IMPAIRED PHYSICAL MOBILITY

Impaired Bed Mobility

Impaired Sitting

Impaired Standing

Impaired Transfer Ability

Impaired Walking

Impaired Wheelchair Mobility

Limitation in independent, purposeful movement of the body or of one or more extremities

Altered gait

Decreased fine motor skills

Decreased gross motor skills

Decreased range of motion

Difficulty turning

Engages in substitutions for movement

Expresses discomfort

Movement-induced tremor

Postural instability

Prolonged reaction time

Slowed movement

Spastic movement

Uncoordinated movement

NANDA-I approved*

Pathophysiological

Related to cognitive dysfunction*

Related to depression*

Related to body mass index (BMI) >75th percentile appropriate for age and gender*

Related to decreased muscle strength* and endurance* secondary to:

Disuse*

Decreased muscle control*

Decreased muscle strength*

Sedentary Lifestyle *

Neuromuscular impairment

Autoimmune alterations (e.g., multiple sclerosis, arthritis)

Nervous system diseases (e.g., Parkinson's disease, myasthenia gravis)

Respiratory conditions (e.g., chronic obstructive pulmonary disease [COPD])

Muscular dystrophy

Partial paralysis (spinal cord injury, stroke)

Central nervous system (CNS) tumor

Trauma

Cancer

Increased intracranial pressure

Sensory deficits

Musculoskeletal impairment

Fractures

Connective tissue disease (systemic lupus erythematosus)

Cardiac conditions

Related to joint stiffness* or contractures secondary to:

Inflammatory joint disease

Postjoint replacement or spinal surgery

Degenerative joint disease

Degenerative disc disease

Related to edema

Related to decreased activity tolerance* and deconditioning

Treatment Related

Related to equipment (e.g., ventilators, enteral therapy, dialysis, total parenteral nutrition)

Related to external devices (casts or splints, braces)

Related to insufficient strength and endurance for ambulation with (specify):

Prosthesis

Crutches

Walker

Situational (Personal, Environmental)

Related to inadequate knowledge of value of physical activity*

Related to cultural belief regarding acceptable activity*

Related to inadequate environmental support*

Related to:

Anxiety *

Fatigue

Depressive mood state

Malnutrition*

Reluctance to initiate movement* secondary to

Decreased motivation

Pain*

Joint stiffness*

Physical deconditioning*

Dyspnea

Cognitive impairment*

Maturational

Children

Related to abnormal gait* secondary to:

Congenital skeletal deficiencies

Congenital hip dysplasia

Legg-Calvé-Perthes disease

Osteomyelitis

Older Adult

Related to decreased motor agility

Related to deconditioning*

Altered bone structure integrity

Contractures

Depression

Developmental disabilities

Impaired metabolism

Musculoskeletal impairment

Neuromuscular diseases

Pharmaceutical preparations

Prescribed movement restrictions

Sensory-perceptual impairment

AUTHOR'S NOTE

Impaired Physical Mobility describes an individual with deconditioning from immobility resulting from a medical or surgical condition or personal choice. The literature is full of the effects of immobility on body system function. Early progressive mobility programs or progressive mobility activity protocol (PMAP) is designed to prevent these complications. These programs are appropriate for individuals in intensive care units, other hospital units, in residential nursing care facilities, and in homes.

These programs necessitate a multidisciplinary healthcare team, such as medical, nursing, physical therapy, occupational therapy, and nutritionist involvement.

Gillis et al. reported that time constraints due to increased acuity and staffing issues have lowered the priority and time available for basic mobility (*2008).

Acuity levels on units must address the workload associated with PMAP and factor this into staffing. Several studies have shown the cost effectiveness of PMAP with decreased ICU stays, decreased ventilator use, and decreased hospital stays in addition to decreased complications of immobility, such as deep vein thrombosis, ventilator-associated pneumonia, and delirium.

Nursing interventions for Impaired Physical Mobility focus on early mobilization muscle strengthening, restoring function, and preventing deterioration. Impaired Physical Mobility can also be utilized to describe someone with limited use of arm(s) or leg(s) or limited muscle strength.

Impaired Physical Mobility is one of the cluster of diagnoses in Risk for Disuse Syndrome. Limitation of physical movement of arms/legs also can be the etiology of other nursing diagnoses, such as Self-Care Deficit Syndrome and Risk for Injury. If the individual can exercise, but does not, Sedentary Lifestyle is a more appropriate diagnosis. If the individual has no limitations in movement, but is deconditioned and has reduced endurance, refer to Decreased Activity Tolerance.

Level 1 Fundamental Focused Assessment

Risk for Falls

Dominant Hand

Is the person independent or needs assistance in:

Ability to turn in bed

Ability to sit

Ability to rise from chair

Ability to stand

Ability to transfer

Ability to ambulate

Ability to weight bear both legs? one leg?

Assistive Devices

Crutches

Walker

Prothesis

Braces

Cane

Wheelchair

Restrictive Devices

Casts/splints

Monitor

Dialysis port

Braces

Traction

Ventilator

IV therapy

Infusion port

Range of Motion (Neck, Shoulder, Elbows, Arms, Spine, Hips, Legs)

Full

Limited

None

The individual will report increased strength and endurance of limbs, as evidenced by the following indicators:

• Demonstrates the use of adaptive devices to increase mobility.
• Uses safety measures to minimize risks for injury.
• Demonstrates measures to increase mobility.
• Evaluates pain and quality of management.

Level 1 Fundamental Focused Interventions

Assess for Barriers to Early Mobilization in the Healthcare Setting

R:Early mobility has been linked to decreased morbidity and mortality as inactivity has a profound adverse effect on the brain, skeletal muscle, pulmonary, and cardiovascular systems (Norris, 2019).

Explain to Individual and Family Why the Staff Are Frequently Moving the Individual.

R:An explanation of what the moving is preventing (e.g., muscle wasting, blood clots, and pneumonia) may improve cooperation.

Level 2 Extended Focused Interventions

Consult with Physical Therapist for Evaluation and Development of a Mobility Plan

R:Physical therapists are professional experts on mobility.

Promote Optimal Mobility and Movement in All Healthcare Settings with Stable Individuals Regardless of Ability to Walk

R:"As technology and medications have improved and increased, survival rates are also increasing in intensive care units (ICUs), so it is now important to focus on improving the individual outcomes and recovery. To do this, ICU individuals need to be assessed and started on an early mobility program, if stable" (Zomorodi, Topley, & McAnaw, 2012, p. 1).

Initiate an In-Bed Mobility Program within Hours of Admission if Stable (Vollman, 2012)

• Maintain HOB 30 degrees, including individuals on ventilators unless contraindicated.

R:This allows increased perfusion in all lung tissue.

• Initiate a turning schedule within hours of admission if stable.

R:This can prevent prolonged gravitational equilibrium. Prolonged periods in a stationary position result in greater hemodynamic instability when the individual turned (Vollman, 2012).

• Assess tolerance to position change 5-10 minutes after a position change.

R:This time frame is needed to sufficiently assess response.

• Initially turn slowly to right side.

R:"The right lateral position should be used initially to prevent the hemodynamic challenges reported with use of the left lateral position" (Vollman, 2012, p. 174).

Level 2 Extended Focused Interventions

Promote Motivation and Adherence (*Addams & Clough, 2003; *Halstead & Stoten, 2010)

• Explain the effects of immobility.
• Explain the purpose of progressive mobility and passive and active ROM exercises.
• Establish short-term goals.
• Ensure that initial exercises are easy and require minimal strength and coordination.
• Progress only if the individual is successful at the present exercise.
• Provide written instructions for prescribed exercises after demonstrating and observing return demonstration.
• Document and discuss improvement specifically (e.g., can lift leg 2 inches higher).

R:Mobility is one of the most significant aspects of physiologic functioning because it greatly influences maintenance of independence (Miller, 2019). Motivation can be increased if short-term goals are accomplished.

• Evaluate the level of motivation and depression. Refer to a specialist as needed.

R:Effective management of pain and depression is sometimes necessary. Inadequate pain relief may be a primary factor leading to depression in some people, but depression should not be discounted as a secondary feature of pain. Depression may require aggressive management, including drugs and other therapies.

Increase Limb Mobility and Determine Type of ROM Appropriate for the Individual (Passive, Active Assistive, Active, Active Resistive)

For passive ROM:

• Begin exercises slowly, doing only a few movements at first.
• Support the limb below the joint with one hand
• Move joint slowly and smoothly until you feel the stretch.
• Move the joint to the point of resistance. Stop if the person c/o of discomfort or you observe a facial grimace.
• Do the exercise 10 times and hold the position for a few seconds.
• Do all exercises on one side and then repeat them on the opposite side if indicated.
• If possible, teach the person or caregiver how to do the passive ROM.
• Perform active assistive ROM exercises (frequency determined by individual's condition and physical therapist):
  • If possible, teach the individual/family to perform active ROM exercises on unaffected limbs at least 4 times a day, if possible.
  • Perform ROM on affected limbs. Do the exercises slowly to allow the muscles time to relax, and support the extremity above and below the joint to prevent strain on joints and tissues.
  • For ROM, the supine position is most effective. The individual/family member who performs ROM himself or herself can use a supine or sitting position.
  • Do ROM daily with bed and bath and 3× daily if there are specific problem areas. Try to incorporate into activities of daily living.
• Support extremity with pillows to prevent or reduce swelling.
• Medicate for pain as needed, especially before activity.
• Apply heat or cold to reduce pain, inflammation, and hematoma per instructions.
• Encourage to perform exercise regimens for specific joints as prescribed by physical therapist (e.g., isometric, resistive).

R:Active ROM increases muscle mass, tone, and strength and improves cardiac and respiratory functioning. Passive ROM improves joint mobility and circulation and decreases the likelihood of contractures.

Position in Alignment to Prevent Complications

• Use a footboard.

R:This measure prevents footdrop.

• Avoid prolonged sitting or lying in the same position.

R:This prevents hip flexion contractures.

• Change the position of the shoulder joints every 2 to 4 hours.

R:This helps to prevent shoulder contractures.

• Use a small pillow or no pillow when in Fowler's position.

R:This prevents flexion contracture of neck.

• Support the hand and wrist in natural alignment.

R:This prevents dependent edema and flexion contractures of the hand.

• If it's prone, place a rolled towel or small pillow under the lumbar curvature or under the end of the rib cage.

R:This prevents flexion or hyperflexion of lumbar curvature.

• Place a trochanter roll alongside the hips and upper thighs.

R:This prevents external rotation of the femur and hips.

• If in the lateral position, place pillow(s) to support the leg from groin to foot, and use a pillow to flex the shoulder and elbow slightly. If needed, support the lower foot in dorsal flexion with a towel roll or special boot.

R:These measures prevent internal rotation and adduction of the femur and shoulder and prevent footdrop.

• For upper extremities:
  • Arms abducted from the body with pillows
  • Elbows in slight flexion
  • Wrist in a neutral position, with fingers slightly flexed and thumb abducted and slightly flexed
  • Position of shoulder joints changed during the day (e.g., adduction, abduction, range of circular motion)

R:These positions prevent contractures.

Level 3 Advanced Specialty Interventions (rehabilitation, home care)

R:The PMAP is a nursing and interdisciplinary team approach to increase movement through a series of progressive steps from passive range of motion to ambulating independently as their medical stability increases (*Hopkins & Spuhler, 2009; MD Anderson, 2020).

Initiate early progressive mobility per institution's protocol. Consult with physical therapy and prescribing provider.

Assess for clinical signs and symptoms indicating termination of a mobilization session (Adler & Malone, 2012).

Heart Rate:

> 70% age predicted maximum heart rate,

> 20% decrease in resting HR

<40 beats/minute; > 130 beats/minute

New-onset dysrhythmia

New antiarrhythmia medication

New MI by EKG or cardiac enzymes

Pulse Oximetry/Saturation of Peripheral Oxygen (SpO₂):

> 4% decrease

<88 to 90%

Blood Pressure:

Systolic BP >180 mm Hg

> 20% decrease in systolic/diastolic BP; orthostatic hypotension

Mean arterial blood pressure < 65 mm Hg; >110 mm Hg

Presences of vasopressor medication; new vasopressor or escalating dose of vasopressor medication

Alertness/Agitation and Patient Symptoms:

Patient sedation or coma—Richmond Agitation Sedation Scale ≤−3

Patient agitation requiring addition or escalation of sedative medication; Richmond Agitation Sedation Scale > 2

C/o intolerable dyspnea on exertion