Effects on Cardiovascular Function

The cardiovascular system, including the heart, the arteries, the venous
channels, and the lymph vessels, is designed to deliver blood to and from
the capillaries where the exchange of the vital respiratory gases and other
metabolic substances occurs. Three major changes in cardiovascular
system function have been identified as resulting from immobilitv:
orthostatic hypotension, increased work load of the-heart, and thrombus
formation.

ORTHOSTATIC HYPOTENSION

Perhaps the most dramatic of these changes is the deterioration of the

ability of the autonomic system to equalize the blood supply when a
person who has been recumbent for a long period attempts to stand up.
AII nurses are aware that when patients first get up after several days in
bed, they may suffer from weakness, dizziness, or giddiness. They may
even faint.

Taylor found that when healthy young men were put to bed for 21 days,
the ability of the cardiovascular system to respond to the upright posture
was not regained for more than five weeks after activity was resumed (1).
This was due to two factors: loss of general muscle tone and decrease of
efficiency of the orthostatic neurovascular reflexes. The loss of muscle
tone resulting from complete disuse is estimated to be 10-15 percent of
strength per week. One potent factor assisting venous return is the so-
called "venopressor mechanism" in which the contraction of muscles
causes pressure on veins. The venous valves which prevent the backflow
of blood close, hence muscle action assists venous return of blood to the
heart. In the absence of this type of assistance, the venous blood tends to
pool in the lower parts of the body.

The second factor, decreased efficiency of the orthostatic neurovascular

reflex control of the vessels themselves, is a puzzling complication. At the
very time that there is an inability to maintain blood pressure when erect,
patients show signs of strong activity of the sympathetic nervous system
such as palmar sweating, pallor, and restlessness which proves that the
nerves are intact and central function is normal. Birkhead, who also
demonstrated that persons show decreased tolerance to the erect posture
after 42 days at bed rest, found a normal autonomic response to exercise
in the supine position which confirmed positively that the problem is a
peripheral rather than a central nervous system onset (2). Browse reported
that this local failure of the nervous system may result simply from its
 habituation to the lower pressure. higher flow, and increased diameter of
vessels in the supine position (3). In such a situation the nervous stimuli
and the increased intramural pressure suddenly thrust upon them.

INCREASED WORK LOAD

The second change in cardiovascular system function resulting from

immobility is that the heart itself works harder in the resting supine position
than in the-resting erect position. The physiologic effect-on the heart of
bed rest as a method of treatment for myocardial infarction has received
much attention in recent literature. Coe demonstrated that the heart works
30 percent harder when a person is in the recumbent position than when
he is in a sitting position (4). Several physiologic factors are involved in
this phenomenon.

Changes in the vascular resistance and the hydrostatic pressure

associated with lying down alter the distribution of blood within the body.
With the release of gravity pressure, part of the total blood volume leaves
the legs to be redistributed in other parts of the body, thus increasing the
volume of the circulating blood which must be handled by the heart. The
cardiac output and the stroke volume increase with lying down. Studies by
Chapmen found a 24 percent increase in the cardiac output and a 41
percent increase in the stroke volume when healthy men were put on
enforced bed rest (5). Also the heart rate itself increases progressively as
the patient remains bedfast. Taylor found that, even in healthy young men
who were confined to bed, the cardiac rate at rest increased approximately
0.5 beat per minute per day (l). After three weeks of bed rest, these men
showed an increased heart rate of 40 beats per minute during moderate
work. They required 5 to 10 weeks of reconditioning before their heart
rates during work matched those prior to the prolonged bed rest. This
progressive increase of the testing heart rate and greater tachycardia
during work indicate progressive decrease of ability in cardiovascular
function. During tachycardia the recovery time for the heart muscle is
decreased and the heart muscle fatigues more quickly. Tavlor
demonstrated that the abilitV of healthy young men to walk 3.5 miles an
hour on a 10 percent incline was decreased by -5 percent after only three
weeks in bed due to decreased cardiac reserve (1).

Another factor affecting the work load of the heart during bed rest is
concerned with the Valsalva maneuver. When a person uses his arms and
upper trunk muscles to expedite moving about in bed, he fixes his thorax
and usually holds his breath. In so doing the breath is pressed forcibly
against the closed glottis- the Valsalva maneuver. This same basic action
occurs with straining at the stool. During this period of thoracic fixation
 without expiration. the intrathoracic pressure is elevated and interferes
with entry of venous blood into the large veins. With release of the breath,
there is a consequent fall in intrathoracic pressure, and a large surge of
blood is delivered to the heart at one time. This can result in tachycardia
which, in turn, can result in cardiac arrest if the heart is not functioning
optimally. Estimates on the frequency with which this maneuver is used by
bedfast patients range from 10 to 20 times per hour.

THROMBUS FORMATION

The third major hazard to cardiovascular function resulting from immobility

is thrombus formation. It is believed that immobilitv predisposes to
thrombus by contributing to venous stasis, hypercoagulability of the blood,
and external pressure against the veins. Venous-stasis-in-the legs results
from the lack of muscular contraction which ordinarily promotes venous
return. Evidence that bed rest actually contributes to hypercoagulability of
the blood is difficult to document, but several theories have been
presented. Some physiologists believe that bed rest results in an
increased concentration of the formed eIements in the blood which by
increasing viscosity would predispose to clotting. Dehydration which often
accompanies immobility also is considered a factor leading to
hypercoagulability of the blood. One familiar hypothesis of blood
coagulation states that prothrombin is activated by material from the
platelets and calcium to form thrombin, which, in turn, becomes the
activating enzyme for the conversion of fibrinogen to fibrin. It is believed
that the vital role of calcium in this process of coagulation supports the
theory that the increased blood level of calcium resulting from immobility
may result in hypercoagulability of the blood.

Another factor predisposing to thrombus formation. External pressure on

the blood vessels, is well known to nurses. The danger of restricting
circulation by allowing pressure from the bent knee gatch or pillows under
the knees is often voiced. However,-the lateral recumbent positiion so
often used in positioning patients may also result in both circulatory stasis
and damage to the intima of the blood vessels. The upper leg will rest
heavily on the lower leg unless care is taken to prevent it. When the intima
is damaged a layer of platelets is laid down over the damaged area, and
this plaque may be the basis for a clot.

While studies related to predisposition to thrombus formation because of

immobility are contradictory, a report by Sevitt and Gallagher showed that
on autopsy the number of thrombi found was in direct proportion to the
length of time patients were at bed rest (6). Their findings support the
 contention that venous stasis and the other effects of immobility play a.
major etiological role in venous thrombus formation.

NURSING IMPLICATIONS

These effects of immobility on the cardiovascular system dictate that no

patient should be allowed to remain immobile any longer than absolutely
necessary, Even when bed rest must be imposed, nursing measures,
implied from the physiologic changes discussed, can prevent the hazards
of immobility.

Exercises to prevent loss of muscle tone and to promote muscular

pressure on-veins-to assist the return flow of blood to the heart should be
included in any nursing care plan for the immobilized patient. These might
include passive and active range of joint motion, isometric exercises, and
self-care to the maximum permitted.

Seeing that the patient's position is changed frequently will alter the
intravascular pressure and provide stimulus to the neural reflexes of the
vessels and help prevent hypotension. Probably the most effective
measure is changing the patient's position from horizontal to vertical. This
can be achieved by elevating the head of the bed, or, when permissible,
sitting the patient in a chair.

Patients need to be taught how to move and change position in bed

without building up intrathoracic pressure. An overbed frame and trapeze
can be provided if necessary and the patient taught to use it properly. To
prevent the dangers inherent in repeated Valsalva maneuvers, he should
be told to exhale rather than hold his breath while moving in bed.

The normal person changes position every few minutes, so that to plan
position changes only every two hours is to condemn the person to
discomfort or to the use of his own means of shifting weight or position.

Preventing constipation and positioning the patient for defecation in a well

supported sitting or squatting position also will reduce the work load on the
heart. And, finally, as activity is permitted, it must be gradual to avoid
fatigue.

Effects on Metabolic Equilibrium

The effects of immobility on the metabolic processes cannot be discussed
without some reference to closely related endocrine functions or some
explanation of how interference with metabolic homeostasis profoundly
influences the efficiency of all physiologic processes and other
homeostatic mechanisms.

Functional changes resulting from immobility include reduced metabolic

rate, tissue atrophy and protein catabolism, bone demineralization,
alterations in the exchange of nutrients and other substances between the
extracellular and intracellular fluids, fluid and electrolyte imbalance, and
gastrointestinal by hyper or hypomobility.

When a person is consigned to bed, rest and inactivity, his metabolic rate
falls in response to the decreased; energy requirements of the cells an the
disequilibrium. of metabolic processes. Anabolic processes are retarded
and catabolic activities are accelerated. Many of these have already been
discussed in relation to the dysfunction of various other body systems: the
process of protein breakdown leading to protein deficiency and negative
nitrogen balance; the formation of decubitus ulcers; the excretion of
electrolytes when catabolic processes are accelerated; the
demineralization of bone as a consequence of reduced muscle tension
and absence of weight-bearing stress on the skeleton; and the formation
of urinary tract stones. And there are still other factors associated with bed
rest that affect metabolism and fluid and electrolyte balance and have
important implications for nursing. One of these is body temperature.

Bedclothing prevents the loss of heat by conduction and radiation. The

supine position dilates blood vessels and, in order to throw off
accumulating heat, the patient will sweat wherever skin surfaces touch In
the creases in the neck, under breasts, the abdominal folds, the surfaces
where the am-is rest against the chest, and in the axillary and perineal
regions, sweating increases. All of this fluid loss carries with it essential
electrolytes-sodium, potassium and chloride.)

It is known that the supine position reduces the production of adrenal

cortical hormones, although the exact mechanism whereby this occur is
not known. There are two groups of adrenal-cortical hormones that
influence metabolism. One is the glucocorticoids which affect the
metabolism of carbohydrate, protein, and fat; the other is the
mineralocorticoids which are concerned with electrolyte balance
(especially of sodium, potassium, and chloride).

Authorities currently are examining the influence of immobilization on other

hormones produced in the body, but definitive information is not available
at this time. Recently, a second hormone (thyrocalcitonin) has been
isolated from the thyroid. gland. Its function seems to be an adaptive one
wherein it attempts to lower an elevated serum calcium.

Increased urinary excretion sometimes occurs when the patient is placed

at bed rest especially during the first few days of immobilization. This is
due to the fact that the circulation to the kidneys is increased in the
recumbent position.

Stress reactions, both psychologic and physiologic, are commonly

associated with immobilization and illness. The effect of stress on fluid
electrolyte balance and on Other physiologic functions and psychologic
behavior, should be kept in mind.

Diurnal patterns are the variation which occur in the physiologic operation
of the body during the period of day and night. While an individual is
awake. His metabolic rate, bud temperature, hormonal levels, and renal
functions are active. During sleep the demands on these homeostatic
mechanisms are reduced to a minimum. 'Whether the individual is asleep
or not, the supine position in itself will result in the same minimal functional
output. It is important for the nurse to consider these factors as they may
affect the patient who is not allowed to sleep for any length of time, as in
intensive care units; the individual who sleeps most of the time; and the
patient who is awake all night and sleeps during the day. Each of these
patient will have altered nutritional and fluid requirements.

The nursing measures which can help prevent some of the foregoing
problems are not complex. The patient should remain up until the need for
bed rest is strongly apparent. Allowing the patient to be " up and about,"
while dressed in daytime clothing, would produce a more natural metabolic
state. If the patient is unable to ambulate, sitting in the chair would tend to
prevent fluid and electrolyte loss from perspiration and prevent the basal
metabolic rate and hormonal level changes that occur in the supine
position.

For the patient who must be on bed rest, elevation of the head and upper
torso on a schedule similar to turning schedules would alleviate many of
the problems previously discussed. Minimal but sufficient bedclothing
which is not tight enhances loss of heat by conduction and radiation, thus
reducing the patient's fluid and electrolyte loss.

Increased fluid intake and high protein nutrition are essential to the patient
regardless of the stage of his mobility if healing is to be hastened a
electrolyte balance maintained.
 The prevention of atrophy and of elevated serum calcium levels can be
partially attained by range of motion, passive or active exercises, and
weight bearing within the limits of the individual patient's capability.

Since metabolic homeostasis provides the framework for the composite of

human function, any person when immobilized is confronted with aspects
of the stress cycle. Reducing the effects of this process is contingent upon
the nurse's ability to perceive, to interpret, and to intervene in the
physiologic and psychologic pressure mechanisms

Effects on Motor Function

Motion is a fundamental property of most animal life. It is necessary for the

maintenance of the structural stability and the metabolism of the
musculoskeletal system, and requires both basic tonicity and intermittent
work loads of the skeletal muscles. The daily mechanical stresses of
normal activity promote strength, endurance, and coordination of the
muscles; permit a balance of activities within bone to maintain its solidity
and its capability to support the weight of the body; and contribute to cell
nutrition by maintaining the muscle pump activity upon the blood
circulation.

Motor function is a highly complex process of interaction of man and his

environment, of integration of learned and reflex patterns, and of
coordination of muscles, bones, skin, and the senses through the nervous
system. Musculoskeletal deterioration from immobility is manifested in
three major complications: osteoporosis, contractures. and decubitus
ulcers.

OSTEOPOROSIS

Osteoporosis affects-the osseous structure of the body. Bone is a living

structure, The vital matrix is fundamental to its growth and development
and carries the calcium which gives the bone its solidity. Throughout life,
the matrix and its calcium are continuously being built up and broken down
by opposing cell forces in a dynamic state of equilibrium. Osteoblastic cells
form the osseous matrix, while osteoclastic cells are continuously
destroying the matrix through their opposing function of absorbing and
removing osseous tissue from the bone. Since osteoblasts depend upon
stresses and strains of mobility and weight bearing for proper functioning,
normal motor activity is necessary to their function of building up the bone
 matrix. If there is no activity, as with complete immobility, there is an
absence of these daily stresses and strains.

As a consequence, the process of building up the bone stops, but the

osteoclasts continue their destroying function, disrupting the state of
equilibrium and causing structural changes until the supply of bone
calcium becomes severely depleted. At the same time there is increased
excretion of bone phosphorous and nitrogen, and the bone becomes
demineralized. This change in bone composition results in the condition
known as osteoporosis, or porous bone. As the decalcification process
continues, the bones become spongy or porous and may gradually
compress and deform. Because of the lack of structural firmness, the bone
may be easily fractured.

A healthy, active person is not aware of the weight of his body straining
against his bones for there is no sensation from these stresses. However,
the person with osteoporosis may experience very intense pain when the
bones must bear weight. Advanced osteoporosis causes more pain than
many other chronic diseases, and yet it is often unrecognized and
undiagnosed because at least 30 percent of the calcium must be lost from
the bone before decalcification is revealed on an x-ray film.

Nurses must be aware that decalcification takes place during immobility

regardless of the quantity of calcium intake. Increasing calcium in the diet
is not recommended for it will not be used by the bone of the osteoporotic
patient or the immobile patient. Unneeded calcium will only be added to
the very large amount of calcium being excreted, often precipitating from
the urine as renal calculi. Or it may be deposited in the muscles resulting
in imyositis ossificans, or in the joints causing osteoarthropathy.

Osteoporosis can be largely prevented or decreased by the maintenance

of weight bearing and muscle movement and the avoidance of complete
immobility. The "normal" stress on the bones can be promoted through
placing the patient in a weight-bearing position on a tilt table or an
oscillating bed, or by having him stand or walk between parallel bars if he
is able. A daily program of muscle activities against resistance should be
planned. Not to be underestimated the value of encouraging the patient to
participate in his care to his maximum ability, and thus contribute to his
mobility.

CONTRACTURES

Contractures involving the muscles and other soft tissues surrounding a

joint are the second major complication from decreased mobility. Muscle
makes up 40 percent of the body. It is very important to the individual
because it provides the power for movement and interaction with his
environment. All tissues subjected to prolonged immobility undergo
atrophy and functional incompetence from disuse. Atrophy, or the wasting
away of muscle tissue, leads not only to a decrease in the muscle size but
also to a decrease in functional movement, strength, endurance, and
coordination.

Contractures occur when muscles do not have the activity necessary to

maintain the integrity of their function that is, the full range of shortening
and lengthening of their fibers. Contractures may occur with muscle
imbalance in which one muscle is weak and its antagonist is stronger, or
spastic, or both. Mild muscle spasm is one of nature's means of preventing
further disability from osteoporosis and of splinting a part to prevent pain.
Edema may mechanically splint a part and prevent muscle activity.
Probablv the main cause of contracture of which the nurse must be ever
cognizant is that of prolonged immobilization of a joint in one position. This
may occur as a therapeutic measure or when emphasis has been on the
establishment and maintenance of proper body alignment rather than on
mobility and maintenance of function.

Whatever the predisposing cause of the contracture the fibers of the

involved muscle shorten and atrophy resulting in a limited range of motion
of the joint. Such a process may initially produce a reversible contracture
that can be overcome by exercise and stretching, but eventually it will
involve tendons, ligaments, and joint capsule and become irreversible,
requiring surgical intervention or prolonged mechanical stretching for it
release.

Because the prevention of contractures is much easier then the treatment,

nursing measures are of great value. The first objective is to maintain body
joints in their most fuctional anatomical position. Special care must be
taken to prevent hip and knee-flexion contractures which may result from
prolonged, faulty positioning with improper placement of pillows, or from
gatched beds that keep the hips and knees continuously flexed. A bed
board and a firm mattress are helpful in maintaining correct body
positioning. A footboard can be beneficial in preventing foot drop, but only
if it is used properly. It should be placed firmly against the bottom of the
patient's feet to hold them at a right angle with the legs. It should not be
placed at a distance where stretching to reach it will inadvertently create
the plantar flexion position of foot drop. In such a position the board is only
useful for keeping the bed clothes from resting on the toes.
 Nursing activities should include frequent and scheduled change of patient
positioning and range of motion of all joints. These should be combined
with the use of appropriate devices for temporary maintenance of the
functional position of such parts as the wrist, hand, and fingers. Whenever
possible, the patient should assume some of the responsibility for
checking his position and for performing range of motion exercises. Health
teaching which encourages the participation of the patient and his family
can be vital in the prevention of contractures.

The skin may also be seriously affected by immobility. A normal, active

individual with unimpaired sensory and motor function will change his
position every few moments during waking hours and quite frequently
during sleep. The patient who is paralyzed or debilitated may be unable to
move himself. The patient who is without sensation to a part will not
automaticallv move, for the stimuli of discomfort that usually lead to
automatic shifting of position are not felt.

DECUBITUS ULCERS

Decubitus ulcers occur under many different circumstances. Since proper

circulation of the arterial and venous blood flow is partially dependent upon
normal muscle action, muscle disuse during immobility often decreases
the circulatory exchange in the soft tissues. Prolonged pressure on an
area causes disturbances in the nerve impulses to and from this area, and
also decreases the blood supply which in turn diminishes the nutrition of
that part. In addition, constant pressure, particularly over bony
prominences such as the sacrum, trochanters, ischial tuberosities, and
heels, compresses and obstructs the blood flow causing ischemia or local
anemia of a tissue. Ultimately, ischemia leads to necrosis and ulceration.
The ulcerative areas can become so massive that it may take many
months or years of treatment and costs thousands of dollars to repair them
during which time the patient's mobilitv will be further limited. Although
decubitus ulcers may occur in healthy persons pressure against a part with
resultant ischemia and progressive tissue deterioration they are more
likely to appear in malnourished persons who are in a negative nitrogen
balance. Once the patient regains nitrogen balance, and there is more
nitrogen intake than output, there usually be improvement in regeneration
and growth of the tissues.

When a patient has a decubitus ulcer the prevention of infection is a prime

nursing concern. Infection not only retards healing of the ulcer, but also
may lead to systemic infection. This in turn may cause osteomyelitis for
example, or even death.
 Osteomyelitis seriously effects motor function. The infection destroys the
blood supply to the bone. The bone deprived of nutrition acts as a foreign
object, and a haven for organisms. In order to promote healing, the
necrotic bone is surgically removed and the part is immobilized until the
bone regenerates.

Nursing precautions to prevent such occurrences are paramount. The

development of a decubitus ulcer in any person who has sensation is
completely unwarranted with the present knowledge that is available. Even
in persons who have experienced a loss of sensation, the development of
it bedsore is to be considered an unnecessary complication. The
immobilized patient should be turned frequently. Definite patterns of
helping the patient to shift body weight off the bonv prominences are
necessary or pressure areas will develop and tissue will break down. Such
aids as turning frames, oscillating beds, or air-filled or water-filled
alternating pressure mattresses are useful but do not obviate the need for
constant care to vulnerable areas.

During each position change, the skin should be inspected for areas of
tenderness edema, coldness, or redness. Meticulous skin care should be
given and a dry and, wrinkle-free bed provided. A regular toilet schedule
on a 24-hour basis, time-tailored for ach individual patient, will reduce the
incontinence that contributes to skin breakdown. Two long-standing
techniques of routine hospital care should be abolished. One is the use of
rubber rings and doughnuts which do not prevent decubitus u1cers, but
actually compress it larger area around the pressure point, decrease
circulation to it, and contribute to the formation and enlargement of the
ulcer. The other is the use of alcohol for skin massage since this dries the
oils of the skin and. creates cracks and subsequent broken down areas.

If a pressure area should develop, prompt measure should be taken to

promote healing to close this portal of entry for infection, and to reduce the
loss of serum proteins. The diet should provide enough protein to
compensate for these losses should they occur, and enough
carbohydrates and fats so that maximum utilization of the proteins is
possible.

NURSING GOALS

In summary, prevention is the common thread weaving through nursing

care plans for coping with musculoskeletal deterioration in the immobilized
patient. The main objectives of such nursing care should be: to avoid
complete immobility through it planned program. of exercises and activities
geared to the capability of the patient; to give close visual observation to
 the body positioning and alignment, as well as to skin condition; to see that
the patient has it well-balanced diet, supplemented as necessary to meet
special needs; and to instruct the patient and family so they can assist in
such prevention.

Effects on Respiratory Function

Full utilization of his available pulmonary energy for the activities important
to him is the patient's right -his right to breathe. Respiration as a
physiologic process is the gaseous exchange between an organism and
its environment. Oxygen is absorbed and carbon dioxide is eliminated. The
purpose of the respiratory movements is to renew the air in the alveoli, to
ventilate, to move air in and out. The lungs lie within the thorax and
communicate with the environment via the bronchioles, bronchi and
trachea. As the thoracic cavity changes in size through the contraction and
relaxation of the muscles of respiration (abdominals, external and internal
intercostals, and the diaphragm), the lungs also change in size because of
shifts from negative to positive air pressure. The lungs expand on
inspiration (compliance) and relax on expiration (elastic recoil). These
movements are normally so rhythmic and easy that the individual is not
aware of his breathing.

Gaseous exchange can only occur when the air is in the alveoli, in close
contact with the circulating blood, and when the air is constantly being
changed, providing a fresh supply of oxygen and removing the carbon
dioxide as it accumulates. Physiologists have found that in order for the
exchange of gases to occur there must be a large, thin, moist permeable
membrane and a difference in the concentrations of molecules of the gas
on either side of that membrane. There is a tendency for such a difference
in concentration to be equalized through the movement of molecules from
a higher concentration to the lower concentration. The alveoli and
capillaries provide the large, thin. moist membrane. The differences in the
pressure of the gas in the capillaries and in the alveoli provide the
differences in molecular concentrations. The pressure of oxygen in the
alveoli is higher than the pressure of oxygen in the capillaries. The reverse
is true of carbon dioxide. Thus, oxygen is absorbed into the blood carbon
dioxide is eliminated.

Changes in the normal physiologic functions of the respiratory system

during, short periods of immobility may at first be compensatory or strives
to pre adaptive as the body serve homeostasis. During immobility the
basal metabolism is decreased, and the cells require less oxygen for use
in the synthesis of proteins. As a consequence, less carbon dioxide as it
byproduct of cell metabolism is produced. Respirations become slower
and less deep in order to compensate for the lessened demand and
maintain the needed and constant concentrations of these two elements,
oxygen and carbon dioxide, in the blood and extracellular fluids.

Three physiologic effects on the respiratory system may occur as a result

of immobility-decrease respiratory movement of secretions, and disturbed
oxygen carbon dioxide balance.

1. DECREASED RESPIRATORY MOVEMENT

Respiratory movement may be limited by the counter resistance of

the bed or chair to chest expansion when the patient is allowed to
sit to long or lie too long on his back or side, or in a prone position.
Chest cage expansion may also be limited by sitting or lying
postures, which compress the thorax, by abdominal distention
(secondary to an accumulation of feces, gas or fluid), and by the
use of tight abdominal or chest binders. Anything that creates intra-
abdominal pressure will prevent the normal descent of the
diaphragm and limit inspiration. Movement of the chest may also be
hindered by a diminution of muscle power and coordination. as a
result of muscle disuse or decreased innervation. Further, the
administration of anesthetics, narcotics, sedatives, and other
pharmologic agents acting on the central nervous system may limit
the rate and depth of the respiratory movement by depressing the
respiratory center in the medulla, the sensory and motor areas of
the cerebral cortex, and the cells of the spinal cord. These
limitations to chest cage expansion necessarily result in a limitation
of lung expansion and, eventually, in a substantial decrease in the
compliance and elastic recoil of lung tissue. Thus, decreased lung
expansion hinders the normally efficient and effective ventilation or
the movement of air in and out of the lung time.

2. STASIS OF SECRETIONS

The normal movement of secretions out of the tracheobronchial tree

is decreased whenever one of the normal cleansing mechanisms,
such as coughing and changes in posture or position, is made
ineffective. Prolonged immobility causes stasis and pooling of
secretions. The maintenance of a patent airway may be threatened
or disrupted as the secretions collect. Poor fluid intake, dehydration,
 or anticholinergic drugs may render secretions thick and tenacious,
and further interfere with their movement.

With the stasis of secretion, it is no surprise that the immobilized

patient frequently contracts a tracheitis, bronchitis, or that old
enemy, hypostatic pneumonia. Moreover, the collection of
unmoving secretions provides an ideal medium for bacterial growth
within the body, especially for pneumococcic, pseudominal,
staphylococcic, and streptococcic organism.

Anesthetics, narcotics, and sedatives may also contribute to

respiratorv complications by decreasing the rate and depth of lung
expansion and ventilation, by depressing the cough center, and by
slowing the reflex action of the epiglottis and thus permitting
aspiration of secretions from the nasopharynx. The bulk of the
unmoving secretions or the inflammatory edema may eventually
obstruct the airway. The combination of the necessity to overcome
resistance to chest and lung expansion, diminished muscular
power, and an obstructed airways will require more subjective
efforts for the act of breathing. Increased oxygen will be used and
more carbon dioxide will be produced, in turn demanding that the
immobilized patient try even harder to breathe at a greater rate and
depth in order to counteract this deficient ventilation.

3. OXYGEN-CARBON DIOXIDE IMBALANCE

A decrease in respiratory movement and a decrease in the

movement of secretions, therefore, result primarily in deficient
ventilation and, in turn, limited diffusion of oxygen and carbon
dioxide via the alveolar and capillary membranes. The exchange of
oxygen and carbon dioxide may be further diminished by functional
disabilities on the capillary "side" (as compared with changes on the
lung "side" of membrane) because of the cardiovascular changes
during immobility. The disturbance in the exchange will alter the
normal oxygen-carbon dioxide balance in a cumulative manner,
-with a continuing build-up of carbon dioxide in the blood because it
cannot be adequately expired and a developing hypoxernia,
creating tissue hypoxia, because adequate oxygen cannot be
inspired.

At first, the increased concentration of carbon dioxide in arterial and

venous blood acts as a respiratory stimulus, but continued strong
stimulation of the respiratory centers in the medulla and pons will
eventually depress them and carbon dioxide narcosis will occur. A
 lowered oxygen concentration in the blood may provide respiratory
stimulation via the aortic and carotid bodies for an interval, but,
again, continued stimulation will lead to depression and this
mechanism will also become ineffective.

Increasing arterial and venous concentrations of carbon dioxide, as

carbonic acid and hydrogen ions, will create a respiratory acidosis.
Without intervention, respiratory acidosis or narcosis will lead to
respiratory failure or cardiac failure and death. Thus, a fourth
possible physiologic effect of immobility on the respiratorv svstem is
death!

NURSING IMPLICATIONS

Preventing respiratory physiologic changes from becoming functional

disabilities is of primary importance in the prevention of the patient's right
to breathe. Many of the activities the nurse performs daily pertain to
respiration. One of the most important of these is the observation of
respiratory function. While observing a patient's respiratory rate, she
should also note the quality of the respiration. Are they deep or shallow?
Wet or dry? Easy or labored? Is the patient using his neck muscles or
abdominal muscles in breathing? Does he present any neurologic signs,
such as restlessness or forgetfulness, which often are early indications of
a deficiency of oxygen supply to the tissues? Does he have the late signs
of hypoxia, cyanosis, and dyspnea? An anxious patient, perhaps using his
neck muscles to facilitate breathing that is shallow, wet, or labored, needs
the nurse's immediate care and means that the nurse was late in
recognizing his need to breathe efficiently.

Another nursing activity is to help the patient routinely turn, cough, and
breathe deeply. Patients as well as nurses must understand how beneficial
it is to chest and lung expansion for the patient to turn off his back or side,
stretch, out, and sit up straight at regular and frequent intervals. Also, how
coughing secretions up and out facilitates adequate oxygen-carbon
dioxide exchange. If the patient is unable to cough effectively, it may be
necessary to suggest and use chest tapping to help loosen secretions, and
postural drainage to remove them from the tracheobronchial tree.

The nurse must be able to teach a patient how to breathe deeply using his
abdominal muscles, diaphragm- and intercostals in facilitating deep
inhalation and prolonged expiration, and to encourage him to do breathing
exercises regularly.
 The use of these common nursing measures and the promotion of
physical mobility through self-care activities will contribute to the
prevention of the functional respiratory disabilities which may result from
the physiologic effects of immobility. They will help preserve the patient's
ability to breathe and to use his available cardiopulmonary energy for the
activities, which are important to him.

THE EFFECTS OF IMMOBILITY

a. Cardiovascular System.

• Venous stasis caused by prolonged inactivity that restricts or slows venous

circulation. Muscular activity, especially in the legs, helps move blood toward the
central circulatory system.
• Increased cardiac workload due to increased viscosity from dehydration and
decreased venous return. The heart works more when the body is resting, probably
because there is less resistance offered by the blood vessels and because there is a
change in the distribution of blood in the immobile person. The result is that the heart
rate, cardiac output, and stroke volume increase.
• Thrombus and embolus formation caused by slow flowing blood, which may
begin clotting within hours, and an increased rate in the coagulation of blood. During
periods of immobility, calcium leaves bones and enters the blood, where it has an
influence on blood coagulation.
• Orthostatic hypotension probably due to a decrease in the neurovascular
reflexes, which normally causes vasoconstriction, and to a loss of muscle tone. The
result is that blood pools and does not squeeze from veins in the lower part of the
body to the central circulatory system. The immobile person is more susceptible to
developing orthostatic hypotension. The person tends to feel weak and faint when the
condition occurs.

b. Respiratory System.

Hypostatic pneumonia. The depth and rate of respirations and the movement of secretions in
the respiratory tract is decreased when a person is immobile. The pooling secretions and
congestion predispose to respiratory tract infections. Signs and symptoms include:

• Increased temperature.
• Thick copious secretions.
• Cough.
• Increased pulse.
• Confusion, irritability, or disorientation.
• Sharp chest pain.
• Dyspnea.

Atelectasis. When areas of lung tissue are not used over a period of time, incomplete
expansion or collapse of lung tissue may occur.

Impaired coughing. Impairment of coughing mechanism may be due to the patient's position
in bed decreasing chest cage expansion.

c. Musculoskeletal System.

Muscle atrophy. Disuse leads to decreased muscle size, tone, and strength.
Contracture. Decreased joint movement leads to permanent shortening of muscle tissue,
resistant to stretching. The strong flexor muscles pull tight, causing a contraction of the
extremity or a permanent position of flexion.

Ankylosis. Consolidation and immobility of a joint in a particular position due to contracture.

Osteoporosis. Lack of stress on the bone causes an increase in calcium absorption,

weakening the bone.

d. Nervous System.

Altered sensation caused by prolonged pressure and continual stimulation of nerves. Usually
pain is felt at first and then sensation is altered, and the patient no longer senses the pain.

Peripheral nerve palsy.

e. Gastrointestinal System.

(1) Disturbance in appetite caused by the slowing of gastrointestinal tract, secondary

immobility, and decreased activity resulting in anorexia.

(2) Altered digestion and utilization of nutrients resulting in constipation.

(3) Altered protein metabolism. f. Integumentary System. Risk of skin breakdown, which leads
to necrosis and ulceration of tissues, especially on bony areas.

g. Urinary System.

(1) Renal calculi (kidney stones) caused by stagnation of urine in the renal pelvis and the high
levels of urinary calcium.

(2) Urinary tract infections caused by urinary stasis that favors the growth of bacteria.

(3) Decreased bladder muscle tone resulting in urinary retention.

h. Metabolism.

(1) Increased risk of electrolyte imbalance. An absence of weight on the skeleton and
immobility causes protein to be broken down faster than it is made, resulting in a negative
nitrogen balance.

(2) Decreased metabolic rate.

(3) Altered exchange of nutrients and gases.

i. Psychosocial Functioning.

(1) Decrease in self-concept and increase in sense of powerlessness due to inability to move
purposefully and dependence on someone for assistance with simple self-care activities.

(2) Body image distortions (depends on diagnosis).

(3) Decrease in sensory stimulation due to lack of activity, and altered sleep-wake pattern.
(4) Increased risk of depression, which may cause the patient to become apathetic, possibly
because of decreased sensory stimulation; or the patient may exhibit altered thought
processes.

(5) Decreased social interaction.