A key concept you will start hearing about from almost the first day of nursing school is immobility. If your vision of being a nurse had to do with getting the sick people tucked in and snug in their beds, then you, my friend, are in for a surprise. As great as it sounds to stay cozy in bed when we’re sick, it’s actually one of the worst things we can do. Show
In this lesson, we’ll cover the key reasons immobility is enemy #1 in nursing. Ready? Immobility leads to skin breakdownWhen we think of immobility, probably the first thing that comes to mind is skin breakdown. Patients who are immobile are at huge risk for pressure ulcers and moisture-associated breakdown secondary to incontinence. For all patients, especially ones with decreased mobility, you’ll need to keep a close eye on any bony prominences such as the scapula and sacrum, and also the perineal area in general if the patient is incontinent. It’s crucial that we keep these patients clean and dry, and we often use barrier creams to help keep stool and urine from contacting the skin. Every head-to-toe assessment includes a skin assessment, especially in those at-risk areas. Redness is the first sign that the skin isn’t getting enough oxygen due to compression. If you push on the reddened area, and it blanches (turns pale briefly) then this skin is still getting perfused but is at very high risk for turning into a pressure ulcer. Non-blanchable redness means the skin has already been injured and aggressive treatment may be necessary to prevent a serious wound. What are you going to do about it? Immobility leads to depressed respiratory functionPatients who aren’t moving a lot, also aren’t breathing deeply, coughing up sputum and exercising their lungs. This sets the patient up for general respiratory deconditioning and pneumonia. Without regular exercise, the muscles of respiration become weak, which set the patient up for further respiratory compromise. And, without deep breathing and coughing, mucus and any pathogens in the lungs tend to accumulate putting the patient at high risk for developing pneumonia. The incentive spirometer is a device we encourage patients to use to help keep their lungs open and prevent pneumonia and respiratory deconditioning from setting in. What are you going to do about it? Immobility leads to constipationWhen the body slows down, the GI tract follows. Add in some opioids, and your patient is at very high risk for constipation. Not only is it uncomfortable for the patient, constipation comes with its own set of problems. These include things like fecal impaction, hemorrhoids (which can bleed and even be life threatening), anal fissures, and rectal prolapse. Severe constipation can cause perforations in the bowel (a life-threatening emergency) and decreased blood flow to areas of the bowel, which can lead to ischemia and even death. What are you going to do about it? Immobility leads to renal dysfunctionThe effects of immobility and prolonged bedrest on the renal system are multifactoral.
What are you going to do about it? Immobility leads to physical deconditioningWithout weight bearing exercise and activity, immobility leads to contractures, bone demineralization and the catabolic breakdown of muscle and lean tissue. Patients will be noticeably weaker even after a couple of days of bedrest, and extended periods of immobility can drastically affect their ability to walk unassisted or even perform ADLs. What are you going to do about it? Immobility leads to electrolyte imbalancesSodium levels tend to decrease with immobility and bedrest due to reduced ADH levels, though they eventually stabilize when the release of aldosterone is triggered. However, this increased aldosterone secretion causes potassium losses in the urine, leading to hypokalemia. Additionally, plasma concentrations of calcium increase as bone demineralization occurs, and can be evident within days. What are you going to do about it? Immobility contributes to psychological dysfunctionStudies have shown that immobility contributes to psychological deterioration. A randomized trial of intubated patients showed that those who receive early physical therapy endure half as many days of delirium than do patients who do not increase physical activity. And it’s definitely not restricted to patients on a ventilator. The loss of sensory input that comes with immobility, the isolation, boredom and loss of independence are all key factors in the development or exacerbation of depression, anxiety and confusion. What are you going to do about it? Immobility leads to DVTWithout activity, blood tends to pool in the lower extremities which sets the patient up for the formation of blood clots in the deep veins. Deep vein thromboses (DVTs) are a significant risk factor for pulmonary embolism. What are you going to do about it? Immobility leads to fallsThanks to the weakness, confusion, and orthostatic hypotension that can occur with immobility, these patients are at high risk for falls. What are you going to do about it? Immobility leads to impaired glucose metabolismBedrest durations as short as seven days have been shown to be associated with insulin resistance and impaired glucose metabolism. Studies looking at the early mobilization of ICU patients showed significantly reduced insulin requirements, suggesting it may be just as effective as intense insulin therapy in maintaining euglycemia in mechanically ventilated patients. Another study looked at what happened to participant’s insulin resistance when their step counts decreased to less than 1000 steps per day. Their resistance to insulin increased, blood glucose levels increased, and in patients over age 65, did not return to baseline when their normal levels of activity were resumed. In other words, to promote normal glucose metabolism, get those patients mobilizing as soon as possible…especially your older ones. What are you going to do about it? How to increase mobilityIncreasing mobility does not simply mean “ambulate the patient in the hallway for a distance of 60 feet three times per day.” Mobilization is going to be tailored for each individual patient and is not a one-size, fits all approach. Things to consider when increasing mobility:
In general, you will maximize activity to the greatest extent you can for that patient. Some examples include:
So there you have it…some of the key dangers of immobility and how you (and your patient) can combat it. Get this on audio in episode 154 of the Straight A Nursing podcast!References Brummel, N. E., & Girard, T. D. (2013). Preventing delirium in the intensive care unit. Critical Care Clinics, 29(1), 51–65. https://doi.org/10.1016/j.ccc.2012.10.007 Knight, J. et al. (2019). Effects of bedrest 4: Renal, reproductive and immune systems. Nursing Times, 115(3), 51–54. LuBuono, C. (2018, August 15). Diabetes and bed rest. The Doctor Will See You Now. http://www.thedoctorwillseeyounow.com/content/diabetes/art5649.html Mayo Clinic. (n.d.). Constipation—Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/constipation/symptoms-causes/syc-20354253 McGlory, C., von Allmen, M. T., Stokes, T., Morton, R. W., Hector, A. J., Lago, B. A., Raphenya, A. R., Smith, B. K., McArthur, A. G., Steinberg, G. R., Baker, S. K., & Phillips, S. M. (2018). Failed recovery of glycemic control and myofibrillar protein synthesis with 2 wk of physical inactivity in overweight, prediabetic older adults. The Journals of Gerontology: Series A, 73(8), 1070–1077. https://doi.org/10.1093/gerona/glx203 Patel, B. K., Pohlman, A. S., Hall, J. B., & Kress, J. P. (2014). Impact of early mobilization on glycemic control and icu-acquired weakness in critically ill patients who are mechanically ventilated. Chest, 146(3), 583–589. https://doi.org/10.1378/chest.13-2046 Stuart, C. A., Shangraw, R. E., Prince, M. J., Peters, E. J., & Wolfe, R. R. (1988). Bed-rest-induced insulin resistance occurs primarily in muscle. Metabolism: Clinical and Experimental, 37(8), 802–806. https://doi.org/10.1016/0026-0495(88)90018-2 Which of the following is a physiologic effect of immobility?The hazards or complications of immobility, such as skin breakdown, pressure ulcers, contractures, muscular weakness, muscular atrophy, disuse osteoporosis, renal calculi, urinary stasis, urinary retention, urinary incontinence, urinary tract infections, atelectasis, pneumonia, decreased respiratory vital capacity, ...
What does immobility put patients at risk for?Immobility is independently associated with the development of a series of complications, including pressure ulcer [1], deep vein thrombosis (DVT) [2], pneumonia [3], and urinary tract infection (UTI) [4].
What psychological changes may occur with immobilization?Immobility contributes to psychological dysfunction
The loss of sensory input that comes with immobility, the isolation, boredom and loss of independence are all key factors in the development or exacerbation of depression, anxiety and confusion.
What are the physical effects of immobility on a patient?In addition to deconditioning, prolonged immobility is associated with increased fatigue, low self-esteem and loss of confidence. This can increase the risk of falls and the development of pressure ulcers. Mobility is important because it helps to maintain health and the body's ability to heal and repair.
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