9.2: Assessing Mobility

Learning Objectives

By the end of this section, you will be able to:

• Identify key factors affecting mobility
• Describe techniques for assessing range of motion
• Recognize the effects of immobility on major body systems

Impairments in mobility impact a patient’s community, health, and access to care. The Centers for Disease Control and Prevention (CDC) states that 12.1 percent of all adults in the United States have some type of mobility disability (Figure 9.9) (Centers for Disease Control and Prevention, 2023). Mobility disability is categorized as a serious difficulty in walking or climbing stairs. Imagine the difficulty of daily activities if walking and climbing stairs are an obstacle to overcome. Other types of disabilities include cognitive, independent living, hearing, vision, and self-care.

Figure 9.9: This infographic shows 2021 CDC statistics on the leading disabilities among adults in the United States. (data source: Center for Disease Control; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

As a nurse, it is important to understand the importance of mobility, how internal and external factors can affect patient mobility, and how immobility affects the body. Proper understanding and assessment of a patient’s mobility can help guide the nurse’s plan of care and shape realistic outcome goals in treatment.

Factors Affecting Mobility

A person’s mobility is the ability of a patient to change and control their body position. Physical mobility requires sufficient muscle strength and energy, along with adequate skeletal stability, joint function, and neuromuscular synchronization. Anything that disrupts this integrated process can lead to impaired mobility or immobility. Mobility exists on a continuum ranging from no impairment (the patient can make major and frequent changes in position without assistance) to being completely immobile (the patient is unable to make even slight changes in body or extremity position without assistance). Factors that affect a patient’s mobility status can be internal or external. Internal factors can include chronic disease, congenital abnormalities, fatigue, or stress, and external factors include the environment around the patient.

Life-Stage Context: Mobility Is Key to Independence in Aging

Factors that affect mobility as a person ages, such as chronic disease, and changes in gait, balance, and strength can increase the number and severity of falls. These factors can also lead to the inability to perform ADLs independently or spend time with friends and family. Older adults who experience a loss in mobility

• are less likely to remain living at home;
• have higher rates of disease, disability, hospitalization, and death; and
• have poorer quality of life.

Researchers from the National Institute for Aging (NIA) are identifying risk factors for physical disability to prevent or reverse the loss of mobility and provide healthcare clinicians with interventions to improve physical function following hospitalization. Three current studies funded by the NIA are

• home improvements to help older adults remain independent,
• physical activity to prevent major mobility disability, and
• a reduction of sedentary behavior, such as sitting.

The goals are to enable older adults to age in place and remain as independent as possible to avoid costly institutional care.

Internal Factors

An internal factor that affects mobility is a factor that influences the patient from within, such as a physiological, sociocultural, psychological, or spiritual factor that is specific to each individual. Examples include hearing and visual function, frequent falls due to balance issues, chronic disease, personal attitude toward self-care, and mental health. These factors can vary in the degree in which they affect each patient. One patient may be mildly affected, only requiring minor alterations to lifestyle, while another patient may be so affected they require total care to function.

Congenital Abnormalities

A patient can suffer from impaired mobility due to a congenital abnormality. Congenital abnormalities are impairments of body function or structure present at birth (Table 9.2).

Table 9.2: Congenital Abnormalities and Their Effect on Mobility

Congenital Abnormality	Effects on Mobility
Cerebral palsy	Poor motor coordination Muscle stiffness and weakness Involuntary movements
Club foot	Restriction of normal foot movement Prevention of proper weight distribution on feet
Congenital heart defects	Low tolerance for activity Increased fatigue
Muscular dystrophy	Muscle weakness Possible deformity
Spina bifida	Leg weakness Paralysis

Muscle, Bone, and Joint Development

Joint structure, connective tissue, and changes in elasticity and flexibility of ligaments and tendons play a role in impaired mobility. As a patient ages, muscle is replaced with fibrous connective tissue and adipose tissue. Fibrous connective tissue protects, supports, and holds bones, muscles, organs, and other tissues within the body in place. Adipose tissue is body fat. Loss of bone mass begins to occur among individuals after the age of 40 (Campbell, 2021). Osteoporosis is an age-related disorder that causes the gradual loss of bone density and strength. When the thoracic vertebrae are affected, there can be a gradual collapse of the vertebrae (Figure 9.10). This results in kyphosis, an excessive curvature of the thoracic region. Other factors that can impact mobility include excessive adipose bulk, which can impede range of motion (ROM); a lack of functional activities or exercises to promote flexibility and balance; and injury to muscle, joints, or connective tissues (Table 9.3).

Figure 9.10: Osteoporosis, a progressive loss of bone density, is a factor in the deterioration of bones, muscle weakness, and changes in body composition in older adults. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Table 9.3: Disorders That Affect Mobility

Muscle, Bone, Joint Disorders	Effects on Mobility
Osteoporosis	Progressive bone loss leads to decrease in bone strength.
Muscle loss	Aging results in loss muscle mass.
Increased fibrous connective tissue	Fibrous connective tissues protects, supports, and holds bones, muscles, organs, and other tissues. Aging results in fibrous connective tissue replacing muscle mass.
Increased adipose tissue	Body fat begins to replace muscle mass in aging.

Fatigue and Stress

Stress can lead to fatigue, which can impact daily activities. This fatigue can be due to poor sleep quality, increased anxiety, and the effects of an existing disability. Individuals with disabilities are at a greater risk of experiencing fatigue than the general population, with this risk increasing with age. A person’s well-being may be impacted by physical fatigue, psychological or emotional fatigue, and mental fatigue. Specifically, some disorders that can cause these types of fatigue include multiple sclerosis, muscular dystrophy, post-polio syndrome, and spinal cord injury. Fatigue can also occur by physical or emotional stress from comorbidities, medication side effects, poor diet, inactivity, or a substandard environment.

External Factors

An external factor can also cause mobility issues. External factors are factors that surround the patient that effect mobility, such as climate, terrain, housing design, neighborhood safety, local laws, social attitudes, and support. The U.S. Department of Health and Human Services states that social determinants of health (SDOH) impact health outcomes, including mobility (U.S. Department of Health and Human Services & Office of Disease Prevention and Health Promotion, n.d.). A social determinant of health (SDOH) is a socioeconomic factor such as poverty, employment, and education that have the largest impact on health outcomes, mobility, education, and environmental conditions. Individuals with health-related social needs may lack affordable housing, access to healthy foods, connections with social services, or adequate transportation. For example, a patient who lives on a street without sidewalks or with sidewalks that have been destroyed by tree roots and not maintained will not have the same access to walk as someone who lives on a street with maintained sidewalks. In assessing patients, nurses should ask questions about the patient’s social situations, their support systems, and access to resources that contribute to a healthy lifestyle.

Cultural Context: Culturally and Linguistically Appropriate Services (CLAS)

Health inequities have been identified as a barrier to access health care for many. Two factors are culture and language. Often, information may be difficult to understand based on language, literacy level, or culture relevance. The U.S. Health and Human Services developed CLAS to help eliminate health inequities by tailoring services to an individual’s culture and language preference. Specifically, CLAS takes into account patient’s cultural health beliefs, preferred languages, health literacy levels, and communication needs (HHS, n.d.). Initiatives started by public health departments, hospitals, and ambulatory care centers across the United States include

• training staff in CLAS;
• recruiting a workforce representative of the community served;
• offering comprehensive language assistance services;
• requiring interpreters’ skills be certified or assessed;
• using advanced technology for interpretation services;
• improving the collection of race, ethnicity, and language data; and
• incorporating CLAS into mission, vision, and strategic plans.

Assessing Range of Motion

A person’s range of motion (ROM) is the extent to which a part of the body can be moved around a joint or a fixed point. Assessing ROM includes observing the capability and total movement of the joint. ROM is assessed during active ROM, active-assisted ROM, and passive ROM.

A movement called active ROM is ROM that is done independently by the patient. Patients who can contract, control, and coordinate movement around a joint are able to participate in active ROM exercises. An example of how to perform an active ROM assessment would be for the nurse to ask the patient to mimic their movements. The nurse will then demonstrate flexion, extension, hyperextension, or rotation while the patient tries to duplicate the same motions. Things to assess during active ROM include

• the patient’s willingness to move;
• any onset of pain, including where or when the pain occurs;
• if any movement intensifies pain;
• any visible restrictions to movement, and if there is a pattern; and
• the quality, pattern, and rhythm of the movement.

A movement called active-assisted ROM is ROM performed with partial assistance from an external force; the patient is able to perform ROM but may need additional assistance when they encounter pain or weakness. To assess this, the nurse may ask the patient to mimic their movements, similar to active ROM assessment. When the patient reaches a point of difficulty, the nurse can assist with completion of the movement. Things to assess for during active-assisted ROM include

• any onset of pain; including where or when the pain occurs;
• where the restrictions to movement are, and if there is a pattern;
• if assisted ROM movement intensifies pain; and
• how the patient feels after active-assisted ROM is complete.

A motion called passive range of motion ROM is movement to a joint or body part solely by another person or by a passive-motion machine. When passive range of motion is applied, the joint of an individual receiving exercise is completely relaxed while the outside force moves the body part while they are lying in bed. Things the nurse can assess while performing passive ROM include

• any onset of pain, including where or when the pain occurs;
• any restrictions to movement, and if there is a pattern;
• if movement intensifies pain; and
• how the patient feels after passive ROM is complete.

With this assessment information, nurses can collaborate with the provider and physical therapists to determine why any ROM deficits are occurring and create therapeutic interventions to support optimal ROM goals (Physiopedia, n.d.).

Posture and Gait

A person’s posture and the postural system is a fundamental mechanism to ensure balance against gravity, align the body, and assist in external environmental perception and action. Posture is not simply the act of “sitting up straight” but rather a central, dynamic process that relates to other physical processes such as sensory detection and coordination with the nervous system. Data from posture assessment can contribute to how a person performs ADLs, assessing musculoskeletal injuries, determining effectiveness of physical or occupational therapy interventions, and providing injury prevention information. A neutral posture is when a person’s upper trunk and head are at zero degrees in relation to the vertebral column (Figure 9.11). The nurse’s assessment will include how the patient’s posture compares to a neutral posture. Nurses should observe if the patient is erect or slumped. If the patient’s posture deviates from a neutral position this could be due to deficiencies in postural control and postural orientation and can lead to damage and misalignment of vertebrae. Posture has a direct effect on the movements during gait.

Figure 9.11: A neutral spine posture, that aligns the body’s center of gravity, reduces stress on joints and ligaments. (CC BY 4.0; Rice University & OpenStax)

The body’s gait is defined as a manner of walking or moving on foot. A person has a gait pattern, which is a series of rhythmical, alternating movements of the trunk and the limbs that results in a forward progression (Figure 9.12). The center of gravity, approximately anterior to the second sacral vertebrae (but changes as a person’s anatomical position changes), is the point around where the force of gravity acts. Generally, a person’s gait consists of a stance phase and a swing phase. In these phases, different body positions help to propel a person forward. Any pathological issue can affect this gait pattern, leading to abnormal gait patterns. Examples include joint deformities, muscle weakness, loss of motor function, and pain. Age and pregnancy can also affect gait as increased age is associated with declines in walking speeds and changes in centers of gravity.

Nurses assess gait by observing the patient’s stance phase and swing phase. The patient will walk across the room in different ways. First, the nurse observes patients on their toes, on their heels, and then heel to toe. In observing the gait, the nurse will take note of the patient’s posture, center of gravity, and arm and leg movements. The patient’s posture should be neutral, with slight swaying in the standing position. A patient’s gait should be smooth and rhythmic, with their arms swinging at the sides.

Figure 9.12: A compilation of the phases of a normal gait cycle; movement should be fluid and smooth. (credit: modfication of work "Walking_gait_cycle.png" by “Ducky2315”/Wikimedia Commons, CC BY 3.0)

Coordination and Balance

As mentioned previously, a person’s center of gravity plays a role in gait and posture but also affects coordination and balance. The force of gravity is generally downward; therefore, the body needs to adjust to the force of gravity while moving to promote stability.

A person’s coordination is the organization of different elements of the complex body, including muscular, skeletal, and sensory functions, to enable the elements to work together effectively. The nurse evaluates coordination by having the patient rapidly touch each finger with the thumb, rapidly pat the hand on the thigh, and tap the foot on the floor (or against your hand, if the patient is supine). Repeat the sequence on the opposite limb. Normally, the movements would be coordinated. If the patient is unable to perform these movements, it may indicate disease of the upper motor neurons or cerebellum.

The body’s balance is defined as a state of equilibrium. When a person’s center of gravity falls outside its base of support (a stance with two feet evenly stable on the ground), they can become unstable. Proper coordination and balance are essential for gait stability and posture alignment. The Romberg test is used to test balance and is also used as a test for driving under the influence of an intoxicant. Ask the patient to stand with their feet together and eyes closed. Stand nearby and be prepared to assist if the patient begins to fall. It is expected that the patient will maintain balance and stand erect. A positive Romberg test occurs if the patient sways or is unable to maintain balance. The Romberg test is also a test of the body’s proprioception, which requires healthy functioning of the spinal cord.

Figure 9.13: A nurse stands behind a patient during a Romberg test to make sure the patient does not fall. (credit: “Neuro Exam Image 9.png” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)

A sense called proprioception is the body’s ability to sense movement, action, and location of parts of the body. The sensations come from sensory receptors in the muscle, joints, and central nervous system signals to motor output. These sensory signals help patients perceive limb movements and positions, force, heaviness, and stiffness, and they help locate external objects relative to the body. A person’s vestibular function is their body’s ability to compensate in response to self and external forces and keep balance. If the vestibular system has any damage, it can affect balance, control of eye movements while the head is moving, and a sense of orientation to space. Finally, visual perception is a person’s ability to see and interpret the surrounding environment.

Life-Stage Context: Balance and Coordination: The Aging Process

As adults age, balance and coordination become compromised, which can lead to falls and injuries. Common issues among older adults include

• impaired vision,
• impaired gait due to changes in posture and loss of muscle mass,
• slower reaction time,
• dizziness or lightheadedness caused by medications or low blood pressure, and
• environmental hazards.

Tai chi is an exercise that is gentle and works on strength, flexibility, and balance.

Strength

Posture, gait, coordination, and balance are all affected by strength, which is the quality or state of being strong. Strength is foundational for the body to dynamically adjust and compensate to achieve balance and stability, coordinate parts of the torso and limbs, enhance posture, and correct gait.

Adults begins to lose muscle mass after age 40 with up to an 8 percent decline in muscle mass per decade (Cleveland Clinic, 2022). Muscle mass declines because of a reduction in muscle fibers and fiber size. In addition, the ability of muscles to repair damage also decreases. This process occurs as someone ages because of fluctuations in hormones, including estrogen, testosterone, dehydroepiandrosterone (DHEA), growth hormone, and insulin-like growth factor. Assessment of strength is important to establish a baseline for intervention evaluations.

Muscle strength should be equal bilaterally, and the patient should be able to fully resist an opposing force. Muscle strength varies among people depending on their activity level, genetic predisposition, lifestyle, and history. A common method of evaluating muscle strength is the Medical Research Council Manual Muscle Testing scale (Table 9.4).

Table 9.4: Medical Research Council Manual Muscle Testing Scale

Stage	Description
0	No muscle contraction
1	Trace muscle contraction, such as a twitch
2	Active movement only when gravity eliminated
3	Active movement against gravity but not against resistance
4	Active movement against gravity and some resistance
5	Active movement against gravity and examiner’s full resistance

This method involves testing key muscles from the upper and lower extremities against gravity and the examiner’s resistance and grading the patient’s strength on a scale of 0 to 5. For example, to assess upper extremity strength, first begin by assessing bilateral hand grip strength (Figure 9.14). Extend your index and second fingers on each hand toward the patient and ask them to squeeze them as tightly as possible. Then, ask the patient to extend their arms with their palms up. As you provide resistance on their forearms, ask the patient to pull their arms toward them. Finally, ask the patient to place their palms against yours and press while you provide resistance.

Figure 9.14: These are images of a nurse assessing upper extremity strength. (credit: “Neuro Exam image 38.png,” “Neuro Exam image 41.png,” and “Neuro Exam image 39.jpg” by Meredith Pomietlo/Chippewa Valley Technical College, CCBY 4.0)

Unfolding Case Study: Unfolding Case Study #2: Part 4

Refer back to Chapter 7 Hygiene for Unfolding Case Study Parts 1 to 3 to review the patient data. The nurse is providing care to a 71-year-old male patient in a nursing home setting. The patient is a new resident, having only been in the facility for one month. The patient’s daughter, Alicia, was previously upset by finding her father incontinent. After meeting with the patient’s daughter, a staff meeting was held to reiterate the importance of frequently toileting patients and ensuring they are clean and dry at all times.

Past Medical History

Patient’s medical history includes COPD, GERD, hypertension, hyperlipidemia, and myocardial infarction with stents placed fifteen years ago. Family history: Patient has four adult children, but only one who lives in town. When asked about his children, the patient states, “Only one of my kids, my Alicia, talks to me. The rest live too far away and never call or visit.” Social history: Previous occupation as a farmer. Recently sold the farm to a developer when he moved into the nursing home. Patient states, “I was forced to sell my home and farm because it wasn’t making money anymore.” Current medications: lisinopril (Zestril) 10 mg daily atorvastatin (Lipitor) 20 mg daily hydrochlorothiazide (Hydrodiuril) 50 mg daily

Nursing Notes

1200: Assisted patient to bathroom. While ambulating, the patient stated, “I’m really having a hard time walking these days. Even with help, it’s just too much work. Can’t you just put one of those catheter things in me, so I don’t have to get up?” 1230: Focused musculoskeletal assessment performed. Patient reports bilateral hip pain that is 4/10 at rest and 6/10 with ambulation. Slight back kyphosis noted, and patient reports being unable to stand up completely straight. Shuffling gait with ambulation. Bilateral leg muscle strength rated 3/5.

1.

Recognize cues: Which findings are most pertinent to the patient’s functional status?

2.

Analyze cues: What further information should the nurse gather to evaluate factors (internal and external) that may be affecting the patient’s mobility?

3.

Prioritize hypotheses: What are the priorities of care for the patient at this time?

Effects of Immobility on Major Body Systems

Immobility can pose a significant problem for all major body systems. Prolonged immobilization can affect every organ system and result in complications, including increased morbidity and mortality, prolonged length of stay at facilities, and increased healthcare costs (Brennan, 2023). These complications can considerably affect a person’s quality of life and daily functioning. Immobility has negative effects on a patient’s psychological, cardiovascular, respiratory, gastrointestinal, metabolic, genitourinary, and immune function.

Psychological Effects

Patients who experience difficulties with ADLs are three times more likely to suffer from depression (Gyasi et al., 2023). Limited mobility can also cause anxiety, stress-related alienation from family and friends, emotional dysfunction, and a poor sense of belonging (Gyasi et al., 2023). For example, a patient with pain from arthritis may begin to cancel social meetings with friends and family, decreasing interactions with friends and family, and creating a sense of isolation. This could negatively affect mood and increase the patient’s risk for depression. Depression can then lead to poor dietary habits or inability to follow a daily routine, placing the patient at risk for weight gain and further immobility.

Cardiovascular Effects

With prolonged bedrest and immobility, skeletal muscles that usually help compress valves in the leg veins during ambulation do not adequately contract, causing blood to pool in the veins of the legs. This decrease in venous return to the heart, also known as venous stasis, causes the heart to work harder to circulate blood, elevating the heart rate. The pooling blood in the legs also increases a patient’s risk for venous thrombus formation and orthostatic hypotension. A condition called orthostatic hypotension is a temporary drop in blood pressure when moving from a supine position to a sitting or standing position.

Respiratory Effects

Patients who are active often take deep breaths while actively performing tasks during the day. This stretches their lung muscles and provides them with extra air. Patients who are immobile take shallow breaths because it meets their respiratory needs. Lack of deep breathing deconditions the respiratory muscles and diminishes lung expansion. This can lead to blockages or lack of air to the alveoli and cause atelectasis, or partial or complete collapse of the lung.

Lack of deep breathing also decreases the cough reflex, limiting how well a patient can clear respiratory secretions from the lungs, increasing their risk for pneumonia. Inability of the heart to adequately circulate blood can cause blood to back up into the veins and alveoli of the lungs, causing pulmonary edema.

Gastrointestinal Effects

Immobility can affect digestive function by slowing down peristalsis, or the movement of food through the gastrointestinal system. Decreased peristalsis can cause constipation, increase in intestinal gas, abdominal distention, nausea and vomiting, fecal impaction, and ileus. Stomach acid can flow up from the stomach into the esophagus causing gastric reflux or heartburn. Anorexia and decreased fluid intake can also occur with immobile patients, either because of a lack of hunger or thirst or because of an inability to nourish themselves. Malnutrition can also occur.

Metabolic Effects

Mobility is essential for exercising, walking, and being physically active. When mobility is impaired, or there is a lack of access, a patient may develop metabolic issues. If a patient has a higher weight, or becomes immobile and gains weight, they may not be able to move at an intensity or frequency required to lose weight or prevent weight gain. This can lead to further mobility issues, and the development of metabolic diseases such as diabetes, leading to cardiovascular, neurological, and systematic disorders. Patients who have impaired mobility can still prevent the development of metabolic diseases and disorders by staying mobile even with their limitations, monitoring their nutrition, and setting realistic goals. Nurses should ensure that patients have the right equipment, are addressing the cause of the immobility, and are tailoring interventions specific to their needs and abilities.

Genitourinary Effects

Immobility can cause a patient to experience urinary retention or discomfort when urinating. Prolonged urinary retention can cause urinary tract infection (UTI) or kidney infection. Other examples include patients with incontinence or who void themselves which can cause tissue breakdown. Poor hygiene due to immobility or urinary statis, where urine stays in the bladder too long, can also lead to UTIs, especially in females.

Musculoskeletal Effects

Immobility causes decreased muscle mass, strength, and endurance. Immobility can also decrease flexibility, making movements more difficult and increasing the risk of falls and injuries. Immobilization can contribute to bone demineralization and osteoporosis, weakening the bones and increasing the risk of fractures. Connective tissue also shortens from limited use, and joints become stiff. This can cause complications such as decreased stability and balance, muscle atrophy, joint contractures, foot drop, and increased risk for falls. To mitigate these effects, individuals who are immobilized should receive interventions such as range-of-motion exercises, weight-bearing activities, and proper positioning to maintain musculoskeletal health and function.