Introduction to Medical-Surgical Nursing, 6th ed.
21
Lesson Plans for
Immobility
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 21.1:
2. Discuss the impact of exercise and positioning on preventing complications related to immobility.
4. Describe the stages of pressure ulcers.
5. Describe methods of preventing and treating pressure ulcers.
Lesson 21.2:
6. Discuss measures to manage the effects of immobility on respiratory status, nutrition, and elimination.
CHAPTER TEACHING FOCUS
• In this chapter, students will be introduced to the complications associated with immobility, with special
emphasis on pressure ulcers, respiratory problems, and impaired nutrition and elimination. Students
will have the opportunity to learn about treatment and preventive measures for these complications,
and the use of exercise and positioning to minimize the risks and effects of complications arising from
immobility.
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
Concepts for nursing practice. St. Louis: Elsevier. The specific exemplars chosen and listed below for
each concept have been tailored specifically to correspond to the Linton textbook.
THEME: Protection and Movement
• Concept: Tissue Integrity
• Exemplar: Skin Integrity, p. 328
THEME: Care Competencies
• Concept: Safety
• Exemplar: Prevention Pressure Ulcers, p. 329
• Figure 21-3: Norton scale for the identification of those at risk for the development of pressure
ulcers, p. 330
• Figure 21-4: Specialty beds prevent pressure on the bony prominences, p. 330
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Introduction to Medical-Surgical Nursing, 6th ed.
CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) Immobility combined with urinary incontinence is likely to cause __________.
a) skin breakdown
b) delusions
c) dementia
d) atrophy
2) Passive range-of–motion leg exercises include the __________.
a) patient flexing and relaxing toes while the leg is immobilized
b) patient lifting the leg up from the bed for the count of five
c) therapist helping the patient sit up
d) therapist lifting the patient’s leg for the count of five
3) A foot drop is a(n) __________.
a) contracture that results from a significant weakness of ankle and toe dorsiflexion
b) exercise to increase toe strength
c) ballet move
d) contracture that occurs when the foot bends inward
4) An effective way to prevent foot drop is to __________.
a) perform foot massage daily
b) sit the patient up in bed as often as possible
c) have the patient practice touching his or her toes
d) use a foot board when the patient is in bed
5) If a patient develops finger contractures, his or her __________.
a) fingers are fanned out
b) hands are clenched in fists
c) hands are flaccid
d) fingers are straight and rigid
6) Movement of the arm to the side and away from the body is ___________.
a) rotation
b) adduction
c) abduction
d) contracture
7) Pronation of the patient __________.
a) should be avoided because it leads to suffocation
b) can be used if the patient is comfortable in this position
c) can lead to abdominal pressure ulcers
d) can cause the patient to vomit
8) Pressure ulcers are most likely to occur over the area of __________.
a) the coccyx
b) a finger
c) the forehead
d) the abdomen
9) The most effective way to prevent pressure ulcers is to __________.
a) apply lotion to the patient’s skin
b) alternate putting the patient in bed and in the wheelchair
c) reposition the patient at least every 2 hours
d) change the bed linens daily
10) Constipation can develop in an immobilized patient due to _____________.
a) weakened muscle tone
b) fatigue
c) fear of developing diarrhea
d) inability to perform the Valsalva maneuver
____________________________________________________________________ Chapter 21 Immobility 3
Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: A patient who has rheumatoid arthritis and has had a recent stroke says to the nurse who is
preparing to reposition her: “Please don’t touch me. Every move causes me to hurt. Just let me lie in this
position until morning, and then I’ll try to move.” How should the nurse respond?
Answer: The nurse should remind the patient that immobility could lead to pressure ulcer development
Question: A physical therapist approaches a nurse and says that a patient who has been ordered some
exercises is refusing physical therapy today. The therapist asks the nurse for suggestions on how to get
the patient involved in the therapy. How should the nurse respond?
4 Chapter 21 Immobility _____________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 21.1
Instructor Preparation
Textbook Objectives Covered
1. Describe common problems associated with immobility.
3. Identify the risk factors for pressure ulcers.
5. Describe the methods of preventing and treating pressure ulcers.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Guest speaker: physical therapist
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying the treatment requirements of the immobile patient, including:
• The use of exercise and positioning to minimize the occurrence and adverse effects of
Materials and Supplies
Key Terms
• isometric exercise (p. 328)
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 325-327)
ANSWER – Text
• Review Questions for the NCLEX Examination: 1 (p. 335)
ANSWER – Study Guide
• Part IA: 1 (p. 121)
• Part IC: 1-10 (p. 122)
2
READ – Textbook (pp. 327-328)
ANSWER – Text
• Review Questions for the NCLEX Examination: 2, 3 (p. 335)
ANSWER – Study Guide
• Part IA: 2-5, 7, 8 (p. 121)
• Part IIF: 5 (p. 124)
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 21.1
3
READ – Textbook (pp. 328-330)
REVIEW
• Figure 21-1: Possible locations of pressure ulcers (p. 329)
• Figure 21-3: Norton scale for the identification of those at risk for the development of
pressure ulcers (p. 330)
ANSWER – Study Guide
• Part ID: A-Z (p. 123)
• Part IE: 1, 2 (p. 124)
• Part IIF: 2 (p. 124)
4
READ – Textbook (pp. 331-332)
REVIEW
ANSWER – Study Guide
• Part IB: 1-3 (p. 122)
• Part IIF: 4 (p. 124)
5
READ – Textbook (pp. 330-331)
REVIEW
• Figure 21-4: Specialty beds prevent pressure on bony prominences (p. 331)
ANSWER – Study Guide
• Part IA: 6, 9 (p. 121)
• Part IIF: 3, 6, 7, 10, 12 (pp. 124-125)
• Part IIIG: 1, 2 (p. 125)
6 Chapter 21 Immobility _____________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 21.1
Lecture Outline 20 minutes
Slide 1
Chapter 21
Immobility
1
Slide 2
Immobility
• Restriction imposed on all or part of the body
• Physical factors, such as joint disease, paralysis, or pain; psychological factors, such as
depression or fear
• Therapy
TALKING POINTS:
• What body systems may be affected by immobility?
• The impact of immobilization on an individual depends on the duration, degree, and type
of mobility limitation.
Slide 3
Immobility (cont.)
• Psychosocial changes can impair mobility
• Depression
• Dementia
• Bereavement
• Lack of motivation
TALKING POINTS:
• Whatever the reason for resting part or all of the body, measures must be taken to
manage the adverse effects of immobility.
Slide 4
Immobility (cont.)
• Older adult’s environment can promote or hinder mobility
• An unsafe home setting, hospitalization, or institutionalization associated with reduced
activity
• Hospitalized older adult may quickly become debilitated and dependent as a result of
• Inactivity
____________________________________________________________________ Chapter 21 Immobility 7
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 21.1
2
Slide 5
Exercise
• A well individual of any age can walk, participate in aerobic exercises, swim, engage in
sports activities, garden, or do housework
• Ill and disabled can engage in some form of exercise regardless of severity of their
disease
• Active
• Performed by the patients
• Passive
TALKING POINTS:
• Exercise is the best medicine for immobility.
• Active and passive exercises may be done with the patient lying down in bed, sitting in a
chair, or standing upright.
• What are some examples of bed and chair exercises?
Slide 6
contractures.
Range-of-Motion Exercises
• Help prevent disabilities of the musculoskeletal system as well as other systems
• Muscular activity maintains range of motion (ROM) by allowing the joint to remain flexible
and functional
• Contracture
• Shortening of muscles and tendons
• When little or no movement of a joint, its structures change
TALKING POINTS:
• Each of the joints of the body has a range of motion—that is, the limits to which the joint
may be moved.
• What is the purpose of range-of-motion exercises?
Isometric Exercises
• Muscle tone without moving the joint
TALKING POINTS:
• Isometric exercises help to keep muscles toned and blood moving. These both work
together to prevent complications of immobility.
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 21.1
Slide 8
Positioning
• Change patient’s position at least every 2 hours to prevent undue pressure on the skin
• Maintain joints in their functional positions so that they are not abnormally flexed or
extended
• Use footboards, splints, and bed boards to maintain proper positioning for patients in bed
• Avoid positioning the patient with the knees and hips flexed
TALKING POINTS:
• Proper positioning in a bed or chair is extremely important for preventing many of the side
effects of immobility.
3
Slide 9
Pressure Ulcers
• Localized areas of tissue necrosis that develop when soft tissue is compressed between a
bony prominence and an external surface for a prolonged period
• Pressure points: areas over bony prominences, such as the elbows, hips, shoulders, and
sacrum
TALKING POINTS:
• What are the most common sites of skin breakdown due to pressure?
4
Slide 10
Development of Pressure Ulcers
• Erythema: beginning of a pressure ulcer and a sign that capillaries in the area have
become congested because of impaired blood flow
• Can occur within an hour or two in person with healthy skin and adequate circulation
• Factors in addition to immobility that contribute to the development of pressure ulcers are
• Shearing forces
• Chemical irritants such as urine
• Sedation
• Poor nutrition
TALKING POINTS:
• What makes a person more likely to develop pressure ulcers?
5
Slide 11
Preventing Pressure Ulcers
• First step: identify those at risk
• Norton scale
• The scores for all five categories are added
• If the total score is greater than 14, there is little risk of pressure ulcer
development
TALKING POINTS:
• What are the five categories of the Norton scale?
____________________________________________________________________ Chapter 21 Immobility 9
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 21.1
Slide 12
Prevention Protocol
• Reposition the patient in bed at least every 2 hours
• Position so not resting on pressure points of the skin
• Teach wheelchair patients to shift their weight every 15 minutes if able. Patients who
cannot do this should be repositioned at least hourly
• Keep bed linens dry, smooth, and free of wrinkles
TALKING POINTS:
• How often should the skin of “at risk” patients be assessed and documented?
Slide 13
Prevention Protocol (cont.)
• In bed, keep head lowered as much as possible to reduce shearing force caused by
sliding down
• Special mattress or bed reduces pressure, such as an egg crate foam (minimum 2 inches
thick), static air, alternating air, gel, fluidized air, or water mattress
TALKING POINTS:
• Should pressure points that are red be massaged?
• Rubber rings should not be used to elevate heels or sacral areas.
Slide 14
Stages of Pressure Ulcers
• Stage I
• Erythema (redness) that does not blanch when pressed
• Color: from red to the dusky blue; called cyanosis
• Irregular and ill-defined area of pressure reflects the shape of the object creating the
TALKING POINTS:
• If pressure ulcers develop despite all preventive measures, assess the stage and describe
it precisely.
• Before stage I begins, what happens when you press on a reddened area of skin?
Stages of Pressure Ulcers (cont.)
• Stage II
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 21.1
Slide 16
Stages of Pressure Ulcers (cont.)
• Stage III
• Full-thickness skin loss involving damage or necrosis of the dermis and subcutaneous
tissue
• Wound may be infected; usually open and draining, with a loss of fluid and protein
• Fever, dehydration, anemia, leukocytosis
Stages of Pressure Ulcers (cont.)
• Stage IV
• Full-thickness skin loss with extensive destruction of the deeper underlying muscle
Slide 18
Stages of Pressure Ulcers (cont.)
• Stages I and II
• Cleaned with mild soap and water or normal saline
• Avoid using pastes, creams, ointments, and powder because they may promote
infection in the ulcer
• Avoid using alcohol, antiseptics, disinfectants, topical and oral antibiotics, and
massage: effectiveness has not been proven, and they may actually cause harm
• The most effective dressing for a stage I or II pressure provides a moist environment
and maintains a temperature close to body temperature
TALKING POINTS:
• The first step in treating pressure ulcers is to continue all preventive measures.
Slide 19
Stages of Pressure Ulcers (cont.)
• Stages III and IV
• More extensive treatment and supportive care
• Irrigation devices: spray bottles, bulb and piston syringes, others
TALKING POINTS:
• How can you evaluate the effectiveness of débridement?
• Supportive care consists of measures to treat anemia, dehydration, protein depletion, and
infection.
Introduction to Medical-Surgical Nursing, 6th ed.
Slide 20
Question 1
• Common aging changes in the elderly that place the older adult at risk for immobility and
its consequences include all of the following EXCEPT __________.
A. decreased flexibility and strength
B. changes in posture and gait
C. chronic conditions that increase the likelihood of immobility
D. increased drug use that improves immobility
TALKING POINTS:
Slide 21
Question 2
• The most frequent site of skin breakdown is the ________.
A. heels
B. sacrum
C. ischial tuberosities
D. scapulae