Negative outcomes of immobility
Pressure injuries
Sleep deprivation
Delirium
Prolonged ventilator days, ICU stay, /hospital stay
Physiological changes such as increased heart rate, decreased vital capacity,pneumonia, muscular weakness, contipation, pain, urinary retention, Atelectasis
Contraindications for mobility progression-MOVE
Myocardial instability- chest pain, ischemia, an arrhythmia requiring an antiarrhythmia in the past 24 hrs
Oxygenation issues-pulse ox less than 90%, resp rate under 10 or over 35, extreme fatigue or dyspnea, receiving MV, or FiO2 greater than 60% and peep over 10
Vasopressors-increase in dose needed in past 2 hrs or pt has 2 or more pressors infusing
Engagement- the patient does not respond to verbal stimulation or follow commands
Strategies to address challengers of early progressive mobility for the cute/critically ill
Consult PT
Provider education on rationale for mobility
Assess for hemodynamic stability
-if unstable attempt position changes or continuous lateral rotation therapy
Address any pt discomfort and explain rationale for and importance of moving to the patient
Schedule and coordinate mobilization with interdisciplinary team
Maintain safety of lines and tubes
Provider safe patient handling equipment
Minimize sedation
Develop and utilize nurse-driven protocol for the progression of patient mobility
Fall prevent risk factors for falls
Over 65 years old
Fall history
Ortho hypotension
Impaired gait or immobility
Altered mental status
Incontinence
Need for assistive devices
Medications (benzo, antihypertensive, diuretics)
Medical devices that limit mobility (urinary catheter, monitor leads, IV lines)
Restraints
Fall prevention strategies
Routinely assess pt fall risk with validated fall risk assessment
Communicate pt’s fall risk status
Provide on-going education
Adhere to hospital procedure and protocols
Provide orientation and ongoing staff education
Ensure adequate staffing
Assess physical environment for safety issues
Accompany pt during mobilization in and out of bed and to commode
Study and learn from past patient falls, perform root cause analysis
Ensure that unit managers are engaged in and communicate about fall prevention in each hospital unit
Rhabdomyolysis
Life threatening syndrome due to massive destruction of skeletal muscle cells
Etiologies include crush injuries, prolonged immobility, compartment syndrome, hyperthermia, and delirium tremens
Acid muscle injury, results in the release of myoglobin and creatinine and potassium into the extracellular and intravascular spaces due to damage muscles
Kidney injury occur once the CK and myoglobin obstruct the renal tubules
Hypovolemia , hyperkalemia, metabolic acidosis, acute renal failure
Signs /symptoms: dark tea colored urine, low urine output, urine dipstick is positive for hemoglobin, but a urinalysis is negative for RBC, arrhythmias, muscle cramping, myoglobin in the urine, elevated CK over 10,000.
Treatment -fluids, normal saline to maintain a urine flow of 300 an hour. Maybe necessary to infuse up to 500 ML an hour of normal saline to maintain a urine output of 300 ML an hour.initiate sodium bicarb refusion to alkalinize the urine. Administer mannitol. Monitor and treat hyperkalemia. Therapy should continue until the urine is cleared up any myoglobin.
Compartment syndrome
The development of elevated pressure within the muscle fascia, which may lead to decrease blood flow. Results in the damage of the muscle tissue and nerves within the compartment.
Causes include crash, injury, or surgery on a limb , fracture, severe muscle hematoma, or sprain, constricting cas or bandage or prolonged tourniquet or positioning during surgery that leads to a loss of blood supply to a limb.
Signs include pain worse than expected based on the assessment of the injury, numbness, a loss of movement, of firm wooden feeling upon palpitations ,and or elevated intracompartmental pressure
Loss of pulse or development of pallor are not reliable clinical signs. May be late signs
Treatment : measure the compartmental pressure as soon as the compartment syndrome is suspected and continue to monitor complemental pressure as indicated
a normal compartment measure pressure is 0 to 8. A compartment Pressure is over 30
if that is the case, emergent decompressive fasciotomy is indicated to prevent permanent nerve and or vascular injuries
Maintain the level of the affected limb at the level of the heart
do not elevate the live higher than the level the heart because elevation decreases arterial blood flow to the tissues
Remove any bandages or cast
Provide pain control with opioids or NSAIDS
Three hours after decompression procedure monitor for any postischemic tissue swelling due to altered capillary permeability (mannitol) may be considered
Monitor for any development of rhabdomyolysis
