20/09/2010

Immobility Effects and Complications

The dangers of going to bed

"The blood clotting in his veins, the lime draining from his bones the bones, scybala stacking up in his colon, the flesh rotting from his seat, the urine leaking from his distended bladder, and the spirit evaporating from his soul".

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BED REST AND IMMOBILITY

The cardiovascular responses to bed rest include redistribution of blood volume from the lower body to the central circulation, a deconditioning , y of the heart, and a reduction in total body water. Venous stasis due to bed rest encourages the development of deep vein thrombosis.

BED REST AND IMMOBILITY

Pulmonary changes due to bed rest include decreased tidal volume and functional residual capacity. Alveoli tend to collapse (atelectasis), resulting i ( t l t i ) lti in areas of f decreased pulmonary ventilation. Bed rest increases the risk of development of renal calculi and urinary tract infections.

BED REST AND IMMOBILITY

Muscle mass is reduced owing to disuse atrophy and bone mass is reduced because of an imbalance of activity between osteoclasts (bone reabsorption) and osteoblasts (bone generation). Decubitus (pressure) ulcers due to tissue ischaemia may develop in areas in constant contact with the bed surface. Psychological effects of bed rest include anxiety depression and decreased ability to concentrate and learn.

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Effects of Gravity and Decreased Use of Skeletal Muscle

Counteracting Gravity

Normally, in an upright position the body compensates for the effects of gravity:
Skeletal muscle contracts against veins and lymphatic vessels, counteracting the hydrostatic effects of gravity that would tend to cause pooling of blood and fluid in dependent areas. Movement against gravity maintains muscle tone. Longitudinal weight bearing of bone maintains calcium in situ.

Immobility complications

Fluid shift:
lying results in 11% of total blood volume shifting away from legs to rest of body 78% of which goes to thorax increase in preload tachycardia

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Cardiovascular Response

After a period of bed rest in the supine position the CVS responds to loss of gravity and exercise stimuli: Redistribution and change in blood volume. Increased cardiac workload. Orthostatic hypotension. Venous stasis => deep vein thrombosis (DVT)

1. 2. 3. 4.

500 ml redistributed from lower extremities to central circulation Most to thoracic cavity Redistribution and Smaller portion to head and arms Change in Blood
Volume

Effects

Headache Swelling of sinuses (nasal) Nasal congestion Swollen eyelids

Increase in Cardiac Workload in Supine Position

Increase in thoracic blood volume leads to: Central Venous Pressure LV EDV (Starlings Law) Stroke Vol CO to 7 8 l/min Initial increase in CO causes: Heart rate Peripheral resistance To maintain arterial BP

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Venous distension Venous return Stabilisation of SV and CO Tachycardia Diastolic Filling Time energy use and oxygen demand by heart to meet metabolic demands. This response is exaggerated when person resumes upright position and resumes activity. Four to 10 weeks of reconditioning exercise required to return parameters to pre-bedrest levels.

With Extended Periods of Bed Rest

Bed rest removes the affect of gravity and hydrostatic pressure from CVS After 3 4 days bed rest, return to upright position orthostatic or postural intolerance central thoracic blood volume (blood to lower extremities) Venous return Stroke volume and CO (why?) HR tachycardia, nausea, diaphoresis, syncope.

Orthostatic Hypotension

Fluid Balance In Supine Position

Central blood volume inhibition of ADH and Aldosterone Water and Sodium diuresis Diuresis starts day one in supine position Haematocrit Haemaglobin Haematocrit, After four days bed rest fluid loss reaches an equilibrium Cause: Vascular Fluid loss oedema stimulus for Salt and Water diuresis

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Immobility complications

Promotion of venous stasis Client positioning Prone to thrombosis P t th b i After 8 days, thromboplastin time shortened weight of legs on bed compress calves

Results from lack of muscle pump that promotes venous return. Supine position increase pressure on veins of lower extremities from contact with bed Compression damage to Intima and increases thrombocyte adherence and clot formation. Virchow Triad = three factors pre-disposing person to DVT: Stasis of flow Hypercoagulability state caused by decreased and increased blood viscosity Vessel injury DVT predisposes person to Pulmonary Embolism. blood volume

Venous Stasis

Immobility complications

Lungs
inspiratory muscles working in different p plane - additional stress abdominal contents push against diaphragm - shallower breathing collapse of alveoli (atelectasis) poor coughing predisposition to infection

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Metabolism changes

Negative nitrogen balance imbalance between breakdown of protein and protein synthesis elevated urine nitrogen loss muscle mass, reduced wound healing Disuse osteoporosis bone demineralisation imbalance - osteoblasts & osteoclasts increased serum Ca++

Elimination changes

Constipation
Abdominal and perineal muscles weakened due to muscle atrophy Gravity not assisting passage of stool Delayed due to embarrassment etc Dehydration frequent

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Elimination

Urinary stasis: may delay voiding due to need for assistance diffi lt relaxing perineal muscles when supine difficulty l i i l l h i detrusor muscles can become overstretched due to full bladder urine flows upward into ureters prostatic enlargement

Urinary problems

UTI stagnant urine - good medium for bacterial growth distension can result in catheterisation Renal calculi increased serum Ca++ and stagnation urinary Ca++ levels raised precipitate to form crystals dehydration enhances calculi formation

Decubitus Ulcers

Four crucial etiological factors pressure, shearing forces, friction & moisture Pathophysiology P th h i l compression > 25 mm Hg occludes blood vessels - anoxia of tissues damage is directly related to extent and duration of pressure bacteria enter broken skin

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Risk factors

Immobility weight bearing bony prominences impaired sensory or cognition pa n, d scomfort L.O.C., unaware of pain, discomfort decreased tissue perfusion diabetes, oedema, poor circulation poor nutrition anaemia, low protein, vitamin, trace elements

Etiological factors

Pressure force per unit area bony prominences lack of subcutaneous tissue occludes blood supply Moisture skin softened, macerated lighter in appearance and easily damaged incontinence, inadequate drying

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Etiological factors

Friction resistance to movement direct damage to skin, abrasion Shearing tissue layers move over each other blood vessels stretched, torn

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Management

Assessment Sequential Repositioning Pressure relieving devices foam air mattress sheepskin gel pad Hygiene Movement

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