Fundamentals - Practice & Skills, part 9: Immobility and Deep Vein Thrombosis
This article covers immobility, deep vein thrombosis (DVT), and nursing care for immobility. You can follow along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
What is immobility?
Immobility, as defined by the North American Nursing Diagnosis Association, is a state in which an individual experiences, or is at risk for experiencing, limitation of physical movement. A change in a person's physical mobility can be a result of prescribed bed rest, movement that is physically restricted by an external device (e.g., a cast), voluntarily restricted movement (something the patient does to limit their movement), or the impairment or loss of motor function.
Immobility effects on the body
Prolonged immobility may negatively affect the body's systems. It can have a deleterious effect on a patient's quality of life and can lead to the development of a series of complications, from prolonged length of stay in the hospital to increased morbidity and mortality.
Immobility can affect the respiratory system, for example, by decreasing lung expansion or increasing the risk of atelectasis (a partial or complete collapse of the lung). A patient who cannot move freely or is constrained to their bed is at risk of contracting respiratory infections (e.g., pneumonia).
Immobility's effect on the cardiovascular system includes the increased risk of blood clots and orthostatic hypotension, which is a form of low blood pressure that occurs when you stand up suddenly.
Immobility can result in muscle atrophy and bone demineralization. That can lead to an increased risk for contractures (when muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) and osteoporosis. When the patient begins to be mobile again, muscle atrophy and bone loss may lead to fractures.
Remember that osteoclasts are the type of cell responsible for bone destruction, while osteoblast cells' job is to produce new bone (called osteoid and made of bone collagen and other protein).
Immobility can affect the gastrointestinal system by decreasing GI motility (the process of food traveling through the digestive tract), which increases the risk of constipation.
The renal system may also be affected by immobility. When calcium from the bones is demineralized (as described above), it is liberated. That is, it is released into the bloodstream which, in turn, is filtered by the kidneys. So an excess of calcium in the blood can lead to kidney stones.
Immobile patients are also at risk for urinary tract infections due to urinary stasis.
When it comes to the integumentary system (skin), immobile patients have an increased risk for pressure injuries. If a patient cannot change their position on their own, they could develop pressure ulcers and sores.
Finally, there are psychosocial effects to immobility, including feelings of isolation, depression, the loss of self esteem and a diminishing of sleep quality.
Immobility effects on function
Immobility, illness, or hospitalization may affect a patient's ability to perform ADLs (activities of daily living) and instrumental ADLs (IADLs). When someone is ill or immobilized or hospitalized, their ability to care for themselves may decrease. It is important to pay attention to a patient's ability to care for themselves.
ADLs are the basic tasks necessary for living (e.g., ambulating, bathing, dressing, eating, toileting). These are things one does to one's own body.
IADLs are more complex, but still important for functioning. Instrumental ADLs focus more on the patient's household — their life outside the hospital setting. This can include things like transportation, finances, and shopping. Meal planning, going to the grocery store, and balancing the household budget are examples of IADLs.
It is important to encourage patients to participate in their own care as much as possible. And even if a patient cannot care for themselves fully, avoid providing their total care. This can help maintain the patient's dignity and also to maintain their function. For example, if a patient is very limited and all they can do is take a washcloth to wash their face, encourage them to wash their face on their own every time.
Note that patients may not report a decrease in their ability to perform ADLs, as this may be embarrassing or upsetting. The best way to assess a patient’s ability to perform ADLs is by observing them.
Deep vein thrombosis
Deep vein thrombosis (DVT) is when a thrombus (blood clot) forms in a deep vein in an extremity, usually in the lower leg (calf and thigh).
Prevention of DVT may include:
- Early and frequent ambulation. That is, getting the patient to get up and start walking about as soon after their surgery as possible. This physical activity helps to strengthen joints and muscles (and can reduce the length of time the patient must remain in the hospital).
- Compression stockings (e.g., TED hose). TED stands for "thrombo-embolic deterrent." Compression stockings help venous and lymphatic drainage of the leg, which reduces the chances of DVT formation, especially in immobile patients.
- Sequential compression device (SCD). SCDs are inflatable sleeves that are worn on the lower legs while recovering from an illness or surgery in the hospital. SCDs, like compression stockings, help improve blood flow in the legs by compressing every so often, giving the leg a squeeze to help to move blood back up from the legs.
- Prophylactic medications, such as heparin, which can be administered through an IV or through a subcutaneous injection, and enoxaparin (Lovenox), which is low-molecular-weight heparin used to treat and prevent the formation of blood clots. Note that enoxaparin is only given subcutaneously and not through an IV.
Signs and symptoms
Signs and symptoms of deep vein thrombosis include erythema (skin redness at the site), probably on the calf.
The patient may suffer from swelling (edema) at the site due to vascular congestion.
Patients may also experience extreme pain at the location (again, usually the calf), especially when they flex their foot. This is sometimes called a positive Homans' sign. This movement is also known as dorsiflexion, that is, the backward bending and contracting of the foot (or hand). This motion will cause the patient pain. Don't encourage the patient to make this motion, but do pay attention in case they report pain in their calf when flexing their foot. That could be a sign of DVT.
Nursing care includes elevating the extremity, but avoid placing a pillow or adjusting the knee gatch (a mechanism on the bed that helps to angle the mattress under the patient's knee), which can cut off the blood supply. An inclined pillow (not placed under the knee) can be effective.
Applying a warm, moist compress can help relieve some of the pain.
Do not massage the limb. Massaging the affected area could dislodge the clot, which could lead to the patient developing a pulmonary embolism, a life-threatening blood clot in the lung.
It is vitally important to monitor for and report any sign or symptom of a pulmonary embolism, such as shortness of breath, chest pain, tachycardia, or hypotension (as noted above, a form of low blood pressure that occurs when the patient stands up suddenly).
Combatting the effects of immobility
As a nurse, combatting the effects of immobility in your patient is so important — both by helping prevent them in the first place, and treating any effects of immobility as they occur.
Many of these strategies and practices have been discussed above:
- Encourage coughing, deep breathing, and incentive spirometry to help keep the patient's lungs open and moving air.
- Apply TED hose (compression hose) or SCDs (sequential compression devices) to promote blood return from the legs.
- Provide anticoagulation as ordered. Medications often include Lovenox, a low-molecular-weight heparin also known as enoxaparin, which is administered subcutaneously to help prevent deep vein thrombosis (DVT).
- Reposition the patient every two hours. Also: keep their skin clean and dry. Encourage the patient to work their range of motion through the completion of passive and active exercises. Remember: while you can do this for them, it is important that the patient makes the physical effort themselves as part of their healing process.
- Increase fiber and fluid to help with bowel and urinary symptoms. Encourage the patient to move as tolerated or allowed.
- Coordinate referrals to physical therapy and occupational therapy as needed to help the patient, especially after they have been discharged from hospital care.
Again, it is important for the patient's healing process that they accomplish as many of these things as they can on their own. It will help them build their strength, post-op; it will build their self-esteem; and it can mean a shorter hospital stay and a more successful long-term outcome.
Hi, I'm Meris. And in this video I'm going to be talking to you about the effects of immobility, deep vein thrombosis, and nursing care for immobility. I'm going to be following along with our Fundamentals of Nursing flashcards. These are available on our website with many more at leveluprn.com. If you are following along with me with your own set, I'm starting on card number 68. So let's get started.
So first up, we're talking about the effects that immobility has on body systems. You'll see here a really nice table on this card that separates out the body systems and their effects so that way you can clearly see what they are. There's way too much for me to go into with you in this video so definitely be sure to look at this card in-depth. But there are some big ones I want to hit on. Decreased lung expansion and increased risk of atelectasis for your respiratory system. Very important. Cardiovascular. Increased risk of blood clots. Blood clots. Very, very important. We're going to be talking about that next, so definitely pay attention to that. Musculoskeletal. We have muscle atrophy but we also have bone demineralization. Tell me in the comments which type of cell is responsible for the destruction of bone. Is it osteoblasts or osteoclasts? Tell me below. So this is going to give us an increased risk for fractures if a patient begins to be mobile again and they fall and hurt themselves, right?
Gastrointestinal. Decreased GI motility means increased risk for constipation. Renal. We're going to have kidney stones, right, because that calcium from the bones that is demineralized from the bones is liberated, is released into the blood. And what filters the blood? The kidneys. And what do we get when we have a lot of calcium in the blood? Kidney stones. We may also have UTIs from urinary stasis. And then of course we have the risk for pressure injuries. Very important stuff here.
Now we, on the next card, have effects on function. So this is how does immobility actually affect the patient's ability to function. And we see here that we talk about the impact on a patient's ADLs, activities of daily living. So we're going to see that when you are ill or immobilized or hospitalized your ability to care for yourself may decrease. So we need to be paying attention to our patient's ability to care for themselves. Now pay attention here that we have something called instrumental ADLs, IADLs. This is more about how do I care for the household. So this is meal planning, going to the grocery store, balancing the budget. Those are IADLs, whereas ADLs are things that I'm doing to my own body, like dressing, bathing, showering, shaving. All of those things are ADLs. And then we also want to encourage our patients to participate in their own care as much as possible. Even if a patient cannot care for themselves fully, I'm not going to provide total care, right? It's very important to maintain my patient's dignity but also to maintain their function. So if my patient is very limited and all they can do is take a washcloth and wash their face, I want them to wash their face every time. I'm going to encourage them to participate in their own care and help me out in that way. It's really, really, really going to be in the best interest of your patient. Okay. Now tell me in the comments what's the best way to assess a patient's ability to perform their ADLs. Is it by asking the family or observing the patient? Let me know below.
Okay. So moving on. This card, I want you to know, is incredibly important for every single thing you do in nursing school. You've got to learn it, accept it, get a necklace that says it, okay? This is deep vein thrombosis. You got to know all about it. So DVTs. This is what happens when we have clotting of blood in a deep vein, so deep vein thrombosis, deep vein clots. This is typically in the calf. It can be other places, but you will see it most of the time in the calf and thigh. Big signs and symptoms to be aware of. We're going to have erythema, redness at the site, so probably the calf. We are going to have swelling, edema, at the site also because we're getting that vascular congestion where there's a traffic jam. We are going to have extreme pain at the location, right? And you may hear this called a positive Homans' sign. Positive Homans' sign is when I am standing with my feet on the floor and I raise my toes to my nose. On the affected site, it's going to hurt a lot. Don't encourage your patient to do that. We don't want them to dislodge the clot. But if they say that, then you know that that's a positive Homans' sign. Things that we need to know. We don't put pillows-- or you'll hear it called knee gatches. We don't put them directly behind the knee because that cuts off that blood supply. But we do want to elevate the legs, so maybe an inclined pillow but nothing directly behind the knee. We never massage the area. Massaging the area puts us at risk for dislodging that clot and developing a pulmonary embolus. And it's also important to know that we can use warm and moist compresses. That's going to help to relieve some of that pain. So elevate, don't massage, and warm, moist compresses.
Now, what do I need to tell the provider? I need to tell the provider if my patient with DVT develops sudden onset chest pain, shortness of breath, if their pulse ox drops, their heart rate goes up. Anything like that could be a sign that they have developed a pulmonary embolism, meaning that part of the clot in the deep vein has broken off and traveled to the lungs. Very, very bad, a true medical emergency. Report those findings immediately. Okay. So last thing we're going to talk about is how do you as a nurse combat the effects of immobility, what do you do to help prevent or treat the things that can happen that we've already talked about. Again, we've got some nice bulleted points here for you. I'm going to tell you: coughing, deep breathing, and incentive spirometry, those three are going to help keep my lungs open and moving air, very important. TED hose. Those are going to be those compression hose, and they're going to help with blood return from the legs. Or SCDs, sequential compression devices, those are the little devices that give your leg a squeeze every now and then, again, helping to move that blood back from the legs. Things we can do as well are going to be providing anticoagulation as ordered. So most hospitalized patients receive Lovenox, which is a low-molecular-weight heparin also called enoxaparin, subcutaneously to help prevent DVTs. We're going to reposition our patient every two hours. We're going to encourage range of motion. Even if all I can do is this, right, I want my patient doing that. That's awesome. Increase fiber and fluid to help with the bowel and urinary symptoms. We are going to encourage our patient to move as tolerated or allowed. And then I'm also going to want to work with physical therapy and occupational therapy as needed to help with these things as well.
So I hope that review was helpful. I'm going to tell you immobility is huge in nursing school. You got to know all about it. So rewatch this if you need to. Leave me a Like if you thought that this was a helpful comment-- excuse me, a helpful video. And I'd love to hear your comments below. If you have a really great way of remembering something, especially when it comes to all the nursing interventions for immobility, I want to hear it. Be sure you subscribe to the channel so that you are the first to know when the next video comes out, which is going to be talking about mobility devices such as canes, walkers, and crutches. Thanks so much, and happy studying.
I took a big breath at the end there. I don't know why. [laughter]
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