Physiologic Effects of Immobilization

Many clinical studies, including space program research, have documented predictable consequences that occur after immobilization and the absence of gravitational force. Functional and metabolic responses to restricted movement can be noted in most of the body systems. Each has a direct influence on the child’s growth and development because of homeostatic mechanisms that thrive on normal use and feedback to maintain dynamic equilibrium. Inactivity leads to a decrease in the functional capabilities of the whole body as dramatically as the lack of physical exercise leads to muscle weakness.

Disuse from illness, injury, or a sedentary lifestyle can limit function and potentially delay age-appropriate milestones. Most of the pathologic changes that occur during immobilization arise from decreased muscle strength and mass, decreased metabolism, and bone demineralization, which are closely interrelated, with one change leading to or affecting the others.

The major effects of immobilization are outlined briefly in Table 31-1 and are related directly or indirectly to decreased muscle activity, which produces numerous primary changes in the musculoskeletal system with secondary alterations in the cardiovascular, respiratory, skeletal, metabolic, and renal systems. The musculoskeletal changes that occur during disuse are a result of alterations in the effect of gravity and stress on the muscles, joints, and bones. Muscle disuse leads to tissue breakdown and loss of muscle mass (atrophy). Muscle atrophy causes decreased strength and endurance, which may take weeks or months to restore.

During immobilization, a joint contracture begins when the arrangement of collagen, the main structural protein of connective tissues, is altered, resulting in a denser tissue that does not glide as easily. Eventually, muscles, tendons, and ligaments can shorten and reduce joint movement, ultimately producing contractures that restrict function. The daily stresses on bone created by motion and weight bearing maintain the balance between bone formation (osteoblastic activity) and bone resorption (osteoclastic activity). During immobilization, increased calcium leaves the bone, causing osteopenia (demineralization of the bones), which may predispose bone to pathologic fractures.

The major musculoskeletal consequences of immobilization are:

Circulatory stasis combined with hypercoagulability of the blood, which results from factors such as damage to the endothelium of blood vessels (Virchow triad), can lead to thrombus and embolus formation. Deep venous thrombosis (DVT) involves the formation of a thrombus in a deep vein such as the iliac and femoral veins and can cause significant morbidity if it remains undetected and untreated. The larger the portion of the body immobilized and the longer the immobilization, the greater the risks of immobility.

Psychologic Effects of Immobilization

For children, one of the most difficult aspects of illness is immobilization. Throughout childhood, physical activity is an integral part of daily life and is essential for physical growth and development. It also serves children as an instrument for communication and expression and as a means for learning about and understanding their world. Activity helps them deal with a variety of feelings and impulses and provides a mechanism by which they can exert control over inner tensions. Children respond to anxiety with increased activity. Removal of this power deprives them of necessary input and a natural outlet for their feelings and fantasies. Through movement, children also gain sensory input, which provides an essential element for developing and maintaining body image.

When children are immobilized by disease or as part of a treatment regimen, they experience diminished environmental stimuli with a loss of tactile input and an altered perception of themselves and their environment. Sudden or gradual immobilization narrows the amount and variety of environmental stimuli children receive by means of all their senses: touch, sight, hearing, taste, smell, and proprioception (a feeling of where they are in their environment). This sensory deprivation frequently leads to feelings of isolation and boredom and of being forgotten, especially by peers.

Physical interference with the activity of infants and young children gives them a feeling of helplessness. Even speech and language skills require sensorimotor activity and experience. For toddlers, exploration and imitative behaviors are essential to developing a sense of autonomy. Preschoolers’ expression of initiative is evidenced by the need for vigorous physical activity. School-age children’s development is strongly influenced by physical achievement and competition. Adolescents rely on mobility to achieve independence. The quest for mastery at every stage of development is related to mobility.

The monotony of immobilization may lead to sluggish intellectual and psychomotor responses; decreased communication skills; increased fantasizing; and rarely, hallucinations and disorientation. Children are likely to become depressed over loss of ability to function or the marked changes in body image. They may regress to earlier developmental behaviors, such as wanting to be fed, bedwetting, and baby talk.

Children may react to immobility by active protest, anger, and aggressive behavior, or they may become quiet, passive, and submissive. They may believe the immobilization is a justified punishment for misbehavior. Children should be allowed to display their anger, but it should be within the limits of safety to their self-esteem and not damaging to the integrity of others (see Providing Opportunities for Play and Expressive Activities, Chapter 21). When children are unable to express anger, aggression is often displayed inappropriately through regressive behavior and outbursts of crying or temper tantrums.

Effect on Families

Even brief periods of immobilization may disrupt family function, and catastrophic illness or disability may severely tax a family’s resources and coping abilities. The family’s needs often must be met by the services of a multidisciplinary team, and nurses play a key role in anticipating the services they will need and in coordinating conferences to plan care. In preparation for discharge, home management is frequently planned before discharge, including special considerations for addressing cultural, economic, physical, and psychological needs. A child with a severe disability is very dependent, and caregivers need respite to revitalize themselves. Individual and group counseling is beneficial for solving problems in advance and provides an emotional support system. Parent groups are also helpful and often allow nonthreatening social contact. The families of children with permanent disabilities need long-term resources because some of the most difficult problems arise as they try to sustain high-quality care for many years (see Chapter 20).

Nursing Care Management

Physical assessment of the child who is immobilized for any number of reasons (e.g., injury or illness) includes a focus not only on the injured part (e.g., fracture) but also on the functioning of other systems that may be affected secondarily—the circulatory, renal, respiratory, muscular, and gastrointestinal systems. With long-term immobilization, there may also be neurologic impairment and changes in electrolytes (especially calcium), nitrogen balance, and the general metabolic rate. The psychological impact of immobilization should also be assessed.

Children who require prolonged total immobility and are unable to move themselves in bed should be placed on a pressure-reduction mattress to prevent skin breakdown. Frequent position changes also help prevent dependent edema and stimulate circulation, respiratory function, gastrointestinal motility, and neurologic sensation. Children at greater risk for skin breakdown include those with prolonged immobilization; mechanical ventilation; orthotic and prosthetic devices, including wheelchairs; and casts. Additional risk factors include poor nutrition, friction (from bed linen with traction), and moist skin (from urine or perspiration). Nursing care of children at risk includes strategies for preventing skin breakdown when such conditions are present. The Braden Q Scale is a reliable, objective tool that may be used in the assessment for pressure ulcer development in children who are acutely ill or who are at risk for skin breakdown from neurologic conditions and immobilization (Noonan, Quigley, and Curley, 2011).

The use of antiembolism stockings or intermittent compression devices prevents circulatory stasis and dependent edema in the lower extremities and the development of DVT. Anticoagulant therapy may also be implemented with low-molecular-weight heparin, vitamin K antagonists, or unfractionated heparin. The child should be allowed as much activity as possible within the limitations of the illness or treatment. Any functional mobility, however minimal, is preferred to total immobility. High-protein, high-calorie foods are encouraged to prevent negative nitrogen balance, which may be difficult to correct by diet, especially if there is anorexia as a result of immobility and decreased gastrointestinal function (decreased motility and possibly constipation). Stimulating the appetite with small servings of attractively arranged, preferred foods may be sufficient. Sometimes supplementary nasogastric or gastrostomy feedings or intravenous (IV) fluids may be needed, but these are reserved for serious disability in which oral intake is impossible.

Adequate hydration and, when possible, an upright position and remobilization promote bowel and kidney function and help prevent complications in these systems. Children are encouraged to be as active as their condition and restrictive devices allow. This poses few problems for children, whose innate ingenuity and natural inclination toward mobility provide them with the impetus for physical activity. They need the opportunity, the materials or objects to stimulate activity, and the encouragement and participation of others. Those who are unable to move benefit from passive exercise and movement in consultation with a physical therapist.

Whenever possible, transporting the child outside the confines of the room increases environmental stimuli and allows social contact with others. Specially designed wheelchairs for increased mobility and independence are available. While hospitalized, children benefit from same-age visitors, computers, books, interactive video games, and other items brought from their own room at home, all of which help them to function in a more normal way. While hospitalized, they also benefit from frequent visitors, accessibility of clocks and calendars, and a program of diversional therapy to help them function more normally. A child life specialist should be consulted for recreational planning. An activity center or slanting tray can be helpful for the child with limited mobility to use for drawing, coloring, writing, and playing with small toys such as trucks and cars. Children are able to express frustration, displeasure, and anger through play activities (see Chapter 21), which is helpful in the child’s recovery. Hospitalized children should be allowed to wear their own clothes (street clothes, especially for preadolescent and adolescent girls) and resume school and preinjury activities. A parent or siblings should be allowed to stay overnight and room in with the hospitalized child to prevent the effects of family disruption from hospitalization. All efforts should be made to minimize family disruption resulting from the hospitalization. Although most of the suggestions discussed relate to hospital care, the same consultations (physical therapist, occupational therapist, child life specialist, speech therapist) and environment may be considered in the home as well to help the child and family achieve independence and normalization (see Chapter 20).

Using dolls, stuffed animals, or puppets to illustrate and explain the immobilization method (e.g., traction, cast) is a valuable tool for small children. Placing a cast, tubing, or other restraining equipment on the doll offers the child a nonthreatening opportunity to express, through the doll, feelings concerning the restrictions and feelings toward the nurse and other health care providers. The doll or puppet may also be used for teaching the child and family procedures such as IV therapy, procedural sedation, and general anesthesia.

One of the most useful interventions to help children cope with immobility is participation in their own care. Self-care to the maximum extent is usually well received by children. They can help plan their daily routine; select their diet; and choose “street clothes,” including innovative adornment, such as a baseball cap or brightly colored stockings to express their autonomy and individuality. They are encouraged to do as much for themselves as they are able to keep their muscles active and their interest alive.

Visits from significant persons, such as family members and friends, offer occasions for emotional support and also provide opportunities for learning how to care for the child. Privacy is necessary, especially for adolescents.

For a child with greatly restricted movement (e.g., child with a large bilateral hip spica cast), nursing care is often a challenge. These situations require long-term care either in the hospital or at home, but wherever the care occurs, consistent planning and coordination of activities with other health care workers and significant others are vital nursing functions.

With the increased trend toward early mobilization, early discharge, and home health care, many children are discharged home within a few days of hospitalization. Follow-up treatment may take place in the home setting or an outpatient ambulatory facility.

Family Support and Home Care

The needs of a child with severe disabilities can be complex, and family members require time to assimilate the teachings and demonstrations needed to understand the child’s situation and care. Even a child who is confined on a short-term basis can be a challenge for the family, which is usually unprepared for the problems imposed by the child’s special needs. Home modification is usually needed for facilitating care, especially when it involves traction, a large cast, or extended confinement. Suitable child care may be needed for times when all family members work.

Just as in the hospital, the child at home is encouraged to be as independent as possible and to follow a schedule that approximates his or her normal lifestyle as nearly as possible, such as continuing school lessons, regular bedtime, and suitable recreational activities.

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