RISK FOR DISUSE SYNDROME
At risk for deterioration of body systems as the result of prescribed
or unavoidable musculoskeletal inactivity
• Altered LOC
• Prescribed immobilization
• Mechanical immobilization
• Severe pain
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
• Respiratory function
• Risk management
• Elimination; nutrition
• Tissue integrity
• Fluid and electrolytes
The patient will
• Have no evidence of altered mental, sensory, or motor ability.
• Have no evidence of thrombus formation or venous stasis.
• Have no evidence of decreased chest movement, cough stimulus,
depth of ventilation, pooling of secretions, or signs of infection.
• Maintain normal bowel elimination patterns.
• Maintain adequate dietary intake, hydration, and weight.
• Have no evidence of urine retention, infection, or renal calculi.
• Maintain muscle strength and tone and joint ROM.
• Have no evidence of contractures or skin breakdown.
• Maintain normal neurologic, cardiovascular, respiratory, GI, nutri-
tional, genitourinary, musculoskeletal, and integumentary function-
ing during period of inactivity.
SUGGESTED NOC OUTCOMES
Coordinated Movement; Endurance; Immobility Consequences: Phys-
iological; Immobility Consequences: Psychocognitive; Mobility; Risk
INTERVENTIONS AND RATIONALES
Determine: Inspect skin every shift and follow facility policy for pre-
vention of pressure ulcers to prevent or mitigate skin breakdown.
Administer anticoagulant therapy, if ordered; monitor for signs and
symptoms of bleeding. Anticoagulant therapy may cause hemorrhage.
Monitor vital signs every 4 hr: Monitor breath sounds and respi-
ratory rate, rhythm, and depth to rule out respiratory complications.
Monitor arterial blood gas levels or pulse oximetry to assess
oxygenation, ventilation, and metabolic status.
Monitor urine characteristics and patient’s subjective complaints
typical of UTIs, such as burning, frequency, and urgency. Obtain urine
cultures, as ordered. These measures aid early detection of UTI.
Identify functional level to provide baseline for future assessment,
and encourage appropriate participation in care to prevent complica-
tions of immobility and increase patient’s feelings of self-esteem.
Perform: Avoid positions that put prolonged pressure on body parts
and compress blood vessels; reposition patient at least every 2 hr
within prescribed limits. These measures enhance circulation and
help prevent tissue or skin breakdown.
Use pressure-reducing or pressure-equalizing equipment, as
indicated or ordered (ﬂotation pad, air pressure mattress, sheepskin
pads, or special bed). This helps prevent skin breakdown by reliev-
Apply antiembolism stockings; remove for 1 hr every 8 hr. Stock-
ings promote venous return to heart, prevent venous stasis, and
decrease or prevent swelling of lower extremities.
Suction airway, as needed and ordered, to clear airway and stimu-
late cough reﬂex. Note secretion characteristics.
Provide small, frequent meals of favorite foods to increase dietary
intake. Increase ﬁber content to enhance bowel elimination. Increase
protein and vitamin C to promote wound healing; limit calcium to
reduce risk of renal and bladder calculi.
Perform active or passive ROM exercises at least once per shift.
Teach and monitor appropriate isotonic and isometric exercises.
These measures prevent joint contractures, muscle atrophy, and
other complications of prolonged inactivity.
Provide or help with daily hygiene; keep skin dry and lubricated
to prevent cracking and possible infection.
Inform: Teach and monitor deep breathing, coughing, and use of
incentive spirometer to help clear airways, expand lungs, and
prevent respiratory complications. Maintain regimen every 2 hr.
Instruct patient to avoid straining during bowel movements that
may be hazardous to patients with cardiovascular disorders and
increased intracranial pressure. Teach to administer stool softeners,
suppositories, or laxatives, as ordered, and monitor effectiveness.
Attend: Encourage ﬂuid intake of 21⁄2–31⁄2 qt (2.5–3.5 L) daily,
unless contraindicated, to maintain urine output and aid bowel elim-
ination. Encourage patient and family to verbalize frustrations to
help patient and family cope with treatment.
SUGGESTED NIC INTERVENTIONS
Activity Therapy; Body Mechanics Promotion; Cognitive
Stimulation; Energy Management; Exercise Promotion; Exercise
Therapy: Ambulation; Fluid Management; Nutrition Management
Gillis, A., & MacDonald, B. (2005, June). Deconditioning in the hospitalized
elderly. The Canadian Nurse, 101(6), 16–20.