2.3 Prevention of Complications
Key Takeaways
- Immobility causes predictable complications: deep vein thrombosis (DVT), joint contractures, muscle deconditioning, orthostatic hypotension, and pressure injuries; prevention is a core rehabilitation nursing responsibility.
- Autonomic dysreflexia is a life-threatening emergency in spinal cord injury at T6 or above: act immediately by sitting the patient up, loosening constrictive items, and finding and removing the noxious stimulus (most often a distended bladder).
- Spasticity is managed with a stepped approach: positioning, range-of-motion and stretching, splinting, oral antispasmodics, and targeted injections or intrathecal therapy when needed.
- Orthostatic hypotension is prevented with gradual position changes, compression garments, an abdominal binder, and adequate hydration.
- Safe patient handling and mobility (SPHM) programs and mechanical lifts protect both patients and staff and are an expected standard of care.
Why This Matters for the CRRN Exam
The CRRN exam heavily tests prevention of secondary complications because most are predictable and largely preventable through nursing care. Expect priority and emergency-action questions — especially autonomic dysreflexia, which is the single most time-critical rehabilitation emergency.
Complications of Immobility
Prolonged immobility produces a cascade of system effects. Rehabilitation nurses anticipate and prevent them through early mobilization and structured programs.
| Complication | Mechanism | Key Prevention |
|---|---|---|
| Deep vein thrombosis (DVT) | Venous stasis with hypercoagulability and endothelial injury (Virchow triad) | Early mobilization, prescribed prophylaxis (mechanical and/or pharmacologic), leg exercises, hydration |
| Joint contracture | Soft tissue shortening across an immobilized joint | Routine range-of-motion (ROM), proper positioning, splints, frequent repositioning |
| Muscle deconditioning / atrophy | Disuse loss of strength and endurance | Progressive activity, strengthening, out-of-bed time |
| Orthostatic hypotension | Impaired autonomic compensation to upright posture | Gradual position changes, compression, hydration |
| Pressure injury | Sustained pressure/shear over bony prominences | Repositioning, support surfaces, skin care |
| Disuse osteoporosis | Reduced mechanical loading of bone | Weight-bearing as tolerated, activity |
| Atelectasis / pneumonia | Reduced lung expansion and secretion clearance | Deep breathing, incentive spirometry, mobilization |
A classic exam point: a unilaterally warm, swollen, tender calf in an immobile patient suggests DVT — do not vigorously massage the limb; notify the provider and follow the anticoagulation/diagnostic plan.
Autonomic Dysreflexia: A Rehabilitation Emergency
Autonomic dysreflexia (AD) is a sudden, exaggerated sympathetic response to a noxious stimulus below the level of injury in patients with spinal cord injury (SCI) at T6 or above. Untreated, it can cause stroke, seizure, or death.
Recognize: sudden, severe hypertension, pounding headache, bradycardia, profuse sweating and flushing above the lesion, and pallor/goosebumps below it.
Most common triggers: a distended bladder (kinked catheter, blocked drainage) is the leading cause, followed by bowel impaction, then skin irritation or other noxious stimuli below the injury.
Immediate nursing actions (memorize the sequence):
- Sit the patient upright and lower the legs to use orthostatic effect to drop blood pressure.
- Loosen constrictive clothing, binders, and devices.
- Monitor blood pressure frequently (every 2–5 minutes).
- Find and remove the noxious stimulus — check the bladder first (unkink/drain or catheterize), then check for bowel impaction, then inspect skin.
- Notify the provider and give prescribed rapid-acting antihypertensives if blood pressure remains dangerously high; document the event.
The first physical action is to sit the patient up, not to lie them down — a frequently tested distinction.
Spasticity Management
Spasticity is a velocity-dependent increase in muscle tone from upper motor neuron lesions (e.g., SCI, stroke, traumatic brain injury). Some tone can aid function (transfers, standing), so the goal is management, not always elimination, guided by function and comfort.
Stepped approach:
- Non-pharmacologic first: proper positioning, daily range-of-motion and sustained stretching, splinting/orthoses, and removing aggravating stimuli (pain, infection, pressure injury, full bladder).
- Oral agents: baclofen, tizanidine, or dantrolene as prescribed; monitor for sedation and weakness.
- Focal/targeted therapy: botulinum toxin injections for localized spasticity.
- Advanced therapy: an intrathecal baclofen pump for severe, generalized spasticity unresponsive to other measures.
A sudden increase in spasticity often signals a new noxious stimulus (urinary tract infection, pressure injury, impaction) — assess for an underlying cause rather than only increasing medication.
Orthostatic Hypotension
Orthostatic (postural) hypotension is a drop in blood pressure with upright positioning, common in prolonged bed rest and in SCI above the mid-thoracic level. It causes dizziness, light-headedness, and falls and can stall mobilization.
Prevention and management:
- Change positions gradually: flat → sitting → dangling → standing, with pauses.
- Use compression stockings and an abdominal binder to reduce venous pooling.
- Ensure adequate hydration and review contributing medications with the team.
- Use a tilt table or progressive sitting schedule for severe cases; monitor symptoms and blood pressure.
Safe Patient Handling and Mobility (SPHM)
Safe patient handling and mobility (SPHM) programs use mechanical lifts, friction-reducing devices, and assessment-based handling algorithms to move dependent patients. They are an expected standard of care that protects patients from falls and skin injury and protects staff from musculoskeletal injury.
Key principles:
- Assess the patient’s ability and use the least manual, safest method (e.g., full mechanical lift for fully dependent patients).
- Use enough trained staff and the correct equipment; never “manually heroic” lift a dependent patient.
- Apply good body mechanics, lock wheels/brakes, and use gait/transfer belts for appropriate patients.
Heterotopic Ossification and Contracture
Heterotopic ossification (HO) is abnormal bone formation in soft tissue around a joint, common after spinal cord injury, traumatic brain injury, and hip surgery. Early signs mimic deep vein thrombosis — warmth, swelling, decreased range of motion, and a low-grade temperature around a joint (often the hip) — so HO is a frequent distractor. Report new joint warmth and lost range of motion; management includes gentle range of motion, prescribed medication (for example, etidronate or NSAIDs), and sometimes later surgical excision.
Contractures are permanent soft-tissue shortening that, once fixed, sharply limit function and complicate hygiene and positioning. Prevention is far easier than correction: daily range-of-motion, functional positioning (for example, a resting hand splint, foot in neutral to prevent foot drop, hips in slight abduction), frequent repositioning, and avoiding prolonged flexion. A common exam point is that preventing a contracture is a priority, because reversing one may require serial casting or surgery.
Cardiopulmonary and Other Immobility Effects
Prolonged bed rest also reduces cardiac reserve and plasma volume, worsening orthostatic intolerance, and impairs pulmonary toilet, raising atelectasis and pneumonia risk — addressed with deep breathing, incentive spirometry, position changes, and early mobilization. Disuse osteoporosis raises fracture risk, so transfers and range of motion must be performed gently. Recognizing that nearly every body system deconditions with immobility is the conceptual anchor for this domain: the rehabilitation nurse's job is to keep the patient moving and to run structured prevention programs.
Connecting to Exam Scenarios
The highest-yield item is autonomic dysreflexia: in an SCI patient at T6 or above with sudden severe hypertension and headache, the correct first action is to sit the patient up and then look for a distended bladder. Other common items test distinguishing DVT from heterotopic ossification, preventing contractures with daily range of motion, gradual mobilization for orthostatic hypotension, and choosing an SPHM-compliant transfer method.
A patient with a spinal cord injury at T4 suddenly develops a severe pounding headache, blood pressure of 210/110, flushing above the injury, and sweating. What is the nurse's FIRST action?
An immobile rehabilitation patient develops a unilaterally warm, swollen, and tender calf. Which nursing action is appropriate?
A rehabilitation nurse notes a sudden, marked increase in a spinal cord injury patient's lower-extremity spasticity. What is the BEST initial nursing response?
Which set of interventions BEST prevents orthostatic hypotension during early mobilization of a patient after prolonged bed rest?