1 Pressure Injuries and Immobility

How immobility affects the body

The effects of immobility vary with its duration, a person’s health, and other risk factors. Limited movement can contribute to pressure injury, respiratory complications, venous thromboembolism (VTE), muscle loss and weakness, and constipation. These risks may occur together: weakness can make repositioning harder, increasing pressure-injury risk while also reducing the leg-muscle pump and cough effectiveness.

• Pressure injury: Sustained pressure, often combined with shear, can reduce blood flow and damage tissue. Risk is greater when a person cannot move or feel discomfort, or has moisture exposure or poor perfusion.

• Atelectasis and pneumonia: Reduced chest expansion and weaker coughing can impair lung expansion and the clearance of secretions.

• VTE: Less leg movement weakens the muscle pump that helps return blood to the heart, encouraging venous stasis.

• Muscle loss and weakness: Muscles lose strength and mass when they are not regularly used.

• Constipation: Reduced activity may slow bowel movement; low fluid or food intake and some medicines can add to the risk.

Assessing pressure-injury risk

A pressure injury is localized damage to skin or underlying tissue, often over a bony prominence or beneath a medical device. Immobility is a key risk because a person may not shift weight often enough to relieve pressure. Pressure and shear can combine, for example when a person slides down in bed.

Screen for risk as early as possible, reassess periodically, and reassess when the person’s condition worsens. A structured tool such as the Braden Scale can help organize assessment when appropriate, but its score should not replace clinical judgment or determine prevention by itself.

Assess the following:

• Mobility and activity: Determine whether the person can change position independently and often enough.

• Skin and tissue: Inspect bony prominences, heels, skin folds, and areas beneath devices. Note pain, persistent redness, discoloration, temperature change, swelling, or altered tissue firmness. Color changes may be less apparent in darker skin tones, so consider other signs as well.

• Other individual risks: Consider sensation, perfusion, moisture or incontinence, nutrition, existing or previous pressure injuries, and medical devices.

Document findings, act on identified risks, and update the plan as mobility, skin condition, or overall health changes.

Preventing pressure injuries

Prevention should respond to the person’s risks and changing condition. Repositioning frequency is not a universal fixed schedule: consider mobility, skin response, clinical condition, comfort, goals of care, and the support surface in use. Current international guidance suggests that two- or three-hour intervals may suit many at-risk people using an appropriate pressure-redistribution surface, but this does not apply to everyone. Reassess and adjust if early skin changes appear.

• Reposition and mobilize: Encourage independent movement where possible and assist with repositioning when needed. No support surface replaces repositioning.

• Offload vulnerable areas: Relieve pressure on heels and other high-risk areas. Use positioning aids to distribute pressure, and avoid placing the person directly on an area that is damaged or showing concerning changes.

• Reduce friction and shear: Use appropriate transfer or repositioning techniques and equipment; avoid dragging the person across sheets. Consider whether bed positioning may cause sliding.

• Choose suitable support surfaces: Match mattress and seating surfaces to risk, while continuing skin checks and repositioning.

• Manage moisture and support skin health: Cleanse and protect skin after incontinence or other moisture exposure. Support adequate nutrition and hydration according to the person’s needs and care plan.

• Inspect and reassess: Check pressure points during repositioning and perform comprehensive skin assessments as appropriate. Report new or worsening skin changes and review the prevention plan.

Individualizing care and responding to risk

A pressure-risk tool score that does not indicate high risk does not rule out the need for prevention. For example, a bedbound person who cannot reposition independently still has a mobility limitation that matters; use clinical judgment and assess the person’s skin and other risks.

A fixed turning schedule is not appropriate for everyone because people differ in mobility, skin tolerance, clinical condition, comfort, goals, and support surfaces. Individualize repositioning frequency and revise it if skin changes occur.

For VTE prevention, reduced leg movement can weaken the muscle pump and promote venous stasis. Promote safe mobility and leg movement, and use prescribed mechanical or medication-based VTE prevention according to the person’s clinical plan.

Putting prevention together

Prevention of pressure injuries combines risk assessment and skin assessment with attention to individual needs. Reposition and mobilize appropriately, offload pressure, reduce shear and moisture, and reassess the plan. Risk tools and support surfaces can assist, but do not replace clinical judgment, skin assessment, or movement.