ATI Engage Fundamentals: Immobility and Mobility

Vocabulary and concepts regarding immobility, mobility nursing interventions, proper body mechanics, and the staging of pressure injuries as outlined by ATI.

Immobility

An inability to move one or more body parts which, if prolonged, can negatively affect all major body systems.

Venous stasis

The slowing of blood flow caused by prolonged bedrest, standing, or sitting, which increases the risk for blood clots.

Fibrofatty connective tissue

Abnormal adhesions that form within and between joint spaces during prolonged immobilization, restricting joint nourishment.

Synovial joints

A fluid filled capsule that enables movement and flexibility.

Osteoporosis prevention in older adults

Includes encouraging movement and ensuring the diet includes calcium, which is stored in the bones.

Constipation interventions

Encourage ambulation (if not contraindicated) and increase fiber and fluid intake.

Immobile client risks

Prone to respiratory tract infections, pressure injuries, constipation, and urinary retention.

Urinary retention monitoring

If an immobile client experiences this, the nurse should monitor for urinary tract infection (UTI).

Passive range of motion

Exercises performed to increase joint flexibility and reduce joint stiffness.

Mobility assessment data points

Includes the client's ability to sit (on the edge of the bed for 2 minutes), the condition of the skin, and the need for assistance with ADLs.

Cane stairs technique

Instruct the client to keep the cane at the same level as the affected leg when climbing stairs.

Body mechanics for lifting

Stand close to the object being moved and keep the back straight.

Stage 1 Pressure Injury

Intact skin with nonblanchable redness and no maroon or purplish discoloration.

Stage 2 Pressure Injury

Partial-thickness skin loss with a pink/red wound bed that is moist and viable; may include a ruptured or intact serum-filled blister.

Stage 3 Pressure Injury

Full-thickness skin loss where fat (adipose) and granulation tissue are visible; rolled wound edges, slough, or eschar may be present, but bone and muscle are not visible.

Stage 4 Pressure Injury

Full-thickness loss of skin and tissue with exposed fascia, muscle, ligaments, cartilage, or bone; tunneling and undermining are likely.

Unstageable pressure injury

Slough and eschar conceal the extent of tissue loss, making it impossible to determine if the injury is a stage 3 or 4.

Deep tissue pressure injury

A localized area with nonblanchable deep red, maroon, or purple discoloration, which may include an intact blood-filled blister.