Mobility/Immobility (Nursing)

00:01 Welcome! We’re going to talk about mobility and immobility. My name is Diana Shenefield, and this is going to be a big part of NCLEX as well, and it falls under basic caring comfort.

00:12 So, what’s this topic about? We’re going to talk about a little bit of an overview.

00:17 When we’re looking at comfort and we’re looking at taking care of our patients, mobility and immobility are a big part of that. And so we’re going to look at what's the complications and what’s the importance of making sure that our patients are moving.

00:32 Our learning outcomes, as we know, our mobility and immobility has to do with promoting circulation and maintaining correct body alignment. So you want to make sure that you go back and you look in your fundamentals book on positioning and different positions on whether it’s Fowler or semi-Fowler’s, again, Sims’ position, supine, prone. Make sure you go back and you review that, because as we talk about mobility or immobility, positioning is a big part of that. You need to identify the complications of immobility. What happens if our patients don’t move? And why is that that they’re not moving and what can we do as nurses to promote that? And then assessing the patient’s mobility, their gait, strength and motor skills. That sounds like neurological assessment. And so we want to make sure that we’re watching that and that we notice any changes in our patient.

01:23 So here’s a sample question that you might see on NCLEX. An elderly patient has a noncemented total hip joint replaced. So picture that in your mind. I know if you’ve been on the med/surg floor, you’ve probably had some hip replacements. Postoperative activity for this patient should include. So again, think back to that patient and think back to what has happened to that patient, and that there're an elderly patient. What are you going to do? How about number A? Bed rest for six weeks with continuous passive motion. Remember, continuous passive motion as the CPM machines. What about B? Touch-down weight-bearing starting first postoperative day, or C, head of the bed flat for 48 hours, or D, hip immobilization for three to four weeks with no weight-bearing. So think about what is going to be best for your elderly patient, not just because of the hip, but also because of all the other body systems that are affected by this illness. Again, hopefully, you picked B. We want them to be up moving around, but we don’t want them putting a lot of weight on that hip.

02:30 So, what’s our responsibility as far as immobility and mobility? Well, we need to assess our patient. Who can get up and walk? And what is their gait? We want to make sure we’re keeping our patients safe, and that means knowing which patients are at risk for falls. And we can only know that by getting our patients up or getting a history on how well they can walk. Do they need a walker? Do they need a cane? Are they unsteady? Are they on medications in the hospital that make them unsteady but they’re normally steady? And how do we adjust that to keep our patients safe? And then what are the causes of immobility? I know you’re thinking in your mind.

03:08 Well, I could think of a bunch of them. But let’s look at some of the causes so that you can be prepared as a nurse on how to take care of these patients and prevent some complications.

03:18 So, what are our main causes of immobility? We could see the first one listed there is a pain. And pain is one of those things that should not keep a patient from moving.

03:28 If my patient says to me, “I’m not getting up because I hurt too bad,” then that’s a problem that I have. I need to make sure that I’m medicating my patient so they can get up and about. And if the medication I’m giving them isn’t working, it’s my responsibility to call the physician and try to work something else out or look for other ways so that my patient isn’t in as much pain. Pain shouldn’t be a big excuse for not getting up and walking around. We have trauma, injury. Again, just like we had the man in the question that had the noncemented hip. Things happen that keep us from moving around, but again, is that an excuse or is there something as a nurse that I can do to help my patient still get up and move around? You could have motor or nervous system impairment. Maybe you have a patient that has had a stroke, and maybe one side of their body is paralyzed.

04:18 Again, immobility doesn’t mean, “Well, I’d just leave you lay there.” We know as nurses, that we can still move people around, but I need to be aware of that so that I’m watching for those signs and symptoms. What about somebody who’s in traction? That’s a whole different bugging. They’re in traction, I can’t just say, “Well, today, we’re going to get up and walk.” So, what can I do to help my patient not have all the complications of immobility because they’re stuck in traction? What about just a generalized weakness? Maybe there are patient that’s suffering from multiple sclerosis and their disease is getting worse, and they don’t have the energy. Again, does that mean I just let them lay there? Or does that mean that I look for creative ways to help them be as mobile as possible? Then we have psychological problems. There’s a whole range of diseases where people feel like they can’t get up and move. Again, I don’t just leave them there because they think they can’t get up and move. But what can I do to prevent complications? And then side effects of medications, if I just gave my patient a big dose of a narcotic, they may be asleep, they may be uneasy on their feet. Or maybe I’ve given them a medicine that may help them sleep and they’ve very, very sleep? Again, that’s a temporary thing, but I can’t let my patient just lay there and give the excuse that they’re on a medication.

05:42 So, what are the types of immobility? Well, the main one that we think of is physical.

05:46 There’s something wrong, either they’re older and their joints don’t work, or they’ve been in an accident, or they have a broken leg. There's lots of physical things that can keep people from getting up and moving around. What about intellectual, lack of knowledge? Maybe your patient just doesn’t understand how important it is to get up and move.

06:08 You know, we all know it’s sometimes easier just to lie in bed or just to sit in the recliner.

06:13 But does your patient understand the importance? And then emotional. Again, sometimes people that are highly stressed, it’s easy to just kind of close in, maybe cover your head with the blanket. You don’t want to deal with things. And before you know it, time has moved on.

06:28 So again, understanding that and being sensitive to your highly stressed patients, but also helping them still move around and deal with their stress. And then social, sometimes socially, it’s nice to get people to take care of you if they think you can’t move around or maybe you’re not able. Maybe you don’t live somewhere where you have a nice recliner to sit in or a nice place to walk. Again, just saying, “Well, that’s okay.

06:55 You don’t need to move around.” As a nurse, I need to work on that and I need to find ways to keep my patients as mobile as possible so that they don’t develop the complications we’re going to talk about. So, what complications? There are things I see and there are objective things. And the first thing is they’re going to have a decreased motivation. The longer you’re immobile, the less motivated you’re going to be to get up and move around. You can kind of look at people and exercise. The longer a person goes without going to the gym, the easier it is to not go to the gym, and it’s the same with our patients. The easier it is to just sit in the chair, the harder it is to get up and move around. So we’re looking at motivation. We’re looking at problem-solving abilities. Maybe they can’t get around because there's rugs all over. That’s a pretty easy one for us but maybe not for them to realize that we can move those rugs. How can we make a place for the patient to move? If they’re in traction, what can we do? We can’t just start getting them up and moving around, but what can we do? What kind of problem solving can we do to help that patient move around? What about diminished drive? Again, is it a depression problem? Is it that they don’t care or lack of self-esteem? Again, identifying that and then being able to address interventions to go with that. Changes in body image can have a big effect depending on what has happened with your patient. Emotional reactions. If I have an exacerbated mode or emotions, you know, all of the sudden, everything is a crisis. And we’ve had patients where they have no coping skills. And whatever has happened to them has put them into a crisis that they can’t function. Again, we don’t want that to lead to problems of mobility.

08:40 Deterioration of time perception. People that are in the ICUs lose all track of time.

08:46 And so, you know, maybe it seems like I’ve only been in bed for a day, and all of the sudden, it’s been a week. So, helping our patients, keeping them oriented.

08:55 Fear and anxiety. Is it going to hurt when I get up and move around? It’s easier to just stay still. What about sensory deprivation, sensory overload, or “I don’t have enough sense for sensory deprivation”? So again, what am I doing with my patient? Am I teaching them or am I just leaving them lay there? And then as we talked about before, depression.

09:16 Depression is huge with our patients. They’re dealing with illnesses. They’re dealing with financial problems, with family loss, with job loss. Our patients don’t just come to us with a COPD. They come to us with their whole lives. And so, understanding that and what motivates them is really important as nurses. And then objective. What kind of other complications for immobility? Well, orthostatic hypertension. Remember, that’s when you’re taking the blood pressure when they’re lying, sitting, standing. We know if somebody lies too long, when they go to stand up, they get very dizzy, risk for falls. So again, understanding that. And it doesn’t mean that they’ve been lying for days, maybe they’ve only been lying for an hour. But that is a complication of immobility. Thrombus formation, always watching for those DVTs. We know that our patients, even if they can’t get up, we can do things to help them move their legs, pump their ankles, so that we don’t get a DVT. Anorexia, a lot of people, especially our older people will just not be hungry. Why? Because they sit around all day long.

10:21 And so, just think about those patients, and that is a complication because then they’re not getting enough nutrients. So maybe if we got them up and walked them a little bit that they would have that drive to eat. Diarrhea and constipation. Different people react different ways, but definitely, constipation, if you’re not getting up and moving around. Tissue and muscle atrophy is a big problem. We know just somebody that has had a cast on. I’m sure you’ve seen somebody that has had their cast taken off and how their tissue and muscle has atrophied. If we’d leave it like that, they’ll lose function of that limb.

10:54 So again, making sure that you’re moving people as much as possible so that their tissues and muscles don’t atrophy. Fluid and electrolyte balances. Kindeys. Need to have you up and moving around.

11:05 They need gravity to help. So again, be watching your lab results. Contractures is another big problem which we don’t want to happen because of tissue atrophy, but we don’t want people to get stuck in a certain spot to where they can’t move their arms.

11:19 They can’t take care of themselves or feed themselves. And then skin breakdown should be number one on your list. We know people that are immobile are going to have skin breakdown, and we cannot afford our patients having pressure ulcers because we as nurses did not get them and move them around, whether it’s rolling them back and forth, whether it’s changing positions, or whether it’s using special cushions or bed, skin breakdown is a huge problem.

11:44 And then pneumonia. Think about your patient that’s come back from surgery. What do we do right away? We get them up and moving around. We get them taking coughs and deep breaths to get that anesthesia out. Why? Because they will develop a pneumonia, which is another big problem of immobility. Bladder distension. How many people can go to the bathroom lying down? And so, what they do is they hold it and it ends up distending their bladder till when they can’t go and they become uncomfortable. So again, thinking about all of these things. Your patient is not going to be thinking about all these complications.

12:17 These all comes from patient teaching, but it starts with your understanding as a nurse on everything that you’re watching for, so that you can prevent these things.

12:26 Infection and kidney stones are other big problems of complications that happen when patients aren’t moving around. So, what are we going to do to prevent? Why do we get people moving around? We want to get that blood flowing. Blood has to move.

12:40 Gravity will help, but lying flat, it pulls. So we need to make sure we’re getting people moving around. We’re promoting good skin integrity. We’re promoting muscle strength, that we have an awareness of what’s going on with immobility. Again, teaching the patient, teaching the family how important it is and why. Maintaining sensory stimuli, not letting somebody just lay there without being interactive, whether it’s talking to them, whether it’s TV, giving them the motivation to move. And then again, educating on certain devices.

13:15 If your patient needs a cane, they need to be taught how to use a cane, whether it’s a cane, a walker, crutches. Do they know how to use them? Because a lot of times, we assume that they do. They go home and the cane sits in the corner and they sit in the chair because nobody has taught them how to use it. So keep that in mind as well as you’re answering questions. Does the patient understand how to use the devices? So in closing, think about all the patients that you could be taking care of that might be immobile. What patients are at risk? And then what are the complications that they’re at risk for that as a nurse, I’m responsible to prevent. And again, making sure I have buy in with my patient and their family so that they understand how important it is to move. Good luck on NCLEX.