Friday, November 26, 2010

Impaired Physical Mobility

Impaired Physical Mobility

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


Discussion of the Problem
Mobility, the ability to move freely, easily, rhythmically, and purposely in the environment, is an essential part of living. People must move to protect themselves from trauma and to meet their basic needs. Mobility is vital to independence; a fully immobilized person is as vulnerable and dependent as an infant. Alteration in mobility may be a temporary or more permanent problem. Medical conditions that could contribute to impaired physical mobility are the following: amputation, burns, cerebrovascular accident (CVA), stroke, craniocerebral trauma, disc surgery, herniated nucleus pulposus, renal dialysis, rheumatoid arthritis, sickle cell crisis, morbid obesity, multiple sclerosis, spinal cord injury, and total joint replacement. With regards to the aging process, loss of muscle mass, reduction in muscle strength and function, stiffer and less mobile joints, and gait changes develops. For those with impaired mobility, movement must be fostered to the full extent of capability to facilitate a satisfying life. No matter what their level of mobility, they must be encouraged to breathe fully, engage their abdominal muscles, and move as much as possible to prevent the physical and psychoemotional hazards of immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, ensure a safe environment, increase tolerance for physical activity, enhance physical fitness, restore or improve capability to ambulate, and improve social, emotional, and intellectual well-being.

Nursing Interventions Classification (NIC)
  • Amputation Care
  • Bed Rest Care
  • Body Mechanics Promotion
  • Exercise Therapy: Ambulation, Muscle ControlFall Precautions
  • Joint Mobility
  • Positioning
  • Self-care Assistance

Nursing Outcomes Classification (NOC)
  • Ambulation: Walking
  • Immobility Consequences: Physiological
  • Joint Movement: Active
  • Knowledge: Personal Safety
  • Mobility Level
  • Muscle Function
  • Risk Control
  • Self-Care: Activities of Daily Living

Goal and Objectives
·                   Pateint will sustain skin integrity, as well ass bladder and bowel function.
  • Patient will be free of complications of immobility, as manifested by intact skin, absence of thrombophlebitis, and normal bowel pattern.
·         Patient will be free of complications.
·         Patient will continue or augment strength and function of affected and/or compensatory body part.
·         Patient will demonstrate methods/actions that allow carrying on of activities.
  • Patient will show eagerness and executes physical activity independently or with assistive devices as necessary.
·         Patient will uphold position of function as manifested by absence of contractures.
·         Patient will verbalize understanding of individual situation, management regimen, and safety procedures.

Subjective and Objective Data
  • Decreased muscle endurance, strength, control, or mass
  • Generalized weakness
·         Impaired coordination
  • Imposed restrictions of movement including mechanical, medical protocol, and impaired coordination
  • Inability to move purposefully within physical environment, including bed mobility, transfers, and ambulation
  • Inability to perform action as instructed
  • Limited range of motion (ROM)
·         Muscle atrophy; contractures
·         Paralysis
  • Reluctance to attempt movement

Related Factors
  • Activity intolerance
·         Bacterial infections (osteomyelitis)
·         Decreased strength and endurance
  • Depression or severe anxiety
·         Fear of/real danger of dislodging dialysis lines/catheter
·         Immobilization by traction
·         Limitations imposed by condition; pain or discomfort, muscle spasms
  • Limited strength
·         Loss of a limb (particularly a lower extremity)
  • Medical restrictions
·         Multiple/recurrent bone infarctions or infections (weight-bearing bones)
·         Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic paralysis (initially); spastic paralysis
·         Osteoporosis with fragmentation/collapse of femoral head or vertebra (compression deformities)
  • Perceptual or cognitive impairment (altered sense of balance)
·         Restrictive therapies (bedrest),
·         Restrictive therapies/safety precautions, e.g., bedrest, traction, limb immobilization; contractures
·         Skeletal deformity

Assessment (Dx)
  • Check for functional level of mobility. Recognizing the particular level guides the design of best possible management plan.

FUNCTIONAL LEVEL CLASSIFICATION (GORDON, 1987)
Level 1
Walk, regular pace, on level indefinitely; one flight or more but more short of breath than normally
Level 2
Walk one city block or 500 ft on level; climb one flight slowly without stopping
Level 3
Walk no more than 50 ft on level without stopping; unable to climb one flight of stairs without stopping
Level 4
Dyspnea and fatigue at rest

  • Evaluate patient’s aptitude to execute Activities of Daily Living efficiently and safely on a daily basis.
Suggested Code for Functional Level Classification
0
Completely independent
1
Requires use of equipment or device
2
Requires help from another person for assistance, supervision, or teaching
3
Requires help from another person and equipment or device
4
Is dependent, does not participate in activity

Limited movement affects the capability to execute most activities of daily living. Safety with ambulation is a significant concern. Determines strengths or insufficiency and may give information regarding recovery. This helps out in preference of actions since different methods are used for the following: flaccid and spastic paralysis.

  • Assess input and output record and nutritional pattern. Monitor nutritional needs as they relate to immobility. Decubitus ulcers build up more rapidly in patients with a nutritional insufficiency. Good nutrition also gives required energy for participating in an exercise or rehabilitative activities.

  • Assess need for assistive devices. Correct utilization of wheelchairs, canes, transfer bars, and other assistance can enhance activity and lessen danger of falls.

·         Assess presence or degree of exercise-related pain and alterations in joint mobility. Examines development or recession of complications. May require to postpone augmenting exercises and stop until further healing occurs.

·         Assess skin on a regular basis, specially over bony prominences. Note affected side for color, edema, or other signs of compromised circulation. Softly massage any reddened areas and give aids such as sheepskin pads as indicated. Edematous tissue is prone to trauma and heals more gradually. Pressure points over bony prominences are most at risk for reduced perfusion. Circulatory stimulation and padding help avoid skin breakdown and ulcer progression.

  • Assess the safety of the environment. Blockages such as throw rugs, children’s toys, and pets can further hinder one’s aptitude to ambulate safely.

  • Check skin integrity. Assess for signs of redness, tissue ischemia particularly over ears, shoulders, elbows, sacrum, hips, heels, ankles, and toes.

  • Evaluate patient or caregiver’s awareness of immobility and its implications. Even patients who are for the moment immobile are at risk for effects of immobility such as the following: skin breakdown, muscle weakness, thrombophlebitis, constipation, pneumonia, and depression.

  • Note elimination status. Immobility promotes constipation.

  • Note for progressing thrombophlebitis. Prolonged bed rest or immobility allows clot formation.

Therapeutic Interventions (Tx)
·         Assist patient correctly execute muscle exercises as able or when allowed out of bed; execute abdominal-tightening exercises and knee bends; hop on foot; stand on toes. Adds to gaining ehnanced sense of balance and strengthens compensatory body parts.

  • Clean, dry, and moisturize skin as necessary.

  • Execute passive or active assistive ROM exercises to all extremities. Exercise enhances increased venous return, avoids stiffness, and sustains muscle strength and stamina. Avoids contracture deformities, which can build up quickly and could hinder prosthesis usage.

  • Give foam or flotation mattress, water or air mattress or kinetic therapy bed, as needed. Decreases pressure on skin or tissues that can damage circulation, potentiating risk of tissue ischemia or breakdown and decubitus formation.

·         Give medications before activity or exercises as suitable. Decreases muscle or tissue stiffness and tension, allowing patient to be more active and enabling participation. Muscle spasms or spasticity may hinder mobility

  • Give positive reinforcement during activity. Patients may be unwilling to move or initiate new activity because of fear of falling.

·         Give safety needs. Helps avoid accidental injuries or falls.

  • Help out with transfer methods by using fitting assistance of persons or devices when transferring patients to bed, chair, or stretcher. Show the use of mobility aids, such as the following: trapeze, crutches, or walker. Promotes self-care and patient’s independence. Correct transfer methods avoid shearing abrasions related to “scooting.”

  • Help patient in accepting limitations. Point out aptitudes.

·         Help to develop sitting balance and standing balance. Helps out in retraining neuronal pathways, promoting proprioception and motor response.

·         Hold up head and trunk, arms and shoulders, feet and legs when patient is in wheelchair or recliner. Pad chair seat with foam or water-filled cushion, and help patient to shift weight at numerous intervals. Sustain comfortable, safe, and functional posture, and avoids or lessens risk of skin breakdown.

·         Include ADLs with physical therapy, hydrotherapy, and nursing care. Combining activities create enhanced results by complementing effects of each.

  • Keep limbs in functional alignment with one or more of the following: pillows, sandbags, wedges, or prefabricated splints. This avoids footdrop and/or too much plantar flexion or tightness. Maintain feet in dorsiflexed position.


  • Maintain side rails up and bed in low position. This provides a safe environment.

  • Make a bowel program, for example, sufficient fluid, foods high in bulk, physical activity, stool softeners, laxatives, as required. Document bowel activity level.

  • Make use of bed cradle. This keeps heavy bed linens off feet.

  • Make use of incentive spirometer. This maximizes lung expansion. Diminished chest excursions and stasis of secretions are related with immobility.

·         Offer diversional activities. Observe emotional or behavioral reactions to immobility. Decreases risk of constipation associated to reduced level of activity. Forced immobility may heighten restlessness, irritability. Diversional activity helps in refocusing attention and promotes coping with limitations.

·         Offer means to call for help, such as call bell and special sensitive call light. Allows patient to have a sense of control, and lowerss fear of being left alone. Note: Quadriplegic on ventilator needs constant inspection in early management.

·         Pace treatments and care activities to give periods of uninterrupted rest. Augments patient’s strength and tolerance for activity. Promotess healing and builds muscle strength and stamina. Patient participation enhances independence and sense of control.

  • Permits patient to execute tasks at his or her own pace. Never rush patient. Persuade independent activity as able and safe. Hospital workers and family caregivers are often in a hurry and do more for patients than required, thus making the recovery of the patient sluggish and lowers his or herself-esteem.

  • Persuade diet high in fiber and liquid intake of 2000 to 3000 ml per day unless contraindicated. Liquids maximize hydration status and avoid hardening of stool. Decreases risk of skin irritation or breakdown.

  • Promote early ambulation and other ADLs when possible. Help out with each initial change such as dangling, sitting in chair, ambulation. The longer the patient stays immobile the higher the level of debilitation that will take place.

  • Prop up resistance training services. It was found out in researches that strength training and other forms of exercise in older adults can maintain the aptitude to sustain independent living status and lower risk of falling.

·         Put antiembolic hose(or leotard) or sequential compression devices (SCDs) to legs as suitable. Prevents pooling of blood in lower extremities or abdomen, therefore enhancing vasomotor tone and decreased occurrence of thrombus formation and pulmonary emboli. Enhance venous return, lowering risk of Deep Vein Thrombosis.

·         Set goals with patient or Significant Other for involvement in activities or exercise and position changes. Enhances sense of anticipation of progress or improvement, and givess some sense of control or independence.

  • Start nutritional counseling as necessary if impairment results from obesity. Correct nutrition is necessary to keep sufficient energy level.

·         Support extremities in functional position; utilize footboard during the period of flaccid paralysis. Uphold neutral position of head. Avoids contractures or footdrop and enhaces use when or if function returns. Flaccid paralysis may impede with aptitude to support head, while spastic paralysis may lead to deviation of head to one side.

·         Take care of  pressure garment when utilized. Hypertrophic scarring can build up around grafted areas or at the site of deep partial-thickness wounds. Pressure dressings diminish scar tissue by maintaning it flat, soft, and flexible, promoting movement.

  • Turn and position every 2 hours or as indicated and perhaps more frequently if placed on affected side. This maximizes circulation to all tissues and alleviates pressure. Lowers risk of tissue ischemiaor injury. Affected side has poorer circulation and diminished sensation and is more inclined to skin breakdown.

  • Warn against keeping pillow under lower-extremity stump or allowing BKA limb to hang dependently over side of bed or chair. Utilization of pillows can cause lasting flexion contracture of hip; a dependent position of stump impedes venous return and may augment edema formation.

Educative (Edx)
  • Educate on energy-saving strategies. These maximize patient’s limited reserves.

  • Emphasize principles of progressive exercise, reinforcing that joints are to be exercised to the point of pain, not beyond. "No pain, no gain" is not always true. Organize exercise program into self-care and homemaker activities, such as, dressing self, washing, dusting, mopping, and leisure activities, for instance swimming. Patient is typically more eager to partake or finds it easier to keep an exercise program that fits into lifestyle and completes tasks as well.

  • Give explanation about progressive activity to patient. Assist patient or caregivers to institute practical and obtainable goals.

·         Istruct do perform deep breathing and coughing exercises. lift up head of bed as appropriate. Mobilizes secretions, enhaces lung expansion, and decreases risk of respiratory complications, for instance, atelectasis, and pneumonia.

  • Persuade appropriate utilization of assistive devices in the home setting. Mobility aids can augment level of mobility.

  • Persuade expression of feelings, strengths, weaknesses, and concerns.

  • Persuade family or significant other support and assistance with ROM exercises. Give emphasis to the significance of actions such as position change, ROM, coughing, and exercises. Permits family or Significant Other to be active in patient care and facilitates more consistent therapy.

·         Persuade patient to help out with movement and exercises using unaffected extremity to support or move weaker side. May react as if affected side is no longer part of body and requires support and active training to “reincorporate” it as a part of own body.

  • Teach patient or family regarding necessitates making home atmosphere safe. A safe milieu is a precondition to enhanced mobility.
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