This article covers immobility, deep vein thrombosis (DVT), and nursing care for immobility. You can follow along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
What is immobility?
Immobility, as defined by the North American Nursing Diagnosis Association, is a state in which an individual experiences, or is at risk for experiencing, limitation of physical movement. A change in a person's physical mobility can be a result of prescribed bed rest, movement that is physically restricted by an external device (e.g., a cast), voluntarily restricted movement (something the patient does to limit their movement), or the impairment or loss of motor function.
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Immobility effects on the body
Prolonged immobility may negatively affect the body's systems. It can have a deleterious effect on a patient's quality of life and can lead to the development of a series of complications, from prolonged length of stay in the hospital to increased morbidity and mortality.
Respiratory
Immobility can affect the respiratory system, for example, by decreasing lung expansion or increasing the risk of atelectasis (a partial or complete collapse of the lung). A patient who cannot move freely or is constrained to their bed is at risk of contracting respiratory infections (e.g., pneumonia).
Cardiovascular
Immobility's effect on the cardiovascular system includes the increased risk of blood clots and orthostatic hypotension, which is a form of low blood pressure that occurs when you stand up suddenly.
Musculoskeletal
Immobility can result in muscle atrophy and bone demineralization. That can lead to an increased risk for contractures (when muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) and osteoporosis. When the patient begins to be mobile again, muscle atrophy and bone loss may lead to fractures.
Remember that osteoclasts are the type of cell responsible for bone destruction, while osteoblast cells' job is to produce new bone (called osteoid and made of bone collagen and other protein).
Gastrointestinal
Immobility can affect the gastrointestinal system by decreasing GI motility (the process of food traveling through the digestive tract), which increases the risk of constipation.
Renal
The renal system may also be affected by immobility. When calcium from the bones is demineralized (as described above), it is liberated. That is, it is released into the bloodstream which, in turn, is filtered by the kidneys. So an excess of calcium in the blood can lead to kidney stones.
Immobile patients are also at risk for urinary tract infections due to urinary stasis.
Integumentary
When it comes to the integumentary system (skin), immobile patients have an increased risk for pressure injuries. If a patient cannot change their position on their own, they could develop pressure ulcers and sores.
Psychosocial
Finally, there are psychosocial effects to immobility, including feelings of isolation, depression, the loss of self esteem and a diminishing of sleep quality.
Immobility effects on function
Immobility, illness, or hospitalization may affect a patient's ability to perform ADLs (activities of daily living) and instrumental ADLs (IADLs). When someone is ill or immobilized or hospitalized, their ability to care for themselves may decrease. It is important to pay attention to a patient's ability to care for themselves.
ADLs
ADLs are the basic tasks necessary for living (e.g., ambulating, bathing, dressing, eating, toileting). These are things one does to one's own body.
IADLs
IADLs are more complex, but still important for functioning. Instrumental ADLs focus more on the patient's household — their life outside the hospital setting. This can include things like transportation, finances, and shopping. Meal planning, going to the grocery store, and balancing the household budget are examples of IADLs.
Nursing care
It is important to encourage patients to participate in their own care as much as possible. And even if a patient cannot care for themselves fully, avoid providing their total care. This can help maintain the patient's dignity and also to maintain their function. For example, if a patient is very limited and all they can do is take a washcloth to wash their face, encourage them to wash their face on their own every time.
Note that patients may not report a decrease in their ability to perform ADLs, as this may be embarrassing or upsetting. The best way to assess a patient’s ability to perform ADLs is by observing them.
Deep vein thrombosis
Deep vein thrombosis (DVT) is when a thrombus (blood clot) forms in a deep vein in an extremity, usually in the lower leg (calf and thigh).
Preventing DVT
Prevention of DVT may include:
- Early and frequent ambulation. That is, getting the patient to get up and start walking about as soon after their surgery as possible. This physical activity helps to strengthen joints and muscles (and can reduce the length of time the patient must remain in the hospital).
- Compression stockings (e.g., TED hose). TED stands for "thrombo-embolic deterrent." Compression stockings help venous and lymphatic drainage of the leg, which reduces the chances of DVT formation, especially in immobile patients.
- Sequential compression device (SCD). SCDs are inflatable sleeves that are worn on the lower legs while recovering from an illness or surgery in the hospital. SCDs, like compression stockings, help improve blood flow in the legs by compressing every so often, giving the leg a squeeze to help to move blood back up from the legs.
- Prophylactic medications, such as heparin, which can be administered through an IV or through a subcutaneous injection, and enoxaparin (Lovenox), which is low-molecular-weight heparin used to treat and prevent the formation of blood clots. Note that enoxaparin is only given subcutaneously and not through an IV.
Signs and symptoms
Signs and symptoms of deep vein thrombosis include erythema (skin redness at the site), probably on the calf.
The patient may suffer from swelling (edema) at the site due to vascular congestion.
Patients may also experience extreme pain at the location (again, usually the calf), especially when they flex their foot. This is sometimes called a positive Homans' sign. This movement is also known as dorsiflexion, that is, the backward bending and contracting of the foot (or hand). This motion will cause the patient pain. Don't encourage the patient to make this motion, but do pay attention in case they report pain in their calf when flexing their foot. That could be a sign of DVT.
Nursing care
Nursing care includes elevating the extremity, but avoid placing a pillow or adjusting the knee gatch (a mechanism on the bed that helps to angle the mattress under the patient's knee), which can cut off the blood supply. An inclined pillow (not placed under the knee) can be effective.
Applying a warm, moist compress can help relieve some of the pain.
Do not massage the limb. Massaging the affected area could dislodge the clot, which could lead to the patient developing a pulmonary embolism, a life-threatening blood clot in the lung.
It is vitally important to monitor for and report any sign or symptom of a pulmonary embolism, such as shortness of breath, chest pain, tachycardia, or hypotension (as noted above, a form of low blood pressure that occurs when the patient stands up suddenly).
Combatting the effects of immobility
As a nurse, combatting the effects of immobility in your patient is so important — both by helping prevent them in the first place, and treating any effects of immobility as they occur.
Many of these strategies and practices have been discussed above:
- Encourage coughing, deep breathing, and incentive spirometry to help keep the patient's lungs open and moving air.
- Apply TED hose (compression hose) or SCDs (sequential compression devices) to promote blood return from the legs.
- Provide anticoagulation as ordered. Medications often include Lovenox, a low-molecular-weight heparin also known as enoxaparin, which is administered subcutaneously to help prevent deep vein thrombosis (DVT).
- Reposition the patient every two hours. Also: keep their skin clean and dry. Encourage the patient to work their range of motion through the completion of passive and active exercises. Remember: while you can do this for them, it is important that the patient makes the physical effort themselves as part of their healing process.
- Increase fiber and fluid to help with bowel and urinary symptoms. Encourage the patient to move as tolerated or allowed.
- Coordinate referrals to physical therapy and occupational therapy as needed to help the patient, especially after they have been discharged from hospital care.
Again, it is important for the patient's healing process that they accomplish as many of these things as they can on their own. It will help them build their strength, post-op; it will build their self-esteem; and it can mean a shorter hospital stay and a more successful long-term outcome.
2 comments
osteoclasts!
You’re heaven sent!