Nursing diagnosis – RISK FOR DISUSE SYNDROME

RISK  FOR  DISUSE  SYNDROME

DEFINITION

At risk for deterioration of body systems as the result of prescribed

or unavoidable musculoskeletal inactivity

RISK FACTORS

•   Altered LOC

•   Prescribed immobilization

•   Mechanical immobilization

•   Severe pain

•   Paralysis

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition

• Cardiac function

• Respiratory function

• Coping

• Risk management

• Elimination; nutrition

• Tissue integrity

• Fluid and electrolytes

EXPECTED OUTCOMES

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

Control

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.

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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-

ing pressure.

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

Reference

Gillis, A., & MacDonald, B. (2005, June). Deconditioning in the hospitalized

elderly. The Canadian Nurse, 101(6), 16–20.

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