The ability to move freely and easily is a prized possession. The functioning of all body systems is directly or indirectly enhanced by periodic changes in body positions. Unfortunately, unrestricted mobility is not always possible. AU disease and rehabilitative states involve some degree of immobility. With aging, potential for the occurrence of decreased mobility increases and the possibility of untoward outcomes also increases. Nursing management is central to maximize an individual's full mobility.
Impaired physical mobility may result quickly or insidiously. The duration may be time limited or chronic. One of the greatest tragedies occurs when an individual is impaired with an acute problem, and later develops a chronic problem because of interactive effects and nursing management deficiencies. This article will address such a problem by presenting the onset and progression, through a case study, of an individual with a nursing diagnosis of impaired physical mobility. In addition, an explanation of the background of the problem and a prescription for interventions, that effectively prevent or negate the pathological responses, will be covered. The presentation will focus on the musculoskeletal system.
Alice P is a 74-year-old female admitted to the hospital with acute abdominal pain. Prior to the onset of pain, she lived by herself and was very active ("I usually walk every day," "I do all my own house work"). Her younger sister, who lived two blocks from her, stated that "it's hard to keep up with her, she's always on the go." On admission, Mrs. P had complete range of motion of all joints, except her right knee which was limited from full motion from pain of arthritis. Her muscle tone and strength were good; but her movements were restricted because of pain.
A nursing diagnosis of impaired physical mobility was made because of Mrs. P's reluctance to attempt movement (see Table). Voluntary curtailment of movement helps to control, relieve, or prevent pain; yet this curtailment of movement has serious implications for an older individual.
A period of decreased physical activity impacts on an already affected musculoskeletal system. Aging has been shown in both human and animal studies to directly or indirectly produce changes in muscle and joints. For example, peak muscle force and power are reached by early adulthood, after which there is a marked and steady decline in muscle strength.1 Leg and back muscles have greater strength loss than arm muscles.2,3 The decline is reflective of the changes that occur in both the fast twitch muscle fibers that produce power and strength, and slow fibers that provide anaerobic endurance.4 The greatest loss occurs in the fast twitch fibers; hence, strength is more affected than is endurance.5-8
Flexibility of joint movement is affected both by the length and composition of muscle fibers. With aging, the length of the fiber decreases9 and collagen content of the connective tissue progressively increases.10-11 The result is an increase in stiffness of tissue and a decrease in joint mobility.
Nursing care for the older adult with impaired physical mobility is directed towards neutralizing the deleterious effects by maximizing mobility within the limits of the individual's condition. The ultimate nursing goals are the maintenance of abilities and prevention of impairment.
Specific goals address three major areas. The first area is the maintenance of muscle strength and endurance which involves: a) a daily conditioning exercise program which includes both isometric and isotonic muscle contractions and b) the promotion of protein anabolism. The second goal involves maintenance of joint flexibility. Interventions include range-of-motion exercise, proper positioning, and activities of daily living. The last goal relates to the attitudes or motivations of both the nurse and the patient. Attitudes of the nurse are important because unless the nurse values preventative interventions, none will be initiated. Unlike curative interventions, preventative interventions often do not have a high visibility factor.
Isometric Muscle Contractions. Isometric muscle contraction increases muscle tension without changing the length of the muscle or moving the joint. These tightening contractions help maintain the strength of muscle groups while not producing work or movement. Isometric exercises are particularly helpful in maintaining the strength of the quadriceps, abdominal, and gluteal muscles which are needed for upright mobility.
Isometric muscle contractions are useful when it is essential to avoid increasing cardiovascular load. Isometric contractions produce elevation of both systolic and diastolic blood pressure; but this change persists only during the exercise period.12 Additional stress to the cardiovascular system can result from the inadvertent use of the Valsalva maneuver, which increases the intrathoracic pressure by forcible exhalation against a closed glottis. The use of this maneuver can be prevented by having patients breathe through their mouth while exercising.
Isometric exercises involve alternately tightening muscles as hard as possible and then relaxing the muscle. The stronger the contraction the greater the benefit. An exercise schedule of five maximal isometric contractions each held for six seconds with a two-minute relaxation period between contractions has been found to increase muscle strength in healthy young males.13
Isotonic Muscle Contraction. Isotonic muscle contractions change the length of a muscle without changing the tension. As muscles shorten and lengthen, work is accomplished.
Isotonic exercises can be accomplished by pushing or pulling against a stationary object. Examples for a bedfast individual include: pressing feet against footboard; lifting body off bed using a trapeze; pushing body to a sitting position; and lifting buttock off bed by pushing with the hands against the mattress.
Isotonic exercises produce cardiovascular changes. The systolic blood pressure becomes elevated during the exercise and the elevation persists after the contraction is completed. This exercise should be used with caution in patients with compromised cardiovascular status. Further stress may be produced by the inadvertent use of the Valsalva maneuver.
Promote Protein Anabolism. The promotion of protein anabolism involves conservation and replenishment of energy stores. Energy conservation results from a decrease in stressors, such as anxiety or elevated temperature. Replenishment of energy stores involves adequate intake of protein and calories. A primary indicator of an adequate intake is maintenance or increase in weight.
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Positioning. Alignment of the body, regardless of the position, affects mobility. All positions should be evaluated with the normal upright standing position as the reference. The spine should be kept straight, the neck without lateral or anterior flexion, and the extremities in extension.
Range-of-Motion Exercise. Active and passive range-of-motion exercise provides different benefits for the immobilized individual. Active rangeof-motion exercise provides joint movement and stress on the bones. Active motion is beneficial for the maintenance of joint flexibility, skeletal strength, and muscle strength. In contrast, passive range of motion, where the individual's joints are moved through their range of motion, provides only for the maintenance of joint flexibility.
Attitude. The patient's attitude regarding exercise is an important variable for the maintenance of an intact functional musculoskeletal system. Often an individual does not value the benefits of early and repeated exercise during a period of decreased activity. A general belief is that the need for exercise diminishes with age. A person is expected to "act his age," to "slow down a bit," or to "enjoy a well-earned rest." A second reason for devaluing behavior relates to the perception of the sick-role. That is, when individuals become ill they must rest to get well. Activity is viewed as detrimental to recovery.
To negate or overcome such attitudes, interventions may need a twofold approach. The first relates to increasing the individual's cognitive base. Knowlege about the importance of exercise facilitates a more active productive life as well as allows an individual to feel in control during the period of decreased activity. The second approach is the use of benchmarking, directing an individual's attention to specific abilities that have been retained or improved.
Two weeks after admission and after two surgeries, colon resection for ruptured diverticulitis and colostomy for bowel obstruction, Mrs. P appears older than her stated age. Her muscular strength and endurance have decreased. She is not able to stand or ambulate without the assistance of two nurses. When she stands she cannot maintain a straight upright posture, and her height appears to have decreased five inches. Her body is in a flexed position as she attempts to walk (shoulders hunched and rotated forward, upper body leaning forward, head lowered looking at floor, and hips and knees in flexed position).
The nursing diagnosis of impaired physical mobility is still present. In fact, Mrs. P now exhibits all the major defining characteristics (see Table). Her functional level classification has increased from one to three, requiring help from another person and equipment devices.
From the period of physical inactivity, Mrs. P has incurred the two major complications associated with the musculoskeletal system: a loss of muscular strength and endurance, and a loss of joint mobility. Compounding the problem for Mrs. P was an inadequate nutritional intake and an increase in energy requirements.
The decrease in caloric and protein intake resulted from the routine postoperative fluid maintenance while NPO. The increase in metabolic demand resulted from the stressors, such as surgery and an elevated temperature. The result was the endogenous catabolism of muscle protein to meet the body's needs.
Loss of Muscular Strength and Endurance. Changes in muscular strength occur both in the aging adult and in the individual with impaired mobility. The common denominator for this occurrence is a decrease or lack of physical activity. Muscular strength is dependent on the tension of frequent contractions of muscle fibers.14 When tension produced within a muscle is decreased, a loss of muscle mass and a concomitant loss of muscle strength results.
Loss of strength was studied in a group of normal healthy young adult males who were maintained on bedrest for six weeks without an exercise program. The loss of muscle strength ranged from 0.04 to 5.5% per day. The greatest decrease in strength occurred during the initial period of bedrest. A plateau of muscle loss occurred as the period lengthened.15
No comparative study has been reported on older adults who already have decreased strength. It is theorized that the total loss of muscle strength will be less than a muscularly developed young adult. The impact of the loss, however, should be greater for the older adult both for the immediate effect on remobilization and for regaining strength to previous levels. Often compounding the problem for the older adult is a history of inadequate protein intake. This condition accelerates loss of muscle strength with inactivity and also hinders the body's ability to anabolize protein during the rehabilitative phase.
The rate of muscle strength loss is mainly dependent on the one factor of activity, muscle contraction with tension. The greater the amount of movement, the less the loss of muscle strength. Not all of the body's muscles are equally affected with impaired mobility.
Muscles most affected are the muscles which facilitate locomotion and maintenance of an upright position.16,17 These muscles include the gastrocnemius-soleus group, quadriceps, glutei, and erector spinae.
If muscle mass is lost, the return of muscle strength and mass is a slow process. When mere is no planned exercise program, recovery of muscle strength will approximate the period of inactivity.15,16,18 The slow twitch endurance muscle fibers recover faster than the fast twitch.18
As muscle strength and mass decrease, so does endurance. Muscles are less able to sustain activity without fatiguing. Muscular endurance is further reduced when the circulation is impeded. Nutrients cannot be supplied to the muscles and waste products cannot be removed.
Loss of Joint Mobility. Motion in joints and soft tissue is maintained by normal movement of body parts, including joint capsules, muscles, tendons, and subcutaneous tissues through full range of motion. If, for any reason, range of motion is restricted, tightness develops which restricts the arc of motion.
With reduced joint movement, ligaments and tendons shorten and composition of connective tissue changes. In animal studies, the connective tissue undergoes a marked increase in collagen; these changes occur very early.19 Joint changes can be accelerated if pain, edema, inflammatory exudate, trauma, impaired circulation, spasticity, and degenerative joint changes are present.
Muscle weakness affects joint mobility. Both flexors and extensors have a reduction in muscular strength; the greatest loss occurs in the extensor muscles.17,20 Flexion of the joint results as the extensor muscle becomes weak and fatigued.
Although all of the body's joints are susceptible to structural changes, the hip, knee, and ankle joints of upright mobility are most frequently affected. The hip joint becomes involved because full extension of the hip is difficult in all positions except during relaxed standing. In all other positions, partial flexion of the hip is always present. Even prone hip extension is still 10 to 20 degrees less than when upright.21 Sitting, elevation of the headrest, use of pillows under the knee, or elevation of the legs all increase flexion of the hip.
Full extension of the knee while in bed seldom occurs without conscious effort. All positions, except prone, favor flexion. The dominant muscle of the lower leg, the hamstring muscle group, tends to draw the knee into flexion. Other factors contributing to flexion of the knee include use of pillows under the knee, painful disabilities, and stationary positions.
The ankle has a high risk for the development of flexion contractions (drop foot) because of the effects of gravity and the strength of the plantar flexor muscle group. In addition, the weight of the bed clothes contributes to fatigue of the dorsal flexor muscles. If flexion is maintained, reambulation is difficult if not impossible.
Goals and interventions for an individual who has complications associated with the musculoskeletal system from decreased physical activity, are the same as the interventions to prevent complications. Major differences are the need for greater commitment on the nurse's part to help the patient and for greater awareness by the nurse of the essential interactive factors.
Essentials to consider when selecting interventions for goal attainment are the pathological process precipitating the inactivity period, the concurrent limits imposed by medical therapy, and the individual's abilities and limitations. Likewise, the potential adverse effects of activity and exercise on all body systems must be assessed. Without this knowledge, inappropriate and potentially detrimental nursing care may be prescribed.
The success of nursing interventions can be measured by evaluating the tone, strength, and size of muscles, endurance ability, and range of motion. To facilitate this evaluation, an initial collection of baseline information must occur as close to the onset of a period of decreased activity as possible. Maintenance or improvement of functioning is the measure of successful intervention.
To evaluate muscle tone, the individual is observed in a relaxed, comfortable position. The tautness of relaxed muscle indicates tone. Greater reliability of such subjective measurement can be attained if the same person repeats the assessment. Strength can also be evaluated subjectively by the degree of resistance muscle groups afford or by strength of hand grip. A more objective measure of strength can be obtained by the use of an ergometer. Size can be evaluated via circumferential measurements of appendages. A prominent landmark affords a point of reference to ensure reliability of repeated measurements.
Levels of daily living activities can provide endurance indicators. Statements regarding weakness or tiredness reflect endurance patterns. In addition, the length of performance of a task can be used to measure endurance. When an activity is stopped earlier than previously due to fatigue, endurance may be decreasing. Objective evidence of decreased endurance is reflected by an increase in heart and respiratory rate during the activity.
Joint mobility can be evaluated subjectively by observation of activities of daily living. A more objective measurement of joint motion is obtained with the use of a goniometer.
The nurse is the key to the planning, implementation, and evaluation of an intervention program for an individual with impaired mobility. Inherent in this program is the individual patient's motivation to gain daily adherence to an activity program. Without interventions, loss of muscular strength, endurance, and joint mobility will result. Early initiation and consistent application of an activity program has the power to negate or prevent the deleterious effects associated with decreased physical activity. In addition, such a program has the opportunity to help the older adult view exercise as an integral and essential component of an active life.
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