Let’s keep Them Moving: Promoting Mobility Lesson

 

Learning Objectives;

• The Nurse Assistant will demonstrate an understanding of risk factors related to functional decline and impaired physical mobility.
• The Nurse Assistant will be able to list the signs and symptoms of impaired mobility
• The Nurse Assistant will demonstrate an understanding of at least two psychological changes that occur during prolonged bed rest.
• The Nurse Assistant will demonstrate an understanding of strategic interventions to promote mobility and reduce functional decline in hospitalized patients
• The Nurse Assistant will be able to list three nursing interventions that minimize complications of bed rest.
• The Nurse Assistant will be able to describe interventions to promote mobility among hospitalized elders.

 

Key Points

• Functional status or the ability to perform self-care and physical needs activities is an important component of independence. Maintaining function is central to fostering health and independence in hospitalized patients.
• The hospitalized elderly are at risk for decreased mobility and functional status.
• Hospitalization has been associated with low mobility and functional disability.
• Comprehensive initial and ongoing assessments assist in identifying those at risk for decline, enabling timely and targeted implementation of strategies.  Nurse Assistants should coordinate with the primary nurse in order to keep apprised of the plan of care and the appropriate activity level for the patient.
• Targeting risk factors like cognitive impairment, pre-hospitalization functional impairment and low social activity level that can contribute to functional decline during hospitalization can promote better outcomes.
• Encouraging activity during hospitalization can help to prevent functional decline, interventions such as structural exercise, progressive resistance strength training and walking programs have been implemented to target functioning during hospitalization.
• Re-designing of the environment and processes of care can improve the quality of care delivered.

 

Background

Impaired mobility is a physical limitation that severely restricts independent purposeful movement of the body, including limitation of independent movement from one position to another, independent transfer and ambulation activities. Functional Decline refers to the loss of basic skills needed for independent mobility and self-care.

The musculoskeletal system is one of the first systems of the body to suffer the devastating effects of immobility with changes occurring to the muscle fibers. These changes include the loss of muscle strength and endurance, reduced skeletal muscle fiber size, diameter and capillarity (atrophy); and contractures, disuse osteoporosis and degenerative joint disease. The severity of muscle deconditioning is related to the duration and magnitude of the activity limitation. If immobility continues, this muscle wasting can lead to muscle atrophy, joint ankylosis and fibrofatty tissue proliferation, which leads to the formation of adhesions, scar tissue and contractures , further impairing functional capacity and permanently damaging the muscle.

An estimated half of hospitalized adults are 65 years of age or older and the proportion of hospitalized adults who are elderly is only expected to increase as the population ages.  Hospitalization is one of the greatest risk factor for immobility and functional decline. Immobility refers to any disease or disability that requires complete bed rest or extremely limits an individual’s ability to move. Mobility is related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, joints becoming stiffer and less mobile, and gait changes affecting balance can significantly compromise the mobility of elder patients. Advanced age, acute and chronic disease and illness, functional limitations and deconditioning all contribute to the older adult’s vulnerability to functional decline during hospitalization.

Patients admitted to hospitals, intermediate, and long-term care facilities need a mobility and functional assessment and early interventions to prevent permanent disabilities and potential life-threatening complications that can result from bed rest and immobility. Nurses and Nurse Assistants need to initiate consistent interventions to prevent psychological and physical deconditioning, progressive dependence and deterioration, and possible death. They can achieve this goal by keeping these patients moving.

During hospitalization, the elderly patient often experiences reduced mobility and activity levels. Functional decline, including changes in physical status and mobility, has been identified as the leading complication of hospitalization for the elderly. Functional status is determined by the ability to perform activities of daily living (ADLs)—eating, dressing, bathing, ambulating, and toileting. But this functional status is severely threatened by hospitalization due to acute illness, decreased mobility, pain, dehydration and/or malnutrition, medication side effects, associated hospital treatment measures such as invasive lines and catheters that limit mobility, surgical procedures, and the negative effects of bedrest such as pressure ulcers. The hazards of bed rest during hospitalization are well documented and include immobility, accelerated bone loss, dehydration, malnutrition, delirium, sensory deprivation, isolation, and skin breakdown which could lead to pressure ulcers.

In acute care settings, the hospital environment is mostly focused on management of illness through effective care delivery of treatment regimens resulting in low levels of mobility and high incidences of bedrest. The focus of assessment and care is generally on resolving the immediate illness or chief problem that triggered hospitalization and not on improving patient functioning. Nursing staff are usually focused on promoting patient safety and avoiding injuries to a patient through falls thus they are more likely to offer a patient a bedpan rather than take the patient to the bathroom.

The causes of immobility can be divided into intrapersonal factors including psychological factors (depression, fear, motivation); physiological factors (cardiovascular, neurological, musculoskeletal and pain management); and environmental causes like unfamiliar surroundings, lack of adequate lighting, cluttered hallways.

RELATED RISK FACTORS

PERSONAL

• sensory, perceptual and/or cognitive impairment (e.g., unilateral neglect, peripheral neuropathy)
• anxiety, depression
• fear of falling
• developmental delay
• cultural beliefs regarding age-appropriate activity
• intolerance for activity
• decreased strength and endurance
• lack of knowledge regarding value of physical activity
• reluctance to initiate movement
• BMI at or above 75th percentile (age appropriate scale)
• lack of physical or social environmental supports
• lack of motivation
• fatigue
• pain/discomfort

 

PHYSIOLOGICAL

• musculoskeletal disorders
• acute (e.g., fracture, dislocations, sprains, strains, spasms)
• chronic [e.g., hemiparesis secondary to stroke, myasthenia gravis, muscular dystrophy, Parkinson’s disease, multiple sclerosis, osteoporosis, gout, nonfunctioning or missing limbs]
• integumentary disorders (e.g., edema, burns, trauma)

 

PHYSIOLOGICAL

• respiratory insufficiency (e.g., dyspnea on exertion, hypoxia)
• gait disturbances
• malnutrition
• limited cardiovascular endurance for self -care activity and mobility
• altered cellular metabolism
• neurological disorders, neurologic mass, neuropathy
• neuromuscular decline (e.g., muscle strength, motor control, balance)
• deconditioning, sedentary lifestyle
• sensory impairment (e.g., blindness, peripheral neuropathy)
• decreased range of motion, joint stiffness, decreased muscle length, contractures
• acute (e.g., trauma, infections, increased intracranial pressure, stroke, depression)
• chronic (e.g., tumor, spinal cord injury, congenital anomalies of central nervous system, seizures, depression)
• neuromuscular disorders (e.g., stroke, postpolio syndrome, Guillain-Barre’,multiple sclerosis, cerebral palsy, amyotrophic lateral sclerosis)

 

TREATMENT RELATED

• restrictive devices (e.g., IV, tubes, casts, drainage devices)
• surgery or surgical procedures
• painful movement
• prescribed movement restrictions
• bedrest/traction
• medications (e.g., central nervous system depressants, neuromuscular blocking agents, neuroleptics)

 

SIGNS AND SYMPTOMS:

•  inability to purposefully move in the environment (e.g., bed mobility, transfers, ambulation, perform ADL’s)
• decreased balance (static and dynamic)
• unsafe transfers and ambulation
• holding on to furniture while walking through a room
• fear/anxiety related to mobility
• limited ability to perform gross and/or fine motor skills
• postural instability with activity

 

Barriers to patient mobility

Falls is the number one mobility problem that older people experience especially in an unfamiliar environment like a hospital. Falls result in broken bones, bruises, and fear of falling.  An injury from a fall may result in limited or reduced mobility. Unfortunately, this can worsen existing medical illnesses and lead to new ones such as circulatory problems including blood clots in the legs, further loss of strength and functional status, pressure ulcers, or pneumonia.

Older patients with a history of falls are fearful of falling again. This can lead to inactivity that can cause additional health problems.  As a Nurse Assistant, one of the most important things you can do to help someone with mobility problems and fear of falling is to encourage physical activity. Even a little activity strengthens bones and muscles, improves steadiness when walking, and helps prevent fractures. If the older person is afraid of falling, suggest using a cane or a walker for mobility.

Patient-related factors like acute illness and mental status are other barriers to mobility in the elderly as well as treatment-related factors like side effects of medications that might make a patient too sleepy and lethargic or too weak to tolerate any mobility activities.  Lack of enough staff or under staffing is another hindrance to mobility where a Nurse Assistant has more assigned patients than she is able to handle.

For patients who are obese, lack of ambulatory devices and equipment to assist with mobility and lack of enough staff to get a 400 pounds patient out of bed only subjects these patients to more immobility as the nursing staff are safely unable to physically get the patient out of bed. In acute care setting, invasive lines like multiple intravenous lines and drains are also a barrier to mobility. Attitudinal factors  from nursing staff with concern about falls encourages more bedrest where staff are quick to insist to the patients that they stay in bed due to concerns for falls and injuries.  Nursing staff perceive getting patient up as a risk for falls and a risk for pulling out their IVs or any other medical device and mobility is not viewed as an important factor in someone who is recovering from an acute illness.

Teaching patients to move autonomously requires extra nursing time. Unfortunately the nursing staff are not able to get everyone up from bed due to the many tasks assigned to them for patient care and walking becomes less of a priority amongst other patient tasks like feeding and toileting. This is a system issue and involves getting the facility administration involved in changing staffing ratios and more nursing staff to cover sick calls.

It is important for Nurse Assistants to know that deconditioning and functional decline from baseline have been found to occur by day two of hospitalization in older patients. Reducing the risk for functional decline in hospitalized older adults can make a significant impact on their function and quality of life. A number of evidence-based strategies have been identified for reducing deterioration in hospitalized older adults.

Strategies to promote mobility

1. Nurses should conduct comprehensive and interdisciplinary geriatric assessment of physical, psychosocial, and functional status at admission, formulate a careplan based on their findings, and share the plan of care with other disciplines and especially the Nurse Assistants who are the front line caregivers and can enhance mobility in hospitalized patients.
2. Nurse Assistants with other Nursing staff should encourage activity during hospitalization with structured exercise, progressive resistance strength training, and walking programs, in coordination with rehabilitation therapies (physical and occupational).
3. Nurse Assistants with other Nursing staff should implement early mobilization for acute and critically ill patients based on MD’s orders for activity level and the plan of care for the patient.
4. Nurse Assistants should use adapted techniques to perform safe mobility skills like assistive devices and safe/appropriate use of grab bars in bathroom.
5. Nurse Assistants should ensure patient’s own assistive devices are in available: hearing aids in place; glasses on; walker or cane.
6. Nurse Assistants should ensure use of appropriate non skid footwear to encourage mobility and prevent falls.
7. Nurse Assistants should adapt use of environmental enhancements for eldercare including handrails, uncluttered hallways, large clocks and calendars, elevated toilet seats, and door levers.
8. Nurse Assistants should integrate established protocols aimed at reducing the risk for geriatric syndromes and improving self care, continence, nutrition, mobility, sleep, skin care, cognition, and promoting adequate sleep for optimal health.
9. Nurse Assistants should promote safety while encouraging independence and maintaining dignity.

 

Range-Of-Motion Exercises

The ranges of motion (ROM) of body joints generally diminish with age. Patients whose mobility is restricted because of illness, disability or trauma require ROM exercises to reduce the hazards of immobility. ROM exercises may be active (patients are able to move all joints through their ROM unassisted) or passive (patients are unable to move independently, and the nurse moves each joint through its ROM), or somewhere in between. With a weak patient, for example, the nurse may merely provide support while the patient performs most of the movement, or the patient may be able to move some joints actively while the nurse passively moves others. The nurse first assesses the patient’s ability to engage in active ROM exercises and the need for assistance, teaching or reinforcement. In general, exercises should be as active as health and mobility allow. Contractures may develop in joints not moved periodically through their full ROM.

 

Consequences of prolonged immobility

Prolonged bedrest and inactivity can lead to elevated lactic acid production and adversely affects adenosine triphosphate (ATP) concentrations, a vital energy source for muscle. Bed rest also diminishes protein synthesis and glycogen, augmenting fat stores, causing a glucose intolerance that requires more insulin for carbohydrate metabolism and resulting in reduced muscle mass and strength and oxidative capacity. Nurse Assistants must be willing to turn bedridden patients frequently or at least every two hours. Bedridden patients with weakened muscles who are incapable of moving independently are prone to pressure ulcers particularly over the bony prominences and it is imperative for Nurse Assistants to reposition them.

Immobilization also causes loss of normal muscle contraction in the lower extremities and contributes to venous pooling and venous stasis in dependent parts of the body which can lead to hypercoagulability of the blood. This hypercoagulability can lead to deep vein thrombosis which is a blood clot mostly occurring on lower extremities. This DVT can travel to the lungs causing a life-threatening pulmonary emboli. Many surgical patients, the elderly and those with prolonged immobilization are at risk for developing DVT and PE.  Nurse Assistants can reduce this risk by keeping the patient moving, engaging the patients with active and passive range of motion to the lower extremities, early ambulation, compression stockings, intermittent pneumatic compression devices also called SCD’s (sequential compression devices) or foot pumps. Immobility can also results in osteoporosis which further places the patients at risk for pathological fractures.  Immobility can also cause pneumonia due to weakened respiratory muscles hindering the effective clearing of pulmonary secretions and causing atelectasis and impaired gas exchange. This is especially more concerning for surgical patients. The Nurse Assistant can provide an incentive spirometry (IS) to the patient and encourage them to use it as often as they can tolerate to expand their lung function.

Mobilization of mechanically ventilated, critically ill patients must be based upon the critical judgment of the healthcare team, however, considerations must include cognitive status, respiratory and cardiovascular stability and the presence of any acute fractures or injuries. It is important to remember that the effects of deconditioning begin within 24 hours and may be irreversible in the elderly population. Loss of significant muscle mass is common among critically ill, mechanically ventilated patients and the only way to counter these effects is through mobilization of the patient.

Impaired taste and smell, as well as difficulty in swallowing while in a recumbent position, all contribute to a reduction in appetite and fluid intake which can lead to dehydration and malnutrition. Diminished peristalsis, associated with inactivity, impaired fluid intake, and physiological fluid shifts, can lead to constipation, nausea and vomiting, or even paralytic ileus, or bowel obstruction.

Patients on prolonged bed rest, especially the elderly, are susceptible to complications of urinary retention and mineral loss. The supine position hinders drainage of urine from the renal pelvis to the bladder. Patients often have difficulty using a urinal or bedpan because of the supine position or feeling embarrassed. Avoidance of urinating can lead to over distention of the bladder muscle. As the bladder becomes more distended, patients may lose the sensation to void and experience even more difficulty, resulting in urinary retention, stasis and infection.

Safety First

To provide a safe environment that will minimize risk of falls and promote mobility, the nurse assistant should adapt the following safety precautions;

• Ensure patient call light is within reach at all times and bed is in lowest position with brakes locked
•  Use of alarms as appropriate to alert caregivers when a confused patient is getting out of bed
•  Use of nonslip, appropriately fitting footwear
•  Determine appropriate side rail use
•  Minimize use of restraints
•  Provide appropriate level of assistance for activity/mobility
•  Provide appropriate assistive devices like canes or rolling walkers
•  Make sure there is adequate lighting (day/night) to allow for safe ambulation
•  Ensure the floors are clean, dry, uncluttered and free of tripping hazards
•  Instruct patient to stand up/rise slowly
•  Inform patient where their personal possessions are located and provide safe access to them
• Establish schedule for regular/frequent toileting with assistance and monitor patient frequently
• Educate patient and family on issues related to fall risk/fall prevention

 

Interventions

In order to successfully reduce the incidence of immobility-associated complications, hospitals should use an interdisciplinary team approach (nurses, nurse assistants, physical therapists, and occupational therapists), in increasing awareness and improving the consistency with which patient activity is addressed in order to increase patient functional activity and mobility.

• Reposition bedridden patient at least every two hours to relieve pressure
• Utilize mechanical lifts (e.g., full body lift, stand-up lifts) and repositioning aids (e.g., friction-reducing sheets, transfer boards) for patients who are physically dependent or confused/combative until they are able to safely participate in mobility activities
• Determine need for adaptive equipment use during functional/self-care activity to provide a safe environment and increase independence while maintaining weight-bearing restrictions, joint protection techniques, energy conservation and proper body mechanics.
• Advocate for effective pain management by alerting the primary nurse of any reported or observed pain to promote effective mobilization and facilitate increased independence with mobility.
• Encourage adequate sleep/rest, coordinate/schedule activities to allow uninterrupted sleep and make necessary environmental modifications based upon patient preferences [e.g., undisturbed sleep, music for relaxation, frequent rest periods, clustered care].
• Encourage and provide proper nutrition/hydration to ensure adequate protein and caloric intake to support activity level and to encourage proper bowel/bladder function. Allow liberalization of diet choices to include patient’s personal preferences.
• Prevent venous stasis/pooling of blood in extremities [e.g., elastic compression stockings, prevent pressure/constriction, encourage frequent position change, avoid compression of vena cava, encourage ankle dorsi plantar exercises, avoid crossing legs, use of intermittent pneumatic compression, neutral positioning, head of bed (HOB) elevated less than 30 degrees].
• Promote early and frequent ambulation.
• Reduce and redistribute pressure on bony prominences (e.g., small frequent position changes, turn at least every two hours or sooner if high risk, use wedges/pillows to reduce pressure between bony prominences), side lying positioning (30 degree turn) not directly positioned on trochanter, written positioning schedule, free-float heels with devices/pillows pressure-redistribution surfaces/ mattresses, monitor and minimize/eliminate pressure from devices [e.g., oxygen (O2) tubing and masks,  casts/splints, IV tubing and catheters], minimize layers between the patient and support surface.
• Maintain/promote mobility in and out of bed, avoid extended periods of time sitting in chair/wheelchair/bed, encourage weight shifting every 15 minutes when sitting in chair (e.g., repositioning, stand and reseat, chair push-ups), use pressure-redistribution devices for chairs, assess seating and need for adaptations, support legs/feet.

 

 

References

Caregiving How Tos. (n.d.). Retrieved October 19, 2014, from http://www.healthinaging.org/resources/resource:eldercare-at-home-mobility-problems/

Centers for Medicare & Medicaid Services:  Hospital-Acquired Conditions: Hospital-Acquired Conditions: Stage III and IV Pressure Ulcers. Last updated 9/2012. Retrieved from: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html

Centers for Medicare & Medicaid Services:  Hospital-Acquired Conditions: Falls and Trauma (fractures, dislocations, intracranial injuries, crushing injuries, burns, electric shock). Last updated 9/2012. Retrieved from: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/HospitalAcqCond/Hospital-Acquired_Conditions.html

Institute for Healthcare Improvement:  Improvement Map: Venous Thromboembolism (VTE) Prevention and Treatment Process. Retrieved from: http://www.ihi.org/imap/tool/#Process=5b9bfd5a-1e17-433b-a9d4-602fafef73c8

Make a Move: Take steps to keep elderly patients mobile. (n.d.). Retrieved October 19, 2014, from http://www.the-hospitalist.org/details/article/187763/Make_a_Move.html

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel:  Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009.

Performance Measurement. Core Measure Set: Venous Thromboembolism (VTE) Measures. Last updated 12/17/2012. Retrieved from: http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures/

Reducing Functional Decline in Hospitalized Elderly. (n.d.). Retrieved October 19, 2014, from http://www.ncbi.nlm.nih.gov/books/NBK2629/

Safer Healthcare Now!:  Getting Started Kit: Venous thromboembolism Prevention, How to Guide. Last updated 5/2012. Retrieved from: http://www.saferhealthcarenow.ca/EN/Interventions/vte/Documents/VTE%20Getting%20Started%20Kit.pdf

Serious Reportable Events in Healthcare 2011 Update, Care Management Events: Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility. Retrieved from: http://www.qualityforum.org/News_And_Resources/Press_Releases/2011/NQF_Releases_Updated_Serious_Reportable_Events.aspx