Mobility and Immobility: Pressure Injury Prevention, DVT Prophylaxis, and Range of Motion

Mobility and Immobility: Pressure Injury Prevention, DVT Prophylaxis, and Range of Motion

A practical guide for nurses, clinicians, and caregivers

What Is This?

Mobility and immobility management prevents complications in patients who are bedridden, post-surgical, or neurologically impaired. This guide covers pressure injury prevention, deep vein thrombosis (DVT) prophylaxis, and range-of-motion (ROM) exercises—core interventions to maintain skin integrity, circulation, and joint function.

Why use it today? - Pressure injuries (bedsores) cost the U.S. healthcare system $26.8 billion annually and prolong hospital stays. - DVT occurs in 10–40% of medical/surgical patients without prophylaxis, leading to pulmonary embolism (PE), a life-threatening emergency. - Immobility accelerates muscle atrophy, contractures, and functional decline—especially in older adults.

Why It Matters

Key takeaway: These interventions save lives, reduce costs, and preserve quality of life.

Core Concepts

1. Pressure Injury Prevention

Definition: Damage to skin/underlying tissue from prolonged pressure, shear, or friction, typically over bony prominences (sacrum, heels, scapulae).

Pathophysiology: - Pressure > capillary closing pressure (32 mmHg)-ischemia-cell death. - Shear (skin stays in place while underlying tissue moves) worsens damage. - Moisture (incontinence, sweat) macerates skin, increasing vulnerability.

Prevention strategies: - Repositioning: Turn patients every 2 hours (or more frequently for high-risk patients). - Support surfaces: Use pressure-redistributing mattresses (e.g., foam, air-fluidized, low-air-loss). - Skin assessment: Use the Braden Scale (score ?18 = high risk) to evaluate risk factors (sensory perception, moisture, activity, mobility, nutrition, friction/shear). - Nutrition: Ensure adequate protein (1.2–1.5 g/kg/day) and vitamin C/zinc for wound healing.

2. DVT Prophylaxis

Definition: Preventing blood clots in deep veins (usually legs) that can embolize to the lungs (PE).

Virchow’s Triad (3 causes of DVT):
1. Venous stasis (immobility, paralysis).
2. Hypercoagulability (surgery, cancer, inflammation).
3. Endothelial injury (trauma, IV catheters).

Prophylaxis methods: | Method | How It Works | When to Use | Contraindications | |-----------------------|------------------------------------------|------------------------------------------|-------------------------------------------| | Pharmacologic | | | | | - Low-molecular-weight heparin (LMWH) | Inhibits factor Xa-prevents clot formation | High-risk patients (e.g., post-hip/knee surgery) | Active bleeding, renal failure | | - Unfractionated heparin (UFH) | Binds antithrombin-inactivates thrombin | Patients with renal impairment | HIT (heparin-induced thrombocytopenia) | | - Direct oral anticoagulants (DOACs) | Inhibits factor Xa or thrombin | Long-term prophylaxis (e.g., atrial fibrillation) | Mechanical heart valves, severe renal disease | | Mechanical | | | | | - Intermittent pneumatic compression (IPC) | Inflates/deflates sleeves-mimics calf muscle pump | Patients with bleeding risk | Severe peripheral arterial disease | | - Graduated compression stockings (GCS) | Applies graded pressure (highest at ankle) | Low-risk patients | Peripheral neuropathy, skin ulcers | | Early mobilization | Promotes venous return | All patients (if safe) | Unstable fractures, hemodynamic instability |

Key takeaway: Combine pharmacologic + mechanical methods for high-risk patients (e.g., post-major surgery).

3. Range of Motion (ROM) Exercises

Definition: Moving joints through their full available arc of motion to prevent contractures, maintain flexibility, and improve circulation.

Types of ROM: - Passive ROM (PROM): Caregiver moves the patient’s joint (e.g., comatose patient). - Active-assisted ROM (AAROM): Patient moves with assistance (e.g., post-stroke). - Active ROM (AROM): Patient moves independently (e.g., post-op day 1).

Key joints to target: | Joint | Motion | Example Exercise | |-----------------|-------------------------------------|------------------------------------------| | Shoulder | Flexion/extension, abduction/adduction | Arm circles, reaching overhead | | Elbow | Flexion/extension | Bicep curls (with/without resistance) | | Wrist | Flexion/extension, supination/pronation | Wrist rolls, "piano-playing" fingers | | Hip | Flexion/extension, abduction/adduction | Straight leg raises, hip circles | | Knee | Flexion/extension | Seated knee extensions | | Ankle | Dorsiflexion/plantarflexion | Ankle pumps, alphabet writing with toes |

Frequency: - PROM: 2–3x/day, 5–10 reps per joint. - AROM: As tolerated, every 1–2 hours if possible.

Key takeaway: Start ROM early—contractures can develop in days in immobile patients.

How It Works (Step-by-Step Workflow)

1. Assess the Patient

• Pressure injury risk: Use the Braden Scale (score ?18 = high risk).
• DVT risk: Use the Caprini Score (score ?5 = high risk).
• Mobility status: Can the patient move independently? Assist? Not at all?

2. Implement Interventions

Pressure Injury Prevention

1. Repositioning schedule:
2. Every 2 hours for high-risk patients.
3. Use a turning clock (e.g., 30° lateral tilt, not full 90° to avoid shear).
4. Support surfaces:
5. Foam mattress (low-risk patients).
6. Air-fluidized bed (stage III/IV pressure injuries).
7. Skin care:
8. Cleanse with pH-balanced cleansers (avoid soap).
9. Apply barrier creams (e.g., zinc oxide) for incontinence.
10. Nutrition:
11. Protein: 1.2–1.5 g/kg/day.
12. Vitamin C: 500 mg/day.
13. Zinc: 25–50 mg/day.

DVT Prophylaxis

1. Pharmacologic:
2. LMWH (e.g., enoxaparin 40 mg SC daily) for high-risk patients.
3. UFH (5000 units SC q8–12h) for renal impairment.
4. Mechanical:
5. IPC devices (e.g., sequential compression devices).
6. GCS (knee-high, 15–20 mmHg pressure).
7. Early mobilization:
8. Dangle legs at bedside on post-op day 0.
9. Ambulate as soon as possible (even 5–10 steps helps).

Range of Motion

1. Passive ROM (PROM):
2. Support the joint above and below to avoid strain.
3. Move slowly and smoothly (no bouncing).
4. Example: Ankle pumps (dorsiflexion/plantarflexion) for bedridden patients.
5. Active ROM (AROM):
6. Encourage patient to move independently (e.g., "Make a fist and release").
7. Use resistance bands for strength (if tolerated).

3. Monitor and Adjust

• Pressure injuries: Check skin every shift (use the NPUAP staging system).
• DVT: Monitor for unilateral swelling, pain, or warmth (Homan’s sign is unreliable).
• ROM: Document joint stiffness, pain, or contractures.

Hands-On / Getting Started

Prerequisites

• Knowledge:
• Basic anatomy (bony prominences, major joints).
• Braden Scale and Caprini Score.
• Equipment:
• Pillows/wedges for positioning.
• IPC device or GCS.
• ROM exercise chart (for documentation).

Step-by-Step Example: Preventing Pressure Injuries in a Bedridden Patient

1. Assess risk:
2. Braden Scale score = 14 (high risk).
3. Reposition:
4. Turn patient every 2 hours (use a turning schedule).
5. Place pillows to offload heels and sacrum.
6. Support surface:
7. Switch to a low-air-loss mattress.
8. Skin care:
9. Cleanse with pH-balanced cleanser.
10. Apply zinc oxide barrier cream to perineum.
11. Nutrition:
12. Ensure protein shake with meals.
13. Document:
14. Note skin condition, interventions, and patient response.

Expected outcome: - No new pressure injuries after 72 hours. - Patient reports comfort with repositioning.

Common Pitfalls & Mistakes

Best Practices

Pressure Injury Prevention

Use the "30° rule": Elevate the head of the bed ?30° to reduce shear. ? Float heels: Place a pillow under the calves to offload heels. ? Moisture management: Use absorbent pads for incontinence.

DVT Prophylaxis

Combine methods: Use LMWH + IPC for high-risk patients. ? Start early: Begin prophylaxis within 24 hours of surgery. ? Monitor for HIT: Check platelet counts if using heparin.

Range of Motion

Start PROM early: Begin day 1 of immobility. ? Involve the patient: Encourage active participation (even if minimal). ? Document progress: Note joint stiffness, pain, or improvements.

Tools & Frameworks

Real-World Use Cases

1. Post-Stroke Patient (Neurological Immobility)

• Problem: Right-sided hemiplegia-shoulder subluxation, DVT risk, pressure injuries.
• Interventions:
• PROM: Daily shoulder/elbow ROM to prevent contractures.
• DVT prophylaxis: LMWH + IPC (patient has high Caprini score).
• Pressure injury prevention: 30° lateral positioning, air mattress.
• Outcome: No DVT or pressure injuries; regains partial shoulder mobility in 4 weeks.

2. Post-Hip Replacement (Orthopedic Surgery)

• Problem: High DVT risk (Caprini score = 8), limited mobility.
• Interventions:
• DVT prophylaxis: Enoxaparin 40 mg SC daily + IPC.
• Early mobilization: Ambulate with walker post-op day 1.
• Pressure injury prevention: Foam mattress, heel offloading.
• Outcome: No DVT; discharged home on day 3.

3. ICU Patient (Prolonged Immobility)

• Problem: Sedated, ventilated-pressure injuries, joint contractures, DVT.
• Interventions:
• PROM: 2x/day (ankles, knees, shoulders).
• DVT prophylaxis: UFH (renal impairment) + IPC.
• Pressure injury prevention: Air-fluidized bed, turning every 2 hours.
• Outcome: No new pressure injuries; extubated on day 5.

Check Your Understanding (MCQs)

Question 1

A 78-year-old patient is bedridden after a stroke. Which intervention is most critical to prevent pressure injuries? A. Administering LMWH for DVT prophylaxis B. Repositioning the patient every 4 hours C. Applying a low-air-loss mattress and turning every 2 hours D. Performing active ROM exercises 3x/day

Correct Answer: C Explanation: Pressure injuries develop in 2–6 hours of unrelieved pressure. A low-air-loss mattress + turning every 2 hours directly addresses this risk. Why the distractors are tempting: - A: Important for DVT but doesn’t prevent pressure injuries. - B: 4 hours is too long—pressure injuries can develop in 2 hours. - D: ROM helps mobility but doesn’t replace pressure redistribution.

Question 2

A post-op patient refuses to wear IPC sleeves due to discomfort. What is the best alternative for DVT prophylaxis? A. Skip mechanical prophylaxis and rely on LMWH alone B. Apply graduated compression stockings (GCS) instead C. Increase the LMWH dose to compensate D. Encourage early ambulation and ankle pumps

Correct Answer: D Explanation: Early ambulation + ankle pumps are first-line for DVT prevention and address the root cause (venous stasis). GCS (B) are less effective than IPC. Why the distractors are tempting: - A: LMWH alone is less effective than combined methods. - B: GCS are not as effective as IPC for high-risk patients. - C: Increasing LMWH dose increases bleeding risk without added benefit.

Question 3

A patient with a stage II pressure injury on the sacrum asks how to prevent worsening. What is the most important instruction? A. "Apply a hydrocolloid dressing and keep the area dry." B. "Lie on your side at a 30° angle to offload the sacrum." C. "Increase protein intake to 1.5 g/kg/day." D. "Perform passive ROM exercises for your hips."

Correct Answer: B Explanation: Offloading pressure is the #1 priority for healing. A 30° lateral tilt reduces