Mobility is the ability to move freely and purposefully. It depends on intact bones, joints, muscles, nerves, balance, cardiopulmonary reserve, cognition, and motivation. Immobility — whether from prescribed bed rest, illness, sedation, pain, or fear of falling — affects every body system, often within days. Older adults lose strength and function fastest, and hospital-associated disability is common after even a short admission.
Hazards of immobility
| System | Changes | Resulting problems |
|---|
| Musculoskeletal | Loss of muscle strength (earliest change), atrophy, bone resorption, shortening of muscles and joint capsules | Weakness, contractures (e.g., footdrop, hip flexion), disuse osteoporosis |
| Cardiovascular | Venous stasis, hypercoagulability, vessel wall injury (Virchow's triad); reduced baroreceptor response; increased cardiac workload | Deep vein thrombosis (DVT) and pulmonary embolism, orthostatic hypotension |
| Respiratory | Reduced chest expansion, pooled secretions, weaker cough | Atelectasis, hypostatic pneumonia |
| Integumentary | Sustained pressure and shear over bony prominences | Pressure injuries (sacrum, heels, trochanters; ischial tuberosities in wheelchair users) |
| Urinary | Urinary stasis in the renal pelvis and bladder; calcium released from bone | Urinary tract infection, renal calculi (hypercalciuria), retention |
| Gastrointestinal | Slowed peristalsis, reduced appetite | Constipation, impaction |
| Metabolic | Negative nitrogen balance, hypercalcemia, insulin resistance | Muscle wasting, poor wound healing |
| Psychosocial | Sensory deprivation, loss of roles | Depression, sleep disturbance, delirium in older adults |
Mobility and function
- Gait: posture, balance, stride length, base of support (step width), arm swing, smoothness. The gait cycle runs from one heel strike to the next heel strike of the same foot (stance phase plus swing phase).
- Timed Up and Go test: rise from a chair, walk 3 m (10 ft), turn, walk back, sit; 12 seconds or longer suggests increased fall risk.
- Range of motion (ROM): active first, then passive; a goniometer measures joint angles.
- Muscle tone: resistance to passive movement, feel on palpation, and reflexes — flaccid, normal, or spastic/rigid.
- Muscle strength — Manual Muscle Testing (0–5 scale)
| Grade | Finding |
|---|
| 5 | Normal — full ROM against gravity and full resistance |
| 4 | Full ROM against gravity and some resistance |
| 3 | Full ROM against gravity, no resistance |
| 2 | Full ROM with gravity eliminated |
| 1 | Trace contraction, no movement |
| 0 | No contraction |
Functional status tools
| Tool | What it measures |
|---|
| Katz Index, Barthel Index | Basic activities of daily living (ADLs) — bathing, dressing, toileting, transferring, continence, feeding |
| Lawton IADL Scale | Instrumental ADLs — using the telephone, shopping, cooking, housekeeping, laundry, transportation, managing medications and money |
| Functional Independence Measure (FIM) | 18 items in motor (self-care, sphincter control, transfers, locomotion) and cognitive (communication, social cognition) domains, each scored 1–7 |
| Mini-Mental State Examination / Mini-Cog | Cognition — not an ADL tool |
Signs of immobility complications: calf pain, swelling, warmth, or redness (DVT — though often silent); dizziness on standing; diminished breath sounds or crackles at the bases; nonblanchable redness; decreased bowel sounds; concentrated urine; flank pain; low mood.
Subjective vs. objective data: "I get short of breath after climbing five stairs" is subjective (reported by the client); a respiratory rate of 28/min after walking is objective.
- Duplex ultrasound for suspected DVT; D-dimer to help exclude it in low-risk clients
- Chest X-ray for atelectasis or pneumonia
- Serum calcium, urinalysis (UTI, crystals)
- Bone density (DXA) for long-term immobility or osteoporosis risk
- Braden Scale for pressure injury risk (lower score = higher risk; 18 or below indicates risk)
- Fall risk tools (e.g., Morse Fall Scale) on admission and with changes
- Early mobilization protocols — progressive activity as soon as the client is stable, including in intensive care
- Physical and occupational therapy referral
- VTE prophylaxis based on risk assessment:
| Measure | Safety points |
|---|
| Low-molecular-weight heparin (enoxaparin) | Subcutaneous in the abdomen at least 5 cm from the umbilicus, do not expel the air bubble in prefilled syringes or rub the site; bleeding; heparin-induced thrombocytopenia (HIT) — monitor platelets; dose adjustment in kidney impairment; risk of spinal hematoma with neuraxial anesthesia; contraindicated with a history of HIT |
| Unfractionated heparin | Bleeding, HIT; antidote protamine sulfate (only partially reverses LMWH); monitor platelets (and aPTT when therapeutic dosing) |
| Direct oral anticoagulants (e.g., rivaroxaban, apixaban) | Bleeding; avoid in severe kidney impairment per product; not interchangeable without guidance; do not skip or double doses; reversal: idarucizumab (dabigatran); 4-factor PCC for factor Xa inhibitors in the US (andexanet alfa withdrawn from the US market December 2025; availability elsewhere may differ) |
| Intermittent pneumatic compression devices | Use when anticoagulants are contraindicated or with them; do not apply to a limb with a known or suspected DVT; remove only briefly; check skin |
| Graduated compression stockings | Correct size and fit; remove daily for skin check; avoid in peripheral arterial disease; not recommended for VTE prevention after stroke (CLOTS trial) |
- Prevent and detect life-threatening complications first: watch for sudden dyspnea, chest pain, and tachycardia (pulmonary embolism); report unilateral leg swelling; never massage a leg suspected of DVT.
- Mobilize early and often. Early ambulation after surgery prevents pneumonia and venous thromboembolism; progress from sitting on the edge of the bed to standing to walking.
- Prevent orthostatic hypotension: raise the head of the bed gradually, have the client dangle the legs for a few minutes, check BP and dizziness, then stand with assistance; ensure hydration; review BP-lowering drugs.
- Maintain muscle and joint function
- Passive ROM for clients who cannot move — maintains joint mobility and prevents contractures (it does not build strength)
- Active or active-assisted ROM whenever the client can participate
- Isometric exercise (e.g., quadriceps and gluteal setting — tightening muscles without moving the joint) maintains muscle strength and tone during bed rest
- Perform ROM at least 2–3 times daily, each movement several times, gently and within the pain-free range; support the joint above and below
- Respiratory care: turn at least every 2 hours, deep breathing, coughing, incentive spirometry.
- Skin care: reposition regularly (at least every 2 hours in bed per risk and surface), shift weight every 15 minutes in a wheelchair (every hour if assisted), use pressure-redistribution surfaces, float heels, keep skin clean and dry.
- Elimination: fluids 2–3 L/day unless restricted (do not restrict fluids to "prevent" incontinence), fiber, regular toileting, upright positioning for voiding.
- Hemiplegia: place items and approach from the unaffected side for safety; teach the client to lead with the strong side when getting up and to use the strong arm and leg to move the weak side; protect the affected shoulder from pulling.
- Fall prevention: remove clutter and spills, good lighting, nonskid footwear, bed low and locked, call bell within reach, scheduled toileting.
- Psychosocial: keep a normal day-night routine, provide stimulation and social contact, involve the client in goal setting.
Nursing diagnoses: impaired physical mobility (e.g., cannot turn or change position in bed independently), activity intolerance (fatigue or dyspnea with activity), risk for disuse syndrome, risk for impaired skin integrity.
Assistive devices
- Cane: hold on the stronger side; top of the cane at the greater trochanter (wrist crease level), elbow flexed about 15–30°; advance the cane with the weaker leg, then step through with the stronger leg.
- Walker: stand inside the frame, elbows slightly flexed; move the walker forward about one step's length, step into it with the weaker leg first, then the stronger leg; do not pull on it to stand.
- Crutches: top of the crutch about 2–3 finger widths (about 5 cm) below the axilla; elbows flexed 20–30°; bear weight on the hands, not the axillae (pressure on the axilla can damage the brachial plexus).
- Stairs with crutches or a cane: up with the good leg first, down with the affected leg (and crutches) first.
General
- Keep moving at home; build activity gradually; wear supportive shoes.
- Report calf pain, swelling, sudden breathlessness, or chest pain.
- Rise slowly from bed or chair.
| Complication | Warning signs |
|---|
| Pulmonary embolism | Sudden dyspnea, pleuritic chest pain, tachycardia, anxiety, hypoxemia — emergency |
| DVT | Unilateral calf swelling, warmth, tenderness |
| Orthostatic hypotension | Dizziness, fainting, fall on standing |
| Pneumonia / atelectasis | Fever, crackles, reduced breath sounds, falling SpO₂ |
| Pressure injury | Nonblanchable redness over bony prominences |
| Contracture | Fixed joint limitation, footdrop |
| Renal calculi | Flank pain, hematuria |
- Loss of muscle strength is the earliest musculoskeletal change of bed rest; atrophy and contractures follow
- Virchow's triad: stasis, hypercoagulability, vessel injury → DVT
- Early ambulation prevents postoperative pneumonia and VTE
- Passive ROM prevents contractures; isometric exercise maintains strength without joint movement
- Orthostatic hypotension: dangle before standing, rise gradually
- MMT: 3 = full ROM against gravity, 5 = normal; goniometer measures ROM
- ADL: Katz/Barthel; IADL (telephone, shopping, finances, medications): Lawton; FIM = motor + cognitive
- Wheelchair users: highest pressure over the ischial tuberosities; shift weight every 15 minutes
- Hemiplegia: lead with the strong side; cane on the strong side, advanced with the weak leg
- Crutches: weight on hands, not axillae; stairs — up with the good, down with the bad
- Do not apply compression devices to a limb with a known DVT; monitor platelets with heparin products
Country Notes
United States
- Hospitals follow VTE risk assessment and prophylaxis quality measures; early mobility protocols are common in intensive care units.
- Durable medical equipment (walkers, wheelchairs) may be covered by Medicare with a provider's order.
Philippines
- Family members or a "watcher" usually stay at the bedside and help with turning, ambulation, and exercises — include them in teaching on safe transfers and fall prevention.
- Physical rehabilitation services are concentrated in larger hospitals and cities; teach a home exercise program before discharge.