Which nursing intervention will the nurse use to prevent complications of immobility in a client who has had a stroke?

Impaired physical mobility is a common nursing diagnosis found among most patients at one time or another. It can be a temporary, permanent or worsening problem and has the potential to create larger issues such as skin breakdown, infections, falls, and social isolation.

Índice Show

Causes of Impaired Physical Mobility (Related to)
Signs and Symptoms (As evidenced by)
Subjective: (Patient reports)
Objective: (Nurse assesses)
Expected Outcomes
Nursing Assessment for Impaired Physical Mobility
Nursing Interventions for Impaired Physical Mobility
References and Sources

Advancing age is the most common risk factor of impaired physical mobility which increases the risk of morbidity and mortality for this population. Enhancing mobility is important to also improve the quality of life of patients and lessen the burden on caregivers and the healthcare system.

Nurses must recognize risk factors of impaired physical mobility and work to prevent or improve poor mobility as much as possible. This requires a multidisciplinary team approach utilizing physical and occupational therapists, prosthetic services, rehabilitation centers, and other ongoing support to maintain physical progress.

Aging
Sedentary lifestyle
Deconditioning
Decreased endurance
Limited range of motion
Recent surgical intervention
Decreased muscle strength or control
Joint stiffness
Chronic pain and/or acute pain
Depression
Contractures
Neuromuscular impairment
Cognitive impairment
Developmental delay
Malnutrition
Obesity
Lack of access or support (social or physical)
Prescribed bedrest, immobilizers, or movement restrictions
Physical or chemical (sedatives) restraints
Reluctance or disinterest in movement

Signs and Symptoms (As evidenced by)

Subjective: (Patient reports)

Expression of pain and discomfort with movement
Refusal to move

Objective: (Nurse assesses)

Limited range of motion
Uncoordinated movements
Poor balance
Inability to turn in bed, transfer, or ambulate
Postural instability
Gait disturbances
Reliance on assistive devices
Contractures
Decreased muscle strength
Inability to follow or complete instructions

Expected Outcomes

Patient will participate in ADLs and prescribed therapies
Patient will display improvement in physical mobility by transferring from bed to wheelchair independently
Patient will remain free of contractures and decubitus ulcers from impaired mobility
Patient will demonstrate exercises to improve physical mobility

Nursing Assessment for Impaired Physical Mobility

1. Assess for conditions that contribute to impaired mobility.
Stroke, multiple sclerosis, dementia, paralysis, cerebral palsy, fractures, and arthritis are only a few disorders that can prevent purposeful movement.

2. Take note of prescribed movement limitations.
Following surgery patients may be prescribed bed rest to prevent injury. Other orders such as “non-weight bearing” status or the use of braces, slings, and immobilizers must be considered.

3. Assess for pain and limited range of motion.
Pain and stiffness will prevent the patient from participating fully in their care.

4. Assess strength and range of motion.
Deconditioned patients either from lack of exercise or illness may not possess the strength necessary to carry out ADLs or movement. Assessing the patient’s range of motion prior to movement will show the nurse what the patient is or is not capable of.

5. Use nursing judgment before implementing mobility.
Patients who are older in age, obese, or cognitively limited may not be able to transfer or ambulate without proper assistance. The nurse must first assess abilities and have adequate support available (other staff, PT, equipment) before assisting a patient to move as this could place the patient at risk for falls or injury. Never force a patient to move beyond what they are physically capable of.

6. Evaluate the need for multidisciplinary care.
Extensive mobility limitations may require rehabilitation and specialized therapies. The nurse is often the coordinator of additional support.

7. Assess equipment needs.
Additional support from walkers, wheelchairs, grab bars, commodes, adaptive equipment, prosthetics, and more can promote independence and optimize mobility.

8. Note feelings of disinterest or unwillingness.
The nurse may need to explore feelings of depression or lack of motivation before the patient will participate in their mobility. Embarrassment, hopelessness, and knowledge deficits are potential barriers that can be overcome.

9. Assess for a lack of appropriate environment or support.
Nurses may need to assess the patient’s home environment and the ability of caregivers. An unsafe living situation or lack of competent caregivers may be the reason for their impaired mobility and will further increase debility and place the patient at risk for injury or falls.

Nursing Interventions for Impaired Physical Mobility

1. Encourage the patient to do as much as they can.
Once the nurse has assessed the degree of immobility, they should encourage independence aligned with the patient’s capabilities. This decreases dependence on others and increases the patient’s self-esteem.

2. Medicate for pain.
If pain and discomfort are a barrier, the nurse can provide analgesics prior to performing exercises or planned ADLs. Even simple interventions such as a heating pad or ice packs may alleviate muscle and joint pain and increase movement.

3. Schedule activities around rest periods.
Allow the patient to determine the best times for exercise or movement related to their energy levels. Do not overwhelm or exhaust and allow periods of rest between activities.

4. Provide adaptive equipment.
Provide equipment that allows for maximum movement related to the patient’s capabilities. For example, if bed-bound but able to use upper extremities, a trapeze bar can help the patient can pull themselves up.

5. Provide passive ROM.
If the patient is unable to perform exercises independently, the nurse should provide passive ROM several times per day to prevent contractures and muscle weakness.

6. Promote proper nutrition and hydration.
Malnourishment prevents recovery and contributes to a higher risk of functional disability. Adequate caloric intake is required for energy with high-protein foods supporting muscle mass and strength. Hydration will prevent dehydration and promote circulation and keep skin, tissues, and muscles hydrated.

7. Incorporate family and caregivers.
Patients who feel supported by their families and spouses will feel committed to increasing their mobility. Families may need education on how to best support their loved ones, how to keep them safe, and how to use equipment.

8. Consult with the multidisciplinary team.
Impaired mobility may require the support of PT and OT to instruct on exercises and perform activities that stimulate muscle control and fine motor movement.

9. Coordinate ongoing support at discharge.
Patients may require ongoing support either at home through home health services or at a rehab center. Coordinating with the case manager to ensure the patient receives the appropriate care at discharge is vital to preserving their progress.

10. Set goals.
Patients may feel overwhelmed or hopeless if their barriers seem impossible. Helping them choose small goals, such as brushing their hair or sitting up in bed, gives them the motivation to keep going.

11. Provide positive reinforcement.
A patient that is making an effort, no matter how small will be more inclined to continue when their accomplishments are noticed and praised.

References and Sources

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
Milaneschi, Y., Tanaka, T., & Ferrucci, L. (2010). Nutritional determinants of mobility. Current opinion in clinical nutrition and metabolic care, 13(6), 625–629. https://doi.org/10.1097/MCO.0b013e32833e337d
Lim E. J. (2018). Factors Influencing Mobility Relative to Nutritional Status among Elderly Women with Diabetes Mellitus. Iranian journal of public health, 47(6), 814–823. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6077640/

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Risk Factor Recommendations Followed by Class/Level of Evidence

Recommendations for Treatable Vascular Risk Factors

Hypertension

Antihypertensive treatment is recommended for prevention of recurrent stroke and other vascular events in persons who have had an ischemic stroke and are beyond the hyperacute period. 1/A
Because this benefit extends to persons with and without a history of hypertension, this recommendation should be considered for all ischemic stroke and TIA patients. 1/B
An absolute target BP level and degree of reduction should be individualized, but benefit has been associated with an average reduction of less than 10/5 mm Hg, and normal BP levels have been defined as less than 120/80 by JNC-7. 1/B
Several lifestyle modifications have been associated with BP reductions and should be included as part of a comprehensive approach antihypertensive therapy (e.g. low sodium diet and regular exercise). 1/C
Optimal drug regimen remains uncertain; however, available data support the use of diuretics and the combination of diuretics and an ACEI. Choice of specific drugs and targets should be individualized on the basis of reviewed data and consideration, as well as specific patient characteristics (eg, extracranial cerebrovascular occlusive disease, renal impairment, cardiac disease, and DM). I/A

Diabetes

More rigorous control of blood pressure and lipids should be considered in patients with diabetes. I/B
Although all major classes of antihypertensives are suitable for the control of BP, most patients will require greater than 1 agent. ACEIs and ARBs are more effective in reducing the progression of renal disease and are recommended as first-choice medications for patients with DM. I/A
Glucose control is recommended to near-normoglycemic levels among diabetics with ischemic stroke or TIA to reduce microvascular complications. I/A
The goal for Hb A1c should be less than or equal to 7%. I/B

Cholesterol

Ischemic stroke or TIA patients with elevated cholesterol, comorbid CAD, or evidence of an atherosclerotic origin should be managed according to NCEP III guidelines, which include lifestyle modification, dietary guidelines, and medication recommendations. 1/A
Statin agents are recommended, and the target goal for cholesterol lowering for those with CHD or symptomatic atherosclerotic disease is an LDL-C of less than 100 mg/dL and LDL-C less than 70 mg/dL for very-high-risk persons with multiple risk factors. I/A
Patients with ischemic stroke or TIA presumed to be due to an atherosclerotic origin but with no preexisting indications for statins (normal cholesterol levels, no comorbid CAD, or no evidence of atherosclerosis) are reasonable to consider for treatment with a statin agent to reduce the risk of vascular events. IIa/B
Ischemic stroke or TIA patients with low HDL-C may be considered for treatment with niacin or gemfibrozil. IIb/B

Recommendations for Modifiable Behavioral Risk Factors

Smoking

All ischemic stroke or TIA patients who have smoked in the past year should be strongly encouraged not to smoke. I/C
Avoid environmental smoke. I/C
Counseling, nicotine products, and oral smoking cessation medications have been found to be effective for smokers. IIa/B

Alcohol

Patients with prior ischemic stroke or TIA who are heavy drinkers should eliminate or reduce their consumption of alcohol. I/A
Light to moderate levels of less than or equal 2 drinks per day for men and 1 drink per day for nonpregnant women may be considered. IIb/C

Obesity

Weight reduction may be considered for all overweight ischemic stroke or TIA patients to maintain the goal of a BMI of 18.5 to 24.9 kg/ m2 and a waist circumference of less than 35 in for women and less than 40 in for men. Clinicians should encourage weight management through an appropriate balance of caloric intake, physical activity, and behavioral counseling. IIb/C

Physical activity

For those with ischemic stroke or TIA who are capable of engaging in physical activity, at least 30 min of moderate-intensity physical exercise most days may be considered to reduce risk factors and comorbid conditions that increase the likelihood of recurrence of stroke IIb/C
For those with disability after ischemic stroke, a supervised therapeutic exercise regimen is recommended. IIb/C

Recommendations for Interventional Approaches to Patients With Stroke Caused by Large-Artery Atherosclerotic Disease

Extracranial carotid disease

For patients with recent TIA or ischemic stroke within the last 6 mo and ipsilateral severe (70% to 99%) carotid artery stenosis, CEA is recommended by a surgeon with a perioperative morbidity and mortality of less than 6%. I/A
For patients with recent TIA or ischemic stroke and ipsilateral moderate (50% to 69%) carotid stenosis, CEA is recommended, depending on patient-specific factors such as age, gender, comorbidities, and severity of initial symptoms. I/A
When degree of stenosis is less than 50%, there is no indication for CEA. III/A
When CEA is indicated, surgery within 2 weeks rather than delayed surgery is suggested. I/B
Among patients with symptomatic severe stenosis (greater than 70%) in whom the stenosis is difficult to access surgically, medical conditions are present that greatly increase the risk for surgery, or when other specific circumstances exist such as radiation-induced stenosis or restenosis after CEA, CAS is not inferior to endarterectomy and may be considered. IIb/B
CAS is reasonable when performed by operators with established periprocedural morbidity and mortality rates of 4% to 6%, similar to that observed in trials of CEA and CAS. IIa/B
Among patients with symptomatic carotid occlusion, EC/IC bypass surgery is not recommended routinely. IIIA

Extracranial vertebrobasilar disease

Endovascular treatment of patients with symptomatic extracranial vertebral stenosis may be considered when patients are having symptoms despite medical therapies (antithrombotics, statins, and other treatments for risk factors). IIb/C

Intracranial arterial disease

The usefulness of endovascular therapy (angioplasty and/or stent placement) is uncertain for patients with hemodynamically significant intracranial stenoses who have symptoms despite medical therapies (antithrombotics, statins, and other treatments for risk factors) and is considered investigational. IIb/C

Recommendations for Patients With Cardioembolic Stroke Types

Atrial fibrillation (AF)

For patients with ischemic stroke or TIA with persistent or paroxysmal (intermittent) AF, anticoagulation with adjusted-dose warfarin (target INR, 2.5; range, 2.0–3.0) is recommended. I/A
In patients unable to take oral anticoagulants, aspirin 325 mg/d is recommended. I/A
Acute MI and LV thrombus For patients with an ischemic stroke caused by an acute MI in whom LV mural thrombus is identified by echocardiography or another form of cardiac imaging, oral anticoagulation is reasonable, aiming for an INR of 2.0 to 3.0 for at least 3 mo and up to 1 y. IIa/B
Aspirin should be used concurrently for the ischemic CAD patient during oral anticoagulant therapy in doses up to 162 mg/d, preferably in the enteric-coated form. I/A

Cardiomyopathy

For patients with ischemic stroke or TIA who have dilated cardiomyopathy, either warfarin (INR, 2.0 to 3.0) or antiplatelet therapy may be considered for prevention of recurrent events. IIb/C

Valvular heart disease, Rheumatic mitral valve disease

For patients with ischemic stroke or TIA who have rheumatic mitral valve disease, whether or not AF is present, long-term warfarin therapy is reasonable, with a target INR of 2.5 (range, 2.0–3.0). IIa/C
Antiplatelet agents should not be routinely added to warfarin in the interest of avoiding additional bleeding risk. III/C
For ischemic stroke or TIA patients with rheumatic mitral valve disease, whether or not AF is present, who have a recurrent embolism while receiving warfarin, adding aspirin (81 mg/d) may be indicated. II/C

Mitral valve prolapse (MVP)

For patients with MVP who have ischemic stroke or TIAs, long-term antiplatelet therapy is reasonable. IIa/C

MAC

For patients with ischemic stroke or TIA and MAC not documented to be calcific, antiplatelet therapy may be considered. IIb/C
Among patients with mitral regurgitation resulting from MAC without AF, antiplatelet or warfarin therapy may be considered. IIb/C

Aortic valve disease

For patients with ischemic stroke or TIA and aortic valve disease who do not have AF, antiplatelet therapy may be considered. IIb,C

Prosthetic heart valves

For patients with ischemic stroke or TIA with modern mechanical prosthetic heart valves, oral anticoagulants recommended, with an INR target of 3.0 (2.5–3.5). I/B
For patients with mechanical prosthetic heart valves who have an ischemic stroke or systemic embolism despite adequate therapy with oral anticoagulants, aspirin 75 to 100 mg/d, in addition to oral anticoagulants, and maintenance of the INR at a target of 3.0 (range, 2.5–3.5) is reasonable. IIa/B
For patients with ischemic stroke or TIA who have bioprosthetic heart valves with no other source of thromboembolism, anticoagulation with warfarin (INR, 2.0–3.0) may be considered. IIb/C

Patent foramen ovale

Patent foramen ovale (PFO) with an atrial septal aneurysm (ASA) is associated with increased stroke risk in aspirin-treated patients less than 55 years old.
There is currently no evidence regarding optimal treatment (i.e. use of antiplatelet therapy versus anticoagulation versus surgical or endovascular closure) Trials investigating mechanical closure are underway.
PFO alone has not been shown to increase the risk of recurrent stroke among aspirin-treated cryptogenic stroke patients. IIb/C