MOBILITY AND
IMMOBILITY,
SKIN
INTEGRITY AND WOUND CARE
Movement is an activity most people take
for granted. The
ability to move and be active benefits health status, whereas immobility
presents a threat to one’s physical, mental, and social well-being. This chapter explores nursing
responses to individuals with impaired ability to move.
OVERVIEW OF MOBILITY
Mobility refers to the ability to engage in activity and free movement which
includes walking, running, sitting, standing, lifting, pushing, pulling, and
performing activities of daily living (ADLs).
Mobility is often considered an indicator of health status because it
influences the correct functioning of many body systems, especially the
respiratory, gastrointestinal, and urinary systems. Mobility enhances muscle
tone, increases energy levels, and is associated with psychological benefits
such as independence and freedom.
Body Alignment
Body alignment refers to the position of body parts in relation to each other. Proper
body alignment (also called posture) results in balance, which is an
individual’s ability to maintain equilibrium. When the body is in good posture,
the center of gravity (the center point of an object’s mass) is evenly
distributed over the foundation points. Good posture promotes balance, reduces
strain and injury to support structures, facilitates respiratory effort,
enhances gastrointestinal processes, and gives an appearance of confidence and
health. A correct postural stance is maintained by a well-functioning
musculoskeletal system. The normal alignment of the spine has a cervical
concavity, a thoracic convexity, and a lumbar concavity.
Proper standing body alignment is characterized by the following:
• Head upright
• Face forward
• Shoulders squared
• Back straight
• Abdominal muscles tucked in
• Arms straight at side
• Hands palm forward
• Legs straight
• Feet forward
The sitting position in proper alignment has similar characteristics;
however, the hips and knees are flexed.
shows proper alignment and posture for the sitting position. Proper alignment
and posture of the client lying in bed appear similar to the standing position;
however, the client is supine.
The benefits of proper alignment and posture include
(1) client comfort;
(2) prevention of contractures;
(3) promotion of circulation;
(4) less stress on muscle, tendons, nerves, and
joints; and
(5) prevention of foot drop (plantar flexion).
In a person standing upright, the center of gravity is located in the
middle of the pelvis about halfway between the umbilicus and the symphysis pubis.
The base of support is the foundation on which a
person or object rests. Stability of one’s balance is promoted by a steady base
of support and a low center of gravity. Muscle tone and bone strength allow a
person to maintain an erect posture. Muscle contour is affected by the
individual’s exercise and activity patterns.Muscle
tone is the normal state of
balanced tension present in the body; it allows a muscle to respond quickly to
stimuli. Two aberrations of muscle tone includehypotonicity (flaccidity), which is a
decrease in muscle tone, and spasticity, which is an increase in muscle tension
and is often noted with extreme flexion or extension. Muscle shape should be
symmetrical. There may be hypertrophy (increased muscle size and shape due
to an increase in muscle fibers) or atrophy (a reduction in muscle size and
shape) which manifests as thin, flabby muscles with indistinct contour
Atrophy is usually a result of disuse, whereas hypertrophy occurs when
the muscle is overworked.
Body Mechanics
Functional mobility is governed by body
mechanics, the purposeful and coordinated use of body parts and positions
during activity. Use of proper body mechanics maximizes the effectiveness of
the efforts of the musculoskeletal and neurological systems and reduces the
body’s exposure to strain or injury during movement. Proper body mechanics are
as important to the nurse as to the client. The purpose of proper body
mechanics is prevention of strain and injury to the muscles, joints, and
tendons. Range of motion reflects the extent to which a
joint can move. The ranges vary with each joint and are affected by several
factors, including age, physical condition, and heredity. Parameters for range
of motion are outlined in Tables 34-1 and 34-2. The clinical application of
body mechanics is described later in the implementation section of this
chapter.
PHYSIOLOGY OF MOBILITY
Mobility is regulated by the coordinated effort of the musculoskeletal
and neurological systems. The major functions of the musculoskeletal system are
to maintain body alignment and to facilitate mobility. The musculoskeletal
system consists of a framework of bones, muscles, joints, tendons, ligaments, bursae, and
cartilage.
The Musculoskeletal System
Bone is the foundation of the musculoskeletal system. Mobility and
weight-bearing capacity are directly related to the bone’s size and shape.
Joints work with muscles to provide motion and flexibility. Skeletal muscles
overlying the joint exert opposing forces and, therefore, cause movement. Muscles
are basically machines that convert energy into mechanical work. Contractility
is the common property among the three types of muscles: smooth, cardiac, and
skeletal. Skeletal muscle fibers are innervated by somatic nerves, and,
therefore are generally under voluntary control. The muscles work in
cooperation with the nervous system to maintain body alignment and cause
movement. Muscles act in pairs to perform work. One muscle of the pair produces
movement in a single direction. The other muscle of the pair produces movement
in the opposite direction. When one muscle of the pair is contracted, the other
is relaxed. The opposing actions of contraction and relaxation make motion
possible. The position of the tendons upon the bones and the articulation of the
bones make possible types of motion such as flexion, extension,circumduction, rotation, and gliding. Muscles that
maintain body alignment work together to stabilize surrounding body parts and
to support the body’s weight. Posture is maintained primarily by the muscles in
the back, neck, trunk, and lower extremities.
Nervous System
Muscle contraction is controlled by the central nervous system (CNS) and
is influenced by the transport of nutrients and oxygen and by the removal of
waste products. An intact CNS is essential for coordinated movement to occur.
Nerve impulses stimulate the muscles to contract. The myoneuronal junction is the point at which nerve
endings come into contact with muscle cells. The afferent pathway conveys
information from sensory receptors to the CNS; these neurons conduct impulses
throughout the body. The CNS processes the sensory input and determines a
response. The efferent pathway transmits the desired response to skeletal
muscles via the somatic nervous system. If the nerve impulses are interrupted,
the muscle is paralyzed and cannot contract.
Proprioception
Proprioception is the awareness of posture, movement, and changes in equilibrium and
the knowledge of posi-tion, weight, and resistance of objects in relation to
the body. Nerve endings in muscles, tendons, and joints (proprioceptors)
continuously provide input to the brain, which, in turn, regulates smooth
coordinated involuntary movement.
Postural Reflexes
Postural tonus is maintained by postural or righting reflexes.
EXERCISE
Exercise is any physical activity involving muscles that elevates the
heart rate above resting levels. Exercise reduces joint pain and stiffness, and
increases flexibility, muscle strength, and endurance. It also helps with
weight reduction and contributes to an improved sense of well-being (National
Institute of Arthritis and Musculoskeletal and Skin Diseases, 1997). Americans
have become less active in recent years (Bray, 1998). The U.S. Surgeon
General’s Report on Physical Health and Activity (Centers for Disease Control
and Prevention, 1999) lists the following facts about exercise:
• People who are usually inactive can improve their health and well-being
by becoming even moderately active on a regular basis.
• Physical activity need not be strenuous to achieve health benefits.
• Greater health benefits can be achieved by increasing the amount
(duration, frequency, or intensity) of physical activity.
Table 20-9 in Chapter 20
describes the physiologic benefits of exercise. Vigorous exercise stimulates an
increased production of endorphins, which promote a sense of wellbeing.
However, it is important to caution people not to overdo the exercise,
especially when first starting a new regimen. The following may be signs of too
much exercise: unusual or persistent fatigue, increased weakness, decreased
range of motion, joint swelling, or continuing pain (pain that lasts more than
1 hour after exercising) (National Institute of Arthritis and Musculoskeletal
System, 1997). Instruct clients, especially those with sedentary lifestyles, to
consult their nurse practitioner or physician before beginning an exercise
program.
Types of Exercise
There are several types of exercise that promote physical and psychologic health.
Range-of-Motion Exercise Active range-of-motion (ROM) activities are performed independently by the client. During
active ROM exercises, the client moves various muscle groups. Passive ROM exercises are done by the nurse to
help maintain or restore a client’s mobility by achieving several outcomes; see
the accompanying display.
Physical Fitness
The ultimate outcome of regular physical activity is physical fitness
that affects an individual’s functional ability. There are four components of
physical fitness: endurance and strength, joint flexibility, cardiorespiratory fitness, and body composition.
Endurance and Strength
Endurance is the ability to withstand movement in terms of duration and
absence of fatigue. A physically fit individual has adequate muscular strength
and endurance to accomplish one’s goals. Muscle strength is the amount of force
exerted by the muscles against resistance. Good muscle strength allows an
individual to lift more safely.
Joint Flexibility
The ability to use a muscle through its complete range of motion is referred to as flexibility for a complete description of joint
movement. People with limited flexibility are likely to experience shortened
muscles and tendons with resultant imbalance in muscle strength and joint
injury. Flexibility can be improved by stretching exercises such as yoga, tai
chi, and dancing. Performance of ADLs also
helps maintain flexibility. Walking, stooping, and lifting activities can
promote and maintain flexibility.
Cardiorespiratory Fitness
To improve cardiorespiratory function,
physical activity must be maintained for at least 20 minutes in order to raise
the heart rate to the target level.
Body Composition
The recommended proportion of fat to lean body tissue is referred to as
body composition. Having a body that falls within the normal range of body
weight and percentage of body fat depends on balancing caloric intake and
expenditure. Any type of physical activity can be useful in developing and
maintaining physical fitness.
Fitness in Older Adults
Approximately 33% of those ages 65 and older fall each year (Lamb &
Cummings, 2000). “No one is too old to enjoy the benefits of regular physical
activity. Of special interest to older adults is evidence that
muscle-strengthening exercises can reduce the risk of fall and fracturing bones
and improve the ability to live independently” (Centers for Disease Control
& Prevention, 1999, p. 5). The accompanying display lists benefits of
physical exercise in older adults.
FACTORS AFFECTING MOBILITY
Mobility and activity level can be influenced by many factors, including
overall health status, developmental stage, environment, attitudes, beliefs,
and lifestyle.
Health Status
An individual’s general health status will influence desire for exercise
and activity tolerance. Compromised status of any of the body systems may
affect an individual’s mobility and may, in turn, be affected by a lack of
activity. Physical conditioning will also influence mobility and stamina.
Physical factors interfering with mobility or exercise include fatigue, muscle
cramping, dyspnea,
neuromuscular or perceptual deficits, and chest pain. Mental status is often
manifested as changes in mobility or appearance. For instance, a client who
shuffles into the room, slumps down into a chair, and avoids eye contact may be
sending a message of depression through low activity levels, poor posture, and
a flattened affect.
Developmental Stage An
individual’s developmental stage will affect the parameters of targeted
mobility levels.
Children
Developmental norms related to mobility have been established for the
infant and toddler. Childhood development is monitored through achievement of
milestones such as sitting, crawling, walking, running, and hopping. For infants, the mobility focus is
on gross motor behavior such as posture, head balance, grasping, sitting,
creeping, and standing. Toddlers are more active, with walking,
running, jumping, kicking, and going up and down stairs. Activity and mobility
parameters for the toddler encompass gross and fine motor behaviors, manual
dexterity, and exploration within environmental safety parameters. The preschooler increases strength and refines
skills by walking, running, and jumping. During middle childhood (from 6 to 12 years of age)
children have improved posture and locomotion abilities and increased muscle
efficiency of the extremities and trunk; these children also have an increase
in muscle tissue with a decrease of fat. For both preschool and middle
childhood, activity and mobility expectations are centered on development of
strength, coordination, and physical capacities.
Adolescents
The adolescent years (approximately ages 12 to
18) begin with onset of puberty and end with cessation of somatic growth.
Changes are dramatic at this stage, with physical growth and development of
secondary sex characteristics. Activity and mobility landmarks are development
of muscles plus cardiac, respiratory, and metabolic functions through physical
conditioning.
Adults
Adulthood is divided into young, middle, and elderly age groups.
The young adult has well-developed myoskeletal and nervous systems which ideally
function at peak efficiency.
The middle-aged adult has a gradual decrease in muscle
mass, strength, and agility. The focus of activity and mobility for both these
groups is on maintaining or developing tone, strength, and coordination of the
musculoskeletal system.
Older adults often have progressive changes in the physiological systems. The rate of
bone reabsorption (which affects bone density) increases
with aging. Bone density loss accelerates in postmenopausal females due to
estrogen deficiency. Decreased bone density makes a person more vulnerable to
fractures, kyphosis,
and a reduction in height. Aging also negatively impacts muscles and connective
tissue. The development of muscle atrophy is a gradual process in which muscle
fibers deteriorate and are replaced by fibrous connective tissue. Muscle
atrophy is accompanied by reduced muscle mass, a loss of muscle strength, and a
reduction in overall body mass. The degree of muscle atrophy will be affected
by the person’s activity level. Staying physically active helps prevent disuse
muscle atrophy and helps maximize muscle strength. Cartilage ages better than
bone or muscle; however, some changes occur that do
affect joint flexibility. Aging leads to a loss of water content of hyaline
cartilage and a reduction in the ability of cartilage to regenerate following
trauma. Articulating cartilage may slightly deteriorate as a result of lifetime
wear and tear. Aging also affects the health of intervertebral disks. For example, the water content
of the disks decreases which leads to less vertebral flexibility. Thinning of
the disks causes older individuals to be more vulnerable to back pain and
injury. As a result of the age-related physical changes, older people often experience
some functional alterations in mobility. Ambulation may be altered as a result
of joint inflexibility and decreased muscle strength; such alterations are
noticed as a reduction in step height and length as demonstrated in a shuffling
gait. Vertebral inflexibility and reduced muscle strength may cause difficulty
with client transfers in and out of a sitting position. The elderly client may
need assistance in rising from a chair, ambulating, or climbing stairs
Environment
Environment can influence activity level in several ways. Home
environments, for instance, can be considered safe and “mobility friendly” if
they are free of hazards that can disrupt or endanger mobility and activity
(see the accompanying display). Work environments can also affect mobility;
repetitive handwork, such askeystroking or sewing, can impair mobility and
worsen arthritis. A sedentary lifestyle can lead to muscle atrophy, weakened
bones, and a lack of motivation and energy to engage in physical activity.
Attitudes and Beliefs
Influential factors related to exercise are one’s attitudes and beliefs,
which are greatly affected by culture and family. Leisure activities provide a
clue to the person’s value system.
Individuals who engage in hiking, bicycle riding, or swimming for recreation
value an active lifestyle. On the other hand, individuals who consider work to
be the dominant area of life may view exercise as “a waste of time.” Does the
individual go everywhere in a car, or is walking a part of normal
transportation? Are elevators routinely used instead of climbing stairs?
Activities enjoyed by the individual are less likely to produce fatigue than
are activities that hold no interest for the person. Thus, preferences should
be matched with capabilities when planning an exercise program.
Lifestyle
Modern lifestyles require little physical activity; thus, few adults in
PHYSIOLOGICAL EFFECTS OF MOBILITY AND IMMOBILITY
Maintaining functional mobility and desired activity levels is important
for both psychological and physiological reasons. Mobility and lack thereof
will both affect the various systems of the body.
summarizes the major complications associated with immobility.
Neurological Effects/ Mental Status
As for mental status, mobility and activity can increase an individual’s
energy levels and sense of well-being. Activity and exercise are excellent
means to relieve tension and reduce stress, which result in better sleep
patterns and an enhanced sense of well-being. Client inactivity and immobility
are stressors that can lead to frustration, lower self-esteem, anxiety,
helplessness, depression, general dissatisfaction, restlessness, unhappiness,
and decreased competency self-rating. Immobility impacts cognitive abilities,
affect, lifestyle, and social and family responsibilities. The fear of falls,
pain, and sensory deficits such as visual problems, fatigue, and weakness are
compounding factors that increase inactivity and immobility.
Cardiovascular Effects
The cardiovascular system reaps many benefits from mobility and
exercise. The heart becomes more efficient as it adapts to increased demands
for oxygen, and cardiac output increases. A healthy heart muscle leads to a
decreased resting heart rate and decreased resting blood pressure, which mean
that the heart does not have to work as hard in an individual who exercises
regularly as it does in an individual who leads a sedentary lifestyle. Activity
increases the oxygen supply to the heart and muscles and thereby benefits
overall health. Immobility increases the workload on the heart as the supine
position increases the volume of blood circulating to the heart. This fluid
shift increases central venous pressure along with left ventricular diastolic
volume and stroke volume, and the cardiac workload increases. The
cardiovascular system is prone to form thrombi,
or blood clots, due to venous stasis related to lack of muscle contractions of
the legs and pressure on veins, especially the poplitealareas Thrombi are caused by increased coagulation
of the blood due to free calcium from bone demineralization, stasis of venous
blood, and intimal damage to veins (as from venipuncture).
Another cardiovascular problem related to immobility is orthostatic hypotension, or a
decrease in blood pressure resulting from sudden position changes,caused by
decreased vessel tone. In orthostatic hypotension, the blood pressure
parameters drop at least 25 mm systolic and 10 mm diastolic with the postural changes.
Orthostatic hypotension is a result of several factors associated with
immobility, including:
• Decreased circulating fluid volume
• Decreased autonomic nervous system response
• Blood pooling in lower extremities
These factors lead to decreased venous return which negatively affects
cardiac output. Thus, the blood pressure is lowered. Orthostatic hypotension is
an indication that the heart is working harder and less efficiently. Clients
who have experienced immobility (such as with bed rest) need to have blood
pressure checked lying down, sitting, then standing. This is done to establish
baseline parameters to assist in determining the presence of postural-related
changes in blood pressure.
Respiratory Effects
The respiratory system response to activity and mobility is increased
intake of oxygen, which results in increased overall respiratory capacity and
an easing in the work of breathing. The effects of oxygenation to the tissues
are enhanced and pooling of secretions in the bronchioles is less likely.
Immobility from sitting or lying limits chest expansion, which is compounded by
the effects of respiratory muscle atrophy and ineffective cough
Stasis of respiratory secretions can be worsened by the use of
CNS-depressant medications and dehydration, and can lead to hypostatic
pneumonia andatelectasis.
Musculoskeletal Effects
Musculoskeletal responses to activity are numerous, including stronger
and better-defined muscles, stronger bones, and increased mobility and range of
motion of the joints. Exercise can enhance endurance and tolerance of the
muscle groups. Weight-bearing exercises such as walking (as opposed to
swimming) are especially beneficial in preventing osteoporosis, or loss of
strength and minerals in the bones. Decreased physical mobility results in
gross musculoskeletal impairment, especially when muscular atrophy occurs.
Decreased mobilization alters muscle structure by reducing muscle mass and
decreasing muscle cell diameter and the actual number of muscle cells. Clients
experience rapid fatigue, decreased muscle strength and tone, decreased
endurance, decreased mobility of joints, muscle stiffness, joint contracture,
and negative nitrogen balance due to protein catabolism. Loss of calcium is a
response to immobility and indicates an imbalance between bone formation and
breakdown. The lack of pressure (e.g., weight bearing) on bones triggers
calcium loss. Bone demineralization occurs as early as 2 or 3 days after onset
of immobility and may lead to pathological fractures, renal calculi, and
osteoporosis.
Digestive Effects
Digestive responses to activity include increased appetite and thirst,
which indicate that the body’s rate of processing nutritional intake is
increased. Loss of appetite is commonly related to lack of activity, negative
nitrogen balance, and altered elimination patterns. Negative nitrogen balance
occurs when the nitrogen output exceeds nitrogen intake. The causes of negative
nitrogen balance include the increased need for protein in situations of
extensive tissue damage, such as following surgery, and extended immobility.
Extended periods of immobility cause muscle atrophy or muscle wasting; thus
there is a need for extra protein intake to provide for muscle repair.
Elimination Effects
Elimination patterns are facilitated by mobility in that retention of
wastes is usually prevented and the risk of constipation is reduced or avoided.
The muscles become stronger and more efficient, thus enhancing the overall
efficiency of elimination. Constipation and fecal impaction are frequent
complications of immobility. Variables contributing to these elimination
problems are:
• Lack of activity, which decreases peristalsis
• Lack of privacy
• Inability to sit upright
• Improper diet
• Inadequate fluid intake
• Use of some medications, especially narcotics
Urinary stasis and urinary infections are related to the recumbent
position of the immobile person. Decreased peristalsis of the ureters leads to stasis of urine, which is the
etiology of urinary calculi (stones) and infection. Bladder distention occurs
due to difficult relaxation of the external sphincter and decreased
intra-abdominal pressure, thus causing overflow incontinence (loss of bladder control) and
infection. The combination of increased urinary calcium, urinary stasis, and
urinary infection leads to calculi formation.
Integumentary Effects
The integumentary system benefits from activity and
exercise in that increased circulation and blood flow enhance oxygenation of
tissues, maintaining the turgorand luster of the skin and hair. Pressure ulcers are
serious problems related to immobility. Prolonged pressure, shearing force,
friction (rubbing), and moisture lead to tissue ischemia (impaired blood
circulation), causing skin breakdown and decubiti. Moisture in the form of urine, feces,
perspiration, and wound drainage can also lead to skin softening, which
increases decubiti risk. Secondary factors contributing
to pressure sore development are decreased nutrition, decreased arterial
pressure, increased age, and edema. Refer to Chapter 35 for a discussion of
pressure ulcers.
ASSESSMENT
During the assessment phase of the nursing process, data regarding
activity and mobility of the client are gathered. Assessment data are used to
initiate, individualize, plan, evaluate, and modify care on the basis of the
client’s strengths and limitations. Assessment of mobility status includes a
health history and physical examination.
Health History
Taking a client’s health history is the first step in determining the
mobility needs and concerns of a client. Basic information about ADL, exercise
patterns (type, frequency), lifestyle (active, sedentary), activity tolerance,
and use of medications should be discussed. If an alteration or recent change
in status is noted, then a detailed health history is in order. The nurse
should ask what impact the mobility impairment has had on the client’s ADL and
should have the client describe the exact nature of the problem (onset,
duration, associated factors, aggravating factors, alleviating factors). The
nurse should ask clients about the use (past and current) of medications, both
prescription and over-thecounter, with the
explanation that many drugs negatively affect the musculoskeletal system
It is also important to ask about the use of calcium supplements and
estrogen replacement medication.
Physical Examination
The physical examination of mobility status typically covers three basic
areas: musculoskeletal assessment, neurological assessment, and functional
assessment.
Musculoskeletal Assessment
The nurse observes musculoskeletal functioning during every interaction
with the client. Specific factors for objective assessment include the
following:
• Body alignment
• Body mechanics
• Posture (sitting and standing)
• Range of motion of joints
• Strength of muscles
• Endurance
• Muscle tone
• Size and contour of joints
• Inspection of the skin
• Palpation of skin, muscles, and joints
Subjective data include assessment of client’s pain, joint stiffness,
muscle cramping, fatigue, weakness, exercise habits, and environmental
variables. Children should be evaluated by comparing physical development and
abilities with normal values for the age. The elderly should be evaluated on
functional abilities, strengths, weaknesses, joint limitations, and use of
assistive devices such as canes or walkers to assist the client in ADLs. A
complete musculoskeletal assessment needs to include data related to client
weakness, stiffness, and pain related to movement. A 0–10 intensity scale can
be used to assess these subjective factors. When assessing weakness, zero
represents complete absence of weakness and 10 represents weakness requiring
complete bed rest. For determining stiffness, zero represents complete absence
of stiffness and 10 represents total inflexibility. See Chapter 32 for
directions on using the 1–10 scale for measuring pain intensity.
Movement and Gait
Gait, the way that one walks, is assessed to determine a baseline.
Normal gait is characterized by a smooth rhythmic movement of muscles when
walking. Step height and length are symmetrical for each foot and the arms
swing freely at each side of the torso in opposite movement of the legs.
Normally, the lower limbs are able to bear full body weight during standing and
ambulation. Gait is described in terms of smoothness, balance, arm movement,
effectiveness, and the length and width of the step.
Alignment
When assessing body alignment, the nurse seeks to determine whether the
movement results in fatigue, muscle stress, or strain. Structural deformities
may interfere with body alignment and functional ability
Endurance
When assessing a client’s endurance during physical activity, look for
reactions such as mood changes, indicators of pain, presence of fatigue, and
changes in respiratory and circulatory status. Oxygen consumption increases
during muscle activity, thus, assessment of vital signs is essential. The time
required for vital signs to return to the normal (baseline) resting values is a
significant factor to include in the assessment of mobility.
Pathological Alterations
Assessment to determine the presence of pathological alterations—such as
bone disorders, joint impairment, impaired muscle development, postural
abnormalities, musculoskeletal trauma, and neurological damage— can offer
important data for the determination of mobility limitations. Muscle
Impairments Overuse injuries are a common type of musculoskeletal problem,
especially in people who exercise too much and/or incorrectly.
Contractures A contracture develops when the muscle fibers become unable to flex
Each muscle has an antagonist that works in the opposite
direction. If a muscle group is not moved for a period of time or if proper
body alignment is not maintained, the stronger muscle will predominate, causing
contracture deformities. Once a contracture occurs, the only corrective action
is surgery to release the fibrous tissue. Prevention of contractures is a major
nursing focus with immobile clients. Nursing interventions to prevent a muscle
contracture include:
• Encouraging clients to be as active as possible
• Performing ROM exercises
• Positioning to maintain proper body alignment
• Repositioning every 2 hours or more often as needed
Musculoskeletal Trauma
Trauma to musculoskeletal tissues can result in many types of
impairments (such as those described in the display on overuse disorders).
Another common type of musculoskeletal trauma is a fracture (broken bone). The
second type of trauma discussed below is surgical amputation.
Fractures
According to Lamb and Cummings (2000), hip fractures are the most
disabling for older people. Hip fractures are usually a result of falls and
approximately 24% of those with hip fracture die from complications within 1
year after the injury. Hip fracture complications result from immobility and
include pressure ulcers, pneumonia, and sepsis from urinary tract infections.
When a fracture is suspected, the nurse should assess the area for mobility,
pain, color, temperature, pulse, and sensation. Amputation Any
condition in which circulation is inadequate to maintain cellular function can
necessitate amputation. For example, lower limb amputations are often required
as a result of infection, peripheral vascular disease (PVD), neoplasm, and
trauma. Pressure ulcers, if inadequately treated, can also lead to the loss of
a limb. When the decubiti do
not heal, infection and gangrene develop. Gangrene first manifests as a
blackened area and is often accompanied by pain. Lower limb amputation is
either above the knee or below the knee; the level of amputation depends on the
extent of the disease process. Below-the-knee amputation is the most commonly
performed type. The goal of the surgery is to preserve the length of the
extremity in order to assist with prosthetic fitting. Therefore, as much limb
as possible is salvaged.
Central Nervous System Damage
As movement is a result of coordination between muscles and nerves, an
intact central nervous system is necessary for mobility. Any disruption in the
CNS, such as those occurring with spinal cord injury, can impair mobility.
Spinal cord injury can lead to partial paralysis or complete loss of mobility.
Spinal Cord Injury
There are 15,000 to 20,000 traumatic spinal cord injuries each year in
the
Neurological Assessment
An intact neurological system is essential for activity and mobility.
Objective neurological assessment includes
(1) cranial nerves,
(2) motor system,
(3) sensory system, and
(4) reflexes.
The nurse assesses the motor system for the following variables:
• Size, strength, and tone of muscles
• Presence of involuntary movements
• Balance
• Gait
• Coordination
• Proprioception
• Fine motor function
• Gross motor function
The sensory system is assessed for integrity of peripheral nerves, pain,
tactile discrimination (fine touch), and sensation of vibration. Assessment of
deep tendon or stretch reflexes focuses on the biceps, triceps, brachioradialis,
quadriceps, and Achilles reflexes.
Functional Assessment
Functional assessment focuses on the client’s abilities to perform ADL. The client’s
functional status is assessed in terms of the ability to feed, dress, toilet,
move, transfer, and ambulate self independently or with some degree of required
assistance
Functional assessment data are used for initial planning, for discharge
planning, for planning continuity of care in a nursing home or private home,
and to provide baseline and ongoing data for rehabilitation. Clients at
high-risk for falls include those with prolonged hospitalization, those taking
sedatives or tranquilizers, confused clients, or those with a history of
physical restraint use.
A great majority of falls:
• Occur in the evening
• Occur in the client’s room
• Involve wheelchairs
• Involve unattended clients
• Involve clients with poor footwear
• Occur with poor lighting
• Involve clients with poor vision
• Occur with clients experiencing neuromuscular impairment
Awareness of these risk factors for falls allows the nurse to prevent
many client injuries. The nurse continually evaluates the client’s strength and
endurance during the entire ambulation process. The Risk Assessment Tool (RAT)
for falls was developed to identify clients at high risk for falls and to
individualize care (Brians, Alexander, Grota, Chen,
& Dumas, 1991). See the accompanying Nursing Checklist for the RAT and
Chapter 31 for further discussion of fall prevention.
NURSING DIAGNOSIS
Nursing diagnoses related to mobility focus primarily on activity and
mobility levels, and the psychosocial impact that alterations in mobility can
have on a client and the client’s family. Common NANDA nursing diagnoses
related to the physical adaptations or risks resulting from altered mobility
include:
• Activity Intolerance related to bed rest and immobility, generalized weakness, sedentary
lifestyle, and imbalance between oxygen supply and demand; see the Nursing
Process Highlight.
• Impaired Physical Mobility related to intolerance to activity or decreased strength and endurance,
pain, perceptual or cognitive impairment, neuromuscular impairment,
musculoskeletal impairment, and depression or severe anxiety; see the Nursing
Process Highlight.
• Risk for Disuse Syndrome per risk factors of paralysis, mechanical immobilization, prescribed
immobilization, and severe pain
• Self-Care Deficits related to inability to wash body or body parts, inability to obtain or
get to water source, activity intolerance, decreased strength and endurance,
pain, and impaired transfer ability
• Ineffective Health Maintenance related to lack of or significant alteration in communication skills
(written, nonverbal)
• Risk for Falls related to impaired mobility.
Alterations in family and social processes may also result from
immobility and inactivity. Disruption in activity and mobility leads to
impairment of the ability to perform one’s usual social, vocational,
educational, and family roles. There are often changes in the client’s
perception of role.
Disturbed Body Image and Situational Low
Self-Esteem can result from:
1. Changes in physical abilities
2. Changes in family responsibilities
3. Lack of knowledge regarding rehabilitation
4. Denial of abilities and strengths
5. Social insecurity
6. Feelings of worthlessness, hopelessness, or depression
PLANNING AND OUTCOME IDENTIFICATION
In the development of outcomes for clients with mobility needs, client
involvement is essential. Realistic outcomes can be targeted by considering the
client’s
(1) understanding of mobility status;
(2) values,
thoughts, and concerns regarding mobility problems;
(3) general health status; and
(4) ability to solve problems.
The goal of the interdisciplinary health team during acute
hospitalization and rehabilitation is to restore function, thus maximizing the
level of the client’s independence. Maximal independence includes the ability
to function in ADL (eating, dressing, bathing, and moving).
• Eating (e.g., plate guards and hand splints to hold utensils)
• Bathing (e.g., shower chairs and long-handled sponges)
• Dressing (e.g., Velcro closures and zipper pulls)
• Toileting (e.g., elevated toilet seats)
• Mobility (e.g., walkers)
Continued practice in self-care activities with adaptive devices
promotes confidence. Interdisciplinary cooperation can be used to plan
modifications for the home for activity and mobility, especially in the
bathroom and kitchen. Physical modifications with adaptive equipment in home
environments maximize client activity and mobility.
Bed Rest
Bed rest is a therapeutic intervention that achieves several objectives,
including the following:
• Provide rest for clients who are exhausted.
• Decrease the body’s oxygen consumption.
• Reduce pain and discomfort.
The planned duration of bed rest depends on the client’s physical
condition and ability to move. Even though implemented for therapeutic reasons,
bed rest can be counterproductive to a client’s recovery. The inactivity
imposed by bed rest causes structural changes in joints and shortens muscles.
Such changes, which may lead to decreased range of motion and contractures, can
occur within 48 hours of bed rest (Lamb & Cummings, 2000). To prevent such
complications, bed rest should be avoided as much as possible. For clients
whose medical condition necessitates bed rest, range-of-motion exercises must
be implemented. When planning care, it is important to “prevent immobility if
possible; approximately 7 days are needed for the client to regain the function
lost during 1 day of bedrest” (Eliopoulous, 1999, p.
278).
Restorative Nursing Care
Being able to move about independently is an important part of the recovery
process and can determine whether the client is cared for at home or in a
health care facility. Environmental evaluation is particularly important, with
the focus on ease and safety of mobility. Promotion of activity through
environmental modification increases the quality of life for the client whether
injured, ill, or aging. Efforts by the client and the rehabilitation team to
promote activity and mobility can be negated quickly by environmental barriers
such as stairs and narrow passageways. Clients who have limited mobility may be
at risk for falls. To decrease the probability of falls at home, client
education should focus on creating a safe environment for ambulation; see
Client Teaching Checklist. The accompanying display lists some assistive devices
for clients receiving care in the home setting. Other types of assistive
devices are available to help clients perform ADL.
Health Promotion and Fitness
The client’s long-term goals include the promotion of activity,
mobility, and fitness. Therapeutic exercises maintain flexibility, strength of
muscles, range of motion, and energy and increase endurance and sense of
well-being. Health promotion models stress the importance of cognitive and
perceptual factors on exercise participation. Factors affecting targeted health
promotion outcomes include perceived health status, perceived benefits of
exercise, perceived barriers to exercise, and attitudes toward exercise.
Perceived benefits of exercise and exercise attitudes held by the client have
been identified as critical in goal setting for a program of health promotion
and fitness.
IMPLEMENTATION
Interventions for clients with impaired mobility include meeting
psychosocial needs, using body mechanics, maintaining body alignment,
performing ROM exercises, transferring clients, assisting with ambulation,
promoting wellness, using complementary treatment approaches, and
documentation.
Meeting Psychosocial Needs
Nursing interventions for role change due to deficits in activity and
mobility include
(1) fostering open family communication,
(2) providing opportunities for family role
resumption,
(3) prioritizing family roles and responsibilities, and
(4) modifying family roles and responsibilities.
The accompanying Nursing Process Highlight lists nursing interventions
that encourage socialization.
Applying Principles of Body Mechanics
Often nurses are required to have physical strength in order to assist
clients in achieving mobility. Carrying, pulling, pushing, or lifting clients
and/or equipment are all activities involved in the delivery of nursing care.
Nurses’ implementation of correct body mechanics help
minimize the following:
• Client injury
• Nurse work-related musculoskeletal injury
• Nurse fatigue “Back injury is mainly caused by lifting unreasonable loads
the most stressful tasks involve the transferring of patients (from a bed to a
chair, for example)” (Owen, 1999, p. 76).
The following variables can increase the risk of nurse injury:
• Client weight
• Client weight-bearing ability
• Client combativeness and unpredictability
• Height of bed • Confined work space
• Wheelchairs without adjustable arms
Educating staff about the use of proper body mechanics is
essential in preventing injury.
The U.S. Department of Labor Occupational Safety & Health Administration
(OSHA) has implemented new standards for the prevention of musculoskeletal
injuries. OSHA (2000) defines musculoskeletal disorders (MSDs)
as injuries and disorders of the muscles, nerves, tendons, ligaments, joints,
cartilage, and spinal discs. Examples of MSDs include
carpal tunnel syndrome, tendonitis, sciatica, herniated disc, and low back
pain. Work-related MSDs account
for more than one-third of all occupational injuries and illnesses that are
serious enough to result in days away from work (OSHA, 2000). MSDs are preventable by educating the
workers and modifying the work environment. The following recommendations are
made by OSHA (2000) to prevent MSDs:
• Adjust the height of working surfaces to reduce long reaches and awkward
postures.
• Reduce the weight and size of items that workers must lift.
• Provide mechanical lifting equipment.
Maintaining Body Alignment: Positioning
Clients cannot always move independently and reposition themselves in
bed. In such instances, nurses must use proper turning and positioning
techniques in order to achieve the following outcomes:
• Increase client comfort
• Prevent contractures
• Prevent decubiti (pressure
sores)
• Make portions of the client’s body accessible for procedures
• Help clients access their environment
Clients who cannot move independently must be repositioned every 2
hours. Repositioning must be done more often for clients who are uncomfortable
or incontinent, or who have fragile skin, poor circulation, fragile skin,
decreased sensation, poor nutritional status, or impaired mental status. Nurses
need to be aware of three essential concepts when positioning clients:
pressure, friction, and skin shear. A pressure site is any skin surface area on
which the client is lying or sitting. The force of the pressure
can compromise
circulation and lead to skin breakdown and ulceration. Tissue areas over bony
prominences are more likely to experience impaired skin integrity. It is
important to always inspect the skin and tissue areas under increased pressure
for signs of irritation (i.e., redness). Friction is caused when the skin is
dragged across a rough surface such as bedsheets or
stretcher surfaces. Friction causes heat, which damages the skin and may lead
to decreased skin integrity with resultant infection and/or skin breakdown.
Skin
shear is
the result of dragging skin across a hard surface. The force of resistance to
being dragged tears the deep layers of skin which can lead to skin ulceration.
For
clients in bed, limit the number of pillows under the head in order to avoid
neck flexion. Arms should be abducted from the body and straight with slight
flexion. Hands should rest comfortably in a flat position with fingers open.
The knees and hips should be aligned; use sandbags or pillows to prevent external
hip rotation. Avoid flexing the knees by the use of pillows placed behind the
knees. Ankles should be flexed at 90 degrees; use pillows or footboard if
necessary. To maintain proper positioning for a client seated in a chair, be
sure the head is straight without bending the neck or head dangling. The trunk
should be upright without bending or curving. Arms and hands are to be
supported on armrests or the tabletop; avoid dangling the arms. The hands
should be in a flat position with the fingers open. Hips and knees should be
flexed. The feet are to be flat on the floor or footrest with the ankles at a
90 degree angle. If the legs are supported on leg rests and are straight, keep
the ankles flexed at a 90 degree angle. Often the client is unable to assist in
repositioning; in such cases, it is best to use two or more staff members to
reposition the client in order to prevent injury. Specialized equipment used
for client positioning includes pillows, foam wedges, trochanter rolls, footboards, bed boards, hand-wrist
splints, traction, side rails, restraints, and trapeze bars. Hand-wrist
splints can facilitate extension of the wristhand- fingers, prevent contracture, and reduce spasticity.
The goal for splint use is to maintain a functional hand for the client.
For
clients who are at risk for falls, side rails should always be used; however,
they should not give nurses a sense of security. Beds must still be place in
the lowest position to reduce the force of a possible fall, should one occur.
Also, clients identified as being at-risk for falls should be closely
monitored. Some clients resist the use of side rails because they feel their
independence is altered. It is important that the nurse teach clients and
families the purpose of side rails, focusing on safety promotion. Note that
some health care agencies require signed notification consenting to the use of
raised side rails. Restraints are protective devices used to limit physical
activity or to immobilize a client or body part. Restraints are used for the
following purposes: to protect the client from falls; to protect a body part;
to prevent the client from interfering with therapies (i.e., pulling out tubes
or catheters); and to reduce the risk of injury to others. See Chapter 31 for a
complete discussion of restraints and the procedure for applying restraints.
Traction may be used to maintain alignment, especially following injury or
surgery. There are several traction techniques, including manual, skin, and skeletal .
Performing Range-of-Motion Exercises
Range-of-motion exercises are performed several times a day by placing
each joint through its full functional motion. The purposes of ROM exercises
are to maintain full flexibility, maintain muscle tone and strength, prevent
contractures, and improve circulation.
Transfer Techniques
Planning plays a major role in safe effective client transfers; the
nurse must determine to what extent the client is able to help with the transfer.
Moving Clients
Prolonged immobility can cause discomfort, muscle wasting, clot
formation, and skin breakdown. Also, the client who slides down toward the foot
of the bed while the head is elevated can experience reduced lung capacity and
impaired respiratory effort. Nurses often must move clients up in the bed or
reposition them. Moving a client may sometimes be done by one person, but often
requires two staff members to ensure safe transfer.
Logrolling the Client
Logrolling is a technique for moving a client whose body must remain in
straight alignment. Situations requiring total alignment of the spine include
spinal injury or recovery from spinal surgery. Logrolling is accomplished by
two or three nurses working in a coordinated fashion.
Transferring from Bed to Chair A client may need to be moved from the bed to a chair, commode, or
wheelchair. A wheelchair is a means of transportation for clients unable to
support their weight while standing;
Safety instructions for use of a wheelchair include the need to keep the
wheels locked when not deliberately moving and to move the footrests out of the
way when getting in and out of the wheelchair; see the previous Nursing Tip for
other recommendations for wheelchair usage.
Transferring from Bed to Stretcher
Some clients (e.g., those who are too weak to sit upright, those who are
unconscious, or those with injuries prohibiting the erect position) must lie
flat during transfers. In such situations, a stretcher (gurney) is used to
facilitate client transfer. Stretchers have several safety features, including
side rails, safety belts/straps, and locking wheels. The nurse should caution
clients to move carefully while on the stretcher as it is more narrow than the bed. Reassure the client that
side rails will be used to prevent falls for instructions on moving clients who
need minimal and maximal assistance.
Assistive Devices
There are several devices available for helping with client transfers.
Slide boards or transfer boards assist the bed-wheelchair transfer by bridging
the same level space between the bed and the wheelchair. Note that specialized
wheelchairs with removable armrests are used with slide boards. As the client
becomes more independent, the slide board can be used to transfer from
wheelchair to car.
A client may be transferred to a chair, wheelchair, bedside commode,
stretcher, or scale using a hydraulic lift. The manufacturer’s equipment
instructions should be followed and the weight limits must not exceed the
manufacturer’s specifications. Two staff members are needed to safely operate a
hydraulic lift. Hydraulic lifts are not for use with clients who have spinal
cord injury as spinal alignment is not maintained during use of the lift.
Assisting with Ambulation
Client ambulation (assisted or unassisted walking)
is encouraged soon after the onset of illness or surgery to prevent the
complications of immobility. In planning ambulation, the nurse assesses the
client’s strength, endurance, and mobility status. Can the client walk alone,
or is assistance needed? The presence of equipment (e.g., urinary catheters, IV
infusions, drainage tubes) requires assistance; see the Nursing Checklist. In
order to maintain client safety, ambulation must occur in progressive stages.
First the client should be able to tolerate sitting on the bedside and dangling
the feet. The next step is client tolerance of standing at the side of the bed.
Then progressive ambulation can be initiated.
As ambulation activities are initiated, it is important to assess the
client’s blood pressure, respiratory rate, pulse, skin color and moisture, and
subjective responses. While the client is walking, observe for signs of exertion, including diaphoresis,
shortness of breath, or weakness. It is also important to assess for the
presence of orthostatic hypotension in order to prevent falls. Depending on the
client’s physical conditioning and the effects of orthostatic hypotension, the
client may need to slowly progress to independent ambulation. Once the activity
is completed, the nurse evaluates the client evaluation focusing on progression
of activity. Continuous evaluation of the client’s strength and endurance is
performed by the nurse.
Preparing the Client to Walk
One of the best ways to encourage ambulation is to help the client
become and remain as independent as possible while lying in bed. This includes
urging clients to participate in ROM exercises and perform self-care activities
as much as possible. Independent mobility, the goal of most clients, is the
ability to walk, run, sit, and turn without mechanical or personal aid.
Progressive exercises and activities that promote independent mobility include:
1. Turning. The client can turn in bed using
side rails for stabilization and leverage.
2. Sitting. The client can raise the head of
the bed and lower the height of the bed. Then the client turns to the side of the bed and swings legs over
the side of the bed to assume the dangling position. Arms held in the tripod
position give balance to the sitting position.
3. Standing. The client dangles for a few
minutes to assure balance and then bears weight with both feet at the side of
the bed. For additional stability and balance, the client can perch on the edge
of the bed for several minutes.
4. Walking. The client assesses strength and
balance while walking, thus allowing a gradual progression of the duration of
walking. Instruct clients to rest by sitting or standing still stabilized with
a guide rail if fatigued.
Client Education
Prior to ambulation, clients who have been immobile need to be prepared
adequately in order to prevent injury. Listing the therapeutic outcomes of
ambulation is one way to teach clients the importance of ambulation. Clients
should also be taught to sit down or use side rails if dizziness occurs. Teach
clients the technique for safe falling in order to minimize risk of injury.
Clients should be told that if they begin to feel faint they should fall
toward the affected side of the body and to use the unaffected side to raise
self from the floor or chair.
Preambulatory Exercise
Helping immobile clients to prepare for ambulation includes instruction
of preambulatory exercises in order to strengthen and
tone muscles. The quadricepsfemoris is the major muscle used for walking,
thus, clients should be directed to gently contract and release the leg muscles
several times a day. Clients who will be walking with the assistance of walkers
and crutches need upper body strength. Instruction in the safe use of
ambulatory assistive devices is also necessary for many clients with impaired
mobility.
Assistive Devices
Clients who are unable to ambulate independently can use devices
designed to help them walk safely. Determination of which device to use is
based on the following:
• Upper arm strength
• Endurance (stamina)
• Presence or absence of one-sided weakness
• Weight-bearing ability for a
comparison of the three most common devices used to assist in walking: canes,
walkers, and crutches. Canes A cane is to be used by clients who can bear weight on both legs but
have some weakness in one leg or hip. The straight (standard) cane is used most
often; canes with three or four legs are used with clients who need more
stability than provided by the straight cane. Quad canes provide more stability
but are sometimes more awkward to use than the straight cane.
Walkers
A walker is a waist-high metal tubular device with a handgrip and four
legs. Some walkers have rubber tips on all four legs, whereas others have
wheels on the two front legs. The advantages of using a walker include
provision of extra support, provision of a sense of security, and independence.
The client first moves the walker forward and then takes a step while balancing
his or her weight on the walker. A walker is used by clients who need more
support than that provided by a cane. Walkers are available with and without
wheels. The walker without wheels provides more stability but also requires
more client stamina in order to lift the walker. Walkers with wheels are
intended for use by clients with limited upper body strength. The nurse should
determine the following for clients using walkers:
1. Amount of weight bearing allowed on lower limb
2. Appropriateness for client’s height
3. Type of walker (pick-up or rolling)
4. With pick-up walker: client’s ability to grip, lift, and propel the walker
forward
5. With rolling walker: client’s ability to grip and propel the walker
forward
When educating clients about the use of walkers, inform them when
transferring from chair or commode they should back the walker to the toilet
seat and use arms of chair or commode to assist in standing. Teach clients to
always use both hands when using a walker to transfer from standing to sitting
Crutches
A crutch is a wooden or metal staff used to increase client mobility.
There are two types of crutches: axillary and
forearm. The most commonly used type, theaxillary crutch, fits under the axilla with the weight being placed on the
handgrips. The forearm crutch, which has
a handgrip and a metal cuff that fits around the arm, is more convenient but
provides less stability than the axillary crutch.
To prevent slipping, crutches have rubber tips, which must be kept dry. If the
tips are worn or loose, they must be replaced. The crutch must be regularly
inspected; if cracks or bends are present, the person’s weight will not be
properly supported. Crutches can be used by clients who are unable to bear any
weight on one leg, clients who can bear partial weight on one leg, as well as
clients who have full weight bearing on both legs. Several gaits are used with
crutches: the four-point gait, three-point gait, two-point gait, and
swing-through gait. The four-point
gait for weight bearing with
both legs follows the pattern of right crutch forward, left foot forward, left
crutch forward, then right foot forward. The four-point gait with crutches is
very stable but slow. The two-point
gait for weight bearing with
both legs has the pattern of right crutch and left foot forward together, then
left crutch and right foot forward together. The two-point gait requires more
balance but is a faster gait. The three-point
gait for weight bearing with
one leg has the pattern of crutches and weak leg forward together, then
weight-bearing leg forward. The swing-through
gait has the pattern of
crutches forward, then legs swing forward together. The swing-through gait has
the advantage of speed; however, it requires good balance.
Wellness Promotion
Wellness promotion emphasizes the need for physical fitness, which
increases well-being, increases sympathetic nervous system activity, improves
cardiovascular functioning, and produces and maintains weight loss. “Increasing physical
activity is beneficial for all ages and all groups” (Bray, 1998, p. 238). The nurse should identify activities
enjoyed by the client and encourage increased participation. When planning an
exercise program, the following elements should be considered:
• Health status (existing medical conditions)
• Physical condition
• Age
• Preferences for types of activities
Complementary Treatment Modalities
EVALUATION
Family support for a client with activity or mobility deficits is a
delicate balance between independence and dependence that is necessary for
positive self-esteem and confidence. This healthy balance can be influenced by
the client’s family and friends. Healthy balance is fostered through support of
the client as requested and needed, and through encouragement and positive
acceptance and affection. Family members are often unaware of the client’s
potential to improve. Thus, they give unnecessary assistance in activities and
mobility rather than allow the client to function independently. The client
then becomes resentful because there is a loss of self-control. Resentment can
also occur with the family who has accepted the heavy responsibilities of caregiving.
For the client who overestimates his or her own cognitive and physical
capabilities and energy level, safety becomes an important issue. Actual
long-term activity and mobility are the foci of evaluation as the client
transfers skills and knowledge from the acute-care hospital or rehabilitation
facility to home. Common areas of concern regarding activity include:
• Mobility status
• Activities of daily living capacity
• Use of appropriate adaptive devices
• Expansion of client activities
• Use of activities as a basis for building areas of competence and
achievement
There are numerous complementary modalities that help improve
musculoskeletal health; see the accompanying display. Also, physical activity
and relaxation exercises help reduce muscular tension and improve functional
abilities. Measures
of physical assessment, functional assessment, and performance of ADLs are used for follow-up evaluation of
the client’s status for activity and mobility. Ongoing assessment of the
client’s activity and mobility is important because compliance with home
exercise programs may lessen over time after discharge. When evaluating
long-term activity and mobility goal achievement, the nurse should observe the
client in the home setting to note the client’s ability to function within his
or her own environment.
KEY CONCEPTS
• The nurse must assess the client on an ongoing basis for activity and
mobility during acute hospitalization, rehabilitation, and postdischarge.
• Collaboration between client, family, and members of the
interdisciplinary health care team is essential for establishing and modifying
goals for activity and mobility.
• Nursing interventions are individualized to maximize activity, mobility,
and independence for the client and family.
• The nurse should be aware of the home environment and lifestyle of the
client.
• Continuity of care among nurses and the interdisciplinary health care
team is facilitated.
• The family or caregivers should be included in educational sessions
regarding activity and mobility. Practice sessions of activities and mobility
by client, family, and caregivers under the direction of the nurse are
essential.
• The need for adaptive equipment should be assessed and acquisition of
equipment facilitated.
• The client, family, and caregiver should be provided instructions in
many forms: demonstrations, videos, pamphlets, handouts.
• The client and family should be informed of community resources to
maximize activity, mobility, and independence.
• The nurse should be available to assist the client with problem solving
after discharge.