00040 Risk Of Disuse Syndrome

Domain 4: activity/rest
Class 2: activity/exercise
Diagnostic Code: <00040
Nanda label: disused syndrome risk
Diagnostic focus: disuse syndrome
Approved 1988 • Revised 2013, 2017

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of disuse syndrome is defined as: susceptible to deterioration of body systems as a result of prescribed or inevitable musculoskeletal inactivity, which can compromise health. /p>

Risk factors

  • Pain

Associated problems

  • Decrease in the level of consciousness
  • Immobilization
  • Paralysis
  • Restriction of prescribed mobility

Suggestions of use

  • This label describes the set of possible immobility complications (for example risk of constipation or risk of deterioration of skin integrity). This is the diagnosis of a syndrome that groups different real and potential problems. Therefore, when the risk factor is immobility, it is not necessary to write different risk diagnoses, as a risk of deterioration of skin integrity. These more specific labels should be used only if a problem appears (for example, real deterioration of skin integrity related to immobility), or if the risk factor is not immobility (as in the risk of deterioration of skin integrity related to malnutrition) ‘, even, this diagnosis should not be written with an etiology.
  • As a syndrome diagnosis, the etiology (disuse) is included in the same label.
  • Even when Nanda-I terminology is still at risk of disuse syndrome, carpenito-moyet (2006b, p. 272) recommends that syndromes diagnoses do not include the term “risk of”, since they understand diagnoses of diagnoses of Risk and real problems. In that case, disuse syndrome would be used for both patients with the risk factor of immobility, and for those who present the defining characteristics of disuse syndrome.

Suggested alternative diagnostics

  • If a real problem occurs as a result of immobility, or if the etiology of a possible problem is not immobility, the use of a more restricted physiological nursing diagnosis should be considered, as some of the following:
  • Real problem or risk of:
  • Activity, intolerance to
  • swallowing, deterioration of the
  • Constipation
  • Body image,
  • disorder

  • Impotence
  • Cutaneous integrity, deterioration of the
  • Physical mobility, deterioration of
  • Respiratory pattern, ineffective
  • ineffective sexual patterns
  • Inephic peripheral tissue perfusion
  • Urinary retention
  • Risk of:
  • Peripheral neurovascular dysfunction
  • Infection
  • Injury

NOC Results

  • Consequences of immobility: physiological: severity of the risk for physiological functioning due to a deterioration of physical mobility
  • Consequences of immobility: psychocognitive: severity of the risk for psychocognitive functioning due to a deterioration of physical mobility
  • Affected side care: Personal actions to recognize, protect and integrate the affected part of the body at the cognitive self

Evaluation objectives and criteria

  • • The risk factors are controlled and the patient does not experience disuse syndrome, which is manifested by the care of the affected side and the physiological and psychocognitive consequences of immobility
  • • The patient shows the consequences of immobility: physiological, which are manifested by the following indicators (specify from 1 to 5: serious, important, moderate, light or none):
    • Constipation, impact, intestinal hearing loss or paralysis of
    • Ileo
    • Urinary calculations, urinary retention or urinary tract infection
    • Bone fracture, contraction or ankylosing of the joints
    • Orthostatic hypotension
    • Venous thrombosis
    • Pneumonia
  • • The patient demonstrates the consequences of immobility: physiological, which are manifested by the following indicators (specify from 1 to 5: severely, importantly, moderately, slightly or not committed):
    • Nutritional status
    • Muscle strength and tone
    • Joint movement
    • Effective cough
    • Vital capacity
  • Other examples

    The objectives of care for this diagnosis are numerous and focus on preventing immobility complications for all body systems. For example, the patient will be able to:

    • • Stay oriented in time, place and person
    • • Have adequate peripheral circulation
    • • Maintain optimal respiratory function (for example, effective cough, without pulmonary congestion, normal vital capacity)
    • • Maintain a satisfactory body image
    • • Demonstrate concentration and interest in the environment
    • • Obtain laboratory values ??within normal limits (for example, oxygen concentrations, glucose, hemoglobin and hematocrit, in addition to serum electrolytic concentrations)

    NIC Interventions

    • Administration of analgesics: use of pharmacological agents to reduce or eliminate pain
    • Gymy care: Maintenance: care of a plaster after the drying period
    • Care during bed rest: improvement of comfort and safety, as well as prevention of complications of a patient who cannot get out of bed
    • Unilateral neglect management: safe protection and reintegration of the part of the affected body while the patient is helped to adapt to the alteration in their perception skills
    • Position: Deliberate placement of the patient, or of a part of his body, to stimulate physiological and psychological well -being
    • Exercise therapy: Muscle control: Use of activity protocols or specific exercises to improve or restore controlled body movement
    • Exercise therapy: joint mobility: use of active or liability body movement to maintain or restore the flexibility of joints
    • Surveillance: Collection, interpretation and synthesis of patient data, continuously and with an end, to make clinical decisions S

    Nursing Activities

    Note : In addition to the generic activities indicated below, the results and interventions selected for this diagnosis are determined according to the affected body system and the degree of disuse. To see the objectives of the patient and the specific nursing activities for each body system, consult the

    Valuations

    • • Perform all the evaluations indicated in the Evaluation objectives/criteria for this diagnosis
    • • Watch if depression is presented
    • • (NIC) care during bed rest:
      • Take care of skin conditions
      • Watch if there is constipation
      • Monitor the urinary function
      • Monitor the pulmonary state

    Patient and family education

    • • (NIC) care during bed rest:
      • Explain the reasons for bed rest
      • Teach bed exercises, as relevant

    Collaboration activities

    • • Consult with the physiotherapist ways to improve mobility
    • • Consult with the dietitian about an increase in the intake of high energy food

    Others

    • • Plan and put into practice a posture change program
    • • (NIC) care during bed rest:
      • Place the patient in a suitable therapeutic bed or mattress
      • Place the patient with adequate body alignment
      • Avoid the use of rough bed clothes
      • Put the control to change the bed position
      • Make small changes in body weight
      • Use passive and/or active exercises with movement rank
      • Use anti -mebolic stockings

    At home

    • • Most previous interventions can be adapted for home use
    • • Check that the patient has all the necessary devices at home
    • • Teach the patient and his family to recognize the signs and symptoms of fatigue that require a reduction in activity

    Babies and Children

    • • Evaluate the signs of delay in language development in children under four years of age who have to be immobilized, for example, by traction
    • • Observe the regression and self -absorption signs that could occur in response to the disease or immobility
    • • Ask the family to take their special toys
    • • Keep toys available to the child, which must be appropriate to their development age
    • • Take the child out of the room (for example, to the game room, to the lobby) as much as possible

    Older people

    • • Age -related changes with respect to muscles, joints and connective tissues, make the elderly more vulnerable to disuse syndrome
    • • It is of special importance to recover mobility as soon as possible to avoid rapid deterioration
    • • If the patient is at absolute rest, place it vertically several times a day
    • • Consider the channeling of the patient to physiotherapy to perform resistance and strength exercises
    • • Resort to case management if necessary, in order to facilitate the patient’s ability to live in their home