1. The effects of Immobility

2. Factors Influencing obility/Immobility
Ability to move about freely
Immobility
Inability to move about freely
Bed rest
An intervention that restricts patients for therapeutic reasons
•Patients may experience mobility and immobility in degrees. Mobility can be thought of on a continuum as patients can move in and out of a mobile state.
•Musculoskeletal deconditioning and lack of activity can result in a series of symptoms often referred to as hazards of immobility.

3. Systemic Effects Metabolic
Endocrine, calcium absorption, and GI function
Respiratory
Atelectasis and hypostatic pneumonia
Cardiovascular
Orthostatic hypotension
Thrombus
Musculoskeletal changes
Loss of endurance and muscle mass and decreased stability and balance
Muscle effects
Loss of muscle mass
Muscle atrophy
Skeletal effects
Impaired calcium absorption
Joint abnormalities
Urinary elimination
Urinary stasis
Renal calculi
Integumentary
Pressure ulcer
Ischemia
•It is important to stress that the longer the patient is immobile, the greater and more pronounced the consequences of immobility will be.
•Prolonged bed rest increases the heart’s workload, producing an increase in oxygen demand.
•Immobility can lead to joint contracture, which is characterized by abnormal fixation of a joint.
•Immobility presents hazards in the physiological, psychological, and developmental dimensions.
•The risk of disabilities related to immobilization depends on the extent and duration of immobilization and the patient’s overall level of health.

4. Metabolic Changes
•When the patient is immobile, the body often excretes more nitrogen than it ingests protein, which causes a negative nitrogen balance leading to weight loss, decreased muscle mass, and weakness resulting from tissue breakdown (catabolism).
[Image is Figure 47-4 on text p Factors contributing to negative nitrogen balance associated with immobility.]

5. Respiratory Changes
•Lack of movement and exercise places patients at higher risk for respiratory complications.
•Patients who are immobile are at high risk for developing pulmonary complications.
•The most common respiratory complications are atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions).
[Left image is Figure 47-5 on text p Effect of recumbency and gravity on distribution of respiratory tract and diameter of bronchiolar lumen.]
[Right image is Figure 47-6 on text p Pooling of secretions in dependent regions of lungs in supine position.]

6. Cardiovascular Changes
Orthostatic hypotension
Increased cardiac workload
Thrombus formation
[Image is Figure 47-7 on text p Thrombus formation in a vessel.]

7. Musculoskeletal Changes
Muscle effects
Patient loses lean body mass.
Muscle weakness/ atrophy
Skeletal effects
Disuse osteoporosis
Joint contracture
•The patient loses lean body mass owing to protein breakdown, which results in increasing fatigue. If immobility continues and the patient does not exercise, the patient loses more muscle mass, which in turn makes movement increasingly difficult and puts the patient at risk for falls. Muscle weakness and atrophy are common results of prolonged immobilization.
•Immobilization causes two skeletal changes: impaired calcium metabolism and joint abnormalities.
•Immobilization results in bone resorption; bone tissue is less dense or atrophied and disuse osteoporosis occurs, which can lead to pathological fractures.
•Immobility can also lead to joint contractures. A joint contracture is an abnormal and possibly permanent condition characterized by fixation of the joint. One such condition is footdrop.
[Image is Figure 47-8 on text p Footdrop. Ankle is fixed in plantar flexion. Normally ankle is able to flex (dotted line), which eases walking.]

8. Urinary Elimination Changes
Urinary stasis
Renal calculi
Infection
•Without the aid of gravity, the renal pelvis fills before urine enters the ureters, resulting in urinary stasis, a condition that increases the risks of urinary infection and renal calculi.
•Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients frequently have conditions that increase the likelihood of renal calculi, such as hypercalcemia and concentrated urine due to dehydration.
•Urinary catheters and inappropriate perineal care increase the risk of urinary tract infection.
[Image is Figure 47-9 on text p Stasis of urine with reflux to ureters.]

9. Integumentary Changes
Pressure ulcers
Inflammation
Ischemia
Older adults at greater risk
•A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) in tissues.
•The ulcer is characterized initially by inflammation and usually forms over a bony prominence.
•Ischemia develops when pressure on the skin is greater than pressure inside the small peripheral blood vessels supplying blood to the skin.
•The older adult is especially at risk. For example, an older adult who is immobilized on a backboard following a trauma can develop skin breakdown within 3 hours.
[See Box 47-1 on text p Focus on Older Adults: Problems of Nutrition As They Relate to Hospitalized Immobile Older Adults.]

10. Psychosocial Effects Emotional and behavioral responses
Hostility, giddiness, fear, anxiety
Sensory alterations
Altered sleep patterns
Changes in coping
Depression, sadness, dejection
•Immobilization changes the patient’s daily routine, and the patient has more time to worry about disability.
•Withdrawn patients often do not want to participate in their own care.

11. Developmental Changes
Infants, Toddlers, Preschoolers
Prolonged immobility delays gross motor skills, intellectual development, or musculoskeletal development
Adolescents
Delayed in gaining independence and in accomplishing skills
Social isolation can occur
Adults
Physiological systems are at risk
Changes in family and social structures
Older Adults
Decreased physical activity
Hormonal changes
Bone reabsorption
•Across the life span, each age group will experience problems when immobility is experienced.
•Developmental stages influence body alignment and mobility; the greatest impact of physiological changes on the musculoskeletal system is observed in children and older adults.

12. Nursing Process: Assessment (cont’d)
Mobility
Gait (a particular manner or style of walking)
Exercise (physical activity for conditioning the body, improving health, and maintaining fitness)
Activity tolerance
Physiological
Emotional
Developmental
•Assessing a patient’s gait allows you to draw conclusions about balance, posture, safety, and ability to walk without assistance.
•Nurses use exercise as therapy to correct a deformity or restore the overall body to a maximal state of health.
•Assessment of the patient’s energy level includes the physiological effects of exercise and activity tolerance.
•Activity tolerance is the type and amount of exercise or work that a person is able to perform.
•Assessment of activity tolerance is necessary when planning activity such as walking, ROM exercises, or activities of daily living (ADLs).
•Activity tolerance assessment includes data from physiological, emotional, and developmental domains.
•Monitor patients for fatigue during exercise, and assess the time required for recovery from fatigue.
•Lessening the time it takes for a patient to recover from fatigue is an indicator of improved activity tolerance.
•Activity tolerance changes over the life span and in response to illness/trauma, depression, anxiety, and worry.

13. Nursing Process: Assessment (cont’d)
Mobility
Body alignment is used for:
Determining normal physical changes
Identifying deviations in body alignment
Patient awareness of posture
Identifying postural learning needs of patients
Identifying trauma, muscle damage, or nerve dysfunction
Obtaining information on incorrect alignment (i.e., fatigue, malnutrition, psychological problems)
•Body alignment is the condition of joints, tendons, ligaments, and muscles in various body positions.
•Balance occurs when a wide base of support is present, the center of gravity falls within the base of support, and a vertical line falls from the center of gravity through the base of support.
•Perform assessment of body alignment with the patient standing, sitting, or lying down. This assessment has the following objectives:
Determining normal physiological changes in body alignment resulting from growth and development
Identifying deviations in body alignment caused by incorrect posture
Providing opportunities for patients to observe their posture
Identifying learning needs of patients for maintaining correct body alignment
Identifying trauma, muscle damage, or nerve dysfunction
Obtaining information concerning other factors that contribute to incorrect alignment such as fatigue, malnutrition, and psychological problems

14. Nursing Process: Assessment (cont’d)
Body alignment
Lying
[Ask your students: How would you achieve correct lying posture in an immobilized patient? Discuss: removing positioning supports from the bed, except for pillows under the head, using an adequate mattress and proper positioning.]
[Image is Figure on text p Correct body alignment when lying down.]

15. Nursing Process: Assessment (cont’d)
Immobility
Metabolic
Respiratory
Cardiovascular
Musculoskeletal
Integumentary
Elimination
Psychosocial
Developmental
[Table 47-3 on text p presents an assessment of the physiological hazards of immobility.]
•Metabolic assessment includes anthropometric measurements and analysis of intake and output to assess for dehydration.
•The respiratory assessment includes inspecting the chest for wall movement and auscultating the lungs for decreased breath sounds, crackles, and wheezes.
•The cardiovascular assessment includes measurement of vital signs, peripheral pulses, apical pulse, orthostatic hypotension, deep vein thrombosis (DVT), and edema.
•A dislodged venous thrombus, called an embolus, can travel through the circulatory system to the lungs and impair circulation and oxygenation, resulting in tachycardia and shortness of breath.
•The musculoskeletal assessment includes assessing muscle strength and tone, loss of muscle mass, incidence of contractures, and ROM.
•The skin needs to be assessed for integrity or early changes in skin condition.
•When assessing the elimination system, intake and output, bowel sounds, and bowel and bladder habits need to be checked.
•During the psychosocial assessment, you will focus on the patient’s emotional state, behavior, and sleep-wake cycle.
•The developmental assessment looks at how immobility affects the normal development of patients across the life span.

16. Nursing Diagnosis and Planning
Impaired physical mobility
Risk for disuse syndrome
Ineffective airway clearance
Ineffective coping
Risk for injury
Risk for impaired skin integrity
Insomnia
Social isolation
•The list of potential diagnoses is extensive because immobility affects multiple body systems. Common diagnoses are listed on the slide.
•A nursing diagnosis will be selected after the assessment has been made.
•Remember to care for the physiological, psychosocial, and developmental dimensions: all are important to health.
•Be alert for potential complications (e.g., renal calculi, DVT, pulmonary emboli, pneumonia).
[Box 47-3 on text p provides an example of the nursing diagnostic process for impaired mobility related to left hip/left leg pain.]

17. Nursing Diagnosis and Planning (cont’d)
Goals and outcomes
Setting priorities
Teamwork and collaboration
•The planning phase will establish patient goals and outcomes.
•Develop goals and expected outcomes to assist the patient in achieving his or her highest level of mobility and reducing the hazards of immobility.
•Set priorities when planning care to ensure that immediate needs are met first. This is particularly important when patients have multiple diagnoses.
•Plan therapies according to severity of risks to the patient; individualize the plan according to the patient’s developmental stage, level of health, and lifestyle.
•Do not overlook potential complications.
•Care of the patient experiencing alterations in mobility requires a team approach.
•Nurses often delegate some interventions to nursing assistive personnel.
•Collaborate with other health care team members such as physical or occupational therapists when it is essential to consider mobility needs.
•In anticipation of the patient’s discharge from an institution, make referrals or consult a case manager or a discharge planner to ensure that the patient’s needs are met at home.
[A sample nursing care plan for impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement is provided on text p ]
[See Figure on text p for a concept map for Ms. Cavello with fractured left hip; Figure on text p provides the critical thinking model for immobility planning.]

18. Implementation: Acute Care
Metabolic
Provide high-protein, high-calorie diet with vitamin B and C supplements.
Respiratory
Cough and deep breathe every 1 to 2 hours.
Provide chest physiotherapy.
•The body needs protein to repair damaged or injured tissues and to rebuild any depleted stores. Vitamin B is needed for skin integrity and wound healing.
•It will be important to turn, cough, and deep breathe the patient often to assist in lung expansion and airway clearance.
•Chest physiotherapy consisting of percussion and positioning will clear airways and help prevent pneumonia.

19. Implementation Cardiovascular Musculoskeletal
Progress from bed to chair to ambulation.
SCDs, TED hose, and leg exercises
Musculoskeletal
Passive ROM
CPM
Active ROM
•Immobilized patients have an increased workload on the heart, can experience orthostatic hypotension, and can experience thrombus.
•It will be necessary to assist patients with active and passive ROM exercises to decrease the incidence of hazards of immobility.
[Image is Figure on text p Continuous passive range of motion machine.]
CPM, Continuous passive motion; ROM, range of motion; SCD, sequential compression device;
TED, thromboembolic deterrent.

20. Implementation Integumentary system Elimination system
Reposition every 1 to 2 hours.
Provide skin care.
Elimination system
Provide adequate hydration.
Serve a diet rich in fluids, fruits, vegetables, and fiber.
Psychosocial changes
Developmental changes
•Repositioning every 2 hours and providing skin care will help to prevent pressure ulcers.
•Patients need between 2000 and 3000 mL of fluids per day to help prevent renal calculi and urinary tract infection (UTI). Monitor intake and output to ensure that fluid balance is maintained.

21. Implementation (cont’d)
Positioning techniques
Supported Fowler’s
Supine
Prone
Side-lying
Sims’
•In the supported Fowler’s position, the head of the bed is elevated 45 to 60 degrees, and the patient’s knees are slightly elevated without pressure to restrict circulation in the lower legs.
•Patients in the supine position rest on their backs.
•The patient in the prone position lies face or chest down.
•In the side-lying (or lateral) position, the patient rests on the side with the major portion of body weight on the dependent hip and shoulder.
•Sims’ position differs from the side-lying position in the distribution of the patient’s weight.

22. Implementation Restorative and continuing care IADLs ROM exercise
Walking
•The goal of restorative care for the patient who is immobile is to maximize functional mobility and independence and reduce residual functional deficits such as impaired gait and decreased endurance.
•The focus in restorative care is not only on ADLs that relate to physical self-care, but also on instrumental activities of daily living (IADLs).
•IADLs are activities that are necessary to be independent in society beyond eating, grooming, transferring, and toileting; they include such skills as shopping, preparing meals, banking, and taking medications.
•Work collaboratively with patients.
•To ensure adequate joint mobility, teach the patient about ROM exercises.
•When performing passive ROM exercises, stand at the side of the bed closest to the joint being exercised. Perform passive ROM exercises using a head-to-toe sequence and moving from larger to smaller joints. If an extremity is to be moved or lifted, place a cupped hand under the joint to support it, support the joint by holding the adjacent distal and proximal areas, or support the joint with one hand and cradle the distal portion of the extremity with the remaining arm.
•Walking also increases joint mobility. When a patient has a limited ability to walk, assess his or her activity tolerance, tolerance to the upright position (orthostatic hypotension), strength, presence of pain, coordination, and balance to determine the amount of assistance needed.
•Provide support at the waist by using a gait belt so the patient’s center of gravity remains midline.
•Patients with hemiplegia (one-sided paralysis) or hemiparesis (one-sided weakness) often need assistance with walking.
[Top image is Figure on text p Supporting joint by holding distal and proximal areas adjacent to joint.]
[Bottom image is Figure on text p Cradling distal portion of extremity.]
IADLs, Instrumental activities of daily living; ROM, range of motion.

23. Evaluation Have the patient’s goals been met?
Have outcomes been met? If not, ask questions:
Are there ways we can assist you to increase your activity?
Which activities are you having trouble completing right now?
How do you feel about not being able to dress yourself and make your own meals?
Which exercises do you find most helpful?
What goals for your activity would you like to set now?
•It is essential to have the patient’s evaluation of the plan of care. Were the goals met? Or is more work required?
•From your perspective as the nurse, you are to evaluate outcomes and response to nursing care and to compare the patient’s actual outcomes with outcomes selected during planning, such as his or her ability to maintain or improve body alignment, joint mobility, walking, moving, or transferring.
•Once these questions have been asked and you have addressed the limited mobility and its associated problems through the patient’s eyes, you are prepared to adjust the plan of care to address the remaining clinical problems that your patient is experiencing in relation to immobility.
[See Figure on text p for a critical thinking model for immobility evaluation.]

24. Safety Guidelines Communicate clearly. Mentally review transfer steps.
Assess patient mobility and strength.
Determine assistance needed.
Raise side rail on opposite side of bed.
Arrange equipment.
Evaluate body alignment.
Understand use of equipment.
Educate patient.
•Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with members of the health care team, access and incorporate the patient’s priorities of care and preferences, and use the best evidence when making decisions about your patient’s care. When performing the skills in this chapter, remember the following points to ensure safe, individualized patient-centered care:
•Mentally review the transfer steps before beginning the procedure; this ensures both the patient’s safety and your safety.
•Assess the patient’s mobility and strength to determine the assistance that he or she is able to offer during transfer. Stand on patient’s weak side when assisting.
•Determine the amount and type of assistance required for safe positioning and transfer, including the type of transfer equipment and the number of personnel needed to safely transfer patient while preventing harm to patient and health care providers.
•Raise the side rail on the side of the bed opposite to where you are standing to keep the patient from falling out of bed on that side.
•Arrange equipment (e.g., intravenous lines, feeding tube, Foley catheter) so it does not interfere with the positioning or transfer process.
•Evaluate the patient for correct body alignment and pressure risks after the transfer.
•Make sure that all personnel understand how equipment functions before it is used.
•Educate patients about how equipment functions to reduce their anxiety, and enlist their cooperation.