Possibly evidenced by
Inability to purposefully move within the physical environment, including bed mobility, transfer, ambulation
Impaired coordination, limited ROM, decreased muscle strength or control
Desired Outcomes/Evaluation Criteria—Client Will
Immobility Consequences: Physiological
Maintain or increase strength and function of affected or compensatory body part(s).
Regain or maintain optimal position of function, as evidenced by absence of contractures and footdrop.
Demonstrate techniques or behaviors that enable resumption of activities.
Maintain skin integrity and bladder and bowel function.
Nursing intervention with rationale:
1. Review functional ability and reasons for impairment
Rationale: Identifies probable functional impairments and influences choice of interventions.
2. Assess degree of immobility, using a scale to rate dependence (0 to 4).
Rationale: The client may be completely independent (0), may require minimal assistance or equipment (1), moderate assistance or supervision and teaching (2), extensive assistance or equipment and devices (3), or be completely dependent on caregivers (4). Persons in all categories are at risk for injury, but those in categories 2 to 4 are at greatest risk.
3. Provide or assist with ROM exercises.
Rationale: Helps in maintaining movement and functional alignment of joints and extremities.
4. Instruct and assist client with exercise program and use of mobility aids. Increase activity and participation in self-care as tolerated.
Rationale: Lengthy convalescence often follows brain injury, and physical reconditioning is an essential part of the program.
5. Position client to avoid skin and tissue pressure damage. Turn at regular intervals, and make small position changes between turns.
Rationale: Regular turning more normally distributes body weight and promotes circulation to all areas. If paralysis or limited cognition is present, client should be repositioned frequently.
6. Provide meticulous skin care, massaging with emollients. Remove wet linen and clothing, and keep bedding free of wrinkles.
Rationale: Promotes circulation and skin elasticity and reduces risk of skin excoriation.
7. Maintain functional body alignment—hips, feet, and hands. Monitor for proper placement of devices and signs of pressure from devices.
Rationale: Use of high-top tennis shoes, “space boots,” and T-bar sheepskin devices can help prevent footdrop. Hand splints are variable and designed to prevent hand deformities and
promote optimal function. Use of pillows, bedrolls, and sandbags can help prevent abnormal hip rotation.
8. Support head and trunk, arms and shoulders, and feet and legs when client is in wheelchair or recliner. Pad chair seat with foam or water-filled cushion, and assist client to shift weight at frequent intervals.
Rationale: Maintains comfortable, safe, and functional posture, and prevents or reduces risk of skin breakdown.
9. Provide eye care with artificial tears and eye patches, as indicated.
Rationale: Protects delicate eye tissues from drying. Client may require patches during sleep to protect eyes from trauma if unable to keep eyes closed.
10. Monitor urinary output. Note color and odor of urine. Assist with bladder retraining when appropriate.
Rationale: Indwelling catheter used during the acute phase of injury may be needed for an extended period of time before bladder retraining is possible. Once the catheter is removed,
several methods of continence control may be tried, such as intermittent catheterization for residual and complete emptying, external catheter, planned intervals on commode, and incontinence pads.