A MERLIN Site



Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
Back to 5th edition


Physical Mobility, Impaired - Immobility
Linda Arsenault, RN, MSN, CNRN
Marilyn Magafas, RN,C, BSN, MBA
Meg Gulanick, PhD, RN

NANDA: A state in which the individual experiences a limitation of ability for independent physical movement

Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility, as seen in strokes, leg fracture, trauma, morbid obesity, multiple sclerosis, and others. With the longer life expectancy for most Americans, the incidence of disease and disability continues to grow. And with shorter hospital stays, patients are being transferred to rehabilitation facilities or sent home for physical therapy in the home environment.

Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, joints becoming stiffer and less mobile, and gait changes affecting balance can significantly compromise the mobility of elder patients. Mobility is paramount if elder patients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Elderly patients are also at increased risk for the complications of immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, and ensure a safe environment.

Related Factors

Defining Characteristics

Expected Outcomes

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Assess for impediments to mobility (see Related Factors of this care plan).
Identifying the specific cause (e.g., chronic arthritis versus stroke versus chronic neurological disease) guides design of optimal treatment plan.
(i) Assess patient's ability to perform ADLs effectively and safely on a daily basis.
Restricted movement affects the ability to perform most ADLs. Safety with ambulation is an important concern.
Suggested Code for Functional Level Classification*
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 or device
4 Is dependent, does not participate in activity
*Code adapted by North American Nursing Diagnosis Association: Taxonomy I (Rev. 1990), St. Louis: NANDA. From Jones E et al: Patient classification for long-term care: users' manual, Pub. No. HRA-74-3107, November 1974, HEW.
(i) Assess patient or caregivers knowledge of immobility and its implications.
Even patients who are temporarily immobile are at risk for some of the effects of immobility, such as skin breakdown, muscle weakness, thrombophlebitis, constipation, pneumonia, and depression).
(i) Assess for developing thrombophlebitis (calf pain, Homans' sign, redness, localized swelling, and rise in temperature).
Bed rest or immobility promotes clot formation.
(i) Assess skin integrity. Check for signs of redness, tissue ischemia (especially over ears, shoulders, elbows, sacrum, hips, heels, ankles, and toes).
(i) Monitor input and output record and nutritional pattern. Assess nutritional needs as they relate to immobility (possible hypocalcemia, negative nitrogen balance).
Pressure sores develop more quickly in patients with a nutritional deficit. Proper nutrition also provides needed energy for participating in an exercise or rehabilitative program.
(i) Assess elimination status (usual pattern, present patterns, signs of constipation).
Immobility promotes constipation.
(i) Assess emotional response to disability or limitation.
(i) Evaluate need for home assistance (physical therapy, visiting nurse).
(i) Evaluate need for assistive devices.
Proper use of wheelchairs, canes, transfer bars, and other assistance can promote activity and reduce danger of falls.
(i) Evaluate the safety of the immediate environment.
Obstacles such as throw rugs, children's toys, pets, and others can further impede one's ability to ambulate safely.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Encourage and facilitate early ambulation and other ADLs when possible. Assist with each initial change: dangling, sitting in chair, ambulation.
The longer the patient remains immobile the greater the level of debilitation that will occur.
(i) Facilitate transfer training by using appropriate assistance of persons or devices when transferring patients to bed, chair, or stretcher.
(i) Encourage appropriate use of assistive devices in the home setting.
Mobility aids can increase level of mobility.
(i) Provide positive reinforcement during activity.
Patients may be reluctant to move or initiate new activity from a fear of falling.
(i) Allow patient to perform tasks at his or her own rate. Do not rush patient. Encourage independent activity as able and safe.
Hospital workers and family caregivers are often in a hurry and do more for patients than needed, thereby slowing patient's recovery and reducing his or her self-esteem.
(i) Keep side rails up and bed in low position.
To promote safe environment.
(i) Turn and position every 2 hours, or as needed.
To optimize circulation to all tissues and to relieve pressure.
(i) Maintain limbs in functional alignment (e.g., with pillows, sandbags, wedges, or prefabricated splints).
To prevent footdrop and/or excessive plantar flexion or tightness.
Support feet in dorsiflexed position
Use bed cradle
To keep heavy bed linens off feet.
(i) Perform passive or active assistive ROM exercises to all extremities
To promote increased venous return, prevent stiffness, and maintain muscle strength and endurance.
(i) Promote resistance training services.
Research supports that strength training and other forms of exercise in older adults can preserve the ability to maintain independent living status and reduce risk of falling.
(i) Turn patient to prone or semiprone position once daily unless contraindicated.
To drain bronchial tree.
(i) Use prophylactic antipressure devices as appropriate
To prevent tissue breakdown.
(i) Clean, dry, and moisturize skin as needed.
(i) Encourage coughing and deep-breathing exercises. Use suction as needed.
To prevent buildup of secretions.
Use incentive spirometer to increase lung expansion.
Decreased chest excursions, and stasis of secretions are associated with immobility.
(i) Encourage liquid intake of 2000 to 3000 ml per day unless contraindicated.
To optimize hydration status and prevent hardening of stool.
(i) Initiate supplemental high-protein feedings as appropriate.
Proper nutrition is required to maintain adequate energy level.
If impairment results from obesity, initiate nutritional counseling as indicated.
(c) Set up a bowel program (adequate fluid, foods high in bulk, physical activity, stool softeners, laxatives) as needed. Record bowel activity level.
(c) Administer medications as appropriate.
Antispasmotic medications may reduce muscle spasms or spasticity that interfere with mobility.
(i) Teach energy saving techniques.
To optimize patient's limited reserves.
(i) Assist patient in accepting limitations. Emphasize abilities.

Education/Continuity of Care

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Explain progressive activity to patient. Help patient or caregivers to establish reasonable and obtainable goals.
(i) Instruct patient or caregivers regarding hazards of immobility. Emphasize importance of position change, ROM, coughing, exercises, and others.
(i) Reinforce principles of progressive exercise, emphasizing that joints are to be exercised to the point of pain, not beyond.
No pain, no gain is not always true!
(i) Instruct patient/family regarding need to make home environment safe.
A safe environment is a prerequisite to improved mobility.
(c) Refer to multidisciplinary health team as appropriate.
Physical therapists can provide specialized services
(i) Encourage verbalization of feelings, strengths, weaknesses, and concerns.

NIC

Exercise Therapy: Ambulation; Joint Mobility; Fall Precautions; Positioning; Bed Rest Care

~ Care Plan Index ~ Outcomes Index ~
~ Care Plan Constructor Home ~