To keep patients on the move, healthcare professionals need to make planned mobility a priority intervention. Progressive mobility (also known as early mobilization) starts slowly and moves the patient toward more range-of-motion exercises, longer sitting times in a chair, and more frequent and longer walks in the hallway.
Although progressive mobility isn’t a new concept, one aspect is relatively new—the initial start time. Traditionally, patients haven’t been encouraged to ambulate or sit up early during their stays or after surgery. Instead, clinicians viewed bed rest as an important aid to healing, especially during an acute illness. For example, patients used to be placed on 3 days of bed rest after an uncomplicated acute myocardial infarction. But with research now supporting early mobilization, this no longer happens. Today, most patients are encouraged to move from the beginning of their stay, to prevent negative bed-rest outcomes, such as blood clots, pneumonia, delirium, and ultimately, patient dissatisfaction and longer stays.
How can nurses get patients moving earlier? Ambulation is the most common way. If your patient is unable to ambulate, consider other methods, such as elevating the head of the bed, passive range of motion (ROM), manual turning, dangling, and assistance to a chair. No set standard of care exists on when to start the mobilization process. What’s more, in some situations, barriers exist. (See Barriers to mobilization.)
As a standard of care, mobilization requires planning. If the provider hasn’t given orders to mobilize your patient, contact him or her to validate the mobilization plan. Normally, this isn’t a major issue—just one that takes precious nursing time. But forgetting to contact the provider or relegating this task to the bottom of your to-do list isn’t an option.
Get assistance—and assistive devices
Mobilizing patients also requires access to staff and resources. Some patients are unable to move or ambulate without assistance. For these patients, turn to devices such as lifts and slings to transfer patients and use assistive tools such as gait belts and walkers to help them move. As needed, recruit other team members to help mobilize patients.
Keep in mind that lack of assistive devices isn’t an excuse for failing to implement mobility protocols. Advocate within your organi- zation to obtain these devices, which protect patients and staff.
Progressive ambulation protocols
Progressive ambulation protocols serve as implementation guides in setting mobility expectations for a specific patient population throughout the hospital stay. Because these protocols standardize bed, transfer, and ambulation activities, they eliminate the need for nurses to wait for physician rounds or new orders to progress patients to the next step in the protocol.
Early mobilization in the ICU
In the ICU, the first step in progressive mobility is assessing the patient for mobility initiation. The healthcare team evaluates the patient to ensure early mobility isn’t contraindicated and communicates all steps of the process to the patient. Contraindications for early mobility in the ICU include one or more of the following:
- unstable blood pressure (mean pressure below 65 mm Hg)
- heart rate below 60 or above 120 beats/minute
- respiratory rate less than 10 or more than 32 breaths/minute
- oxygen saturation below 90%
- anxiety or agitation requiring sedation
- insecure airway device
- difficult airway access.
Be aware that patient devices, active intubation, or continuous I.V. medication infusions are not contraindications.
The scenario below illustrates an early progressive mobilization protocol for an ICU patient.
Mr. Jones, age 52, just had coronary artery bypass surgery. Awake and still intubated, he is receiving I.V. infusions, with sequential compression devices applied to his legs. His plan of care includes early progressive mobilization.
Before mobilization begins, the nurse explains the process to Mr. Jones and instructs him on how to signal anxiety, pain, or a feeling that something is changing. To ensure he is fully prepared for mobilization, a designated team member is assigned a communication-only role. Charged with instructing the patient, this team member stays directly in front of him during the entire exercise.
After assessing Mr. Jones for contraindications to early mobility and explaining the process to him, the team determines if early progressive mobility can safely begin. To ensure the patient, healthcare team, and equipment are secure and safe, the nurse assesses all devices for secure attachments, stops unnecessary I.V. infusions, and moves indwelling devices to the side of the bed. Other team members verify that the wheelchair is secure and close to the bed for the transfer. The respiratory therapist confirms that the mechanical ventilator is switched to a transport ventilator and the endotracheal tube is secure.
After verifying the safety of all devices, the team assists Mr. Jones to the side of the bed. Then they implement active range-of-motion (ROM) exercises in this position before transfer. The designated communicator uses one-sentence commands to ensure that the patient and all team members understand each step of the transfer process.
Early mobilization on the orthopedic unit
Early progressive mobility on the orthopedic unit resembles the process used in the ICU. After joint- replacement therapy, progressive mobility starts by moving the patient to the side of the bed or implementing active ROM exercises. Patients who’ve had this type of surgery or other leg surgery typically have difficulty at this stage and may need pain medication before mobilization. Remember—although progressive mobility should begin early, this doesn’t necessarily mean the patient should ambulate quickly.
The scenario below describes an early progressive mobility protocol on the orthopedic unit.
Mrs. Smith, age 65, is recovering from right total knee replacement surgery. Her plan of care includes early progressive mobility. The nurse assesses her for contraindications to mobility. She knows that patients who’ve just had joint replacement may progress to ambulation more slowly than other patients.
After the nurse determines it’s safe for Mrs. Smith to move, she has her perform active ROM exercises three times. Before advancing her to standing, the nurse recruits a second staff member to assist her for added safety.
Once Mrs. Smith has mastered standing, the nurse helps her ambulate with a walker or other assistive device. During ambulation, one staff member is designated to communicate with Mrs. Smith to avoid confusion or mixed messages about her next step. To promote early discharge and enable her to remain in her home, team members provide thorough instructions on proper ambulation techniques and the assistive device she’ll be using at home.
Obtaining appropriate assistive devices is important for both patients’ and employees’ safety. After discharge, these devices can help the patient ambulate at home and in the community.
Although some nurses may be uncomfortable about moving a patient only a few hours after major surgery, receiving training in progressive early mobility protocols can give them more confidence. These protocols promote better patient outcomes and help reduce hospital stays and readmissions. So get your patients moving—now!
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Current Topics in Safe Patient Handling and Mobility. Supplement to American Nurse Today. September 2014.
Klein K, Mulkey M, Bena JF, Albert NM. Clinical and psychologic effects of early mobilization in patients treated in a neurologic ICU: a comparative study. Crit Care Med. 2015;43(4):865-73.
Mikkelsen LR, Mechlenburg I, Soballe K, et al. Effect of early supervised progressive resistance training compared to unsupervised home-based exercise after fast-track total hip replacement applied to patients with preoperative functional limitations. A single-blinded randomised controlled trial. Osteoarthritis Cartilage. 2014;22(12):2051-8.
Morris PE, Griffin L, Berry M, et al. Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci. 2011;341(5):373-7.
The authors work at Texas Tech University Health Science Center in Lubbock. Amanda Veesart is an assistant professor and clinical director. Alyce S. Ashcraft is a professor and associate dean of research. (Names in scenarios are fictitious.)
Thank you for a great and helpful article on early mobility.
Benefited greatly from this topic. I was looking for purpose of ambulation together with the use of anticoagulant after surgery.