INTRODUCTION

In the Intensive Care Units (ICU), prolonged bed rest is used as a therapeutic measure necessary for the clinical stabilization of hospitalized patients. However, the deleterious effects of immobility can be more serious than the clinical situation that generates them, transforming a temporary functional capacity reduction into incapacity¹ recognizing that immobility compromises people's quality of life². Furthermore, there is currently an increase in the number of survivors of critical illness with sequelae of neuromuscular dysfunction and physical disability, related to their hospitalization in the ICU^3,4.

The harmful effects of prolonged immobility in people in critical condition lead to, among others, severe dysfunctions in the osteomyoarticular system⁵, such as the development of joint contractures⁶. Another study⁷ stated that generalized muscle weakness is a common consequence in people who are immobilized and particularly in those who need invasive ventilatory support. In these people, muscle weakness associated with the ineffectiveness of the ciliary lining reduces the effectiveness of coughing, which contributes to an increment of secretions and increase risk of respiratory infections¹. Ventilation and pulmonary perfusion are also affected, which translates into episodes of hypoxemia, reduced ventilatory reserve capacity, increased dyspnea and greater difficulty in the ventilatory weaning process⁸. Another problem associated with immobility is the appearance of pressure ulcers, which represent a serious health problem, with repercussions on the person, in terms of mortality and morbidity, and their prevalence values ​​tend to increase in populations at risk, particularly people in a state critical¹.

These are some of the reasons that justify the investment in preventing the consequences of immobility and it is essential to find evidence that address effective nursing interventions in preventing and reducing the problem⁹.

In this sense rehabilitation nurses (RNs), who work in the ICU, play a key role in the development and implementation of rehabilitation programs aimed at minimizing the consequences of immobility. The prevention of complications, in order to avoid or minimize disabilities, is one of the key aspects of RNs performance¹⁰, which gains greater importance in the ICU environment, as one of the purposes of providing Rehabilitation Nursing care for people in critical condition is to avoid and reduce complications resulting from immobility in bed¹¹, namely respiratory, motor and functional complications¹². It is emphasized that one of the essential contributions to prevent the consequences of immobility is the adequate planning of Rehabilitation Nursing care, which includes interventions that promote mobility and subsequent self-care¹. Other authors¹³ reinforce the importance of rehabilitation and early mobilization programs, aimed at people in critical condition, with an early start, that is, immediately after the stabilization of vital functions, usually in the first two to five days of hospitalization of people in ICU.

In addition, promoting the safety of people is an important objective in the practice of Rehabilitation Nursing¹⁴ and the provision of Rehabilitation Nursing care in preventing the consequences of immobility of people in critical situations allows avoiding situations and adverse effects that compromise their safety.

Hospitalization in ICU and the resulting consequences, such as immobility, are events that trigger various transitions in people, more specifically, health/disease and situational transitions¹⁵. As nurses play a leading role in facilitating transitions, this role takes on a particular meaning in the health/disease transition processes and in these, it is essential that nurses adopt a posture of listening and acceptance of the other, education and guidance, promoting the self-care and comfort¹⁶, and may also intervene in anticipatory periods, preparation for changing roles, preventing the negative effects of the disease on people¹⁷, as is the case with the consequences of immobility.

Through the literature review, it was found that the studies carried out by nurses in the area of ​​preventing the consequences of immobility in people in critical situations are scarce, compared to studies carried out by other professionals in the field of rehabilitation.

In order to be able to contribute to the prevention of the consequences of immobility, and to describe these contributions, an early intervention project in Rehabilitation Nursing was developed focusing on people in critical situations affected by immobility, hospitalized in ICU, to whom were provided organized and systematized Rehabilitation Nursing care.

The focus is, by definition of the International Classification of Nursing Practice (ICNP®), an area of ​​intervention that is relevant for nursing¹⁸ and in the context of this project, the focuses identified as relevant were airway cleaning, ventilation, joint stiffness and pressure ulcers, associated with the respiratory, joint and integumentary system consequences of immobility.

The intervention project has as a general objective, to prevent the consequences of immobility of people hospitalized in ICU and as specific objectives, to carry out an initial assessment of people that includes the assessment of ventilatory function and airway cleaning mechanisms, assessment of skin integrity as well as the risk of compromise and the assessment of joint range, through direct observation and the application of assessment instruments adapted to the Portuguese population; to identify the risk of developing respiratory, integumentary, and musculoskeletal changes and to formulate associated diagnoses; to implement a respiratory and motor rehabilitation nursing intervention program; to describe the contributions of the intervention program through the reassessment of the person, including ventilatory function and airway clearance mechanisms, skin integrity and joint range.

METHOD

For the elaboration of the intervention project, the methodology of case studies was adopted, since this research strategy is mainly intended to describe, to understand and to explain¹⁹, allowing the study of a phenomenon (in this case the consequences of immobility in people in critical situations ) in a holistic perspective and in a real context, with different sources of evidence, obtaining a wealth of descriptive information, also allowing reflection and the search for alternatives to solve the problem²⁰. Despite presenting as a limitation the impossibility of generalizing the results obtained in nursing, it makes it possible to know in depth the aspects of the phenomenon under study²¹.

This project describes the cases of people hospitalized in ICU of a Hospital Center in Lisbon, who presented a potential risk of developing integumentary, musculoskeletal and respiratory alterations, associated with immobility, a selection criterion for participation in the intervention project. It took place from October to November 2018, after approval by the Ethics Committee for Health and authorization by the Board of Directors of the aforementioned Hospital Center.

The importance of nursing as a theoretical-practical science must be sensitive to multiple focuses of interest and intervene in the transition process and this practical intervention will be based on facilitating the transitions of patients and families where health and well-being are perceived as results^16,17. Therefore, the intervention project was based on the methodology of the nursing process.

Based on the four defined nursing focuses and criteria supported by the Documentary Standard of Nursing Care of the Rehabilitation Nursing Specialty²² and others considered relevant and described in the literature, the initial assessment of people included the assessment of vital parameters, monitoring of skin integrity, pulmonary auscultation and assessment of the cough reflex and breathing pattern through direct observation; the assessment of the state of consciousness through the application of the Glasgow Coma Scale (GCS)²³; assessment of the risk of developing pressure ulcers, with the application of the Braden scale²⁴. The range of motion (ROM) of the joints at the level of the shoulders, elbows, knees and ankles was also evaluated through goniometry. The use of standardized assessment instruments allows for the documentation of specialized care, its continuity and also the development of research projects that can be assumed as good practices and replicated²⁵.

After identifying the real and potential problems from the data collected in the initial assessment, Rehabilitation Nursing diagnoses related to each nursing focus were elaborated, using the ICNP® language, and interventions based on scientific evidence and explained in the Documentary Pattern were stratified. of Nursing Care of the Rehabilitation Nursing Specialty, within the scope of Functional Motor Reeducation (FMR), prevention of pressure ulcers and Functional Respiratory Reeducation (FRR).

It was defined that the assessment of nursing focuses on airway cleaning and ventilation would be carried out at the beginning and at the end of each FRR session, since the interventions performed in each session are expected to promote, in principle, an immediate improvement. Regarding the assessment of the nursing focuses of joint stiffness and pressure ulcers, it was defined that it would be carried out in three moments of the intervention plan - initial, intermediate and final - since the visibility of the results occurs over a longer period, in contrast with the previous focuses.

To ensure the integrity of the investigation, all phases of this project are based on ethical principles defended by nursing, respecting and safeguarding confidentiality and anonymity, both of the institution where the project took place, and of the participants, having been represented by letters. All necessary steps were also taken to obtain an informed, expressed and free consent.

RESULTS

The information obtained was subjected to descriptive analysis procedures, which make it possible to describe the characteristics of the cases studied and the values obtained by measuring the variables²⁶.

DISCUSSION

After the initial assessment of the four people participating in the project, the Rehabilitation Nursing diagnoses were formulated, and the interventions that best adapted to each person's situation were carried out, taking into account the literature review carried out. It was found that the diagnoses of Risk for pressure ulcer in a high stage; Ineffective airway clearance and impaired ventilation were present in participants A, B and D. The diagnosis of Risk for joint stiffness was common to all four participants in this project.

In total, 37 sessions were carried out, 17 under the FRR and 20 under the FMR as a result of identifying the diagnoses. At the same time, a plan of care for the prevention of pressure ulcers was established for people at high risk.

Regarding the risk of joint stiffness, in person C, the instituted nursing interventions contributed to achieving the expected result, that is, the maintenance or improvement of ROM at the level of the shoulder, elbow, knee and ankle joints. In people A, B and D, it was found that the ROM was maintained or improved in some of the joint movements evaluated.

These results are in line with similar cases described in the literature, namely the study by Modragon-Barrera²⁷, whose participants were inpatients in the ICU and where it was also found that after a joint mobilization program was carried out, there was an increase in ROM at the level of shoulder abduction and flexion, hip abduction and ankle dorsiflexion, proving what has been advocated for some time by other authors²⁸ on the benefits of performing passive mobilization exercises, active-assisted in people in critical situations.

However, the result in person A was different from what was expected, since this patient presented a decrease in ROM in terms of shoulder flexion, elbow flexion and ankle plantar flexion; person B showed a decrease in ROM at the level of right shoulder abduction, right elbow flexion and ankle plantar flexion, and person D also decreased ROM at the level of shoulder flexion and right elbow flexion. The difference between the expected results and those obtained in the Reabilitation Nursing programs can be explained by multiple factors, including the fact that the elbow, ankle and shoulder joints have a greater predisposition to the development of contractures6, and that the study of Nepomuceno Júnior, Martinez, Neto²⁹ also proved it with a program of exercises for joint mobilization in these joints. In general, in people who were part of the intervention project, joint ranges were maintained or improved, attesting to the importance of range of motion exercises and therapeutic positioning, in people in critical situations, as these interventions contribute to the prevention of harmful effects of prolonged immobility and for the maintenance or improvement of people's motor functionality^28,30,31.

With regard to the risk of pressure ulcers, during the period in which the intervention project took place, people B and D decreased their risk (assessed with the Braden scale) and person A remained constant. Anticipatory interventions that include the systematic assessment of skin integrity and risk assessment, the repositioning and use of support surfaces and appropriate therapeutic dressings, together with the promotion of skin hydration and the reduction of moisture in the skin have proven effective because, despite of maintaining a high risk of pressure ulcers none of the people developed this consequence of immobility. These results are in line with others already described^32-35, proving that the systematic monitoring of this problem preceded by the awareness of it by the entire nursing team and its valorization, especially by the RN, allowed individual intervention in the people and prevent the emergence of new pressure ulcers, confirming as recommended by the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance³⁶ that the structured approach to risk assessment, which includes an assessment of activity/mobility and the condition of the skin, which has strength of Evidence B, should be strongly recommended.

Overall, after the FRR sessions, people A, B and D improved their breathing pattern, with an increase in respiratory amplitude and chest expansion, noting that in the final sessions they presented a regular, medium-range and mixed breathing pattern. We also found that the episodes of respiratory effort evident in some sessions (a session of person B and a session of person D), were resolved, not being visible in subsequent sessions. Although participants A and B had occasionally (at the end of one or several sessions) an increase in respiratory rate, we observed that in most sessions, respiratory rates decreased in all people, after the FRR interventions. These results demonstrate that the intended objectives with the nursing intervention in the field of FRR were achieved, as asynergy and ventilatory deficiencies were corrected and prevented, which may have contributed to an improvement in respiratory function, as explained by several authors^28,37-39.

With regard to the SpO² parameter, the percentages in participants A, B, and D remained constant after the FRR interventions, or increased slightly. Although the project participants are not ventilated, the results obtained are consistent with those described in the literature, verifying that the implementation of an intervention plan within the scope of FRR in people in critical condition promotes more effective ventilation, with this effect being visible through the increase in SpO2^40,44.

Throughout all the FRR sessions, people kept their cough reflex reduced; it is a situation that may be associated with the presence of an artificial airway (ETT)⁴⁵, or with a decrease in muscle strength due to their critical condition and immobility⁷. It was also found that at the beginning of the sessions, people had the presence of AS (snoring) on ​​pulmonary auscultation, indicative of the presence of secretions⁴⁶. Thus, the association of several bronchial hygiene maneuvers contributed to the expected results being achieved, as evidenced by the absence of AR at the end of the sessions. It can be seen that a care plan that combines different techniques for mobilizing and eliminating secretions promotes greater cleaning of the airways, as was also observed in the studies carried out by Avena, Duarte, Cravo, Sologuren, Gastaldi⁴⁰ and Naue, Forgiarini Junior, Dias, Vieira⁴⁷, minimizing secretion stasis and consequently the episodes of bronchial obstruction that precipitate atelectasis⁴⁸.

The person designated by C, unlike the other people, was aware and oriented, showing the ability to assimilate the information and instruction of the techniques implemented in the intervention plan. In addition, participant also demonstrated to be motivated to acquire new knowledge that would make it possible to prevent the complications arising from immobility and maximize the capabilities in terms of motor and respiratory functions, which was essential for our intervention to be successful. Potential nursing diagnoses to improve ability to perform muscle and joint exercise techniques; potential to improve knowledge about self-control of the breathing pattern; potential to improve knowledge about respiratory technique; potential to improve ability to self-control breathing pattern and potential to improve ability to use breathing techniques were only identified in this person. Thus, throughout the intervention project, person C assimilated the transmitted knowledge and the instructed techniques, being able to independently perform the range of motion exercises and adequately employ the respiratory techniques taught, confirming what Habel⁴⁹ refers, who RN, by investing in people's education, promote their empowerment, since they are provided with the knowledge and skills necessary to manage their own care and control their lives, that is, to be as independent as possible.

The results of this intervention project also allowed us to verify that the early planning of the provision of adequate and individualized rehabilitation nursing care, in the areas of Motor Functional Reeducation, pressure ulcer prevention and Respiratory Functional Reeducation, can contribute to prevention of the motor, integumentary and respiratory consequences of immobility in people in critical condition. Rehabilitation Nursing has a crucial role in promoting preventive practices within the multidisciplinary team. These patient safety-oriented practices meet the first specific competence of the RN, which is to be able to care for people with special needs in all contexts of practice and care²² and who are unable to perform basic activities independently, identifying the needs for specialized intervention, implementing and evaluating programs aimed at reducing risks. And their ways of intervening are the execution, teaching and demonstration of techniques that promote self-care.

In summary, the results obtained in this intervention project prove the importance of anticipatory care¹⁷, since planning and an early RNs intervention prevent the occurrence of negative events, in this case the consequences of immobility, which can compromise a successful health/disease transition, experienced by people in critical situations, which is somewhat in line with what is defended by Ludin, Arbon, Parker¹⁵, who state that people in critical situations need a more comprehensive transition planning, which implies a greater focus on its anticipation and its effects.

CONCLUSION

The results obtained in this intervention project allowed us to verify that the participants maintained or improved range of motion, and despite the high risk, they did not develop pressure ulcers, having also improved their respiratory condition. Although the results cannot be generalized, due to methodological limitations, the expected results derived from the planned interventions implemented, with the collaboration of the other elements of the nursing team, and were achieved.

The time limitation for project implementation was also a limitation. It is considered that in a future replication of this project it would be pertinent to extend its implementation time, allowing for a greater number of cases.

Despite its limitations, this intervention project can be a contribution to the development of knowledge in Rehabilitation Nursing and a propellant for other studies to be created, as it also demonstrates the importance of the RN intervention aimed at people admitted to ICU.