Immobility

A limitation in independent, purposeful physical movement of the body or of one or more extremities

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; limited range of motion; difficulty turning; decreased reaction time; movement-induced shortness of breath; gait changes (e.g., decreased walking speed, difficulty initiating gait, small steps, shuffles feet, exaggerated lateral postural sway); engages in substitutions for movement (e.g., increased attention to other's activity, controlling behavior, focus on preillness/predisability); 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; pain; musculoskeletal impairment; intolerance to activity/decreased strength and endurance; depressive mood state or anxiety; cognitive impairment; decreased muscle strength, control, and/or mass; reluctance to initiate movement; sedentary lifestyle or disuse or deconditioning; selective or generalized malnutrition; loss of integrity of bone structures; developmental delay; joint stiffness or contractures; limited cardiovascular endurance; altered cellular metabolism; lack of physical or social environmental supports; cultural beliefs regarding age-appropriate activity

Suggested functional level classifications0 Completely independent1 Requires use of equipment or device2 Requires help from another person for assistance, supervision, or teaching3 Requires help from another person and equipment device4 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 PerformanceClient 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 mobilityNIC 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 well-being (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 exercisesThese 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 ExercisesTHE EFFECTS OF IMMOBILITYCardiovascular 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.Respiratory 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: Increased temperature. Thick copious secretions. Cough. Increased pulse. Confusion, irritability, or disorientation. Sharp chest pain. 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.4. Osteoporosis. Lack of stress on the bone causes an increase in calcium absorption, weakening the bone.Nervous System.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.Gastrointestinal System.1. Disturbance in appetite caused by the slowing of gastrointestinal tract, secondary immobility, and decreased activity resulting in anorexia.2. Altered digestion and utilization of nutrients resulting in constipation.3. Altered protein metabolism.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.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 EXERCISES1. 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 strength when a joint is immobilized. Full patient cooperation is required. 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 position9. Pronation. The palm or sole is rotated in a downward position.

5-6. GUIDELINES FOR RANGE OF MOTION EXERCISES1. 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.

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.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.