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Immobility

A limitation in independent, purposeful physical


movement of the body or of one or more extremities

pain;

musculoskeletal impairment;

intolerance to activity/decreased strength and


endurance;

depressive mood state or anxiety;

cognitive impairment;

decreased muscle strength, control, and/or


mass;

Defining Characteristics:

Postural instability during performance of


routine activities of daily living (ADLs);

limited ability to perform gross motor skills;

limited ability to perform fine motor skills;

uncoordinated or jerky movements;

reluctance to initiate movement;

limited range of motion;

sedentary lifestyle or disuse or deconditioning;

difficulty turning;

selective or generalized malnutrition;

decreased reaction time;

loss of integrity of bone structures;

movement-induced shortness of breath;

developmental delay;

gait changes (e.g., decreased walking speed,


difficulty initiating gait, small steps, shuffles
feet, exaggerated lateral postural sway);

joint stiffness or contractures;

limited cardiovascular endurance;

engages in substitutions for movement (e.g.,


increased attention to other's activity, controlling
behavior, focus on preillness/predisability);

altered cellular metabolism;

lack of physical or social environmental


supports;

cultural beliefs regarding age-appropriate


activity

slowed movement;

movement-induced tremor

Related Factors:

Medications;

prescribed movement restrictions;

discomfort;

lack of knowledge regarding value of physical


activity;

body mass index >30;

sensoriperceptual impairments;

neuromuscular impairment;

Suggested functional level classifications


0 Completely independent
1 Requires use of equipment or device
2 Requires help from another person for assistance,
supervision, or teaching
3 Requires help from another person and equipment
device
4 Dependentdoes not participate in activity
NOC Outcomes (Nursing Outcomes Classification)

Ambulation: Walking

Ambulation: Wheelchair

Joint Movement: Active

Mobility Level

Self-Care: Activities of Daily Living (ADLs)

Transfer Performance

Client Outcomes

Increases physical activity

Meets mutually defined goals of increased


mobility

Verbalizes feeling of increased strength and


ability to move

Demonstrates use of adaptive equipment (e.g.,


wheelchairs, walkers) to increase mobility

NIC Interventions (Nursing Interventions


Classification)

Exercise Therapy: Ambulation

Exercise Therapy: Joint Mobility

Positioning

Nursing Interventions and Rationales


1. Screen for mobility skills in the following order:
(1) bed mobility;
(2) supported and unsupported sitting;
(3) transition movements such as sit to stand, sitting
down, and transfers; and
(4) standing and walking activities. Use a physical
activity tool if available to evaluate mobility.
Screening mobility skills helps provide baselines of
performance that can guide mobility-enhancement
programming and allows nursing staff to integrate
movement and practice opportunities into daily routines
and regular and customary care. There are many tools
available to measure physical activity; selection of the
appropriate tool depends on the setting and situation
2. Observe client for cause of impaired mobility.
Determine whether cause is physical or psychological.
Some clients choose not to move because of
psychological factors such as an inability to cope or
depression. See interventions for Ineffective Coping or
Hopelessness.

3. Monitor and record client's ability to tolerate activity


and use all four extremities; note pulse rate, blood
pressure, dyspnea, and skin color before and after
activity. See care plan for Activity intolerance.
4. Before activity observe for and, if possible, treat pain.
Ensure that client is not oversedated.
Pain limits mobility and is often exacerbated by
movement.
5. Consult with physical therapist for further evaluation,
strength training, gait training, and development of a
mobility plan.
Techniques such as gait training, strength training, and
exercise to improve balance and coordination can be
very helpful for rehabilitating
6. Obtain any assistive devices needed for activity, such
as walking belts, walkers, canes, crutches, or
wheelchairs, before the activity begins.
Assistive devices can help increase mobility.
7. If client is immobile, perform passive range of motion
(ROM) exercises at least twice a day unless
contraindicated; repeat each maneuver three times.
Passive ROM exercises help maintain joint mobility,
prevent contractures and deformities, increase
circulation, and promote a feeling of comfort and wellbeing (Kottke, Lehmann, 1990; Bolander, 1994).
8. If client is immobile, consult with physician for a
safety evaluation before beginning an exercise program;
if program is approved, begin with the following
exercises:

Active ROM exercises using both upper and


lower extremities (e.g., flexing and extending at
ankles, knees, hips)

Chin-ups and pull-ups using a trapeze in bed


(may be contraindicated in clients with cardiac
conditions)

Strengthening exercises such as gluteal or


quadriceps sitting exercises

These exercises help reverse weakening and atrophy of


muscles.
9. Help client achieve mobility and start walking as soon
as possible if not contraindicated.
The longer a client is immobile, the longer it takes to
regain strength, balance, and coordination (Bolander,
1994). A study has shown that bed rest for primary
treatment of medical conditions or after healthcare

procedures is associated with worse outcomes than early


mobilization (Allen, Glasziou, Del Mar, 1999).
10. Use a walking belt when ambulating the client.
The client can walk independently with a walking belt,
but the nurse can rapidly ensure safety if the knees
buckle.
11. Apply any ordered brace before mobilizing client.
Braces support and stabilize a body part, allowing
increased mobility.
12. Increase independence in ADLs and discourage
helplessness as client gets stronger.
Providing unnecessary assistance with transfers and
bathing activities may promote dependence and a loss of
mobility
13. If client does not feed or groom self, sit side-by-side
with client, put your hand over client's hand, support
client's elbow with your other hand, and help client feed
self; use the same technique to help client comb hair.
This feeding technique increases client mobility, range
of motion, and independence, and clients often eat more
food
Geriatric
1. Help the mostly immobile client achieve mobility as
soon as possible, depending on physical condition.
In the elderly, mobility impairment can predict increased
mortality and dependence; however, this can be
prevented by physical exercise
2. For a client who is mostly immobile, minimize
cardiovascular deconditioning by positioning client as
close to the upright position as possible several times
daily.
The hazards of bed rest in the elderly are multiple,
serious, quick to develop, and slow to reverse.
Deconditioning of the cardiovascular system occurs
within days and involves fluid shifts, fluid loss,
decreased cardiac output, decreased peak oxygen
uptake, and increased resting heart rate
3. If client is mostly immobile, encourage him or her to
attend a low-intensity aerobic chair exercise class that
includes stretching and strengthening chair exercises.
Chair exercises have been shown to increase flexibility
and balance.
4. Initiate a walking program in which client walks with
or without help every day as part of daily routine.
Walking programs have been shown to be effective in
improving ambulatory status and decreasing disability
and the number of falls in the elderly.

5. Evaluate client for signs of depression (flat affect,


insomnia, anorexia, frequent somatic complaints) or
cognitive impairment (use Mini-Mental State Exam
[MMSE]). Refer for treatment or counseling as needed.
Multiple studies have demonstrated that depression and
decreased cognition in the elderly correlate with
decreased levels of functional ability.
6. Watch for orthostatic hypotension when mobilizing
elderly clients. If relevant, have client flex and extend
feet several times after sitting up, then stand up slowly
with someone watching.
Orthostatic hypotension as a result of cardiovascular
system changes, chronic diseases, and medication effects
is common in the elderly.
7. Be very careful when getting a mostly immobile client
up. Be sure to lock the bed and wheelchair and have
sufficient personnel to protect client from falls.
The most important preventative measure to reduce the
risk of injurious falls for nonambulatory residents
involves increasing safety measures while transferring,
including careful locking of equipment such as
wheelchairs and beds before moves. Elderly clients most
commonly sustain the most serious injuries when they
fall.
8. Help clients assume the prone position three times per
week for 20 minutes each time. If clients are unable to
do so, help them turn partially over and assume the
position gradually.
The prone position helps prevent hip deformities that
can interfere with balance and walking. This position
may be contraindicated in some clients, such as
morbidly obese clients, respiratory or cardiac clients
who cannot lie flat, and neurological clients.
9. Do not routinely assist with transfers or bathing
activities unless necessary.
The nursing staff may contribute to impaired mobility by
helping too much. Encourage client independence.
10. Use gestures and nonverbal cues when helping
clients move if they are anxious or have difficulty
understanding and following verbal instructions.
Nonverbal gestures are part of a universal language that
can be understood when the client is having difficulty
with communication.
11. Recognize that wheelchairs are not a good mobility
device and often serve as a mobility restraint.
Wheelchairs can be very effective restraints. In one
study, only 4% of residents in wheelchairs were
observed to propel them independently; only 45% could
propel them, even with cues and prompts; no residents

could unlock them without help; the wheelchairs were


not fitted to residents; and residents were not trained in
propulsion.
12. Ensure that chairs fit clients. Chair seat should be 3
inches above the height of the knee. Provide a raised
toilet seat if needed.
Raising the height of a chair can dramatically improve
the ability of many older clients to stand up. Low, deep,
soft seats with armrests that are far apart reduce a
person's ability to get up and down without help.
13. If client is mainly immobile, provide opportunities
for socialization and sensory stimulation (e.g., television
and visits). See Deficient Diversional activity.
Immobility and a lack of social support and sensory
input may result in confusion or depression in the
elderly). See interventions for Acute Confusion or
Hopelessness as appropriate.
Home Care Interventions
1. Assess home environment for factors that create
barriers to physical mobility. Refer to occupational
therapy services if needed to assist client in restructuring
home and daily living patterns.
2. Refer to home health aide services to support client
and family through changing levels of mobility.
Reinforce need to promote independence in mobility as
tolerated.
Providing unnecessary assistance with transfers and
bathing activities may promote dependence and a loss of
mobility
3. Assess skin condition at every visit. Establish a skin
care program that enhances circulation and maximizes
position changes.
Impaired mobility decreases circulation to dependent
areas. Decreased circulation and shearing place the
client at risk for skin breakdown.
4. Provide support to client and family/caregivers during
long-term impaired mobility.
Long-term impaired mobility may necessitate role
changes within the family and precipitate caregiver
stress
Client/Family Teaching
1. Teach client to get out of bed slowly when transferring
from the bed to the chair.
2. Teach client relaxation techniques to use during
activity.
3. Teach client to use assistive devices such as a cane, a
walker, or crutches to increase mobility.

4. Teach family members and caregivers to work with


clients during self-care activities such as eating, bathing,
grooming, dressing, and transferring rather than having
client be a passive recipient of care.
Maintaining as much independence as possible helps
maintain mobility skills.
5. Develop a series of contracts with mutually agreed on
goals of increased activity. Include measurable
landmarks of progress, consequences for meeting or not
meeting goals, and evaluation dates. Sign the contracts
with the client.
Active and Passive Range of Motion Exercises
THE EFFECTS OF IMMOBILITY
Cardiovascular System.
1. Venous stasis caused by prolonged inactivity
that restricts or slows venous circulation.
Muscular activity, especially in the legs, helps
move blood toward the central circulatory
system.
2. Increased cardiac workload due to increased
viscosity from dehydration and decreased
venous return. The heart works more when the
body is resting, probably because there is less
resistance offered by the blood vessels and
because there is a change in the distribution of
blood in the immobile person. The result is that
the heart rate, cardiac output, and stroke volume
increase.
3. Thrombus and embolus formation caused by
slow flowing blood, which may begin clotting
within hours, and an increased rate in the
coagulation of blood. During periods of
immobility, calcium leaves bones and enters the
blood, where it has an influence on blood
coagulation.
4. Orthostatic hypotension probably due to a
decrease in the neurovascular reflexes, which
normally causes vasoconstriction, and to a loss
of muscle tone. The result is that blood pools
and does not squeeze from veins in the lower
part of the body to the central circulatory
system. The immobile person is more
susceptible to developing orthostatic

hypotension. The person tends to feel weak and


faint when the condition occurs.

4. Osteoporosis. Lack of stress on the bone causes


an increase in calcium absorption, weakening
the bone.

Respiratory System.
Nervous System.
1. Hypostatic pneumonia. The depth and rate of
respirations and the movement of secretions in
the respiratory tract is decreased when a person
is immobile. The pooling secretions and
congestion predispose to respiratory tract
infections. Signs and symptoms include:

1. Altered sensation caused by prolonged pressure


and continual stimulation of nerves. Usually
pain is felt at first and then sensation is altered,
and the patient no longer senses the pain.
2. Peripheral nerve palsy.

Increased temperature.
Gastrointestinal System.

Thick copious secretions.

Cough.

Increased pulse.

Confusion, irritability, or disorientation.

2. Altered digestion and utilization of nutrients


resulting in constipation.

Sharp chest pain.

3. Altered protein metabolism.

Dyspnea.

2. Atelectasis. When areas of lung tissue are not


used over a period of time, incomplete
expansion or collapse of lung tissue may occur.
3. Impaired coughing. Impairment of coughing
mechanism may be due to the patient's position
in bed decreasing chest cage expansion.
Musculoskeletal System.
1. Muscle atrophy. Disuse leads to decreased
muscle size, tone, and strength.
2. Contracture. Decreased joint movement leads to
permanent shortening of muscle tissue, resistant
to stretching. The strong flexor muscles pull
tight, causing a contraction of the extremity or a
permanent position of flexion.
3. Ankylosis. Consolidation and immobility of a
joint in a particular position due to contracture.

1. Disturbance in appetite caused by the slowing of


gastrointestinal tract, secondary immobility, and
decreased activity resulting in anorexia.

Integumentary System. Risk of skin breakdown, which


leads to necrosis and ulceration of tissues, especially on
bony areas.
Urinary System.
1. Renal calculi (kidney stones) caused by
stagnation of urine in the renal pelvis and the
high levels of urinary calcium.
2. Urinary tract infections caused by urinary stasis
that favors the growth of bacteria.
3. Decreased bladder muscle tone resulting in
urinary retention.
Metabolism.
1. Increased risk of electrolyte imbalance. An
absence of weight on the skeleton and
immobility causes protein to be broken down
faster than it is made, resulting in a negative
nitrogen balance.
2. Decreased metabolic rate.

3. Altered exchange of nutrients and gases.

strength when a joint is immobilized. Full


patient cooperation is required.

Psychosocial Functioning.
1. Decrease in self-concept and increase in sense of
powerlessness due to inability to move
purposefully and dependence on someone for
assistance with simple self-care activities.
2. Body image distortions (depends on diagnosis).
3. Decrease in sensory stimulation due to lack of
activity, and altered sleep-wake pattern.
4. Increased risk of depression, which may cause
the patient to become apathetic, possibly
because of decreased sensory stimulation; or the
patient may exhibit altered thought processes.
5. Decreased social interaction.

TYPES OF EXERCISES
1. Passive. These exercises are carried out by the
nurse, without assistance from the patient.
Passive exercises will not preserve muscle mass
or bone mineralization because there is no
voluntary contraction, lengthening of muscle, or
tension on bones.
2. Active Assistive. These exercises are performed
by the patient with assistance from the nurse.
Active assistive exercises encourage normal
muscle function while the nurse supports the
distal joint.
3. Active. Active exercises are performed by the
patient, without assistance, to increase muscle
strength.
4. Resistive. These are active exercises performed
by the patient by pulling or pushing against an
opposing force.
5. Isometric. These exercises are performed by the
patient by contracting and relaxing muscles
while keeping the part in a fixed position.
Isometric exercises are done to maintain muscle

TYPES OF BODY MOVEMENT

1. Flexion. The state of being bent. The cervical


spine is flexed when the chin is moved toward
the chest.
2. Extension. The state of being in a straight line.
The cervical spine is extended when the head is
held straight.
3. Hyperextension. The state of exaggerated
extension. The cervical spine is hyperextended
when the person looks overhead, toward the
ceiling.
4. Abduction. Lateral movement of a body part
away from the midline of the body. The arm is
abducted when it is held away from the body.
5. Adduction. Lateral movement of a body part
toward the midline of the body. The arm is
adducted when it is moved from an outstretched
position toward the body.
6. Rotation. Turning of a body part around an axis.
The head is rotated when moved from side to
side to indicate "no."

7. Circumduction. Rotating an extremity in a


complete circle. Circumduction is a combination
of abduction, adduction, extension, and flexion.
8. Supination. The palm or sole is rotated in an
upward position
9. Pronation. The palm or sole is rotated in a
downward position.

Range-of-motion exercises should be done at least twice


a day. During the bath is one appropriate time. The warm
bath water relaxes the muscles and decreases spasticity
of the joints. Also, during the bath, areas are exposed so
that the joints can be both moved and observed. Another
appropriate time might be before bedtime. The joints of
helpless or immobile patients should be exercised once
every eight hours to prevent contracture from occurring.

5-6. GUIDELINES FOR RANGE OF MOTION


EXERCISES
1. Plan when range of motion exercises should be
done Plan whether exercises will be passive,
active-assistive, or active. Involve the patient in
planning the program of exercises and other
activities because he/she will be more apt to do
the exercises voluntarily.
2. Expect the patient's heart rate and respiratory
rate to increase during exercise.

3. Joints are exercised sequentially, starting with


the neck and moving down. Put each joint
needing exercise through the range of motion
procedure a minimum of three times, and
preferably five times. Avoid overexerting the
patient; do not continue the exercises to the
point that the patient develops fatigue. Some
exercises may need to be delayed until the
patient's condition improves.Start gradually and
move slowly using smooth and rhythmic
movements appropriate for the patient's
condition.
5. Support the extremity when giving passive
exercise to the joints of the arm or leg.
6. Stretch the muscles and keep the joint flexible.
7. Move each joint until there is resistance, but
never force a joint to the point of pain.
8. Keep friction at a minimum to avoid injuring the
skin.
9. Return the joint to its neutral position.
10. Use passive exercises as required, however,
encourage active exercises when the patient is
able to do so.