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 America are naturally fit. The use of many convenience items (e.g., fast food, remote controls) encourage little physical exertion. The sedentary lifestyles of many Americans result in loss of muscle strength, decreased endurance, inadequate cardiorespiratoryfunction, and obesity. Individuals with active lifestyles value exercise and, therefore, are more likely to experience its therapeutic outcomes.

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 United States (Huston, 1998). Damage to the spinal cord can be a result of hyperextension and/or compression. With hyperextension, the spinal cord is overstretched, leading to dislocation of the vertebrae or discs and possible compression of the spinal cord. Hyperextension can also completely dissect the spinal cord. In a complete spinal cord injury, voluntary motor activity, sensory function, andproprioception below the level of the injury are lacking. Compression injuries occur when the force of impact fractures the vertebrae or ruptures the discs, forcing bony fragments or discs into the spinal canal. These particles can lacerate or compress the spinal cord, resulting in paralysis below the level of the injury. Prevention of spinal cord injuries is a major concern of nurses and may be addressed through educating the public on safety precautions related to driving, participation in sports, and leisure activities.

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). Independence in these activities contributes toselfreliance, self-care, self-determination, self-direction, and personal control. Personal client variables determining the maximal level of independence include extent of disability, competence, age, self-confidence, cognitive ability, knowledge level, and mood state. It is important to develop short-term goals that encourage clients to gain a sense of accomplishment. The nurse should recognize and praise the client’s accomplishments that increase mobility. The level of independence and ability for performance of ADL is enhanced or inhibited by the physical environment. Collaboration of the client, family, caregivers, nurses, physical therapists, and occupational therapists is essential for individualizing the physical environment to permit optimal activity and mobilization. Adaptive devices, such as those that follow, enhance independence for personal activities:

 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.