THEORITICAL CONCEPT OF MOBILITY AND IMMOBILITY
A. Medical Concept
1. Definition
a. Mobility
1) Mobility is the state of movement of the facility of movement.(Leahy and Kizilay, 1997)
2) Mobility is a person ability to move about freely.(Perry & Potter, 2003)
3) Mobility is a combination which is integrated between skeletal muscle system and nervous system.(Tarwoto Wartonah, 2006)
4) Mobility is person ability to move about freely, easy, and regularly that has purpose to fulfill healthy life.(Wahid Iqbal Mubarak, 2007)
From some definitions above can be concluded that mobility is a person ability for moving freely that is integrated by skeletal muscle and nervous system in order to fulfill their healthy life that is important for independence.
b. Immobility
1) Immobility is refer to inability to move freely.( Leahy and Kizilay, 1997)
2) Immobility is a person inability to move about freely (Perry & Potter, 2003)
3) Immobility is total of lack of ability or limitation of ability to perform movement or moved all body or part of the body.(Barbar Engram, 1999)
4) Immobility is relative condition which individual loss of movement and decreasing in activities.(Wahid Iqbal Mubarak, 2007)
5) Immobility is a limited condition of physical movement independently. (M.Badrushshalih,2008)
From some definitions above can be conclude that immobility is a person inability that can decrease in activities in normality because of loss of movement independently.
2.
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Factors that can influence mobility and immobility
a. Factors that can influence mobility:
1) Body Developing Level
Age can affect neuromuscular developing level and body proportionally, posture, movement and reflex will has function optimally.
2) Physical Healthy
Disease, body disability, and immobility will affect body movement.
3) Nutrition Status
Lower nutrition can cause muscle weakness and obesity can cause limited movement.
4) Emotion
Feel safe and happy can affect activity of each person. Fidgetiness and difficulty can lost a spirit so that influence their activity directly.
5) Neuromuscular and skeletal weakness
Posture abnormality condition like scoliosis, lordosis, and kifosis can affect the movement.
6) Job
A person who work in the office is less of doing activity if compared with the farmer or laborer.
b. Factors that can influence immobility
1) Musculoskeletal Disorder
a) Ostheoporosis
b) Atrophy
c) Contractur
d) Joint rigidity
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2) Cardiovascular Disorder
a) Hypotensi Postural
b) Vein Vasodilatation
c) Increasing of valsava maneuver usage
3) Respiratory System Disorder
a) Decreasing of respiration movement
b) Increasing of Pulmo secretion
c) Pneumonia Hypostatis.
(Tarwoto Wartonah, 2006)
3. Phatophysiology / Mechanism of Mobility
a. Regulation of movement
It is a coordinated body movement involves integrated functioning of the skeletal system, skeletal muscle and nervous system.(Potter & Perry, 2003)
1) Skeletal System
The functions are to support and form body tissue, to protect vital organs, adhere place of muscle and tendon, mineral source like salt, phospat, and red blood cell production place.(Tarwoto Wartonah, 2006)
a) Bones
Types: long, short, flat, irregular.
Characteristic: firmness, rigidity, elasticity.
b) 4
Joints are connection between bones.
c) Ligaments are white, shiny, flexible bands of fibrous tissue binding joints together, connection bones and cartilage.
d) Tendons are white, glistening, fibrous bands of tissue that connect muscle bone.
e) Cartilage is non vascular supporting connective tissue located chiefly in the joints and thorax, trachea, larynx, nose and ear.
2) Skeletal Muscle
The functions are to movement, form posture, heat production because of contraction and relaxation.(Tarwoto Wartonah, 2006)
a) Muscles are made of fibers that content when stimulated by an electrochemical impulse.
b) Muscle group work together to stabilize and support body weight standing or sitting.
c) Posture and movement also depend on the skeleton shape and development of skeletal muscle.
3) Nervous System
The functions are afferent nervous receive stimulation from the outside then continued to Central Nervous System (CNS), Nervous cell or neuron bring impuls from part of body to another part, Central nervous process impuls and then give a responses through efferent nervous, Efferent nervous receive responses and continued to skeletal muscle.(Tarwoto Wartonah, 2006)
a) 5
Transmission of impulses require a neurotransmitter.
b) Neurotransmitter transfer electric impulse from the nerve across the neuromuscular junction to the mask.
c) Neurotransmitter reaches a muscle and stimulates it, causing movement.
b. Phatological influences of mobility
1) Postural abnormalities
a) Its effect abnormalities affect of the efficiency of the musculoskeletal system.
b) It can cause pain, impair alignment or mobility.
c) Knowledge about characteristics, causes an treatment of common postural abnormalities is necessary for lifting, transferring, and positioning.
2) Impaired muscle development
3) Damage to the Central Nervous System (CNS).
4) Direct trauma to the musculoskeletal system.
(Potter & Perry, 2003)
The condition may result in mobility:
1) Example bed rest is an intervention in when the clients is restricted for a prescribed period o time.
2) Physical restriction or limitation of movement as by a cast is manifested by an imposed reduction of movement.
3) Restriction in changes in body position and posture result loosing of body’s ability to adapt to such changes.
4) 6
Sensory deprivation cause reduction in the stimulus to move and its manifested by even grater physical in activity.
(Leahy and Kizilay, 1997)
4. Clinical Manifestation
Sign and symptom in alteration of the basic of mobility including body response by physiologies and psychologies to mobility.
a. Through immobilization patient can get of physiology change and psychology change respond.
1) Physiology change
a) Musculoskeletal Changes
Every time clients can experience in loss of muscle strength and endurance, if they can not maintain the physical activities. Interference of muscle function by mobility in this case can cause interference of skeletal function. Joint also can get and decrease the muscle size (atrophy).
b) Cardiovascular system
The three major changes are orthostatic hypotension, increased cardiac work load, cardio vascular deconditioning, venous static and thrombus formation.(Olson, 1967)
c) Respiratory changes
Four majors factors are decrease hemoglobin, decrease lungs expansion because the intercosta and diaphragm can not work maximum contraction, generalized muscle weakness and static of secretion.
d) 7
Metabolic and nutrition changes
Immobility disturb normal metabolic function include decreasing BMR (Basal Metabolic Rate) so that is can cause Gastrointestinal disturbance such as decrease appetite and slowing peristaltic.(Price and Wilson, 1997)
e) Genitourinary changes
The renal pelvis may be fill before urine enters the ureters. This condition called urinary stasis. Urinary static can increase the risk for UTI and renal calculi.(Potter & Perry, 2003)
f) Gastrointestinal Changes
Increasing of adrenalin production, decrease the peristaltic and colon movement and sphincter response. Constipation occurs because of atrophy muscles.
g) Integument Changes
Older adult client with paralysis have grater risk for develop pressure ulcer. Any break in the skin integrity is difficult in the mobilized client (Helme, 1994). The ulcer occurs because the blood flow to the tissues obstructed. Commonly pressure ulcer called as decubital ulcers.
2) Psychology response related to the mobility (Potter & Perry, 2003)
Immobility may lead to emotional, social alteration, intellectual and behavioral response, sensory alteration and change in coping. The most common emotional changes are depression, behavioral changes, sleep and wake up disturbance, anxiety, low self esteem and impaired coping.
5. 8
Treatment
a. Preventing Problem for Immobility
1) Musculoskeletal Problem
a)Body repositioning
b) Weight-bearing activity
c)Independence in ADLs
d) Isotonic and isomeric exercise
e)ROM exercise
2) Cardiovascular Problem
a)Movement and Exercise
b) Discouraging use of falsafa maneuver
c)Regaining peripheral vasoconstriction with vertical position
d) Elastic stocking
e)Protecting leg positioning
3) Respiratory Problem
a)Deep breathing and coughing exercise
b) Turning, positioning and exercise
c)Diaphragmatic and abdominal breathing
4) Metabolic and Nutritional Problem
a)Diet: High calories protein
b) Vitamin and mineral supplement
c) 9
Weight bearing and exercise
d) Parenteral and enteral dietary supplement
5) Urinary and Fecal Problems
a)Turing, positioning and exercise
b) Improving hydration
c)Perineal hygiene
d) Acidifying the urine
e)Position and relaxation for urination
f) Urinary catheterization
g) Preventing urinary incontinences
h) Movement and exercise
6) Neuro sensory and Physical Problems
a)Turning, positioning and exercise
b) Increasing tactile stimuli
c)Social stimulation and interaction
d) Maintain self - image
b. Preventing and treating Pressure Sores
1) Prevention
a) Manipulation of the environment
b) Ongoing assessment
c) 10
Proper positioning and exercise
d)Diaphragmatic and abdominal breathing
2) Treatment
a) Irrigation to clean ulcers
b) Application topical agent to promote healing
c) Application of occlusive dressing (e.g: Opsite / hydrocolloid dressing)
d)Debridement
6. Complication
(Barbara Kozier, 1991)
1) Musculoskeletal System
a) Absence of any involuntary muscle contraction, muscle strength decrease 5% per day.
b) Individual who remained in bed for one week, muscle strength will decrease 1-1,5% per day.
c) Contracture and atrophy.
d) Bone density change, loss occur with 10 days of bed rest and take 4
months to restore.
e) Osteophorosis leading to fracture.
f) Osteoathrophy due to calcium salt deposit in the joint.
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2) Gastrointestinal System
a) Negative nitrogen balance because of increasing catabolism, breakdown of tissue and decrease anabolism.
b) Market protein deficiency which can lead to anorexia, malnutrition and decrease tissue.
c) Constipation because of atrophy muscles needed in elimination.
3) Integumentary System
a) Normally, a person change position approximately 50 times per day.
b) If someone change position less than 25 times per day, pressure ulcers will develop (Kottke, 1966 cited by Leahy and Kizilay, 1997)
4) Genitourinary System
a) UTI (Urinary Tract Infection)
b) Renal stones form (30 % of immobilized client with 14-21 days after being put in bed).
5) Cardiovascular System
a) Orthostatic hypotension
b) Venous static and thrombus formation
c) Cardiovascular deconditioning
6) Respiratory System
a) Respiratory infection
b) Pulmonary embolus
c) 12
Pneumonia
d) Atelectasis
e) Respiratory acidosis
7) Metabolic System
Metabolic of carbohydrate, protein, fat because of the supine position decrease
adrenocortical hormone production.
8) Psychological System
a) Low self-esteem
b) Anxiety
c) Depression
- Nursing Care Concept
1) Assessment
(Barbara Kozier, 1995)
a. Nursing History
1) Daily activity level
2) Activity tolerance
3) Type and frequency of exercise
4) Factor affecting mobility (growth and development, physical health, mental health, nutrition, life style, personal value, fatigue and stress, external factor)
b. 13
Physical Examination
1) Body alignment
2) Gait
3) Joint appearance and movement
4) Capabilities and limitation for movement
5) Muscle mass and strength
6) Activity intolerance
7) Physical fitness
8) Problem related to immobility
2) Nursing Diagnoses , Outcome criteria and Interventions
1. Activity intolerance: insufficient physiologic or psychological energy to endure or complete required or desired daily activities.
Defining characteristic:
a. Verbal report of fatigue or weakness.
b. Exertional discomfort or dyspnea.
c. Abnormal heart rate or blood pressure in respone to activity ECG changes reflecting arrhythmia or ischemia.
Related Factor:
a. Bed rest and immobility
b. Generalized weakness.
c. Imbalance between oxygen supply and demand.
d. Sedentary life style.
(NANDA Nursing Diagnosis)
2. 14
Impaired Bed Mobility: Limitation of independent movement from one bed position to another(specify level).
Defining characteristic:
a.Impaired ability to do the following:
1) Move from supine to sitting.
2) Move from sitting to supine.
3) Move from supine to prone.
4) Move from prone to supine.
5) Move from supine to long sitting.
6) Move from long sitting to supine.
7) “scoot” or reposition self in bed.
8) Turn from side to side.
Related Factor:
1) Cognitive impairement.
2) Deconditioning.
3) Deficient knowledge.
4) Environmental constrains (i.e., bed size, bed type, treatment equipment, restrains)
5) Insufficient muscle strength.
6) Musculoskeleletal impairement.
7) Neuromuscular impairement.
8) Obesity.
9) Pain.
10) Sedating medications.
(NANDA Nursing Diagnosis)
3. 15
Impaired physical Mobility: Limitation in independent, purposeful physical movement of the boy or of one or more extremities(specify level):
a. Level 0 : is completely independent.
b. Level 1 : Requires use of equipment or device.
c. Level 2 : Requires help from another person for assistance, supervision, or teaching.
d. Level 3 : Requires help from another person and equipment or device.
e. Level 4 : is dependent (doesn’t participate in activity)
Defining characteristic :
1) decrease reaction team
2) difficulty turning
3) engages in substitutions for movement
4) gait changes
5) limited ability to perform line-motor skills
6) limited ability to perform gross-motor skills
7) limited range of motion
8) movement-induced shortness of breath
9) movement-induced tremor
10) postural inability during performance of routine ADLs
11) slowed movement
12) uncoordinated movements
Related Factors :
1) altered cellular metabolism
2) body mass index above 75th age-appropriate percentile
3) cognitive impairment
4) cultural beliefs regarding age-appropriate activity
5) decreased muscle strength, control, or mass
6) depressive mood state or anxiety
7) developmental delay
8) 16
discomfort
9) intolerance to activity and decreased strength and endurance
10) joint stiffness or contractures
11) lack of knowledge regarding value of physical activity
12) lack of physical or social environmental supports
13) limited cardiovascular endurance
14) loss of integrity of bone structures
15) medications
16) musculoskeletal impairment
17) neuromuscular impairment
18) pain
19) prescribed movement restrictions
20) reluctant to initiate movement
21) sedentary lifestyle, disuse, or deconditioning
22) selective or generalized malnutrition
23) sensory perceptual impairment
(NANDA Nursing Diagnosis)
4. Impaired Wheelchair Mobility : limitation of independent operation of wheelchair within environment (specify level).
Defining Characteristic:
1) impaired ability to operate manual or power wheelchair on an incline or decline
2) impaired ability to operate manual or power wheelchair on even or uneven surface
3) impaired ability to operate wheelchair on curbs
Related factors:
1) Cognitive impairement.
2) Deconditioning.
3) Deficient knowledge.
4) Depressed mood.
5) 17
Enviromental constraints (e.g., stairs, inclines, uneven surfaces, unsafe obstacle, distances, lack of assistive, devices or person, wheelchair type)
6) Impaired vision.
7) Insufficient muscle strength.
8) Limited endurance.
9) Musculoskeletal imapirement (e.g., contractures)
10) Neuromucular imapirement.
11) Obesity.
12) Pain.
7. Evaluation
(Barbara Kozier, 1991)
To evaluate whether client goals have been achieved, the nurse:
a) Ask the client to report adherence to a planned exercise program
b) Demonstrate specific exercise
c) Measure muscle size
d) Observe the client’s activity tolerance when performing self care activities
e) Measure vital sign before and after exercise and ambulation
f) Auscultate the lungs for absence of adventitious breath sound
g) Palpate extremity for temperature and edema
h) Ask the client about any discomfort
i) Observe times of fecal elimination
j) Check fluid balance
k) Observe and evaluate body alignment
l) Observe skin integrity
(Potter and Perry’s)
1. Reassess the client for signs and symptoms of improved or decreased mobility status.
2. Ask for the client’s perception of mobility status after intervention.
3. Ask if the client’s expectation of care are being met.
REFERENCES
Kozier, Barbara. 1995. Fundamental of Nursing: Concept, Process & Practice 4th edition. California: Addison-Wesley Publishing
Kozier, Barbara. 1995. Fundamental of Nursing: Concept, Process & Practice 5th edition. California: Addison-Wesley Publishing.
Potter and Perry’s. 2003. Fundamental of Nursing. Sydney: Mosby
Wilkinson.2007-2008. Nursing Diagnosis Handbook with NIC interventions and NOC Outcomes. . Prentice Hall
Wartonah, Tarwoto.2006.Kebutuhan Dasar Manusia dan Proses Keperawatan Edisi 3.Jakarta: Salemba Medika
Mubarak, Wahid Iqbal.2007.Kebutuhan Dasar Manusia.Jakarta:EGC
http://ahmadalfikri.blogspot.com/2008/06/pengertian-imobilitas.html, access on April 22nd 2010.
