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. 

 

In this lesson, we’ll cover the key reasons immobility is enemy #1 in nursing. Ready? 

 

Immobility leads to skin breakdown

When 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?
Thorough skin assessment, barrier creams, keep patient clean and dry, consider specialty mattress or waffle mattress….and increase mobility.

 

Immobility leads to depressed respiratory function

Patients 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?
Monitor respiratory depth, assess cough, monitor SpO2, utilize IS, encourage cough/deep breathe, treat pain but be careful of over sedation and…increase mobility.

 

Immobility leads to constipation

When 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?
Encourage fluids (dehydration exacerbates constipation), administer stool softeners, laxatives and enemas as needed, get the patient up to the commode to potty, and…increase mobility!

 

Immobility leads to renal dysfunction

The effects of immobility and prolonged bedrest on the renal system are multifactoral. 

  • Decreased GFR leading to decreased urinary excretion of waste products.
  • Increased risk of the formation of renal calculi due to the backflow of urine into the kidneys. 
  • Pooling of urine in the renal calyces set the patient up for UTI.
  • Urinary retention can occur due to lack of pressure placed on the bladder by abdominal organs. Without that added pressure placed on the bladder when in an upright position, the urge to urinate is reduced even when the bladder is full. Additionally, it is more difficult to fully empty the bladder when using a bedpan or urinal, which also sets the patient up for retention. Over time, this over-distended bladder causes the stretch receptors to lose sensitivity.  Without the flushing of the bladder and urinary tract that comes with urination, patients with urinary retention are at heightened risk for UTI. 
  • If urinary or fecal incontinence is also present, this is another huge risk factor for UTI as bacteria migrate into the urinary tract. 

 

What are you going to do about it?
Encourage fluids to keep stimulating those stretch receptors, get the patient up to the commode to urinate (or have men stand), monitor for urinary retention using the bladder scanner and, increase mobility!

 

Immobility leads to physical deconditioning

Without 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?
Assess muscle strength, encourage in-bed exercise, get a PT consult, perform ROM, utilize assistive devices such as walkers and….increase mobility!

 

Immobility leads to electrolyte imbalances

Sodium 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?
Monitor serum electrolytes, replace or treat as needed, and…increase mobility!

 

Immobility contributes to psychological dysfunction

Studies 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?
Assess patient for confusion, depression, anxiety. Place clock and date/calendar in view. Make sure the patient has their glasses or hearing aids in place. Reorient the patient as needed and, increase mobility!

 

Immobility leads to DVT

Without 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?
Ensure the patient is wearing SCDs while in bed, performing ankle pumps, and receiving pharmacologic prophylaxis if warranted (lovenox, heparin), and…increase mobility!

 

Immobility leads to falls

Thanks 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?
In-bed mobilization to increase endurance, ask for PT consult, teach patient to get up slowly, ensure call light is within reach, keep confused patients near nurses’ station, ensure over-bed table is within reach, bed is low and locked, and…increase mobility!

 

Immobility leads to impaired glucose metabolism

Bedrest 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?
Monitor blood sugar, administer insulin as needed, consider consistent-carbohydrate diet, and…increase mobility!

 

How to increase mobility

Increasing 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: 

  • The patient’s physical fitness (or lack thereof)
  • Any limitations – physical or medical
  • The patient’s ability to tolerate activity (hemodynamics, respiratory status, cardiac status)
  • The patient’s ability to follow instructions
  • The patient’s fall risk
  • What resources will be needed – equipment or personnel
  • The patient’s goals and wishes
  • And, of course, the MD orders

 

In general, you will maximize activity to the greatest extent you can for that patient. Some examples include:

  • Passive range of motion and repositioning at least every two hours.
  • Sitting in “beach chair” position, a setting on many ICU beds that assume a chair-like position without having to get the patient up. 
  • Dangling, or sitting on the edge of the bed – we’ll even do this with intubated patients and it’s a great opportunity to inspect the skin on their back and do a little massage with lotion…most people LOVE this!
  • Getting the patient up to the cardiac chair – this is a chair that lies flat for easy transfer from bed to chair. Once the patient is on the chair, it is lifted into a chair position and the patient is strapped in for safety.
  • Assistive standing, where the patient bears weight on his legs/feet but is supported with straps and arm rests. (link to images: https://www.arjo.com/siteassets/inriver/resources/i/icu-mobility-solutions.broch.us)
  • Getting the patient out of bed for meals – many times the MD will order this, but even if they don’t, it’s still a great idea if your patient can tolerate it!
  • Ambulating in the room – this is a great first step if you’re not sure how the patient will tolerate the extra activity. 
  • Ambulate in the halls – this is the end goal for many patients!

 

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 Clinics29(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 Times115(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 A73(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. Chest146(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 Experimental37(8), 802–806. https://doi.org/10.1016/0026-0495(88)90018-2

Why immobility is your #1 enemy - Nursing fundamentals