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DECONDITIONING SYNDROME

BY BED REST
NURYANI SIDARTA
AIM
TO KNOW AND UNDERSTAND THE
COMPLICATION OF BED REST
TO PREVENT THE COMPLICATION OF BED REST
TO KNOW THE PATHOLOGICAL CONDITION
THAT MAY INDUCE DECONDITIONING
SYNDROME
INTRODUCTION
BED REST HAS BEEN ROUTINELY AND OFTEN
CASUALLY PRESCRIBED, DURING A PERIOD OF
INJURY AND RECOVERY.
CAUSES A GENERALIZED DECONDITIONING OF
THE HEALTY SUBJECT INAL, INVOLVING MOST
OF THE PHYSIOLOGICAL SYSTEMS OF THE
BODY, INCLUDING THE CARDIOVASCULAR,
PULMONARY, GASTROINTESTINAL,
HORMONAL, AND SKELETAL SYSTEMS.
DECONDITIONING
AS REDUCED CAPACITY OF THE
MUSCULOSKELETAL AND OTHER BODY
SYSTEMS (DeLisa)

DECONDITIONING
THE MULTIPLE CHANGES IN ORGAN SYSTEM
PHYSIOLOGY THAT ARE INDUCED BY
INACTIVITY AND REVERSED BY ACTIVITY
IMMOBILITY
MUSCULO
SKELETAL
CARDIO
VASCULAR
SKIN
NEUROLOGICAL
EMOTIONAL
GASTO
INTESTINAL
GENITO
URINARY
RESPIRATORY
ENDOCRINE
BODY
COMPOSITION
CARDIOVASCULAR
SYSTEM
CARDIAC :
STROKE VOLUME
HEART RATE
CARDIAC OUTPUT
VO2 MAX
CARDIOVASCULAR
NEUROVASCULAR:
ORTHOSTATIC INTOLERANCE
FLUID BALANCE:
PLASMA VOLUME
TOTAL BODY VOLUME
RED BLOOD CELL MASS
BLOOD COAGULATION:
CALF BLOOD FLOW
VENOUS THROMBOSIS
BLOOD FIBRINOGEN

CARDIO SYSTEM
STROKE VOLUME 30%
HR BEAT/MIN/DAY FRO 3-4 WK
CARDIAC OUTPUT UNCHANGED
OR SLIGHTLY DECREASED
MAXIMUM OXYGEN CONSUMPTION
DECREASED UP TO 28%
ORTHOSTATIC HYPOTENSION
V
A
S
C
U
L
A
R

S
Y
S
T
E
M
BLOOD FLOW IN MUSCLE DUE TO
MUSCULAR PUMPING
BLOOD VISCOSITY RESULTED FROM
INCREASED HT AND BLOOD VISCOSITY
INCREASED PLATELET ADHESIVENESS
INCREASED FIBRINOGEN LEVEL
INCREASED RISK FOR DVT AND PULMONARY EMBOLISM
TILTING TABLE
FORCED VITAL CAPACITY
TOTAL LUNG CAPACITY
(SLIGHT)
RESIDUAL VOLUME
UNCHANGED
RESPIRATORY RATE
VITAL CAPACITY
UNCHANGED
FUNCTIONAL RESIDUAL
CAPACITY UNCHANGED
PULMONARY EMBOLISM
(POSSIBLE)

RESPIRATORY
TREATMENT
EARLY MOBILIZATION
FREQUENT POSITION CHANGES
INCENTIVE SPIROMETRY
DEEP BREATHING
ADEQUATE HYDRATION
GOOD DENTAL CARE
CHEST PERCUSSION WITH POSTURAL DRAINAGE
ANTIOBIOTIC
MUSCLES :
ATROPHY
DECR STRENGTH
DECR ENDURANCE
CONTRACTURE
DECREASED STRENGTH
OF TENDON & LIG
BONE :
OSTEOPOROSIS
JOINTS:
CARTILAGE-
DEGENERATION
FIBROFATTY TISSUE
INFILTRATION
SYNOVIAL ATROPHY
ANKYLOSIS
CONTRACTURE SEQUELAE
HIP JOINT FLEXION COMPENSATORY LORDOSIS, KNEE FLEXION,
SHORT STEPS
HIP JOINT EXT ROTATION EXCESSIVE STRESS ON MEDIAL KNEE LIG.
ANKLE PLANTAR FLEXION GENU RECURVATUM
ABSENCE OF HEEL STRIKE
SHOULDER FLEXION, ADDUCTION CAN NOT REACH BACK POCKET, COMB HAIR
AND INTERNAL ROTATION OR REACH ABOVE SHOULDER LEVEL
WRIST & FINGER FLEXION WEAKEND GRIP
CANNOT OPEN HAND TO GRASP
DECREAESED MUSCLE STRENGTH
STRENGTH DECREASES BY 0.5-1.7%/DAY
MUELLER : 1.0-1.5% OF ISOMETRIC STRENGTH
PER DAY OF BED REST OVER 2 WEEKS
STRENGTH LOSS GENERALLY GREATED IN LEGS
THAN ARMS
ANTIGRAVITY MUSCLES LOSS MORE
STRENGTH

TENDON AND LIGAMENTS
DECREASED TENSILE STRENGTH
INCREASED COLLAGEN TURN OVER
DECREASED COLLAGE MASS
HISTOLOGIC CHANGES :
1. LONGITUDINAL STRESS TO CONNECTIVE
TISSUES FOSTERS PARALLEL LIGAMENT OF FIBERS
2. WITH BED REST, NEWLY FORMED COLLAGEN IS
LAID DOWN IN HAPHAZARD ARRANGEMENT
CALCIUM METABOLISM
MAINTENANCE OF A SKELETON CAPABLE OF
RESISTING THE MECHANICAL FORCES APPLIED
DURING ACTIVITY IS DEPENDENT ON THE
INTTERMITTEN APPLICATION OF THESE SOME
FORCES.
WHEN STRESS IS APPLIED TO A BONE, AS IN
NORMAL ACTIVITY OR EXERCISE, THE STRAIN IS
SENSED, WITH SUBSEQUENT CHANGES IN
OSTEOCLAST AND OSTEOBLAST CELLULAR
ACTIVITY.
IF NO FORCE IS APPLIED TO THE SKELETON,
EITHER BECAUSE OF PLASTER
IMMOBILIZATION, STRICT BED REST,
PARALYSIS, OR WEIGHTLESSNESS OF SPACE
FLIGHT, BONE MINERAL IS LOSS BECAUSE THE
RATE OF BONE FORMATION FALLS BELOW THE
RATE OF BONE MINERAL ABSORPTION.
STUDIES*
URINARY CALCIUM INCREASED AT A RATE OF
12% PER WEEK
LOSSES OF TOTAL BODY CALCIUM IN URINE,
SWEAT, AND FECES AVERAGED 0.5% PER
MONTHS
PARALLEL LOSSES IN PHOSPHORUS AND
HYDROYPROLINE.
PREVENTION & TREATMENT
RELATIVELY INTENSE EXERCISE (ISOTONIC &
ISOKINETIC) IN BED HELP MAINTAIN MUSCLE
STRENGTH
DAILY ROM EXERCISE OF MUSCLES DELAYS
ATROPHY
EARLY MOBILIZATION AND WEIGHT BEARING
ACTIVITY
BODY COMPOSITION, METABOLISM, NUTRITION
LEAN BODY MASS
BODY FAT
NITROGEN LOSS
CALCIUM LOSS
PHOSPHORUS LOSS
SULFUR LOSS
POTASSIUM LOSS
ALTERED CIRCADIAN RHYTYM
ALTERED TEMPERATURE AND
SWEATING RESPONSE
ALTERED REGULATION OF HORMON:
PARATHYROID, ADRENAL, ANDROGEN,
THYROID
IMPAIRED GLUCOSE TOLERANCE
IMPAIRED GLUCOSE TOLERANCE
BECAUSE OF INACTIVITY, MUSCLE DEVELOPS
INSULIN RESISTANCE THAT MAKE REDUCTION
IN PERIPHERAL GLUCOSE UPTAKE WHICH
CAUSED HYPERGLYCEMIA FOLLOWED BY
HYPERINSULINEMIA
OCCURS AS SOON AS 3 DAYS AFTER BEDREST
DECREASE 20-50% BY 14 DAYS
GENITOURINARY
MINERAL
EXCRETION
POSTVOID
RESIDUAL
VOLUME
URINARY
TRACT
INFECTION
OVERFLOW
INCONTINENCE
ABILITY TO
CONCENTRATE
URINE
GFR
CALCULUS
FORMATION
GASTROINTESTINAL
FLUID INTAKE
APPETITE
BOWEL
MOBILITY
GASTRIC
SECRETION
CONSTIPATION
GI ATLERATIONS
DECREASED TRANSIT TIME
SLOWED BY UP TO 66% IN LYING POSITION
COMPARED WITH STANDING
INCREASED GASTRIC ACIDITY BECAUSE OF
ACTIVATION OF THE SYMPATHETIC SYSTEM
INHIBITION OF GASTRIC BICARBONATE
SECRETION.
STOOL CALCIUM LEVEL INCREASED FROM A
MEAN OF 797-911 MG PER DAY WITH BED REST
INTESTINAL ABSORPTION DECREASED FROM 31%
WITH BED REST
PREVENTION & TREATMENT
USE TOILET OR BEDSIDE COMMODE WHEN POSSIBLE
INSTEAD OF BED PAN
ENCOURAGE EARLY MOBILIZATION
USE HIGH FIBER DIET OR FIBER SUPPLEMENTATION
ENSURE ADEQUATE FLUID INTAKE
DECREASE CONSTIPATING MEDICATIONS SUCH AS
NARCOTICS
CONSIDER STOOL SOFTENERS
GLYCERIN ENEMA DAILY AS NEEDED
LAXATIVES (IF NEEDED)
SENSORY DEPRIVATION (ATTENTION
SPAN, TIME AWARENESS, HAND TO
EYE COORDINATION, DEPRESSION,
ANXIETY)
BALANCE
COORDINATION
VISUAL ACUITY
AUDITORY THRESHOLD
NEUROLOGICAL, EMOTIONAL
TREATMENT
STOP MEDICATIONS THAT MAY CAUSE
CHANGES IN MENTAL STATUS
FREQUENTLY ORIENT PATIENT TO TIME AND
PLACE
ENCOURAGE VISITS FROM FAMILY AND
FRIENDS
ENCOURAGE GROUP ACTIVITIES
KEEP PATIENT HEARING AIDS AND GLASSES
EASILY AVAILABLE
PRESSURE
ULCER

S
K
I
N
EDEMA
SUBCUTANEOUS
BURSITIS
INTRINSIC:
ABN SKIN SENSATION
ABN MENTAL STATUS
ALTERED CONCIOUSNESS
ADVANCED AGE
LOCAL TISSUE METABOLIC RATE
PREVIOUS PRESSURE SORE
MUSCLE AND SKIN ATROPHY
SCARS
EDEMA
MALNUTRISI & ANEMIA
OBESITY
INFECTION

EXTRINSIC :
DURATION OF PRESSURE
SKIN MACERATION
PREVENTION PRESSURE ULCER
PROPER TURNING
PRESSURE RELIEVING BED
PROPER SKIN CARE & TOILETING
PROPER SEATING
PROPER NUTRITION
SKIN CARE PROCEDURE
PRESSURE ULCER
ULCUS DECUBITUS
TERM DECUBITUS IS DERIVED FROM LATIN
MEANING LYING DOWN
CAN RESULT FROM ANY PROLONGED,
UNCHANGED POSITION
ARE CLINICAL MANIFESTATION OF LOCAL TISSUE
DEATH AND CATABOLISM
FOUND MOST FREQUENTLY OVER BONY
PROMINENCE EXPOSED TO COMPRESSING
SURFACES
EPIDEMIOLOGY
7.7% OF HOSPITALIZED PATIENTS DEVELOP
PRESSURE ULCER WITHIN 21 DAYS OF
ADMISSION
ORTHOPEDIC & GERIATRIC : 24%
SCI : 24-59%

ETIOLOGIC FACTORS
PRESSURE:
DURATION
INTENSITY
SHEAR:
POOR SITTING
POSITION
POOR BED POS
SPASTICITY
SLIDING
INSTEAD OF
LIFTING PS
WHEN
TRANSFER
FRICTION :
SKIN TEAR
SKIN
ABRASION
SECONDARY
FACTORS :
MOBILITY
NUTRION
AGE
MOISTURE/
INCONTINENCE
DIABETES
SMOKING
FEBRIS
IMPAIRED
MENTAL STATUS
SIX BASIC CONDITION
SEDENTARY LIFE STYLE
REST BY MEDICAL/SURGICAL ILLNESS
MEDICAL/CAREGIVER NEGLECT WITH PATIENT
RESTRICTED FROM MOBILITY
IMMOBILISATION BODY/PART OF BODY BY
CAST/BRACE (AFTER TRAUMA)
DISUSE BY NEUROMUSCULAR DISORDER
(PARALYSIS)
DISUSE BY WEIGHT
ULCUS GRADE 1
ULCUS GRADE 2
ULCUS GRADE 3
ULCUS GRADE 4
PRIMARY PREVENTION
INDICATES AREA OF HIGH RISK IN SITTING,
SUPINE, AND SIDE-LYING POSITIONS
AVOID SLIDING PATIENTS BODY ACROSS
SURFACES
PATIENT SHOULD BE REPOSITIONED EVERY 2
HOURS
INSPECT AND ASSESS SKIN WITH EACH
TURNING
SUPPORT SURFACES
WOUND MANAGEMENT PRIORITIES
REDUCE OR ELIMINATE CAUSATIVE FACTORS
PROVIDE SYSTEMIC SUPPORT FOR WOUND
HEALING
INITIATE APPROPRIATE THERAPY
EDUCATION
SYSTEMIC SUPPORT
TISSUE PERFUSION AND OXYGENATION
NUTRITIONAL AND FLUID SUPPORT:
1. ALBUMIN
2. ZINC : PROTEIN SYNTESIS & REPAIR
3. VIT C : COLLAGEN SYNTHESIS
CONTROL OF SYSTEMIC CONDITIONS AFFECTING
WOUND HEALING


SYSTEMIC CONDITIONS
DIABETES MELLITUS
HEMATOPOIETIC ABNORMALITIES
IMMUNOSUPRESSION
RENAL FAILURE
INITIATE APPOPRIATE THERAPY
DEBRIDEMENT
IDENTIFY AND ELIMINATE INFECTION
MAINTAIN MOIST WOUND SURFACE
PROVIDE THERMAL INSULATION
PROTECT HEALING WOUND
THANK YOU

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