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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021.
Promote the use of effective techniques of body mechanics among caregivers, patients, and significant others
Identify evidence-based practicesSit on a sturdy chair with your legs and arms stretched out in front of you, and then try to stand. This basic mobility task can be impaired during recovery from major surgery or for patients with chronic musculoskeletal conditions. Mobility, which includes moving one’s extremities, changing positions, sitting, standing, and walking, helps avoid degradation of many body systems and prevents complications associated with immobility. Nurses assist patients to be as mobile as possible, based on their individual circumstances, to achieve their highest level of independence, prevent complications, and promote a feeling of well-being. This chapter will discuss nursing assessments and interventions related to promoting mobility.
Before discussing the concept of mobility, it is important to understand the anatomy of the musculoskeletal system, common musculoskeletal conditions, and the components of a musculoskeletal system assessment. Read more about these topics in the “Musculoskeletal Assessment” chapter in Open RN Nursing Skills.
Mobility is the ability of a patient to change and control their body position. Physical mobility requires sufficient muscle strength and energy, along with adequate skeletal stability, joint function, and neuromuscular synchronization. Anything that disrupts this integrated process can lead to impaired mobility or immobility. [ 1 ] Mobility exists on a continuum ranging from no impairment (i.e., the patient can make major and frequent changes in position without assistance) to being completely immobile (i.e., the patient is unable to make even slight changes in body or extremity position without assistance). See Figure 13.1 [ 2 ] for an image of a patient with impaired physical mobility requiring assistance with a wheelchair.
Impaired Physical Mobility
Functional mobility is the ability of a person to move around in their environment, including walking, standing up from a chair, sitting down from standing, and moving around in bed. The three main areas of functional mobility are the following:
Bed Mobility: The ability of a patient to move around in bed, including moving from lying to sitting and sitting to lying.
Transferring: The action of a patient moving from one surface to another. This includes moving from a bed into a chair or moving from one chair to another.
Ambulation: The ability to walk. This includes assistance from another person or an assistive device, such as a cane, walker, or crutches.
Immobility can be caused by several physical and psychological factors, including acute and chronic diseases, traumatic injuries, and chronic pain. Several neurological and musculoskeletal disorders can adversely affect mobility, including osteoarthritis, rheumatoid arthritis, muscular dystrophy, cerebral palsy, multiple sclerosis, and Parkinson’s disease. Traumatic injuries, such as skeletal fractures, head injuries, or spinal injuries, also impair mobility. Diseases that cause fatigue, such as heart failure, chronic obstructive pulmonary disease, and depression, or conditions that cause pain also affect the patient’s desire to move.
Patients who spend an extended period of time in bed as they recover from surgery, injury, or illness can develop a variety of complications due to loss of muscle strength (estimated at a rate of 20% per week of immobility). Regardless of the cause, immobility can cause degradation of cardiovascular, respiratory, gastrointestinal, and musculoskeletal functioning. Promoting mobility can prevent these complications from occurring. Findings from a literature review demonstrated several benefits of mobilization, including less delirium, pain, urinary discomfort, urinary tract infection, fatigue, deep vein thrombosis (DVT), and pneumonia, as well as an improved ability to void. Mobilization also decreased depression, anxiety, and symptom distress, while enhancing comfort, satisfaction, quality of life, and independence. [ 3 ] See Table 13.2a for a summary of the effects of immobility on these body systems. [ 4 ] , [ 5 ] , [ 6 ] Decreased mobility is also a major risk factor for skin breakdown, as indicated on the Braden Scale. See Figure 13.2 [ 7 ] for an image of a patient with impaired mobility who developed a DVT.
Effects of Immobility on Body Systems [ 8 ]
Deep Vein Thrombosis (DVT)
Read additional details about assessing the cardiovascular system and assessing for deep vein thrombosis (DVT) in the “Cardiovascular Assessment” chapter in Open RN Nursing Skills.
Read additional details about performing a “Respiratory Assessment” in Open RN Nursing Skills. Read more about treating hypoxia in the “Oxygenation” chapter of this textbook. Read about preventing pressure injuries in the “Integumentary” chapter of this textbook. Read details about performing a “Musculoskeletal Assessment” in Open RN Nursing Skills.Read more about constipation, impaction, ileus, urinary retention, and urinary tract infection in the “Elimination” chapter of this textbook.
Review how to perform an “Abdominal Assessment” in Open RN Nursing Skills.Strategies to promote patient mobility can be divided into two categories: those used when the patient is in bed and those used when the patient is able to get out of bed. In-bed interventions to enhance mobility include performing repositioning activities, completing range of motion exercises, and assisting the patient to dangle on the edge of a bed. Out-of-bed interventions to enhance mobility include transferring the patient from bed to chair and assisting with ambulation. [ 9 ] Unfortunately, ambulation of patients has been identified as the most frequently missed element of inpatient nursing care with rates as high as 76–88% of the time. [ 10 ] Before discussing these interventions to promote mobility, let’s review the assessments that a nurse must perform prior to safely implementing mobilization interventions.
A patient’s mobility status and their need for assistance affect nursing care decisions, such as handling and transferring procedures, ambulation, and implementation of fall precautions. Initial mobility assessments are typically performed on admission to a facility by a physical therapist (PT). See Table 13.2b for an example of common types of assistance required.
Common Types of Assistance Required [ 11 ]
In addition to the amount of assistance required, physical therapists may determine a patient’s weight-bearing status. For example, patients with lower extremity fractures or those recovering from knee or hip replacement often progress through stages of weight-bearing activity. See Table 13.2c for common weight-bearing prescriptions.
In addition to reviewing orders regarding weight-bearing and assistance required, all staff should assess patient mobility before and during interventions, such as transferring from surface to surface or during ambulation. Staff may frequently rely on the patient’s or a family member’s report on the patient’s ability to stand, transfer, and ambulate, but this information can be unreliable. For example, the patient may have unrecognized physical deconditioning from the disease or injury that necessitated hospitalization, or they may have developed new cognitive impairments related to the admitting diagnosis or their current medications. [ 12 ]
Several objective screening tests, such as the Timed Get Up and Go Test, have traditionally been used by nurses to assess a patient’s mobility status. The Timed Get Up and Go Test begins by having the patient stand up from an armchair, walk three yards, turn around, walk back to the chair, and sit down. As the patient performs these maneuvers, their posture, body alignment, balance, and gait are analyzed. However, this test and other tests do not provide guidance on what the nurse should do if the patient can’t maintain seated balance, bear weight, or stand and walk. The Banner Mobility Assessment Tool (BMAT) was developed to provide guidance regarding safe patient handling and mobility (SPHM). It is used as a nurse-driven bedside assessment of patient mobility and walks the patient through a four-step functional task list and identifies the mobility level the patient can achieve. It then provides guidance regarding the SPHM technology needed to safely lift, transfer, and mobilize the patient. [ 13 ] Read additional information about the Banner Mobility Assessment Tool (BMAT) using the following hyperlink.
See the following box for an example of a nurse using the BMAT.
A 65-year-old male was admitted to the hospital late in the evening. He is 6’2″ tall and weighs 350 lbs. (158 kg). He needed to have a bowel movement but didn’t want to use a bedpan. The nurse wasn’t comfortable getting him up to use the bathroom because he hadn’t yet been evaluated by physical therapy, and a physical therapist wasn’t available until the following morning. Per agency policy, the nurse used the BMAT and determined the patient was currently at Mobility Level 3. He was transferred to the toilet using a nonpowered stand aid. Both the patient and nurse were relieved and satisfied with the outcome.
Assisting patients with decreased immobility poses an increased risk of injury to health care workers. A focus on safe patient handling and mobility (SPHM) in acute and long-term care over the past decade has resulted in decreased staff lifting injuries for the first time in 30 years. Nonetheless, nurses still suffer more musculoskeletal disorders from lifting than other employees in the manufacturing and construction industries. Many employers and nurses previously believed that lifting injuries could be prevented by using proper body mechanics, but evidence contradicts this assumption. Body mechanics involves the coordinated effort of muscles, bones, and one’s nervous system to maintain balance, posture, and alignment when moving, transferring, and positioning patients. [ 16 ] The National Institute of Occupational Safety and Health (NIOSH) calculates maximum loads for lifting, pushing, pulling, and carrying for all types of employees. For example, a maximum load for employees lifting a box with handles is 50 pounds (23 kg), but this weight is decreased when the lifter has to reach, lift from near the floor, or assume a twisted or awkward position. Because patients don’t come in simple shapes and may sit or lie in awkward positions, move unexpectedly, or have wounds or devices that interfere with lifting, the safe lifting load for patients is less than this maximum 50 pound load. Although using proper body mechanics and good lifting techniques are important, they don’t prevent lifting injuries in these patient circumstances [ 17 ] , [ 18 ] , [ 19 ] Factors that increase risk for lifting injuries in nurses are exertion, frequency, posture, and duration of exposure. Combinations of these factors, such as high exertion while in an awkward posture (for example, holding a patient’s leg while bent over and twisted), unpredictable patient movements, and extended reaching, intensify the risk. [ 20 ]
In 2013 the American Nurses Association (ANA) published Safe Patient Handling and Mobility (SPHM) standards. See the standards in the following box. Learn more about safe patient handling using the following hyperlinks.
ANA Standards for Safe Patient Handling and Mobility [ 21 ]
Standard 1: Establish a culture of safety. This standard calls for the employer to establish a commitment to a culture of safety. This means prioritizing safety over competing goals in a blame-free environment where individuals can report errors or incidents without fear. The employer is compelled to evaluate systemic issues that contribute to incidents or accidents. The standard also calls for safe staffing levels and improved communication and collaboration. Every organization should have a procedure for nurses to report safety concerns or refuse an assignment due to concern about patients’ or their own safety.
Standard 2: Implement and sustain an SPHM program. This standard outlines SPHM program components, including patient assessment and written guidelines for safe patient handling by staff.
Standard 3: Incorporate ergonomic design principles to provide a safe care environment. This standard is based on the concept of prevention of injuries through ergonomic design that considers the physical layout, work-process flow, and use of technology to reduce exposure to injury or illness.
Standard 4: Select, install, and maintain SPHM technology. This standard provides guidance in selecting, installing, and maintaining SPHM technology.
Standard 5: Establish a system for education, training, and maintaining competence. This standard outlines SPHM training for employees, including the demonstration of competency before using SPHM technology with patients.
Standard 6: Integrate patient-centered SPHM assessment, plan of care, and use of SPHM technology. This standard focuses on the patient’s needs by establishing assessment guidelines and developing an individual plan of care. It outlines the importance of using SPHM technology in a therapeutic manner with the goal of promoting patients’ independence. For example, a patient may need full-body lift technology immediately after surgery, then progress to a sit-to-stand lift for transfers, and then progress to a technology that supports ambulation.
Standard 7: Include SPHM in reasonable accommodation and post-injury return to work. This standard promotes an employee’s return to work after an injury.
Standard 8: Establish a comprehensive evaluation system. The final standard calls for evaluation of outcomes related to an agency’s implementation of a SPHM program with remediation of deficiencies.
There are several types of assistive devices that a nurse may incorporate during safe patient handling and mobility. An assistive device is an object or piece of equipment designed to help a patient with activities of daily living, such as a walker, cane, gait belt, or mechanical lift. [ 22 ] Assistive devices include other items described below.
Gait belts should be used to ensure stability when assisting patients to stand, ambulate, or transfer from bed to chair. A gait belt is a 2-inch-wide (5 mm) belt, with or without handles, that is placed around a patient’s waist and fastened with a buckle. The gait belt should be applied on top of clothing or a gown to protect the patient’s skin. See Figure 13.3 [ 23 ] for an image of a gait belt.
A slider board (also called a transfer board) is used to transfer an immobile patient from one surface to another while the patient is lying supine (e.g., from a stretcher to hospital bed). [ 24 ] See Figure 13.4 [ 25 ] for an image of a patient being transferred by logrolling off a slider board with several assistants.
Sit to Stand Lifts (also referred to as Sara Lifts, Lift Ups, Stand Assist, or Stand Up Lifts) are mobility devices that assist weight-bearing patients who are unable to transition from a sitting position to a standing position using their own strength. They are used to safely transfer patients who have some muscular strength but not enough strength to safely change positions by themselves. Some sit to stand lifts use a mechanized lift whereas others are nonmechanized. See Figure 13.5 [ 26 ] for an image of a nurse assisting a patient to stand with a sit to stand lift.
Sit to Stand Lift
A mechanical lift is a hydraulic lift with a sling used to move patients who cannot bear weight or have a medical condition that does not allow them to stand or assist with moving. It can be a portable device or permanently attached to the ceiling. See Figure 13.6 [ 27 ] for an image of a mechanical lift.
Most clinical agencies do not allow nursing students to operate mechanical lifts independently without the supervision of agency staff. Review agency policy and obtain assistance as indicated, even if you have experience using mechanical lifts as an employee at another agency.Many hospitals use nurse-driven mobility protocols to encourage early mobility of patients in intensive care units and after surgery. The purpose of early mobility protocols is to maintain the patient’s baseline mobility and functional capacity, decrease the incidence of delirium, and decrease hospital length of stay. Protocols include a coordinated approach by the multidisciplinary team and may include respiratory therapists, physical therapists, pharmacists, occupational therapists, and the health care provider who focus on getting the patient out of bed faster. [ 28 ]
When early mobility protocols are in place, nurses use a screening tool to determine whether a patient is clinically ready to attempt the protocol. This algorithm begins by reviewing the patient’s neurological criteria, such as, does the patient open his or her eyes in response to verbal stimulation? If the patient meets neurological criteria, they are assessed against additional criteria for respiratory, circulatory, neurological, and other considerations. If the patient clears these criteria, a registered nurse may carefully initiate an early mobilization protocol in collaboration with a physical therapist. See Figure 13.7 [ 29 ] for an example of an early mobilization protocol used for patients in an ICU. [ 30 ]
Early Mobilization Protocol for ICU Patients
See the following box for an example of a mobilization protocol in an intermediate care unit.
Here is an example of using an early mobilization protocol in an intermediate care unit with patient care technicians (PCT). Three PCTs collaborate with nurses from 7 a.m. to 7 p.m. Each PCT has eight patients and is responsible for mobilizing patients during each 12-hour shift. Each patient care technician discusses each patient’s level of activity with the RN at the beginning of the shift and determines how many times each patient will be mobilized throughout the day. Any concerns that arise during mobilization are shared with the nurse for appropriate follow-up.
When patients are unable to ambulate or have injury to specific extremities, range of motion (ROM) exercises are often prescribed. ROM exercises facilitate movement of specific joints and promote mobility of the extremities. Because changes in joints can occur after three days of immobility, ROM exercises should be started as soon as possible. There are three types of ROM exercises: passive, active, and active assist. Passive range of motion is movement applied to a joint solely by another person or by a passive motion machine. When passive range of motion is applied, the joint of an individual receiving exercise is completely relaxed while the outside force moves the body part while they are lying in bed. For example, patients who undergo knee replacement surgery may be prescribed a passive motion machine that continuously flexes and extends the patient’s knee while lying in bed. See Figure 13.8 [ 32 ] for an image of a passive motion machine. Active range of motion is movement of a joint by the individual performing the exercise with no outside force aiding in the movement. Active assist range of motion is joint movement with partial assistance from an outside force. For example, during the recovery period after shoulder surgery, a patient attends physical therapy and receives 50% assistance in moving the arm with the help of a physical therapy assistant.
Passive Motion Machine
Patients may receive temporary ROM exercises due to injury, surgery, or other temporary conditions. These patients are expected to make a full recovery and over time will no longer need ROM to ensure the proper functioning of their joint. Other patients require long-term ROM exercises to prevent contractures that can occur in conditions such as spinal cord injury, stroke, neuromuscular diseases, or traumatic brain injury. A contracture is the lack of full passive range of motion due to joint, muscle, or soft tissue limitations. [ 33 ] See Figure 13.9 [ 34 ] for an image of a severe leg contracture in a patient with a terminal neurological condition.
Range of motion exercises are prescribed by a physical therapist and can be performed by physical therapy assistants, nursing assistants, patient technicians, and nurses based on agency policy. Guidelines for performing range of motion exercises include the following:
A program of passive stretching should be started as early as possible in the course of neuromuscular disease to prevent contractures and become part of a regular morning and evening routine.
Proper technique is essential for passive stretching to be effective. With each stretch, the position should be held for a count of 15, and each exercise should be repeated 10 to 15 times during a session (or as prescribed). Stretching should be performed slowly and gently. An overly strenuous stretch may cause discomfort and reduce cooperation.
Written instructional materials should be provided to the patient and family as a supplement to verbal instructions and demonstrations by the physical therapist.
Limb positioning with assistive devices can also be used to prevent contracture formation. The limb should be placed in a resting position that opposes or minimizes flexion. [ 36 ] Positioning aids include pillows, foot boots, handrolls, hand-wrist splints, heel or elbow protectors, abduction pillows, or a trapeze bar. See Figure 13.10 [ 37 ] for an image of a brace used to prevent foot drop in a patient with multiple sclerosis. Foot drop is a complication of immobility that results in plantar flexion of the foot, interfering with the ability to complete weight bearing activities.
Brace to Prevent Foot Drop
Read additional information about range of motion exercises, preventing contractures, and physical therapy using the following hyperlinks.
Repositioning a bedridden patient maintains body alignment and prevents pressure injuries, foot drop, and contractures. Proper positioning also provides comfort for patients who have decreased mobility related to a medical condition or treatment. When repositioning a patient in bed, supportive devices such as pillows, rolls, and blankets can aid in providing comfort and safety. There are several potential positions that are determined based on the patient’s medical condition, preferences, or treatment related to an illness. [ 38 ] It is important to reposition patients appropriately to prevent neurological injury that can occur if a patient is inadvertently placed on their arm.
In supine positioning, the patient lies flat on their back. Pillows or other devices may be used to prevent foot drop. Additional supportive devices, such as pillows under the arms, may be added for comfort. See Figure 13.11 [ 39 ] for an image of a patient in the supine position. [ 40 ]
In prone positioning, the patient lies on their stomach with their head turned to the side. [ 41 ] Pillows may be placed under the lower legs to align the feet. See Figure 13.12 [ 42 ] for an image of a patient in the prone position. Placing patients in the prone position may improve their oxygenation status in certain types of medical disorders, such as COVID-19. [ 43 ]
In lateral positioning, the patient lies on one side of their body with the top leg flexed over the bottom leg. This position helps relieve pressure on the coccyx. [ 44 ] A pillow may be placed under the top arm for comfort. See Figure 13.13 [ 45 ] for an image of a patient in the lateral position. The lateral position is often used for pregnant women to prevent inferior vena cava compression and enhance blood flow to the fetus.
In Sims positioning, the patient is positioned halfway between the supine and prone positions with their legs flexed. A pillow is placed under the top leg. Their arms should be comfortably placed beside them, not underneath. [ 46 ] See Figure 13.14 [ 47 ] for an image of a patient in Sims position. The Sims position is used during some procedures, such as the administration of an enema.
In Fowler’s positioning, the head of bed is placed at a 45- to 90-degree angle. The bed can be positioned to slightly flex the hips to help prevent the patient from migrating downwards in bed. [ 48 ] See Figure 13.15 [ 49 ] for an image of a patient in Fowler’s position. High Fowler’s position refers to the bed being at a 90-degree angle. The Fowler’s position is used to promote lung expansion and improve a patient’s oxygenation. It is also used to prevent aspiration in patients while eating or receiving tube feeding.
In Semi-Fowler’s positioning, the head of bed is placed at a 30- to 45-degree angle. The patient’s hips may or may not be flexed. See Figure 13.16 [ 50 ] for an image of a patient in Semi-Fowler’s position. Semi-Fowler’s position is used for the same purposes as Fowler’s position but is generally better tolerated over long periods of time.
In Trendelenburg positioning, the head of the bed is placed lower than the patient’s feet. This position may be used in certain situations to promote venous return to the head and heart, such as during severe hypotension and medical emergencies. [ 51 ] See Figure 13.17 [ 52 ] for an image of Trendelenburg position.
Patients who are feeling short of breath often naturally assume the tripod position. In the tripod position, the patient leans forward while sitting with their elbows on their knees or resting on a table. Patients experiencing breathing difficulties can be placed in this position to enhance lung expansion and air exchange. See Figure 13.18 [ 53 ] for images of an individual demonstrating breathing difficulty who has assumed the tripod position.
When moving a patient up in bed, first determine the level of assistance needed to provide optimal patient care. It is vital to prevent friction and shear when moving a patient up in bed to prevent pressure injuries. If a patient is unable to assist with repositioning in bed, follow agency policy regarding using lifting devices and mechanical lifts. If the patient is able to assist with repositioning and minimal lifting by staff is required, use the following guidelines with assistance from another health care professional to help with the move and prevent injury. [ 54 ] See Figure 13.19 [ 55 ] for an image of moving a patient up in bed.
Moving a Patient Up in Bed
Explain to the patient what will happen and how the patient can help. Raise the bed to a safe working height and ensure that the brakes are applied.Position the patient in the supine position with the bed flat. Place a pillow at the head of the bed and against the headboard to prevent accidentally bumping the patient’s head on the headboard.
Two health care professionals should stand with feet shoulder width apart between the shoulders and hips of the patient at the bedside. This keeps the heaviest part of the patient closest to the center of gravity of the health care providers. Weight will be shifted from back foot to front foot.
Fan-fold the draw sheet toward the patient with palms facing up. This provides a strong grip to move the patient up with the draw sheet.
Ask the patient to tilt their head toward their chest, fold arms across their chest, and bend their knees to assist with the movement. Let the patient know when the move will happen. This step prevents injury from occurring to the patient and prepares them for the move.
Tighten your gluteal and abdominal muscles, bend your knees, and keep your back straight and neutral. Face the direction of movement. Proper body mechanics can help prevent back injury when used in appropriate patient care situations.
On the count of three by the lead person, gently slide (not lift) the patient up the bed, shifting your weight from the back foot to the front, keeping your back straight and knees slightly bent.
Replace the pillow under the patient’s head, reposition the patient in the bed, and cover them with a sheet or blanket to provide comfort.
Lower the bed, raise the side rails as indicated, and ensure the call light is within reach. Perform hand hygiene. [ 56 ]
Prior to ambulating, repositioning, or transferring a patient from one surface to another (e.g., a bed to a wheelchair), it often necessary to move the patient to the side of the bed to avoid straining or excessive reaching by the health care professional. Positioning the patient to the side of the bed also allows the health care provider to have the patient as close as possible to their center of gravity for optimal balance during patient handling. [ 57 ]
Patients who have been lying in bed may experience vertigo, a sensation of dizziness as if the room is spinning, or orthostatic hypotension, low blood pressure that occurs when a patient changes position from lying to sitting or sitting to standing and causes the patient to feel dizzy, faint, or light-headed. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop of diastolic blood pressure of 10 mm Hg or more within 3 minutes of sitting or standing. For this reason, always begin a transfer or ambulation process by sitting the patient on the side of the bed for a few minutes with their legs dangling. [ 58 ]
Begin by explaining to the patient what will happen and how they can help. Determine if additional assistance or a mechanical lift is needed. [ 59 ] Ensure the bed is in a low and locked position, and then use the following guidelines to assist a patient to the seated position on the edge of the bed. [ 60 ] See Figure 13.20 [ 61 ] for images of a nurse assisting a patient to a seated position.
Assisting a Patient to a Seated Position
Stand facing the head of the bed at a 45-degree angle with your feet apart, with one foot in front of the other. Stand next to the waist of the patient.
Ask the patient to turn onto their side, facing you, as they move closer to the edge of the bed. Place one hand behind the patient’s shoulders, supporting the neck and vertebrae.On the count of three, instruct the patient to use their elbows to push up against the bed and then grasp the side rail as you support their shoulders as they sit. Shift your weight from the front foot to the back foot as you assist them to sit. Do not allow the patient to place their arms around your shoulders because this can lead to serious back injuries.
As you shift your weight, gently grasp the patient’s outer thighs with your other hand and help them slide their feet off the bed to dangle or touch the floor. This step helps the patient sit and move their legs off the bed at the same time. As you perform this action, bend your knees and keep your back straight and neutral.
Assess the patient for symptoms of orthostatic hypotension or vertigo. If they are experiencing any dizziness, request them to sit and dangle on the edge of the bed and determine if the symptoms resolve before transferring or ambulating. [ 62 ]
Ambulation is the ability of a patient to safely walk independently, with assistance from another person, or with an assistive device, such as a cane, walker, or crutches. After a patient has been assessed and determined safe to ambulate, determine if assistive devices or the assistance of a second staff member is required. Assist the patient to sit on the side of the bed and assess for symptoms of vertigo or orthostatic hypotension before proceeding. Ensure the patient is wearing proper footwear, such as shoes or nonslip socks. Apply a gait belt snugly over their clothing and around their waist if any type of assistance is required. See Figure 13.21 [ 63 ] for an image of applying a gait belt. The patient should be cooperative, able to bear weight on their own, have good trunk control, and be able to transition to a standing position on their own. If these criteria are not met, then mechanical devices, such as a sit to stand lift, should be used to assist a weight-bearing patient from a sitting position to a standing position. If a patient uses a walker or cane, these assistive devices should be placed near the bed before beginning this procedure.
Application of a Gait Belt
Stand in front of the patient, with your legs on the outside of their legs. Grasp each side of the gait belt, while keeping your back straight and knees bent, and then rock your weight backwards while gently steadying the patient into a standing position. After the patient is standing and feels stable, move to their unaffected side and grasp the gait belt in the middle of their back. [ 64 ] If needed for stability, place one arm under the patient’s arm, gently grasp their forearm, and lock your arm firmly under the patient’s axilla. In this position, if the patient starts to fall, you can provide support at the patient’s shoulder. [ 65 ] If the patient uses a walker or cane, ensure the patient is using this device before beginning ambulation. See Figure 13.22 [ 66 ] for an image of a nurse assisting the patient to stand.
Assisting a Patient to Stand
Before stepping away from the bed, ask the patient if they feel dizzy or light-headed. If they do, sit the patient back down on the bed until the symptoms resolve. If the patient feels stable, begin walking by matching your steps to the patient’s. Instruct the patient to look ahead and lift each foot off the ground. Walk only as far as the patient can tolerate without feeling dizzy or weak. Periodically ask them how they are feeling to check for dizziness or weakness. [ 67 ] In some situations of early ambulation, it is helpful for a second staff member to follow behind the patient with a wheeled walker or wheelchair in case the patient needs to sit while walking.
To assist the patient back into the bed or a chair, have them stand with the back of their knees touching the bed or chair. Grasp the gait belt and assist them as they lower into a sitting position, keeping your back straight and knees bent. Remove the gait belt. If the patient is returning to bed, place the bed in the lowest position, raise the side rails as indicated, and ensure the call light is within reach. Cover the patient with a sheet or blanket to provide comfort. Document the length of ambulation and the patient’s tolerance of ambulation.
Patients often require assistance when moving from a bed to a chair or wheelchair. A patient must be cooperative and predictable, able to bear weight on both legs, and able to take small steps and pivot to safely transfer with a one-person assist. If any of these criteria are not met, a two-person transfer or mechanical lift is recommended. Always complete a mobility assessment and check the provider’s or physical therapist’s orders prior to transferring patients. [ 68 ]
Begin by explaining to the patient what will happen during the transfer and how they can help. Be sure proper footwear is in place. Lower the bed; set it at a 45-degree angle. Place the wheelchair next to the bed and apply the wheelchair brakes. If the patient has weakness on one side, place the wheelchair on their strong side. [ 69 ]
Assist the patient to a seated position on the side of the bed with their feet on the floor. (See the previous section on how to assist a patient to a seated position.) Apply the gait belt snugly around their waist. Place your legs on the outside of their legs. Ask them to place their hands on your waist as they raise themselves into a standing position. Do not lift the patient. If additional assistance is required, obtain a mechanical lift, such as a sit to stand device. Do not allow them to put their arms around your neck because this can cause back injury. Stay close to the patient during the transfer to keep the patient’s weight close to your center of gravity. Once standing, ask the patient to pivot and then take a few steps back until they can feel the wheelchair on the back of their legs. Have the patient grasp the arm of the wheelchair and lean forward slightly. Assist the patient to lower themselves, while shifting your weight from your back leg to the front leg with your knees bent, trunk straight, and elbows slightly bent. Allow the patient to slowly lower themselves into the wheelchair using the armrests for support.
A patient may begin to fall while ambulating or while being transferred from one surface to another. If a patient begins to fall from a standing position, do not attempt to stop the fall or catch the patient because this can cause back injury. Instead, try to control their fall by lowering them to the floor. [ 72 ]
If a patient starts to fall and you are close by, move behind the patient and take one step back. Support the patient around the waist or hip area or grab the gait belt. Bend one leg and place it between the patient’s legs. Slowly slide the patient down your leg, lowering yourself to the floor at the same time. Always protect their head first. Once the patient is on the floor, assess the patient for injuries prior to moving them. Assess the patient’s need for assistance to get off the floor. If the patient is unable to get up off the floor, use a mechanical lift. Complete an incident report and follow up according to the patient’s condition and agency policy. See Figure 13.24 [ 73 ] for images of lowering a patient to the floor.
Lowering a Patient to the Floor
Falls are a major safety concern in health care. Nurses are responsible for identifying, managing, and eliminating potential fall hazards for patients. All patient-handling activities (positioning, transfers, and ambulation) pose a risk to both patients and health care professionals. Older adults are often at increased risk for falls due to impaired mental status, decreased strength, impaired balance and mobility, and decreased sensory perception. Patients may also be at risk for falls due to gait problems, cognitive ability, visual problems, urinary frequency, generalized weakness, cognitive impairments, or medications that may cause hypotension or drowsiness. [ 74 ] Falls can cause head injuries, fractures, lacerations, and other injuries.
Fall prevention is key. If a patient begins to feel dizzy while ambulating or transferring, assist them to sit on a chair or on the floor to avoid a fall. The head is the most important part of the body, so protect it as much as possible. In the event of a fall, seek help and stay with the patient until assistance arrives. Follow agency policy for reporting, assessing, and documenting. After a fall, always assess a patient for injuries prior to moving them. If the patient remains weak or dizzy, do not attempt to ambulate them, but instead, ask for assistance to transfer them to a chair or bed. [ 75 ]
All patients should be assessed for risk factors for falls and necessary fall precautions implemented per agency policy. Read more information about preventing falls in the “Safety” chapter.
Skalsky A. J., McDonald C. M. Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America. 2012; 23 (3):675–687. ↵ [PMC free article : PMC3482407 ] [PubMed : 22938881 ] [CrossRef]
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This work is a derivative of StatPearls by Javed & Davis and is licensed under CC BY 4.0 ↵.Skalsky A. J., McDonald C. M. Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America. 2012; 23 (3):675–687. ↵ [PMC free article : PMC3482407 ] [PubMed : 22938881 ] [CrossRef]
Skalsky A. J., McDonald C. M. Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America. 2012; 23 (3):675–687. ↵ [PMC free article : PMC3482407 ] [PubMed : 22938881 ] [CrossRef]
Kalisch B., Lee S., Dabney B. Outcomes of inpatient mobilisation: A literature review. Journal of Clinical Nursing. 2013; 23 (11-12):1486–1501. ↵ [PubMed : 24028657 ] [CrossRef]
Miller, B. (n.d.). Functional mobility and physical therapy. Capital Area Physical Therapy and Wellness. https://www .capitalareapt .com/functional-mobility-and-physical-therapy/ ↵.
Boynton T., Kelly L., Perez A., Miller M., An Y., Trudgen C. Banner mobility assessment tool for nurses: Instrument validation. American Journal of Safe Patient Handling & Movement. 2014; 4 (3) https://www .safety.duke .edu/sites/default /files/BMAT%20for%20Nurses.pdf ↵
National Institute for Occupational Safety and Health. (2013, August 2). Safe patient handling and mobility (SPHM). Centers for Disease Control and Prevention. https://www .cdc.gov/niosh /topics/safepatient/default.html ↵.
Francis R., Dawson M. Safe patient handling and mobility: The journey continues. American Nurse Today. 2016; 11 (5) https://www .myamericannurse .com/wp-content /uploads/2016/05/Patient-Handling-Safety-426b.pdf ↵
Agency for Healthcare Research and Quality. (2019, September). Never events. Patient Safety Network. https://psnet .ahrq.gov /primer/never-events ↵.
"invacare-reliant-350-electric-sit-to-stand-lift-3.jpg" by Invacare. This image is included on the basis of Fair Use. ↵.
“molift_air_200_rgosling_mb_env_585707.jpg” by unknown author, courtesy of etac. This image is included on the basis of Fair Use. ↵.
This work is derived from Nurse-Driven Early Mobility Protocols: Facilitator Guide. Content last reviewed January 2017. Agency for Healthcare Research and Quality, Rockville, MD. Access for free at https://www .ahrq.gov /hai/tools/mvp/modules /technical/nurse-early-mobility-protocols-fac-guide.html ↵.
“Continuous _Passive_Motion_Machine.jpg” by User :Ravedave is licensed under CC BY-SA 3.0 ↵.Skalsky A. J., McDonald C. M. Prevention management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America. 2012; 23 (3):675–687. ↵ [PMC free article : PMC3482407 ] [PubMed : 22938881 ] [CrossRef]
Mayo Clinic. (2020, March 30). Passive motion exercises. [Video]. YouTube. All rights reserved. https://youtu .be/EjJ5nX_jM-w ↵ .
Skalsky A. J., McDonald C. M. Prevention management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America. 2012; 23 (3):675–687. ↵ [PMC free article : PMC3482407 ] [PubMed : 22938881 ] [CrossRef]
“AFO _Ankle_Foot_Orthosis_Orthotic_Brace .JPG” by Pagemaker787 is licensed under CC BY-SA 4.0 ↵.Shelhamer M., Wesson P., Solari I. L., Jensen D. L., Steele W. A., Dimitrov V. G., Kelly J. D., Aziz S., Gutierrez V. P., Vittinghoff E., Chung K. K., Menon V. P., Ambris H. A., Baxi S. M. Prone positioning in moderate to severe acute respiratory distress syndrome due to COVID-19: A cohort study and analysis of physiology. Journal of Intensive Care Medicine. 2021; 36 (2):241–252. ↵ [PMC free article : PMC7780273 ] [PubMed : 33380236 ] [CrossRef]
"Tripod_position.png" by Nic Ashman, Chippewa Valley Technical College is licensed under CC BY 4.0 ↵.
“Book-pictures-2015-5851.jpg,” “Book-pictures-2015-587.jpg,” and “Book-pictures-2015-588.jpg” by unknown authors are licensed under CC BY 4.0. Access for free at https://opentextbc .ca /clinicalskills/chapter /3-5-positioning-a-patient-on-the-side-of-a-bed/ ↵.
“Sept-22-2015-122-e1443986200821.jpg,” “Sept-22-2015-124.jpg,” and “Sept-22-2015-128.jpg” by unknown authors are licensed under CC BY 4.0. Access for free at https://opentextbc .ca /clinicalskills/chapter /3-5-positioning-a-patient-on-the-side-of-a-bed/ ↵.
“Book-pictures-2015-603.jpg” and “Book-pictures-2015-6041” by unknown authors are licensed under CC BY 4.0. Access for free at https://opentextbc .ca /clinicalskills/chapter /3-7-transfers-and-ambulation/ ↵.
Thompson Rivers University. (n.d.). Nursing | Assisting from bed to chair with a gait belt or transfer belt. [Video]. All rights reserved. https://barabus .tru.ca /nursing/assisting_from_bed.html ↵.
“Sept-22-2015-132-001.jpg” and “Sept-22-2015-133.jpg” by unknown authors are licensed under CC BY 4.0. Access for free at https://opentextbc .ca /clinicalskills/chapter /3-7-fall-prevention/ ↵.
Because mobility issues are directly related to musculoskeletal disorders, perform a thorough assessment of the musculoskeletal system and its effect on the patient’s mobility status. Assess muscle strength and coordination, and then assess mobility skills in the following order: mobility in bed, dangling on the bed with supported and unsupported sitting, weight-bearing while transferring from sitting to standing or to a chair, standing and walking with assistance, and walking independently.
Because immobility can negatively affect several body systems, perform a thorough assessment for patients with impaired mobility. Assess the cardiovascular system, including blood pressure, heart sounds, apical and peripheral pulses, and capillary refill time. Assess for the presence of lower extremity edema and for signs of a potential deep vein thrombosis (DVT).
Assess the respiratory system, including respiratory rate, oxygen saturation, lung sounds, chest wall movement and symmetry, and depth and effort of respirations. Assess for potential signs of atelectasis and pneumonia.
Assess the gastrointestinal system by inspecting for distension, auscultating bowel sounds, and palpating the abdomen for tenderness. Ask the patient about the date of their last bowel movement, and monitor stool patterns and stool characteristics. If constipation is suspected, palpate the patient’s left lower quadrant for signs of stool presence. Assess for the presence of urinary tract abnormalities related to immobility, such as suprapubic distention or tenderness that can result from urinary retention. Monitor 24-hour trend of intake and output, as well as for symptoms of dysuria, urgency, or frequency. Note if urinary incontinence is occurring due to the inability of the patient to reach the restroom in time. [ 1 ]
At each stage of growth and development, the nurse assesses a patient’s mobility and provides appropriate education. For example, infants move their limbs, hold their head up, roll, sit, crawl, stand, and then eventually walk. Parents are educated about these developmental milestones during well-child visits. When working with school-age children, nurses provide education to prevent injury that can occur with activity, such as using helmets and knee pads to prevent injury while bicycling and skateboarding. As teenagers become adults, the nurse provides education about the effects of alcohol and other drugs on balance and safety while driving. Older adults are at increased risk for immobility. Conditions such as osteoarthritis, orthostatic hypotension, inner ear dysfunction, osteoporosis resulting in hip fractures, stroke, and Parkinson’s disease are among the most common causes of immobility in old age.
Hospitalization poses a risk for altered functional status of older adults due to acute illness, decreased mobility, and the negative effects of bedrest. The American Academy of Nursing issued a recommendation in 2014 stating, “Don’t let older adults lie in bed or only get up to a chair during their hospital stay.” This recommendation highlights the importance of implementing evidence-based measures to promote activity during hospitalization to prevent functional decline in older adults. [ 2 ]
There are several nursing diagnoses related to mobility. Review a nursing care planning source for current NANDA-I approved nursing diagnoses and interventions. A commonly used NANDA-I nursing diagnosis is Impaired Physical Mobility. [ 4 ] See Table 13.3 for the definition and selected defining characteristics of this diagnosis. [ 5 ]
NANDA-I Nursing Diagnosis Impaired Physical Mobility [ 6 ]
A sample nursing diagnosis in PES format is, “Impaired Physical Mobility related to decrease in muscle strength as evidenced by slow movement and alteration in gait.”
A sample overall goal for a patient with Impaired Physical Mobility is, “The patient will participate in activities of daily living to the fullest extent possible for their condition.”
A sample SMART outcome is, “The patient will demonstrate appropriate use of adaptive equipment (e.g., a walker) for safe ambulation by the end of the shift.”
Nursing interventions promote a patient’s mobility and prevent effects of immobility. To avoid or minimize complications of immobility, mobilize the patient as soon as possible and to the fullest extent possible. Mobilization efforts, ranging from dangling on the edge of the bed, sitting up in a chair, and assisting with early ambulation, depend on the patient’s unique circumstances, such as their medical condition and surgery performed. For example, a patient undergoing a cardiac catheterization may be mobilized within a few hours following the procedure, whereas a patient undergoing total knee arthroplasty may begin mobilizing 24 hours following the surgery. [ 7 ] See details about early mobilization protocols earlier in this chapter.
Encourage the patient to perform activities of daily living (ADLs) as independently as possible and participate in prescribed physical therapy. Encourage or perform active or passive range of motion exercises as prescribed by the physical therapist. Be aware that pain and fear of falling can be major deterrents to a patient’s willingness to ambulate or perform physical therapy. Monitor the patient’s level of pain by using a valid pain intensity rating scale. Administer medications if warranted and consider nonpharmacologic measures such as repositioning, splinting, and heat/cold application to reduce musculoskeletal discomfort. Encourage rest between activities. Educate the patient about appropriately using assistive devices and other fall precautions. [ 8 ] , [ 9 ]
For patients at risk for developing pneumonia due to immobility, encourage adequate fluid intake to liquefy pulmonary secretions, and teach deep breathing and coughing exercises to prevent atelectasis. Monitor oxygenation levels and provide supplemental oxygen as prescribed to maintain adequate oxygenation, especially during ambulation. [ 10 ]
For bed-bound patients, elevate the head of the bed to 30 to 45 degrees, unless medically contraindicated, and turn and reposition the patient every two hours. Perform hourly rounding to check on the patient’s needs and prevent falls. Protect the skin as needed to minimize the potential for breakdown, and advocate for devices to prevent contractures, as needed. [ 11 ] , [ 12 ]
When implementing interventions to promote mobility, in addition to reviewing the current orders regarding assistance and weight-bearing, assess the patient’s current status. For example, use the Banner Mobility Assessment Tool to determine the patient’s current mobility status and needs for safe patient handling.
Monitor for signs of vertigo and orthostatic hypotension and assist the patient to a sitting or lying position if they occur. Monitor vital signs before, during, and after physical activity and institute appropriate fall prevention strategies as indicated. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mmHg or more or in diastolic blood pressure of 10 mm Hg or more within three minutes of standing. If orthostatic hypotension is suspected, measure the patient’s vital signs while he or she is supine, sitting, and standing before encouraging ambulation. Monitor and document the patient’s response to activity, such as heart rate, blood pressure, dyspnea, and skin color. [ 13 ] , [ 14 ]
Determine the patient’s progress towards their specific SMART outcomes. Encourage their participation in the setting of realistic goals for mobility and modify these goals as needed for safety.
Skalsky A. J., McDonald C. M. Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America. 2012; 23 (3):675–687. ↵ [PMC free article : PMC3482407 ] [PubMed : 22938881 ] [CrossRef]
American Academy of Nursing's Expert Panel on Acute and Critical Care. (n.d.). Reducing functional decline in older adults during hospitalization. The Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University. https://hign .org/consultgeri /try-this-series /reducing-functional-decline-older-adults-during-hospitalization ↵.
The Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University. (n.d.). Assessment tools for best practices of care for older adults. https://hign .org/consultgeri-resources /try-this-series ↵.
Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, p. 219 ↵.
Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, p. 219 ↵.
Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, p. 219 ↵.
Skalsky A. J., McDonald C. M. Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America. 2012; 23 (3):675–687. ↵ [PMC free article : PMC3482407 ] [PubMed : 22938881 ] [CrossRef]
Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC). Elsevier, pp. 281-282. ↵.
Skalsky A. J., McDonald C. M. Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America. 2012; 23 (3):675–687. ↵ [PMC free article : PMC3482407 ] [PubMed : 22938881 ] [CrossRef]
Skalsky A. J., McDonald C. M. Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America. 2012; 23 (3):675–687. ↵ [PMC free article : PMC3482407 ] [PubMed : 22938881 ] [CrossRef]
Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC). Elsevier, pp. 281-282. ↵.
Skalsky A. J., McDonald C. M. Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America. 2012; 23 (3):675–687. ↵ [PMC free article : PMC3482407 ] [PubMed : 22938881 ] [CrossRef]
Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC). Elsevier, pp. 281-282. ↵.
Skalsky A. J., McDonald C. M. Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America. 2012; 23 (3):675–687. ↵ [PMC free article : PMC3482407 ] [PubMed : 22938881 ] [CrossRef]
Mrs. Howard is a 73-year-old woman who was recently admitted to the medical surgical floor with pneumonia. She has an underlying history of emphysema and has experienced a recent exacerbation in dyspnea during activity. This morning when being assisted to the bathroom, she reports, “I have to stop and catch my breath when walking.” Vital signs this morning indicated oxygen saturation 91% and respiratory rate 18 on room air at rest. During report it was communicated that Mrs. Howard is able to ambulate with the assistance of one but only moves short distances around the room before she needs to stop and rest.
Assessment: The nurse identifies a relevant cue that the patient, diagnosed with pneumonia and a previous history of emphysema, is experiencing increased dyspnea when walking around the room that requires her to stop and rest. Vital signs at 0700 were reviewed, and it was noted that the patient’s respiratory rate was 24 with oxygen saturation level 91% on room air at rest. The nurse gathers additional assessment data while the patient is walking and discovers her respiratory rate increases to 30 and her oxygen saturation level decreases to 85% after walking for 2 minutes. Additionally, the patient stops and catches her breath after walking approximately 10 feet, causing her to limit her mobility.
The nurse reviews the patient’s chart and finds an order for “Oxygen via nasal cannula up to 5 L/min PRN to maintain oxygen saturation at 90%.” The nurse also notes a referral for physical therapy assessment and strengthening exercises.
Based on the assessment information gathered, the following nursing care plan is created for Mrs. Howard:
Nursing Diagnosis: Impaired Physical Mobility r/t activity intolerance as manifested by decreased oxygen saturation, increased respirations, and patient report of “I have to stop and catch my breath while walking.”
Overall Goal: The patient will demonstrate improvement in mobility.
SMART Expected Outcomes:
Mrs. Howard will ambulate 50 feet in the hallway within 24 hours. Mrs. Howard will maintain an oxygen saturation level of 90% or higher while walking within 24 hours.Planning and Implementing Nursing Interventions:
The nurse plans to administer oxygen to the patient via nasal cannula as needed to maintain an oxygen saturation level of 90% or higher. The nurse will teach the patient about the importance of balancing periods of activity with periods of rest and reinforce the use of pursed-lip breathing. The nurse will encourage patient ambulation and her active participation in completing ADLs. The nurse will collaborate with physical therapy to educate the patient regarding strengthening exercises and reinforce principles of progressive exercise. The nurse plans to further assess the patient’s smoking history and promote smoking cessation.
Sample Documentation
At 0800 when assisting the patient to the bathroom, the patient reported, “I have to stop and catch my breath when walking.” Vital signs at 0700 were respiratory rate 24 and oxygen saturation level 91% on room air at rest. At 0830, vital signs were reassessed while the patient was walking. Her respiratory rate increased to 30 and her oxygen saturation level decreased to 85% after 2 minutes of walking. The patient stopped to catch her breath after walking approximately 10 feet. Oxygen via nasal cannula at 1 L/min was applied to the patient before ambulating in the hallway at 1000. The patient’s oxygen saturation level dropped to 88% after one minute of walking and the oxygen was increased to 2 L/min. The patient’s oxygen saturation then remained at 90% for the remainder of the walk, and she was able to ambulate 50 feet. Pursed-lip breathing was demonstrated and reinforced during the walk. Physical therapy was contacted and an assessment scheduled for later this morning. The patient reports a smoking history of a pack per day for 50 years. She is interested in stopping smoking. A smoking cessation brochure was provided and discussed. Dr. Smith was notified of these events at 1030.
Within 24 hours, Mrs. Howard successfully ambulated 50 feet in the hallway while maintaining oxygen saturation level of 90%. SMART outcomes were “met.” Planned interventions will continue. SMART outcome is revised to, “Mrs. Howard will ambulate 100 feet in the hallway within 24 hours.”
(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
Ms. Curtis is a 67-year-old patient admitted for a left total knee replacement. She is post-op Day 2 and is currently receiving care on the medical surgical unit. Ms. Curtis has been complaining of pain and refused her previous two physical therapy appointments. She agrees to sitting up in the chair, but declines walking.
What focused assessments should the nurse perform and why?
What complications could occur related to Ms. Curtis’ immobility?
What SMART outcomes should the nurse plan in collaboration with Ms. Curtis?
List interventions the nurse should plan for Ms. Curtis and their rationale.
How will the nurse evaluate if the interventions are successful?
Mobility Case Study by Susan Jepsen for Lansing Community College are licensed under CC BY 4.0
A patient’s joint receiving partial assistance in movement from an outside force.
Active range of motion
Movement of a joint by the individual performing the exercise.
The ability of a patient to safely walk independently, with assistance from another person, or with an assistive device, such as a cane, walker, or crutches.
An object or piece of equipment designed to help a patient with activities of daily living, such as a walker, cane, gait belt, or mechanical lift.
The ability of a patient to move around in bed, including moving from lying to sitting and sitting to lying.
The coordinated effort of muscles, bones, and the nervous system to maintain balance, posture, and alignment during moving, transferring, and repositioning patients.
A position where the patient is supine with the head of bed placed at a 45- to 90-degree angle. The bed can be used to slightly flex the hips to help prevent the patient from migrating downwards in bed.
The ability of a person to move around in their environment, including walking, standing up from a chair, sitting down from standing, and moving around in bed.
A 2-inch-wide (5 mm) belt, with or without handles, that is fastened around a patient’s waist used to ensure stability when assisting patients to stand, ambulate, or to transfer from bed to chair.
A position where the patient lies on one side of the body with the top leg over the bottom leg. This position helps relieve pressure on the coccyx.
A hydraulic lift with a sling used to move patients who cannot bear weight or have a medical condition that does not allow them to stand or assist with moving. It can be a portable device or permanently attached to the ceiling.
The ability of a patient to change and control body position. Mobility exists on a continuum ranging from no impairment (i.e., the patient can make major and frequent changes in position without assistance) to being completely immobile (i.e., the patient is unable to make even slight changes in body or extremity position without assistance).
Low blood pressure that occurs when a patient changes position from lying to sitting or sitting to standing that causes symptoms of dizziness or light-headedness. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop of diastolic blood pressure of 10 mm Hg or more within three minutes of sitting or standing.
Passive range of motion exercises
Movement applied to a joint solely by another person or a passive motion machine. When passive range of motion is applied, the joint of an individual receiving exercise is completely relaxed while the outside force moves the body part.
A position where the patient lies on their stomach with their head turned to the side.
Range of motion (ROM) exercises
Activities aimed to facilitate movement of specific joints and promote mobility of extremities.
A position where the head of the bed is placed at a 30- to 45-degree angle. The patient’s hips may or may not be flexed.
A position where the patient is positioned halfway between the supine and prone positions with their legs flexed.
Sit to stand lifts
Mobility devices that assist weight-bearing patients who are unable to transition from a sitting position to a standing position by using their own strength. They are used to safely transfer patients who have some muscular strength, but not enough strength to safely change positions by themselves. Some sit to stand lifts use a mechanized lift whereas others are nonmechanized.
A board (also called a transfer board) used to transfer an immobile patient from one surface to another while the patient is lying supine (e.g., from a stretcher to hospital bed).
A position where the patient lies flat on their back.
Timed Get Up and Go Test
A mobility assessment by nurses that begins by having the patient stand up from an armchair, walk three yards, turn, walk back to the chair, and sit down. As the patient performs these maneuvers, their posture, alignment, balance, and gait are analyzed as the patient’s mobility status is assessed.
The action of a patient moving from one surface to another. This includes moving from a bed into a chair or moving from one chair to another.
A position where the head of the bed is placed lower than the patient’s feet. This position is used in situations such as hypotension and medical emergencies because it helps promote venous return to major organs such as the brain and heart.
A position where the patient sits in a chair with their elbows on their knees or at the side of the bed with their arms resting on an overbed table. This position is often naturally assumed by patients with breathing difficulties.
A sensation of dizziness as if the room is spinning.
Assisting a Patient to a Wheelchair
