The Geriatric Resource Nurse Model is used at the University of Virginia to improve the competency of staff in caring for older adults. Eight self-learning educational modules were developed to address common concerns in hospitalized elders. The Immobility: Geriatric Self-Learning Module is published here, along with a post- test. This is the third in a four-part publication of self-learning modules.
The Geriatric Resource Nurses at the University of Virginia developed the Self-Learning Modules in Geriatric Care. The SPPICEES pneumonic addresses the eight distinct modules, each targeting a commonly encountered health concern of older adults across health care settings. These include:
S: Sleep
P: Problems with eating and nutrition
P: Pain
I: Immobility
C: Confusion
E: Elimination
E: Elder abuse
S: Skin
The modules were designed using a case study approach in order to encourage the learner to gain new knowledge as well as apply this knowledge. Each module includes two case studies, one applicable to the care of an older adult in the inpatient setting, and the other applicable to an older adult in the outpatient setting. Each module takes approximately 20 to 30 minutes to complete.
The completion of these self-study modules alone does not ensure the staff member is age-specific competent; this is determined through the observation and demonstration of behaviors while working directly with older adults. However, these modules will enhance the staff member’s knowledge as a foundational step in developing competent behaviors.
Purpose
The purpose of this module is to assist the health care professional in developing an increased awareness and sensitivity to the hazards of immobility in older adults. This module is also intended to enhance the reader’s repertoire of interventions to maximize mobility and prevent immobility.
Target Audience
This self-study module is directed toward health care professionals providing direct care to older adults in the inpatient or outpatient settings.
Objectives
At the conclusion of this module on immobility, the patient care staff will be able to:
1. Describe the vulnerability of older adults to the hazards of immobility.
2. Discuss the effects of immobility on specific body systems.
3. Identify specific interventions that might be taken in order to maximize mobility and minimize immobility in older adults.
Overview
Most individuals make the assumption that rest is an appropriate strategy to be taken when a person is ill or frail. This myth is of particular concern with older adults. Research has demonstrated the damaging effects of prolonged inactivity. Virtually every organ or body system promptly and progressively deteriorates when a person is inactive.
Immobility is of particular concern with hospitalized elders. In hospital settings the patient’s pneumonia may be successfully cured or his hip fracture fixed, but if activity is not encouraged aggressively, the patient may decline functionally during the hospital stay. Maintaining function is central to fostering health and independence in all older adults, regardless of the setting. Appropriate strategies for intervention include avoiding immobilization if at all possible, removing environmental deterrents to safe ambulation, developing an exercise program, and evaluating gait and endurance.
Case Study: Immobility in the Hospitalized Elder
H.H. is a 78-year-old male who has had an extensive cerebrovascular attack. He has limited weight-bearing ability on the left and is flaccid on the right. He is to be out of bed three times daily. The patient care attendant requests that the weight and lift team bring a Hoyer lift to facilitate a daily transfer because the patient is 6’4″ tall and weighs 260 lbs. The evening shift does not have this support available and staff believe they do not have enough assistance to get him out of bed. You express some concerns about this approach and review with the staff the physical and psychological hazards of immobility.
Discussion
By having this patient passively rather than actively participate in mobility, a progressive decline in his functional ability may occur secondary to disuse. It takes more nursing resources to care for a patient like this who is greatly (but not completely) dependent. Therefore, a concern exists that when less staff are available, patients like this quickly lose existing functional capacity.
The Physical Effects of Bedrest
Cardiovascular effects
* Progressive loss of fluid, primarily from the extracellular space
* Intravascular volume preferentially distributed in the upper body
* Loss of orthostatic competence (blood pressure drops positionally)
* Fall in stroke volume and cardiac output
* Increase in resting and submaximal heart rate
Musculoskeletal effects
* Loss of contractile force
* Shortening of muscle fibers and total muscle length
* Increase in calcium loss from the bone
Urinary tract effects
* Stagnation in calyces
* Incomplete bladder emptying
Pulmonary effects
* Cilia less effective
* Mucous pools
* Chest movement restricted in a supine position
Gastrointestinal effects
* Loss of appetite
* Decreased peristalsis
* Decreased ability to eat in a supine position
Skin effects
* Pressure ulcers
Psychological effects
* Anxiety
* Depression
* Disorientation
* Fostered dependency/learned helplessness
Did You Know?
* Pulmonary embolism is the most common cause of sudden unexpected death in the hospital.
* Recovery of orthostatic function in healthy young adults after prolonged bedrest can take several weeks; it may take considerably longer in elders.
* Daily loss of 1.3% to 3% of muscle strength occurs with immobility. A daily loss of 1.5% leg strength means a 10% loss in 1 week of bedrest.
* Contractures can begin to form after 8 hours of immobility. Active and/or passive range of motion can help prevent contractures.
* In a supine position, the vital capacity of the lungs is decreased by about 4%.
* The vulnerable older trauma patient on a backboard in the emergency room can show signs of skin breakdown within 3 hours of immobility.
* Bedrest itself appears to be a subtle form of sensory deprivation. At NASA, studies showed that normal, healthy young men kept in bed for several weeks experienced significant increases in anxiety, hostility, and depression, together with altered sleep pattern.
Case Study: An Outpatient AtRisk for Immobility
A.R. is an 82-year-old female who lives alone in low-income housing area for older adults. She is seen regularly in the outpatient medical clinic for hypertension and carotid stenosis. She has been instructed by her primary care provider to get more exercise and would like to do so, but is concerned about walking in what she considers an unsafe neighborhood. What advice do you give her?
Discussion
A.R. expresses an interest in beginning an exercise program and thus appears to be motivated. It is important to reinforce her willingness to exercise and emphasize the benefits of exercise. It is helpful to have a discussion about the types of exercises
that are important for helping older adults gain health benefits.
Types and Benefits of Exercises
* Endurance exercises increase breathing and heart rate.
* Strength exercises build muscle strength and increase metabolism.
* Balance exercises help prevent falls and the risk of loss of independence.
* Flexibility exercises help keep the body limber.
* In addition to physical benefits, regular exercise can improve mood and feelings of well-being.
Suggestions for designing a walking program when safety is an issue might include finding a walking partner and walking only in well-lit, easily observed areas; some communities have a “shopping mall walking program.”
“The good news…is that people can benefit from even moderate levels of physical activity.” Surgeon General of the United States
Immobility: Geriatric Self-Learning Module Post-Test
1. Hazards of immobility in hospitalized elders include:
a. Pressure ulcer,
b. Deep venous thrombosis.
c. Depression.
d. Pneumonia.
e. a and d.
f. All of the above.
2. The most important strategy in minimizing the risk of immobility is:
a. Avoiding hospitalization.
b. Getting the patient out of bed as soon as possible.
c. Medicating the patient to assure adequate rest at night.
d. Getting a physical therapy consult ordered.
3. The risk of skin breakdown in hospitalized elders is very high; therefore, it is essential to change position and alternate pressure hourly.
a. True
b. False
4. Older adult patients should be given maximal assistance with their activities of daily living because they may be weak and it is expected that hospital staff will provide this service.
a. True
b. False
5. Proper positioning is the most important strategy in preventing a contracture.
a. True
b. False
6. You are more likely to keep doing physical activity if:
a. You think that you will benefit from it.
b. Enjoy the activity.
c. Have access to the activity.
d. Can fit the activity into your daily schedule.
e. All of the above.
Post-Test Answers
1. f
2. a
3. a
4. b
5. b
6. e
Resources
Immobility
Corcoran, P. (1991). Use it or lose it – the hazards of bedrest and inactivity. Western Journal of Medicine, 154(5), 536-538.
Mobily, P.R., & Skemp, K. (1991). latrogenesis in the elderly: Factors of immobility. Journal of Gerontological Nursing, 17(9), 5- 11.
National Institutes of Health, (n.d.) Exercise: A guide from the National Institute on Aging. Retrieved January 6, 200\5, from http:/ /www.niapublic tions.org/exercisebook/index.asp
General Aging
Beers, M.H., & Berkow, R. (Ed.) (2000). Merck manual of geriatrics (3rd ed.). Whitehouse Station, NJ: Merck Research Laboratories.
Ebersole, P., & Hess, P.(Ed.) (1998). Toward healthy aging: Human needs and nursing response (5th ed.). St. Louis: Mosby.
Ham, R.J., & Sloane, P.D. (Eds.) (1997). Primary care geriatrics: A case-based approach (3rd ed.). St. Louis: Mosby.
Lueckenotte, A.G. (Ed.) (2000). Gerontologic nursing (2nd ed.). St. Louis: Mosby.
Kathy Fletcher, MSN, RN, APRN-BC, GNP, is Administrator, Senior Services, and Assistant Professor of Nursing, University of Virginia Health System, Charlottesville, VA.
Note: The Immobility: Geriatric Self-Learning Module is based on an earlier version written by Kathy Fletcher and Pat Hogan.
Copyright 2002 by the Rectors and Visitors of the University of Virginia. Reprinted here with permission.
Copyright Anthony J. Jannetti, Inc. Feb 2005
Comments