 0: The client is completely independent and can move freely without assistance.
Level 1: Requires use of equipment or device.
Level 2: Requires assistance, supervision, or teaching from another person
Level 3: Requires help from another person and equipment device
Level 4: Is dependent and does not participate in movement
Problems related to immobility
When collecting data related to the problems of immobility, the nurse uses the assessment methods of inspection, palpation, and auscultation, checks the results of laboratory tests, and takes measurements, including body weight, fluid intake, and fluid output. Specific techniques for assessing immobility problems and abnormal assessment findings related to the complications of immobility. It is extremely important to obtain and record baselines data soon after the client first becomes immobile. These baseline data serves as the standard against which all data collected throughout the period of immobilization are compared. Because a major nursing responsibility is to prevent the complications of immobility, the nurse needs to identify clients at risk of developing such complications before problems arise. Clients at risk include those who are poorly nourished; have decreased sensitivity to pain, temperature, or pressure; have existing cardiovascular, pulmonary, or neuromuscular problems; and are unconscious.
Psychosocial condition
Changes in psychosocial status usually occur slowly and are often overlooked by health care personnel. The nurse should observe for changes in emotional status (e.g., depression). The nurse also observes for behavioral changes (e.g., the cooperative client who becomes argumentative or the modest client who begins to expose himself or herself repeatedly). The nurse should try to determine the reasons for such behavioral alterations to identify specific nursing therapies.
Changes in the client’s sleep–wake cycle such as difficulty falling asleep or frequent awakenings must be identified and corrected. Many sleep disruptions can be prevented or minimized. Finally, the nurse should observe for changes in the use of normal coping mechanisms to adapt to immobilization. Decreasing coping ability may cause the client to become disoriented, confused, or depressed, or to experience other behavioral changes. Clients may report sensory alterations such as seeing shapes and dots or seeing people and animals or hearing the wind or mechanical noises. The client may find these sensations disturbing and may be reluctant to mention them to the nurse. The nurse may need to watch and listen to the client closely to note these changes. The client may only refer to the sensations casually (e.g., “It sure sounded like a dog was in here last night”). Allowing clients to discuss sensory alterations will help to reassure them they are not losing touch with reality.
Assisting Clients with Mobility
Nursing interventions for the completely or partially immobilized client focus on preventing the hazards of immobility and assisting clients to exercise and move.
Positioning clients in bed properly
When the client is lying in bed, the body position is comfort and stable, and muscles and joints are relaxed.
Keeping spinal column physiological bend
Spinal column and its surrounding muscles in clients restricted to bed for a long period may be deformed, lose its physiological bend and functions, and accordingly the client feel pain in local region and ankylosis in muscles. If permitted, the nurse should assist the client to alter position, strengthen back care and massage pressed muscles, which promote local blood circulation and relieve pain. Furthermore, instruct clients exercise the waist and back muscles, which recover physiological function and range of motion in spinal column.
Preventing pressure ulcer
See chapter 5
Maintaining joint mobility
The immobilized client must receive some exercise to prevent excessive muscle wasting and atrophy and joint contractures.
Range of motion (ROM) is the complete extent of movement of which a joint is normally capable. The following joints may be given special attention: neck, shoulder, elbow, wrist, hip, knee, and ankle.
The terms joint and articulation refer to the area where bones come into close contact with one another. Movement forms of joints are defined in table 6-3.
Table 6-3 common types of joint movement
|Movement |Definition |
|Flexion |Decreasing the angle of the joint (e.g., bending the elbow) |
|Extension |Increasing the angle of the joint (e.g., straightening the arm at the elbow) |
|Abduction |Movement of the bone away from the midline of the body |
|Adduction |Movement of the bone toward the midline of the body |
|Hyperextension |The state of exaggerated extension. It often results in an angle greater than 180° |
|Internal rotation |A body part turning on its axis toward the midline of the body |
|External rotation |A body part turning on its axis away from the midline of the body |
|Circumduction |Movement of the distal part of the bone in a circle while the proximal and remains fixed |
Range of motion exercises may be active (the client is able to move all joints through their range of motion unassisted), passive (the client is unable to move independently, and the nurse moves each joint through its range of motion), or somewhere in between. The nurse first assesses the client’s ability to engage in active range of motion exercises and the need for joint support from the nurse. As a general principle, exercises should be active as the client’s heath and mobility allow.
Clients with restricted mobility are unable to perform some or all range of motion exercises independently. This limitation can be identified in clients who have limited movement in one extremity or in completely immobilized clients. When caring for clients with an actual or potential impaired mobility, the nurse designs interventions directed toward maintaining maximal joint mobility. One such nursing intervention is ROM exercises.
To ensure that clients routinely receive these exercises, the nurse should schedule them at specific times, perhaps along with another nursing activity such as a bath. This enables the nurse to systematically assess and improve the client’s range of motion.
To ensure adequate joint mobility the nurse can teach the client about range of motion exercises. When the client does not have voluntary motor control, the nurse uses passive range of motion exercises. Joint mobility is also increased through walking. Occasionally clients need to use mechanical devices such as crutches to increase the ability to walk.
Contractures may develop in joints that are not moved periodically through their range of motion. A contracture is a permanent shortening of a muscle and the eventual shortening of associated ligaments and tendons. If a contracture occurs because the joint is immobilized for a long time, the client will not be able to use the joint normally and it may become fixed in one position.
Unless contraindicated, the nursing plan should include moving the extremities through as nearly full range of motion as possible. The nurse should move joints to the point of discomfort, tension, or spasm but not beyond. Passive range of motion exercises should be initiated as soon as the client loses the ability to move the extremity or joint. Movements are carried out slowly and smoothly and should not cause pain. Each movement should be repeated five times during the exercise period.
When performing passive range of motion exercises, the nurse stands at the side of the bed closest to the joint being exercised. If an extremity is to be moved or lifted, the nurse places a cupped hand under the joint to support it, supports the joint by holding the adjacent distal and proximal areas, or supports the joint with one hand and cradles the distal portion of the extremity with the remaining arm.
The following sections describe the specific movements for the major joints in the body. Table 6-4 lists range of motion exercises for each area and illustrates the motion of each joint.
Table 6-4 range of motion
|Body parts (type of joint) |Movement |Normal range |
|Neck (pivot joint) |Flexion |45°from midline |
| |Extension |45°from midline |
| |Hypertension |10° |
| |Lateral flexion |40°from midline |
| |Rotation |70°from midline |
|Trunk (gliding joint) |Flexion |70°to 90° |
| |Extension |70°to 90° |
| |Hyperextension |20°to 30° |
| |Lateral flexion |35° |
|Shoulder (ball-and socket |Rotation |30°to 45° |
|joint) |Flexion |180°from the side |
| |Extension |180°from vertical position beside the head |
| |Hyperextension |50°from side position |
| |Abduction |180° |
| |Adduction |230° |
| |Circumduction |360° |
| |External rotation |90° |
|Elbow (hinge joint) |Internal rotation |90° |
| |Flexion |150° |
| |Extension |150° |
| |Rotation for supination |70° to 90° |
|Wrist (condyloid joint) |Rotation for pronation |70° to 90° |
| |Flexion |80° to 90° |
| |Extension |80° to 90° |
| |Hyperextension |70° to 90° |
|Hip (ball-and-socket joint)|Radial flexion |0° to 20° |
| |Ulnar flexion |30° to 50° |
| |Flexion |90° to 120° |
| |Extension |90° to 120° |
| |Hyperextension |30° to 50° |
| |Abduction |45° to 50° |
|Knee (hinge joint) |Adduction |20° to 30° |
| |Internal rotation |90° |
|Ankle (hinge joint) |External rotation |90° |
| |Circumduction |360° |
| |Flexion |120° to 130° |
|Foot (gliding) |Extension |120° to 130° |
| |Extension (planter flexion) |45° to 50° |
| |Flexion (dorsiflexion) | |
| |Eversion |20° |
| |Inversion |5° |
| | |5° |
Cautions
1. Assess physical condition comprehensively including body mobility, cardiovascular and respiratory function, and joint mobility before exercises and then plan exercise program.
2. Keep ward quiet, ventilation, temperature and moisture proper, and assist the client alter loose and comfortable dress convenient to exercise before exercise. Protect privacy of clients.
3.During exercise, observe the reaction to exercises and activity tolerance, and observe whether there are negative effects such as stiff joint, pain, spasm. When the abnormal reaction is found, the nurse should inform the physician.
4. The client with acute arthritis, bone fracture, ligament rupture and joint dislocation does ROM exercise with instruction of physician.
5. Observe changes in heart rate, heart rhythm, blood pressure when the client with heart disease does ROM exercises.
6. The nurse should introduce the client and his relatives the importance of joint ROM exercise and encourage the client participate in exercises, which can eventually make the client to exercise from passively to actively.
7. After exercises, record time, items, times, changes in joint mobility and reaction to exercise of the client timely and properly, which provide evidence for further plan to be made.
Reducing immobility hazards
The hazards of immobility may occur due to prolonged immobility. Nursing interventions should be designed to reduce the hazards of immobility on body systems.
Reducing orthostatic hypotension
Interventions should be directed toward reducing or eliminating the effects of orthostatic hypotension. The nurse attempts to get the client out of bed as soon as the physical condition allows, even if the move is only to a chair. This activity maintains muscle tone and increases venous return. Isometric exercises used during bed rest do not have any beneficial effect on orthostatic hypotension but may improve activity tolerance. When getting an immobile client up for the first time, the nurse should usually get the assistance of at least one other person. This is a precautionary step. The client will still be expected to do as much of the movement as the condition allows.
Preventing thrombus formation
Many interventions reduce the risk of thrombus formation in the immobilized client. Leg exercises, encouraging fluids, position changes, and teaching should begin when the client becomes immobile. Preoperative clients should be given this information before surgery. Other interventions such as medications (Heparin) and intermittent pneumatic compression stockings (elastic stockings) require a physician’s order.
Preventing problems of elimination system
Nursing interventions for maintaining optimal urinary functioning are directed toward keeping the client well hydrated without causing bladder distention and the reflux of urine into the ureters and, in some instances, the renal pelvis.
Adequate hydration helps to prevent renal calculi and urinary tract infections. The client should void large amounts of dilute urine. If the client is also incontinent, the nurse modifies the care plan so the increased urinary output does not cause skin breakdown.
To prevent bladder distention, the nurse assesses the frequency and amount of urinary output. A client who continually dribbles urine and whose bladder is distended has overflow incontinence. If the immobilized client does not have voluntary control of bladder elimination, bladder retraining may be necessary. If the client experiences bladder distention, the nurse may be required to insert a straight catheter or an indwelling Foley catheter.
The nurse must also record the frequency and consistency of bowel movements. A diet rich in fruits and vegetables can help to facilitate normal peristalsis. If a client is unable to maintain normal bowel patterns, the nurse may initiate a bowel training program and the physician may order stool softeners, cathartics, or enemas.
Nursing interventions for respiratory system
Changing the position of the client at least every two hours allows the dependent lung to expand. This maintains the elastic recoil property of the lungs and clears the dependent lung of pulmonary secretions. The client should be encouraged to take deep breath, cough and yawn every 1 to 2 hours while awake. The nurse instructs the client to take in three deep breaths and cough with the third exhalation. This cough technique produces a more forceful, productive cough without excessive fatigue. Chest physiotherapy is also an effective method to prevent secretion stasis of immobilized clients.
Nursing intervention for musculoskeletal system
The immobilized client must receive some exercise to prevent excessive muscle atrophy and joint contractures. If the client cannot move part or all of the body, the nurse should perform passive ROM exercises for him or her at least 2 to 3 times a day. Ambulation should be started as soon as possible to prevent complication of musculoskeletal system. For clients who have some ability of activity, exercises may be integrated with activities of daily living. During recovery stage, the client may take active-resistive exercise to restore activity tolerance.
-----------------------
Conditions requiring bed rest
Cardiovascular conditions
Acute myocardial infarction
Congestive heart failure
Cardiomyopathies
Inflammation of myocardial tissues
Neurological conditions
Head injuries
Spinal cord trauma
Degenerative neurological conditions
Inflammatory diseases of the nervous
system (e.g., Guillain-Barre syndrome)
Bleeding aneurysms
Musculoskeletal conditions
Multiple fracture
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