Immobility

Definition:
Mobility is freedom and independence in purposeful movement.
Mobility refers to adapting to and having self-awareness of the
environment. Functional musculoskeletal and nervous systems are
essential for mobility.
Body part is for use "if you don't use it, you'll lose it."

Immobility is a state in which the individual experiences or is at

risk of experiencing limitation of physical movement.

Patterns of immobility: it may be

 Temporary, such as following knee arthroplasty.
 Permanent, such as paraplegia.
 Sudden onset, such as a fractured arm and leg following a
motor-vehicle crash.
 Slow onset, such as multiple sclerosis.
Causes of immobility:
•Physical:
- Musculoskeletal disorders: Arthritis‘, Osteoporosis, Fractures
(especially hip and femur), Podiatric problems, Other (e.g., Paget's
disease)
- Neurological disorders: Stroke, Parkinson's disease

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- Cardiovascular disease: Congestive heart failure (severe),
Coronary artery disease (frequent angina), Peripheral vascular
disease (frequent claudication)
- Pulmonary disease: Chronic obstructive lung disease (severe)
- Acute and chronic pain
- Sensory factors Impairment of vision
• Psychological:
- Fear (from instability and fear of falling)
- Depression
•Environmental:
- Forced immobility (in hospitals and nursing homes)
- Inadequate aids for mobility.
- Poor lightening.
EFFECTS OF IMMOBILITY ON BODY SYSTEMS:
Immobilization for periods greater than 48 to 72 hours will result
in changes in all body system.
Factors affecting the severity of physical impairment due to
immobility:
 Degree of immobility experienced.
 Length of time of immobilization.
 Overall health status
 Age.

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System Changes
Skin •Skin breakdown
•Pressure ulcer
•Shearing or friction
Musculoskeletal •Muscle atrophy: begins after 1 day of immobilization
by1-3%/day Muscles may lose half of their bulk after 2
months..
• osteoporosis: Lack of stress on the bone causes an
increase in calcium absorption, weakening the bone.
• Contractures: Decreased joint movement leads to
permanent shortening of muscle tissue, resistant to
stretching due to disuse.
Joint stiffness and pain:-if joints are not given adequate
full range of motion. The stiffness is due to tightness of the
muscles and tissues surrounding the joints.
• Foot drop
-Proper dorsiflexion of the ankle is lost and permanent
plantar flexion of the foot develops
-Occurs when toes are allowed to fall toward the foot of the
bed
Genitourinary Decreased voiding (stasis) which leads to:
• Urinary retention: due to decreased bladder muscle tone.
•Increased risk of UTI
•Renal calculi

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Cardiovascular Venous thrombosis, embolism due to:
• venous stasis + increased blood coagulability+ decreased
plasma volume
Orthostatic hypotension (begins after 3 weeks of bed rest
) due to:
1. Excessive pooling of blood in the lower extremities
2. Decreased circulating blood volume
3•20 days of bed rest may lead to a 25% decrease cardiac
out put
Gastrointestinal •Decreased peristalsis
•Constipation
•Distention
•Lack of appetite
Electrolyte Negative nitrogen balance
changes Hypercalcemia “ Ca”: Symptoms may occur within 2–4
weeks. Symptoms of hypercalcemia include anorexia,
abdominal pain, nausea, malaise, headache, polydipsia,
polyuria, lethargy,and coma
Metabolism Decreased basal metabolic rate  Glucose intolerance
Hormonal • Secretion of: aldosterone
• Secretion of: parathyroid, growth hormone, androgen
“spermatogenesis”
Respiratory Risk for Hypostatic pneumonia and atelectasis due to:
•↓ depth of respirations,↓ respiratory capacity, ↓ability to

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 clear secretions (cough reflex) and ↑respiratory rate
•Accumulation of secretions in the lower bronchial tree →
which can block airways
Neurological • 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.
Psychological 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.

Care of immobilized patient

Immobility often cannot be prevented, but many of its adverse
effects can be. Nursing interventions are designed to maintain
mobility and prevent or minimize complications of immobility.

General nursing cues for immobility:

1. Focus on abilities and not disabilities: the use of assistive
devices and making the home accessible.

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2. Assessment of the client focuses on mobility, range of
motion (ROM), gait, exercise status, activity tolerance, and
body alignment while standing, sitting, and lying.
3. Coetaneous stimulation in the form of cold and heat
applications helps relieve pain and promote healing.
4. Promoting venous return is another key component of
reducing the complications of immobility.
5. The principles of body mechanics are based on alignment,
balance, gravity, and friction.
6. Enhance independency with continuous exercises.
7. Use of lifting equipment (Sit-to-stand lifts, hydraulic lifts,
battery-powered lifts) and moving Devices is highly
recommended
8. The patient/significant other should be involved.

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Application of Heat and Cold
Therapeutic effects of heat and cold applications:
Heat Cold
• Increases blood flow • Decreases inflammation
• Increases tissue metabolism • Prevents swelling
• Relaxes muscles • Reduces bleeding
• Eases joint stiffness and pain • Reduces fever
• Diminishes muscle spasms
• Decreases pain by decreasing
the velocity of nerve conduction

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The purposes of exercise for the immobile patient:
1- To maintain joint mobility is done by putting each of the patient's
joints through all possible movements to increase and/or maintain
movement in each joint.
2- To prevent contracture, atony (insufficient muscular tone), and
atrophy of muscles.
3- To stimulate circulation, preventing thrombus and embolus
formation.
4- To improve coordination.
5- To increase tolerance for more activity.
6- To maintain and build muscle strength.
Specific nursing interventions:
Integumentary system:
Assessment - assess risk factors for alteration in skin integrity on
admission
-The patient at risk will be reassessed for alteration in skin integrity
and circulatory impairment each shift (8-12 hours).
-Observe for urinary or bowel incontinence.
Goals: Maintain intact skin / ulcer prevention
Intervention
1. Pressure reduction measures such as heel/elbow pads/ Air
mattress, specialty beds and/or skin care will be utilized, as
appropriate and as ordered.

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2. Pressure devices such as foam or pillows may be placed
between bony prominences to prevent direct contact.
3. change positions at least every two hours
4. Provide skin and perineal care and keep skin dry and clean
5. Use mild soaps for cleansing skin
6. Provide adequate nutrition
7. Inspect bony prominences for redness every 2 hours and
massage area around redness
8. no bed wrinkles

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Musculoskeletal:
Assessment:
•Assess ROM capability, muscle tone & mass, contractures.
• Monitor gait, nutritional intake, use of assistive devices to assist
with ADLs.
Goals –
-Maintain or regain body alignment and stability, decrease skin and
musculoskeletal system changes, achieve full or optimal ROM, and
prevent contractures.
Intervention:
For contracture prevention
1. Do stretching and range-of-motion exercises to each of the joints
every day, and several times a day (active better than passive).
2. Maintain proper body alignment, therapeutic splints.
3. Pain control, treatment of spasticity
4. Apply any supportive or therapeutic devices for maintaining
body alignment
5. Assist with ambulation as soon as orders permit
To prevent Foot drop:
Don’t permit toes to fall toward the foot of the bed
Maintain body alignment:
1. Keep head, trunk, and hips in straight line

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2. Prevent the legs from rotating in the hip socket medially or
laterally—position legs so toes always point in same direction as
anterior side of the body
3. Maintain arms in correct alignment with shoulders—no slumping

Cardiovascular
Assessment:
-Assess for: BP symptoms, apical and peripheral pulses,
dependant edema, and skin for warmth in peripheral areas
-Compare circumference of both calves and thighs
Goals
- Maintain cardiovascular function, increase activity tolerance, and
prevent thrombus formation.
Intervention:
1. Encourage movement of extremities
2. Apply ordered devices to prevent pooling of blood in legs
such as

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 *Elastic Stockings.
*Intermittent Sequential Compression Device.
*Intermittent pneumatic compression.
3. Gradually move patient from lying to sitting or standing
position, advice for isometric exercises
4. Change patient position frequently
5. Remain with patient first few times getting out of bed and
dangling
6. Increase fluid intake if not contraindicated.
7. Teach the client to avoid placing pillows under the knees or
lower extremities, crossing the legs, wearing tight clothes
around the waist or on the legs, sitting for long periods of
time, and massaging the legs.
8. Teach the client to avoid the Valsalva maneuver.
9. Neurovascular check every shift
10.Remove stockings per day and Cleanse skin & Assess skin

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Respiratory:
Assessment: Assess the following/ 2hrs: symmetry of chest wall
movement, breath Sounds and the color, amount, and consistency
of cough secretions.
Goals- Maintain airway patency, achieve optimal lung expansion
and gas exchange, and mobilize airway secretions.
Intervention:
1. Reposition the client every 1 to 2 hr.
2. Teach the client to turn, cough, and deep breathe every 1 to 2
hr while awake.
3. Teach the client to yawn every hr while awake.
4. Teach the client to use an incentive spirometer while awake.
5. Remove abdominal binders every 2 hr, and ensure their
correct placement.
6. Use chest physiotherapy.
7. Auscultate the lungs to determine the effectiveness of chest
physiotherapy or other respiratory therapy.
8. Teach the client to consume at least 2,000 mL of fluid per
day, unless the client’s intake is restricted.
9. Monitor the client’s ability to expectorate secretions.
10.Use suction if the client is unable to expectorate secretions.
Methods of Airway Secretions Elimination:
1. Oral, nasal, or transtracheal suctioning
2. Chest percussion and postural drainage

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 3. Flutter mucus clearance devices
4. Mechanical vibration devices to the chest wall
5. Maintain an adequate fluid intake

Metabolic
Assessment: Assess I&O., feeding status and wound healing.
Goals-Reduce skin injury and maintain metabolism.
Intervention:
1. Inquire about food likes and dislikes and plan balanced meals

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 2. Provide a high-calorie and high-protein diet with vitamin B
and C supplements.
3. Monitor and evaluate oral intake. If the client cannot eat or
drink, enteral or parenteral nutritional therapy may be
indicated.
Elimination
Assessment:
-Assess I&O, bladder distention, urine characteristics, bowel
sounds and feces characteristics.
Goals-
Maintain or achieve normal urinary and bowel elimination patterns.
Intervention:
1. Maintain hydration (at least 2,000 mL/day unless fluid is
restricted.)
2. Teach the client to consume a diet that includes fruits and
vegetables, and is high in fiber.
3. Give a stool softener as prescribed and Consider laxatives
only as a last resort.
4. Provide perineal care.
5. Teach bladder and bowel training if needed.
6. Insert a straight or indwelling catheter as prescribed if the
bladder is distended.
7. Promote urination by pouring warm water over the perineal
area if the client has difficulty urinating.

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Psychological
Assessment: Assess emotional status, mental status, coping skills,
behavior decision-making skills and family support
• Monitor sleep/wake pattern, activities of daily living (ADLs) and
social activities.
Goals-Maintain an acceptable sleep/wake pattern, achieve
socialization, and complete self-care independently.
Intervention:
1. Maintain orientation to time (clock and calendar with date),
person (call by name and introduce self) and place (talk about
treatments, therapy, and length of stay).
2. Involve the client in daily care.
3. Help the client maintain body image by performing or assisting
with hygiene and grooming tasks such as shaving or applying
makeup.
4. Have nurses and other staff interact on an informal social basis.
5. Encourage patients to remain awake during day and do as much
for self as possible
6. Allow patient to express concerns
7. Encourage diversionary activities such as family and friends
visitation, TV, reading, etc.

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