Nursing Diagnosis: Impaired Physical Mobility Application of NANDA, NOC, NIC

Nursing Diagnosis: Impaired Physical Mobility
Teepa Snow and Betty J. Ackley

NANDA Definition: A limitation in independent, purposeful physical movement of the body or of one or more extremities

Defining Characteristics: Postural instability during performance of routine activities of daily living (ADLs); limited ability to perform gross motor skills; limited ability to perform fine motor skills; uncoordinated or jerky movements; limited range of motion; difficulty turning; decreased reaction time; movement-induced shortness of breath; gait changes (e.g., decreased walking speed, difficulty initiating gait, small steps, shuffles feet, exaggerated lateral postural sway); engages in substitutions for movement (e.g., increased attention to other's activity, controlling behavior, focus on preillness/predisability); slowed movement; movement-induced tremor

Related Factors:Medications; prescribed movement restrictions; discomfort; lack of knowledge regarding value of physical activity; body mass index >30; sensoriperceptual impairments; neuromuscular impairment; pain; musculoskeletal impairment; intolerance to activity/decreased strength and endurance; depressive mood state or anxiety; cognitive impairment; decreased muscle strength, control, and/or mass; reluctance to initiate movement; sedentary lifestyle or disuse or deconditioning; selective or generalized malnutrition; loss of integrity of bone structures; developmental delay; joint stiffness or contractures; limited cardiovascular endurance; altered cellular metabolism; lack of physical or social environmental supports; cultural beliefs regarding age-appropriate activity

Suggested functional level classifications
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 device
4   Dependent—does not participate in activity

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Ambulation: Walking

·         Ambulation: Wheelchair

·         Joint Movement: Active

·         Mobility Level

·         Self-Care: Activities of Daily Living (ADLs)

·         Transfer Performance

Client Outcomes

·         Increases physical activity

·         Meets mutually defined goals of increased mobility

·         Verbalizes feeling of increased strength and ability to move

·         Demonstrates use of adaptive equipment (e.g., wheelchairs, walkers) to increase mobility

 NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Exercise Therapy: Ambulation

·         Exercise Therapy: Joint Mobility

·         Positioning

Nursing Interventions and Rationales

·         Screen for mobility skills in the following order: (1) bed mobility; (2) supported and unsupported sitting; (3) transition movements such as sit to stand, sitting down, and transfers; and (4) standing and walking activities. Use a physical activity tool if available to evaluate mobility. Screening mobility skills helps provide baselines of performance that can guide mobility-enhancement programming and allows nursing staff to integrate movement and practice opportunities into daily routines and regular and customary care. There are many tools available to measure physical activity; selection of the appropriate tool depends on the setting and situation (Halfmann, Keller, Allison, 1997).

·         Observe client for cause of impaired mobility. Determine whether cause is physical or psychological. Some clients choose not to move because of psychological factors such as an inability to cope or depression. See interventions for Ineffective Coping or Hopelessness.

·         Monitor and record client's ability to tolerate activity and use all four extremities; note pulse rate, blood pressure, dyspnea, and skin color before and after activity. See care plan for Activity intolerance.

·         Before activity observe for and, if possible, treat pain. Ensure that client is not oversedated. Pain limits mobility and is often exacerbated by movement.

·         Consult with physical therapist for further evaluation, strength training, gait training, and development of a mobility plan. Techniques such as gait training, strength training, and exercise to improve balance and coordination can be very helpful for rehabilitating clients (Tempkin, Tempkin, Goodman, 1997).

·         Obtain any assistive devices needed for activity, such as walking belts, walkers, canes, crutches, or wheelchairs, before the activity begins. Assistive devices can help increase mobility.

·         If client is immobile, perform passive range of motion (ROM) exercises at least twice a day unless contraindicated; repeat each maneuver three times. Passive ROM exercises help maintain joint mobility, prevent contractures and deformities, increase circulation, and promote a feeling of comfort and well-being (Kottke, Lehmann, 1990; Bolander, 1994).

·         If client is immobile, consult with physician for a safety evaluation before beginning an exercise program; if program is approved, begin with the following exercises:

o Active ROM exercises using both upper and lower extremities (e.g., flexing and extending at ankles, knees, hips)

o Chin-ups and pull-ups using a trapeze in bed (may be contraindicated in clients with cardiac conditions)

o Strengthening exercises such as gluteal or quadriceps sitting exercises

These exercises help reverse weakening and atrophy of muscles.

·         Help client achieve mobility and start walking as soon as possible if not contraindicated. The longer a client is immobile, the longer it takes to regain strength, balance, and coordination (Bolander, 1994). A study has shown that bed rest for primary treatment of medical conditions or after healthcare procedures is associated with worse outcomes than early mobilization (Allen, Glasziou, Del Mar, 1999).

·         Use a walking belt when ambulating the client. The client can walk independently with a walking belt, but the nurse can rapidly ensure safety if the knees buckle.

·         Apply any ordered brace before mobilizing client. Braces support and stabilize a body part, allowing increased mobility.

·         Increase independence in ADLs and discourage helplessness as client gets stronger. Providing unnecessary assistance with transfers and bathing activities may promote dependence and a loss of mobility (Mobily, Kelley, 1991).

·         If client does not feed or groom self, sit side-by-side with client, put your hand over client's hand, support client's elbow with your other hand, and help client feed self; use the same technique to help client comb hair. This feeding technique increases client mobility, range of motion, and independence, and clients often eat more food (Pedretti, 1996).

Geriatric

·         Help the mostly immobile client achieve mobility as soon as possible, depending on physical condition. In the elderly, mobility impairment can predict increased mortality and dependence; however, this can be prevented by physical exercise (Hirvensalo, Rantanen, Heikkinen, 2000).

·         For a client who is mostly immobile, minimize cardiovascular deconditioning by positioning client as close to the upright position as possible several times daily. The hazards of bed rest in the elderly are multiple, serious, quick to develop, and slow to reverse. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Resnick, 1998).

·         If client is mostly immobile, encourage him or her to attend a low-intensity aerobic chair exercise class that includes stretching and strengthening chair exercises. Chair exercises have been shown to increase flexibility and balance (Mills, 1994).

·         Initiate a walking program in which client walks with or without help every day as part of daily routine. Walking programs have been shown to be effective in improving ambulatory status and decreasing disability and the number of falls in the elderly (Koroknay et al, 1995).

·         Evaluate client for signs of depression (flat affect, insomnia, anorexia, frequent somatic complaints) or cognitive impairment (use Mini-Mental State Exam [MMSE]). Refer for treatment or counseling as needed. Multiple studies have demonstrated that depression and decreased cognition in the elderly correlate with decreased levels of functional ability (Resnick, 1998).

·         Watch for orthostatic hypotension when mobilizing elderly clients. If relevant, have client flex and extend feet several times after sitting up, then stand up slowly with someone watching. Orthostatic hypotension as a result of cardiovascular system changes, chronic diseases, and medication effects is common in the elderly (Matteson, McConnell, Linton, 1997).

·         Be very careful when getting a mostly immobile client up. Be sure to lock the bed and wheelchair and have sufficient personnel to protect client from falls. The most important preventative measure to reduce the risk of injurious falls for nonambulatory residents involves increasing safety measures while transferring, including careful locking of equipment such as wheelchairs and beds before moves (Thapa et al, 1996). Elderly clients most commonly sustain the most serious injuries when they fall.

·         Help clients assume the prone position three times per week for 20 minutes each time. If clients are unable to do so, help them turn partially over and assume the position gradually. The prone position helps prevent hip deformities that can interfere with balance and walking. This position may be contraindicated in some clients, such as morbidly obese clients, respiratory or cardiac clients who cannot lie flat, and neurological clients.

·         Do not routinely assist with transfers or bathing activities unless necessary. The nursing staff may contribute to impaired mobility by helping too much. Encourage client independence (Mobily, Kelley, 1991).

·         Use gestures and nonverbal cues when helping clients move if they are anxious or have difficulty understanding and following verbal instructions. Nonverbal gestures are part of a universal language that can be understood when the client is having difficulty with communication.

·         Recognize that wheelchairs are not a good mobility device and often serve as a mobility restraint. Wheelchairs can be very effective restraints. In one study, only 4% of residents in wheelchairs were observed to propel them independently; only 45% could propel them, even with cues and prompts; no residents could unlock them without help; the wheelchairs were not fitted to residents; and residents were not trained in propulsion (Simmons et al, 1995).

·         Ensure that chairs fit clients. Chair seat should be 3 inches above the height of the knee. Provide a raised toilet seat if needed. Raising the height of a chair can dramatically improve the ability of many older clients to stand up. Low, deep, soft seats with armrests that are far apart reduce a person's ability to get up and down without help.

·         If client is mainly immobile, provide opportunities for socialization and sensory stimulation (e.g., television and visits). See Deficient Diversional activity. Immobility and a lack of social support and sensory input may result in confusion or depression in the elderly (Mobily, Kelley, 1991). See interventions for Acute Confusion or Hopelessness as appropriate.

Home Care Interventions

·         Assess home environment for factors that create barriers to physical mobility. Refer to occupational therapy services if needed to assist client in restructuring home and daily living patterns.

·         Refer to home health aide services to support client and family through changing levels of mobility. Reinforce need to promote independence in mobility as tolerated. Providing unnecessary assistance with transfers and bathing activities may promote dependence and a loss of mobility (Mobily, Kelley, 1991).

·         Assess skin condition at every visit. Establish a skin care program that enhances circulation and maximizes position changes. Impaired mobility decreases circulation to dependent areas. Decreased circulation and shearing place the client at risk for skin breakdown.

·         Provide support to client and family/caregivers during long-term impaired mobility. Long-term impaired mobility may necessitate role changes within the family and precipitate caregiver stress (see care plan for Caregiver role strain).

Client/Family Teaching

·         Teach client to get out of bed slowly when transferring from the bed to the chair.

·         Teach client relaxation techniques to use during activity.

·         Teach client to use assistive devices such as a cane, a walker, or crutches to increase mobility.

·         Teach family members and caregivers to work with clients during self-care activities such as eating, bathing, grooming, dressing, and transferring rather than having client be a passive recipient of care. Maintaining as much independence as possible helps maintain mobility skills (Lipson, Braun, 1993).

·         Develop a series of contracts with mutually agreed on goals of increased activity. Include measurable landmarks of progress, consequences for meeting or not meeting goals, and evaluation dates. Sign the contracts with the client. Using a series of evolving contracts to modify behavior toward increasing activity, help the client learn skills to change behavior (Boehm, 1992).