Immobility Script 1. My name is Jenny Hurlow. My colleague Tim Paine and I are on the board of directors of the Association for the Advancement of Wound Care; the largest multidisciplinary wound organization in the United States. We have put together an educational program for retirement facilities on the risks associated with immobility and the importance, for all of us, of staying as active as we can. 2. Immobility can be defined as a limitation in independent, purposeful physical movement of the body or of one or more extremities. This loss of purposeful movement evolves slowly. Just as exercise builds strength over time with daily effort, it is true that a lack of regular activity leads to a progressive inability to move freely. A decrease in activity can be triggered by things such as; 3. A stroke which results is reduced muscle control. Without proper intervention this lack of control can lead to muscle weakness and loss of flexibility (contracture) 4. Chronic Obstructive Pulmonary Disease or other respiratory illness leads to SOB, impairing activity tolerance 5. Movement induced discomfort, such as after an acute injury without proper pain management, leads to a reluctance to participate in activities. 6. Simple arthritis, so common in this population, can lead to a reluctance to move yet is so aided when activity is encouraged. (An object at rest…) 7. Dementia can lead to inability to respond purposefully to sensation and cues for movement 8. Depression can cause a resident to become introspective and lose the motivation to maintain mobility 9. Previous falls or relocating to a new setting can cause fearfulness about ability to execute activities in a meaningful way 10. Risk factors for Immobility are varied.

11. A resident with dementia may think to herself, “I feel like moving but where should I go?” 12. A resident with chronic pain may choose to sit because “It hurts too much to move” 13. A resident with SOB may give up on walking because they get too short of breath when they walk. 14. A resident after a recent stroke may give up without encouragement because they can’t move their leg on their own and they don’t want to be a bother to staff. 15. One fall can cause fear of another fall if an activity is undertaken, thus limiting mobility 16. A sense of a safe grip on a walker may be hard to achieve with arthritic discomfort 17. Swollen ankles can ache as well as impair ability to execute the ankle movement required for a steady gait. 18. Loss of control over muscle function can lead to embarrassment at one’s less polished ability to walk 19. An out of date glasses prescription will make walking justifiably feel less safe. 20. Bedrest can be harmful Slide: Progressive heart weakening develops because the heart muscle is not being challenged Postural hypotension leads to dizziness when moving from laying down to sitting or standing up Slide 21. Prolonged bedrest results in an extended period of time without the need for robust circulatory movement which places the patient at a higher risk for medical complications, such as a blood clot in the leg or a pressure ulcer 22. Slide Well, yes, a good night’s rest is very important but…

23. Slide Once strength is lost it will not be regained without a lot of focused, hard effort, especially in the elderly. This is why physical therapy is typically ordered after a surgical intervention or even general hospitalization. Slide 24. Slide 25. So let’s look at how immobility affects each of the body’s major systems. Slide 26. First point on slide. Because the heart must pump more blood against the force of gravity Second and third points on slide. Optimal circulation in the legs is dependent on calf muscle movement. When a leg is hanging down on a w/c leg rest, there is no calf muscle action, so blood in the veins will pool causing swelling, and this will block flow of fresh warm arterial blood flow. This slowed blood flow leads to high risk for a blood clot or deep vein thrombosis. Immobility can also lead to Dizziness upon standing because body systems are not used to responding efficiently to the need to compensate for position changes. 27. In an inactive person, breathing slows and deep breathing is not stimulated. It is also more difficult to fully expand the lungs when lying in bed. Mucous is naturally produced in the lungs to help to clear irritants. However, in an immobile patient, these secretions will pool providing optimal environment for bacterial growth and possibly resulting pneumonia. 28. The bottom of the feet are designed to bear the weight of the body. In the immobile patient, weight bearing shifts from the feet to the body’s bony prominences; the heels and hips, the sacrum, shoulders and head. Pressure from the bed and pillows on these areas squeeze off the fresh blood flow to the tissue which can result in tissue death and ulceration.

Blockage of this fresh blood flow to the tissue normally causes an uncomfortable sensation which triggers the individual to shift position, if they are able to do so. However, a person with dementia, though they may feel the discomfort, has lost the ability to process that this uncomfortable sensation is relieved by repositioning. This increases the risk for pressure related skin damage. 29. The bladder muscle contracts to empty urine, but without the added assistance of gravity gained from upright positioning, residual amounts of urine tend to pool in the bladder, increasing risk for urinary tract infection Slide Loss of independence for toileting… Also, did you know that skin that is too moist…? 30. Slide: Limited activity can cause decreased appetite and decreased peristalsis Peristalsis is the squeezing action of the colon which moves the stool, a bit like squeezing toothpaste through a tube. Peristalsis is encouraged by activity. Moisture is absorbed from the stool as it passes through the colon. Slow movement of the contents of the colon, resulting from decreased appetite and decreased peristalsis, promotes too much moisture absorption leading to risk for constipation and impaction. 31. Our musculoskeletal system is most efficient when used regularly. Without regular use muscles can become stiff (contractures) as well as lose strength and bulk (atrophy). Slide. 1 week of strength lost by inactivity… Muscles also lose coordination leading to decreased ability to rapidly respond to loss of balance (increased fall risk) and without the pull of the muscles on the bones, the bones do not need to be as strong and they will lose density (increased risk of fracture)

32. The body is always trying to be as efficient as it can. If the body is not moving, it has decreased metabolic needs, and will adjust to these decreased needs. Decreased activity can lead to decreased appetite and thirst. Less fluid intake can lead to dehydration and immobility will promote loss of calcium from the bones which can increase the risk of developing kidney stones. 33. As I’ve discussed, immobility leads to generalized muscle weakness. As a result, residents may tend to sleep more during the day, resulting in increased isolation. This isolation and sleeping during the day can result in confusion and insomnia. Immobility and weakness can cause a feeling of helplessness and frustration leading to irritability, boredom, isolation, confusion, and depression. So, Immobility can affect a patient’s mental as well as physical state. 34. Prolonged rest and immobility does not lead to regeneration as one may feel after one good night’s rest. In fact, immobility can lead to the very opposite! It can significantly increase the risk for: SLIDE 35. The less mobile a resident is, the more at risk they are for developing complications Immobility effects every body system, and the recovery time from these effects is MUCH longer than the time spent being immobile. It is much more efficient to maintain the body’s strength than it is to recover lost body function. 36. To help to prevent Immobility, it is important to encourage nursing home residents to be as independent as possible. Every little thing the resident can do for themselves is beneficial. When transferring a resident out of bed, it is best to ASSIST rather DOING the transfer for them. Even if the patient can do only 10% of the work, not only is this less of a workload on the caregiver, but it helps the patient to maintain their function. Over time, the 10% may grow to 20% or more.

It is ok to let a resident struggle with a task, but intervene when they show signs of frustration. Letting a resident do things for themselves may take a bit more time than just doing it for them but, if you think about it you will understand that this is best for the resident. Slide: Teach residents little ways… Research shows that persons in their 90’s can still increase strength and muscular endurance!! 37. Help the resident to be as active as possible, whether it’s turning over in bed or moving the wheels on the own wheelchair. But remember, it is ok to step in to assist when they become frustrated. It is your role to HELP as appropriate and to DO FOR them what they cannot do for themselves. Avoid putting a resident on bedrest.. Slide 38. Slide: These elements are essential to a comprehensive and effective plan of care. 39. The human body was designed to move! Movement is the ‘song of the body’ Help your residents to maintain the best quality for their lives by pushing their ‘activity’ button, the ‘play’ button, whenever appropriate, to help them to prevent succumbing to Immobility