Mobility and Hazards of Immobility

The ability to move freely is fundamental to health. When patients become immobile—whether from illness, surgery, injury, or weakness—every body system suffers. Understanding these hazards allows nurses to implement preventive interventions before complications develop.

Why Immobility Matters

Immobility is never benign. Bed rest, once prescribed as treatment, is now recognized as a source of serious complications. Within 24-48 hours of immobilization, physiological changes begin that can lead to life-threatening conditions.

Key Principle: Prevention is always easier than treatment. The nurse's role is to recognize risk factors and implement interventions before complications occur.

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Hazards of Immobility by Body System

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Respiratory Complications

Atelectasis

Atelectasis is the collapse of alveoli due to inadequate expansion. In immobile patients, secretions accumulate in dependent lung regions, blocking airways and causing alveolar collapse.

Risk Factors:

• Bed rest, especially supine positioning
• Post-surgical patients (especially abdominal or thoracic surgery)
• Decreased cough reflex
• Pain limiting deep breathing

Nursing Interventions:

• Encourage deep breathing exercises every hour while awake
• Use incentive spirometry 10 times per hour
• Reposition every 2 hours
• Administer pain medication before breathing exercises

Hypostatic Pneumonia

When secretions pool in the lungs and aren't cleared, bacteria proliferate, causing pneumonia. This is called hypostatic pneumonia because it results from static (unmoving) fluid in the lungs.

The "Turn, Cough, Deep Breathe" Protocol:

1. Turn the patient to a new position
2. Encourage coughing to clear secretions
3. Instruct deep breathing to fully expand lungs
4. Repeat every 2 hours

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Cardiovascular Complications

Deep Vein Thrombosis (DVT)

Deep Vein Thrombosis occurs when blood clots form in the deep veins, typically in the legs. Immobility causes venous stasis—blood pools rather than flowing, allowing clots to form.

Virchow's Triad (three factors that promote clot formation):

1. Venous stasis — Blood not moving (immobility)
2. Hypercoagulability — Blood clotting too easily (surgery, cancer, pregnancy)
3. Endothelial injury — Damage to vessel walls (IV lines, trauma)

Signs of DVT:

• Unilateral leg swelling
• Warmth and redness over affected area
• Positive Homans' sign (calf pain with dorsiflexion) — Note: This test has low sensitivity and is no longer routinely performed
• Palpable cord in the calf

Prevention Strategies:

Pulmonary Embolism (PE)

A Pulmonary Embolism occurs when a DVT dislodges and travels to the lungs. This is a life-threatening emergency.

Signs of PE:

• Sudden dyspnea
• Sharp chest pain (pleuritic)
• Tachycardia, tachypnea
• Anxiety, sense of impending doom
• Hemoptysis (coughing blood)
• Hypoxia

Nursing Action: This is an emergency. Administer oxygen, position the patient upright, notify the provider immediately, and prepare for anticoagulation therapy.

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Musculoskeletal Complications

Muscle Atrophy and Weakness

Muscles lose mass and strength quickly during immobility—up to 1-1.5% per day in critically ill patients. This "use it or lose it" principle means even a few days of bed rest can significantly impair mobility.

Contractures

Contractures are permanent shortening of muscles and tendons, causing fixed joint deformity. They develop when joints remain in one position without movement.

High-Risk Joints:

• Shoulders (frozen shoulder)
• Hips (flexion contractures)
• Knees (flexion contractures)
• Ankles (footdrop)

Prevention:

• Perform Range of Motion (ROM) exercises at least twice daily
• Position joints in functional alignment
• Use footboards or splints to prevent footdrop
• Avoid prolonged positioning in one position

Range of Motion (ROM) Exercises

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Integumentary Complications: Pressure Injuries

Pressure injuries (formerly called pressure ulcers or decubitus ulcers) develop when sustained pressure on tissue causes ischemia and cell death.

Pressure Injury Stages

High-Risk Areas

Pressure injuries develop over bony prominences:

• Supine: Occiput, scapulae, sacrum, heels
• Lateral: Ears, shoulders, greater trochanter, knees, malleoli
• Prone: Cheeks, shoulders, iliac crests, knees, toes
• Sitting: Ischial tuberosities, sacrum

Prevention Strategies

1. Reposition every 2 hours — The cornerstone of prevention
2. Float heels off the bed — Use pillows under calves (not knees)
3. Use pressure-relieving surfaces — Foam mattresses, air mattresses
4. Keep skin clean and dry — Moisture increases friction
5. Maintain adequate nutrition — Protein is essential for skin integrity
6. Assess skin with every position change — Early detection is key

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On the Exam

NCLEX questions about immobility often test prioritization and prevention:

• Priority: Respiratory complications are often most immediately life-threatening
• Prevention: Expect questions about turning schedules, incentive spirometry, and DVT prophylaxis
• Assessment: Know the signs of DVT, PE, and pressure injuries
• Delegation: UAP can assist with repositioning and ROM, but the RN must assess and plan

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Key Takeaways

• Turn immobile patients every 2 hours to prevent both pressure injuries and respiratory complications
• Use incentive spirometry and deep breathing to prevent atelectasis
• SCDs and early ambulation are key interventions for DVT prevention
• ROM exercises prevent contractures and muscle atrophy
• Pressure injuries are preventable—regular assessment and repositioning are essential