The Nurse's Role in Early Mobility with Heidi Engel, PT, DPT

Today, ICU patients seem to become sicker and more sedated. Sedation medications, such as Propofol, have become more accessible and can be hung up and left on a drip all day. Heidi Engel, PT, DPT argues that less sedation and more mobilization should be thought of as important as taking medications. In this episode, we discuss how nurses can play a crucial role in mobilizing our patients both in the ICU and on the floor.

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Benefits of Early Mobilization:

Prevent pneumonia
Prevent blood clots
Prevent bowel obstructions
Prevent severe muscle wasting
Prevent delirium
Prevent shoulder/back pain
Prevent calf weakness
Decrease length of hospital stay

When to Initiate Mobility?

48 hours is target for initiating mobility because it only takes 48 hrs to start developing diaphragm weakness

We must advocate for our patients who develop anxiety regarding getting out of bed

When a patient is hospitalized and constantly horizontal in a bed, it is associated as their safe space
Patients become terrified of leaving their comfort zone
Nurse should anticipate the fears, anxieties and how much the patient has adapted to their bed

“I say to my students, when we get to the doorway the pt will have a panic attack and we have to help them pass that threshold of the doorway”
Heid Engel, PT, DPT

Strategies for coaching patients through anxiety

Inform patient of session’s measurable goal: “today, we are going to walk out of the room into the hallway and sit at the bench by the window”
Think of the patient as a whole, with questions such as:
- How frail are they?
- How many comorbidities do they have?
- How old are they?
- How much anxiety disorder?
- Do they have at baseline?
- How can we how can we recruit their family members to help cheer them on?
- Or do their family induce more anxiety?

What are some chair and standing exercises RNs can lead with our patients while we’re in the room?

Weight bering exercise to stretch heel cords to prevent calf wasting
Toe taps in chair
Ankle Pumps
- There is EBP that states doing 20 ankle pumps every 20 minutes is far more effective at preventing DVT than SCD’s (also means that the SCD’s would not have to be on as often as they are)Exercises that reach up and overhead to prevent “Frozen Shoulders,” or rotator cuff problems
Coughing and deep breathing/ incentive spirometer use is important to maintain lung elasticity, prevent atelectasis, and decrease risk for infection of airway
Squats and arm raises may be completed while standing and holding onto assistive device or chair, such as shown in this video:

Note: make PT fun by allowing patients to participate as a group. Group exercises to get clients motivated while counting out movements; this can consolidate client needs by getting them in a group and doing exercises all at once

“There is no substitute for getting out of bed…There is no bed exercise that exist that can replicate being out of bed.”
Heidi Engel, PT, DPT

GOAL: We want to normalize activities and being out of bed as much as possible. Getting out of bed is imperative for maintaining mental and physical health

Example of Early Mobility Initiative Success

Inner Mountain Health in in Salt Lake City is an institution that is very aggressive about early mobilization. They have the longest running, most vigorous, mobility program in the country. Patients, ventilated or not, are out of bed and walking twice a day, while getting uninterrupted sleep throughout certain nightly hours. A very high percentage of their ICU patients are able to leave sooner and go straight home after their hospital stay. Here are articles that explain how an initiative encouraged early mobility for a shorter hospital stay.

“In my head, there’s a distinction between allowing a patient to be as independent as possible or to struggle, and empowering a patient. And our goal is to empower the patient. And our goal also is to always, always, always appreciate that our patient is an adult. And we want to to empower them but at the same time, we need to be able to assist them in and give them give them support and a sense of safety because of this vulnerable you know, we can position they’re in at the moment.”
Heidi Engle, PT, DPT

Last Notes:

Mobility should not be viewed as just a PT project.
It is an interprofessional, multidisciplinary, critical care project. It is always composed of TEAMWORK.
The benefits early mobilization will involve improved core strength and returning to normal routines/independence

References

Caple C., Karakashian, AL. (2018). Range-of-Motion Exercises, Active: Teaching. Armenian American Medical Society of California. CINAHL Nursing Guide. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=nup&AN=T705246&site=eds-live&scope=site

Taito, S., Shime, N., Yasuda, H., Ota, K., MD, Sarada, K., Lefor, A.K., Sanui, M. (2018) Out-of-bed mobilization of patients undergoing mechanical ventilation with orotracheal tubes: A survey study. Journal of Critical Care. 47:173-177. DOI: 10.1016/j.jcrc.2018.06.022

Woten M; Pravikoff D. (2018). Early Mobilization of Patients in the Intensive Care Unit (ICU). CINAHL Nursing Guide, EBSCO Publishing, Evidence-Based Care Sheet, Database: Nursing Reference Center Plus. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=nup&AN=T708324&site=eds-live&scope=site

Up My Nursing Game is partnering with VCU Health Continuing Education to offer FREE continuing education credits for registered nurses. Click here to obtain nursing credit (1.00).