Progressive Mobility in The Critically Ill PDF

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Progressive Mobility in the Critically Ill

Introduction to Progressive Mobility tory system include development of compression atelectasis
Kathleen M. Vollman, RN, MSN, CCNS from the formation of dependent edema with the patient
supine and impaired ability to clear the lungs because the nor-
T he term progressive mobility is defined as a series of

planned movements in a sequential manner beginning at
a patient’s current mobility status with a goal of returning to
mal lung-clearing functions of the mucociliary escalator, cough
reflex, and drainage do not work as well with the patient
supine. This impaired clearing places immobilized patients at
his/her baseline (©Advancing Nursing LLC). Progressive greater risk for VAP or hospital-acquired pneumonia.8,10,11
mobility is the term used to describe the graded application of The changes in the cardiovascular system related to bed
the following positioning and mobility techniques: elevation rest are significant. The act of lying down shifts 11% of the
of the head of the bed, manual turning, passive and active total blood volume away from the legs, with most going to the
range-of-motion exercises, continuous lateral rotation therapy chest. Within the first 3 days of bed rest, plasma volume is
(CLRT) and prone positioning (if criteria met), movement reduced 8% to 10%. This loss stabilizes to 15% to 20% by the
against gravity, upright/leg-down position (tilt table and bed fourth week of bed rest.1,8-10,12-14 The result is an increase in car-
egress), chair position, dangling, and ambulation. diovascular workload, elevation of resting heart rate, and a
decrease in stroke volume with a reduction in cardiac output.
Negative Outcomes of Immobility Orthostatic tolerance deteriorates rapidly with immobility.
A meta-analysis1 of 39 randomized trials examining the The maximum effect is seen at 3 weeks. Baroreceptor dysfunc-
effect of bed rest on 15 different medical conditions and proce- tion, changes in autonomic tone, and fluid shifts are thought
dures showed that bed rest was not beneficial and may be asso- to be the cause.8,14,15 The heart muscle itself becomes decondi-
ciated with harm. The short-term adverse outcomes for tioned with bed rest. In healthy persons on 5 days of bed rest,
critically ill patients include ventilator-associated pneumonia insulin resistance and microvascular dysfunction are seen.12
(VAP) and hospital-acquired pneumonia, delayed weaning off of The skin normally does not tolerate prolonged pressure;
mechanical ventilation due to muscle weakness, and the devel- therefore, immobilized patients and patients on bed rest are at
opment of pressure ulcers.2 The major long-term complication greater risk for skin breakdown and delayed wound healing.16
is the diminished quality of life after discharge due to the physi- Interruptions in the skin barrier may place critically ill
cal deconditioning that takes place during the patient’s stay in patients at greater risk for health care–acquired infections.
the intensive care unit (ICU).3-6 Herridge et al3 looked at out- The musculoskeletal system is severely affected by immobility
comes among survivors of acute respiratory distress syndrome and bed rest. ICU-acquired weakness is caused by many fac-
and found that they lost 18% of their body weight at discharge tors: the inflammatory response, glycemic control, use of
from the ICU and had significant functional limitations 1 year myotoxic or neurotoxic medications like corticosteroids or
later because of muscle wasting and fatigue. With more than 5 neuromuscular blocking agents, and immobility.1,8-10 Immobil-
million persons experiencing an ICU stay each year, the short- ity in critically ill patients leads to decreased protein synthesis
and long-term complications of immobility/bed rest signifi- in muscle, increased catabolism of the muscle, and decreased
cantly affect morbidity, mortality, cost, and quality of life.7 muscle mass that is more pronounced in the lower limbs.17-19
Muscle groups that lose the most strength are involved in
System-Specific Changes maintaining posture, transferring activities, and ambulation.20
During bed rest or immobility, adverse effects are seen on Skeletal muscle strength may decline 1% to 1.5% per day of strict
the respiratory, cardiovascular, integumentary, and muscu- bed rest.17,20-22 After 7 days of mechanical ventilation, 25% to 33%
loskeletal systems.1,2,8-11 The major consequences to the respira- of patients experience clinically visible weakness.21 The muscle
atrophy that occurs in patients receiving mechanical ventilation
can cause fatigue of the diaphragm and weaning challenges that
can contribute to an increase in ICU and hospital length of stay.
In a recent study,23 researchers found that more than one-third
CEContinuing Education of patients with stays in the ICU greater than 2 weeks had at
This article has been designated for CE credit. A closed-book, multiple- least 2 functionally significant joint contractures. Because the
choice examination follows this article, which tests your knowledge of the consequences of immobility and bed rest are so severe, mobiliz-
following objectives: ing critically ill patients early appears to have merit.
1. Identify the risks associated with bed rest and immobility in ICU
patients.
2. Describe the process of progressive mobility. Challenges and Barriers
3. Discuss challenges and barriers to making positioning and mobility of The benefits of movement and exercise include improved
patients a priority of practice in the ICU. muscle strength, evidence of reduced oxidative stress and
www.ccnonline.org CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement S3

Apr 2010 suppl_pgs.qxp:Editorial8_08 3/11/10 12:15 PM Page 4
inflammation, positive mood changes, less fatigue, and a movement during the mobility technique. When assessing tol-
greater ability to resume activities of daily living.24-26 However, erance, it is important to remember that most critically ill
making positioning and mobility of patients a priority of prac- patients take 5 to 10 minutes to adapt to a mobility action or a
tice in the ICU can be a challenge. One study27 demonstrated position change. After the appropriate time period, the critical
that during an 8-hour time frame, less than 3% of critically ill care nurse and/or team can safely judge pulmonary and car-
patients were turned in accordance with the standard of prac- diovascular tolerance to the activity and can determine
tice of turning every 2 hours. Close to 50% of patients during whether the patient is ready to be progressed.33,34
that same period had no change in body position.27 In a Significant problems are created for ICU patients when
study28 of the positioning of critically ill patients in a 2-day they are not mobilized effectively. One solution may rest in
period in 40 ICUs in the United Kingdom, the average time working as a team to increase the awareness of the importance
between manual turns was 4.85 hours, with a standard devia- of early mobilization and in shifting the ICU culture from one
tion of 3.3 hours. in which the patient on bed rest is the norm to a culture in
The challenges to mobilizing critically ill patients are which mobilization enables the prevention of complications
numerous. Factors to consider include the safety of tubes and and faster healing and recovery.35 Mobility is a fundamental
lines, hemodynamic instability, personnel and equipment nursing activity that requires knowledge and skill to apply
resources, sedation practices, the patient’s size, the patient’s effectively to critically ill patients. When mobility is a core
pain and discomfort, and the time, valuing, and priority of component of care, it can enhance key outcomes for patients,
mobilization.2,29 Safety with respect to the activity event and improving gas exchange, reducing rates of VAP, shortening the
the patient’s ability to hemodynamically tolerate the move- duration of mechanical ventilation, and enhancing long-term
ment may be the most significant factor. A prospective cohort functional ability. Early progressive mobility can make a dif-
study30 of 103 patients receiving mechanical ventilation was ference. Mobilizing critically ill patients must be viewed along
helpful in evaluating the safety of mobilizing critically ill a progressive continuum based on readiness, specific disease,
patients. During the study, 1449 activity events were per- strategies to prevent complications, and ability to tolerate the
formed and the percentage of adverse events was recorded. activity/movement. We can work to combat the physical
The activity events included sitting on the bed, sitting in a deconditioning that occurs with bed rest by using a stepwise
chair, and ambulating. The adverse events were defined as progression program. Readiness for mobility should be
falling to the knees, line/tube removal, systolic blood pressure assessed daily to determine status for entrance into a progres-
exceeding 200 mm Hg, systolic blood pressure less than 90 sive mobility protocol or advancement within a protocol.
mm Hg, oxygen saturation less than 80%, and extubation. The The definition of progressive mobility was developed so
data showed that early mobilization was safe; not only did that future work on the topic might better stratify the various
fewer than 1% of patients experience an adverse event, but 69% stages in order to test, evaluate, and implement mobilization
were able to ambulate at least 100 feet (30 m) at time of dis- techniques and processes of care. The following sections of
charge from a respiratory ICU.30 this supplement showcase practical and successful strategies
Hemodynamic instability can be a significant barrier in for mobilizing critically ill patients to improve clinical and
the start or progression of a mobility protocol. When individ- financial outcomes. The goal is to provide a road map to help
uals change their gravitational reference from a lying to sitting clinicians get started in developing and implementing unit-
position, the body goes through a series of physiological adap- based protocols for progressive mobility.
©2010 American Association of Critical-Care Nurses

tations to maintain cardiovascular homeostasis. When the
doi: 10.4037/ccn2010803
body’s gravitational plane changes, the cardiovascular system
normally tries to adjust in 2 ways: by plasma volume shifts
that may cause transmission of messages to the autonomic Financial Disclosures
nervous system to change vascular tone or by an inner ear or The author is a Hill-Rom consultant/speaker.
vestibular response that affects the cardiovascular system dur- References
ing a position change. Critically ill patients commonly have 1. Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treat-
ment needing more careful evaluation. Lancet. 1999;354:1229-1233.
poor vascular tone, a dysfunctional autonomic feedback loop, 2. Morris PE. Moving our critically ill patients: mobility barriers and bene-
and/or low cardiovascular reserve.31,32 Often, they are left in a fits. Crit Care Clin. 2007;23(1):1-20.
stationary position for a prolonged period and establish a 3. Herridge MS, Cheung AM, Tansey CM, et al. One year outcomes in sur-
vivors of the acute respiratory distress syndrome. N Engl J Med.
“gravitational equilibrium” over time, making it more difficult 2003;348(8):683-693.
to adapt to a position change. For patients in whom hemody- 4. Hopkins RO, Weaver LK, Collingridge D, et al. Two-year cognitive, emo-
tional, and quality-of-life outcomes in acute respiratory distress syn-
namic instability develops with a manual turn, the solution drome. Am J Respir Crit Care Med. 2005;171(4):340-347.
might be to train the patients to tolerate a position change 5. Dowdy DW, Eid MP, Sedrakyan A, et al. Quality of life in adult sur-
rather than leaving them in a stationary supine position. Rota- vivors of critical illness: a systematic review of the literature. Intensive
Care Med. 2005;31(5):611-620.
tional therapy can gradually retrain patients to tolerate turn- 6. Dowdy DW, Eid MP, Dennison CR, et al. Quality of life after acute respi-
ing because the speed of the turn is much slower than a ratory distress syndrome: a meta-analysis. Intensive Care Med.
2006;32(8):1115-1124.
manual turn. If the instability is not severe, the practitioner 7. Graf J, Koch M, Dujardin R, Kersten A, Janssens U. Health-related qual-
could help cardiovascular adaptation by slowing the patients’ ity of life before, 1 month after, and 9 months after intensive care in
S4 CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement www.ccnonline.org

medical cardiovascular and pulmonary patients. Crit Care Med.

2003;31(8):2163-2169.
8. Truong AD, Fan E, Brower RG, Needham DM. Bench to bedside review: Continuous Lateral Rotation Therapy
mobilizing patients in the intensive care unit–from pathophysiology to Leslie Swadener-Culpepper, RN, MSN, CCRN, CCNS
clinical trials. Crit Care. 2009;13:1-8.
9. Fortney SM, Schneider VS, Greenleaf JE. The Physiology of Bedrest. Vol 2.
10.
New York, NY: Oxford University Press; 1996.
Greenleaf JE, Kozlowski S. Physiological consequences of reduced activ-
ity during bed rest. Exerc Sport Sci Rev. 1982;10:84-119.
P ulmonary complications remain common in critically ill
patients and are especially prevalent in patients who are
intubated and receiving mechanical ventilation. These compli-
11. Stevens RD, Dowdy DW, Michaels RK, Mendez-Tellez PA, Pronovost PJ,
Needham DM. Neuromuscular dysfunction acquired in critical illness: a cations include hypoxia, atelectasis, and hospital-acquired
systematic review. Intensive Care Med. 2007;33(11):1876-1891.
12. Hamburg NM, McMackin CJ, Huang AL, et al. Physical inactivity rap-
infections. The Institute for Healthcare Improvement1 has
idly induces insulin resistance and microvascular dysfunction in healthy reported that ventilator-associated pneumonia is one of the
volunteers. Arterioscler Thromb Vasc Biol. 2007;27(12):2650-2656. most frequent causes of increased hospital morbidity and
13. Gosselink R, Bott J, Johnson M, et al. Physiotherapy for adults with
critical illness: recommendations of the European Respiratory Society mortality. To prevent these complications of therapy, nurses
and European Society of Intensive Care Medicine task force on have traditionally turned patients from side to side every 2
physiotherapy for critically ill patients. Intensive Care Med. 2008;34:
1188-1199. hours. However, this type of manual turning has not been
14. Convertino VA. Cardiovascular consequences of bed rest: effect on max- reported to have a significant effect on pulmonary function.2
imal oxygen uptake. Med Sci Sports Exerc. 1997;29:191-196. Continuous lateral rotation therapy (CLRT), an integral
15. Convertino V, Hung J, Goldwater D, DeBusk RF. Cardiovascular
responses to exercise in middle-aged men after 10 days of bedrest. part of progressive mobility, came into use in the 1970s in an
Circulation. 1982;65:134-140. effort to reduce pulmonary complications of immobility. Lat-
16. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic
review. JAMA. 2006;296(8):974-983. eral rotation therapies were delivered via continuous-motion
17. De Jonghe B, Sharshar T, Lefaucheur JP, et al. Paresis acquired in the bed frames that rotated the patient from side to side. Known
intensive care unit: a prospective multicenter study. JAMA. by many different names, lateral rotation has been most com-
2002;288(22):2859-2867.
18. Pavy-LeTraon A, Heer M, Narici MV, et al. From space to earth: monly referred to as CLRT or kinetic therapy. Over the years,
advances in human physiology for 20 years of bedrest studies (1986- numerous studies have been performed to examine the effec-
2006). Eur J Appl Physiol. 2007;101(2):143-194.
19. Ferrando AA, Lane HW, Stuart CA, et al. Prolonged bed rest decreases tiveness of CLRT. Many studies2-8 have shown improvement in
skeletal muscle and whole body protein synthesis. Am J Physiol. 1996; various pulmonary outcome indicators when lateral rotation
270:E627-E633.
20. Topp R, Ditmyer M, King K, et al. The effect of bedrest and potential
therapies were implemented.
prehabilitation on patients in the intensive care unit. AACN Clin Issues. Mobilization of patients is widely accepted to reduce the
2002;13(2):263-276. impact of prolonged bed rest. However, during critical phases
21. De Jonghe B, Bastuji-Garin S, Durand MC, et al. Respiratory weakness
is associated with limb weakness and delayed weaning in critical illness. of acute illness, early mobilization of patients is difficult to
Crit Care Med. 2007;39:2007-2015. accomplish. Therefore, the introduction of CLRT into patient
22. Siebens H, Aronow H, Edwards D, et al. A randomized controlled trial
of exercise to improve outcomes of acute hospitalization of older adults. care can provide an efficient way of providing early mobility to
J Am Geriatr Soc. 2000;48(12):1545-1552. those critically ill patients whose condition or instability pre-
23. Clavet H, Hébert PC, Fergusson D, Doucette S, Trudel G. Joint contrac- vents implementation of other forms of mobility. Identifica-
ture following prolonged stays in the intensive care unit. CMAJ.
2008;178(6):691-697. tion of patient populations who will benefit from CLRT is an
24. Gomez-Cabrera MC, Domenech E, Viña J. Moderate exercise is an important aspect of maximizing the benefits of therapy.
antioxidant: upregulation of antioxidant genes by training. Free Radic
Biol Med. 2008;44:126-131. McKay6 suggested that CLRTs achieve the best outcomes when
25. Winkelman C, Higgins PA, Chen YJK, et al. Cytokines in chronically criti- implemented within 24 to 48 hours of meeting set criteria and
cally ill patients after activity and rest. Biol Res Nurs. 2007;8:261-271. are maintained for at least 18 hours per day. Swadener-
26. Herridge MS, Batt J, Hopkins RO. The pathophysiology of long-term
outcomes following critical illness. Crit Care Clin. 2008;24:179-199. Culpepper et al8 reported that CLRT patients in an early inter-
27. Krishnagopalan S, Johnson W, Low LL, Kaufman LJ. Body position of vention group (implemented within 48 hours of meeting
intensive care patients: clinical practice versus standards. Crit Care Med.
2002;30:2588-2592. criteria) fared much better on the outcome criteria evaluated
28. Goldhill DR, Badacsonyi A, Goldhill AA, Waldmann C. A prospective than did the late intervention group (CLRT implemented
observational study of ICU patient position and frequency of turning.
Anaesthesia. 2008;63:509-515.
more than 48 hours after criteria were met). Therefore, early
29. Stiller K. Safety issues that should be considered when mobilizing criti- identification of patients who could benefit from therapy has
cally ill patients. Crit Care Clin. 2007;23(1):35-53. the best potential for improving outcomes.
30. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and
safe in respiratory failure patients. Crit Care Med. 2007;35(1):139-145. Many criteria have been suggested in the identification of
31. Convertino VA, Doerr DF, Eckberg DL, et al. Head-down bed rest pulmonary patients who could benefit from CLRT. Methods
impairs vagal baroreflex responses and provokes orthostatic hypoten-
sion. J Appl Physiol. 1990;68:1458-1464. that are quick and simply evaluated are most easily imple-
32. Convertino VA, Previc FH, Ludwig DA, et al. Effects of vestibular and mented in a busy critical care environment. One such method is
oculomotor stimulation on responsiveness of the carotid-cardiac the calculation of the PaO2/FIO2 ratio (P/F ratio). The P/F ratio
baroreflex. Am J Physiol. 1997;273(47):615-622.
33. Vollman KM. Ventilator-associated pneumonia and pressure ulcer pre- reflects the effectiveness of oxygen transfer from the lung to
vention as targets for quality improvement in the ICU. Crit Care Nurs hemoglobin. P/F ratios greater than 300 are considered to indi-
Clin North Am. 2006;18:453-467.
34. Stiller K, Phillips AC, Lambert P. The safety of mobilisation and its cate minor pulmonary insufficiency, but ratios less than 300 are
effect on haemodynamic and respiratory status of intensive care considered to indicate acute lung injury.9 Lower P/F ratios
patients. Physiother Theory Pract. 2004;20:175-185. would indicate worsening of pulmonary function compared
35. Hopkins RO, Spuhler VJ, Thomsen GE. Transforming ICU culture to
facilitate early mobility. Crit Care Clin. 2007;23(1):81-96. with higher ratios. Setting CLRT criteria at a P/F ratio of 300

accomplishes the goal of early intervention rather than waiting when each patient is continuously moved at the maximum
until further deterioration occurs. Other criteria include evalua- angle tolerated for at least 18 hours per day.2-8
tion of a patient’s oxygen and positive end-expiratory pressure Some patients have not tolerated CLRT because of the
requirements to achieve normal PaO2 levels, and assessment for continuous motion of the bed.2-8 Published data are not suffi-
presence of infiltrates and atelectasis on the chest radiograph. cient to support recommendations for increasing sedation to
These criteria also are easily evaluated by bedside staff. promote patients’ tolerance of rotation, nor have reports been
Most imperative in the evaluation of potential CLRT published on outcomes in patients with whom lateral rotation
patients is the consistent evaluation of established criteria was not implemented because the patient was agitated. How-
based on set standards within the institution. The development ever, evaluation of each clinical situation is necessary to deter-
of a standard of care, clinical practice guideline, or care bundle mine the risk/benefit of CLRT. Some patients requiring higher
enables the most consistent implementation and provides the levels of pulmonary support may benefit more from the imple-
best opportunity for improved outcomes. All members of the mentation of rotational therapy with sedation, whereas others
patient care team (nurses, respiratory therapists, and physi- may not. Each situation should be evaluated carefully. Further
cians) can take an active role in the ongoing evaluation of study is needed in this area. Most lateral rotation beds include
patients who would benefit from early progressive mobility an acclimation mode that eases the patient into the prescribed
therapies such as CLRT. Ongoing evaluation, education, and level of rotation rather than starting it all at once. This mode
bedside mentoring are all needed to ensure implementation of also creates an avenue for increasing the patient’s tolerance of
any new or updated practice or care standard. the turning.
Once patients have been deemed suitable for CLRT, many Other concerns related to patients’ tolerance of CLRT are
barriers discourage the implementation and execution of CLRT. related to changes in patients’ hemodynamics or oxygen satu-
Sometimes, just the simple act of transferring a critically ill patient ration during rotation. It is important for bedside nurses to
from one bed to another seems daunting with all of the lines, realize that changes in these physiological parameters during
tubing, and equipment connected to the patient. The additional rotation are not caused by the rotation, but by the patient’s
physical risk to caregivers who are actually moving the patient associated illness/disease. Often the immediate response to
is also a consideration, as is the time lag between patient iden- changes in the patient’s status has been to stop the rotation. If
tification and receipt of a rental bed capable of CLRT. Having rotation is stopped at all, it should be stopped only for long
standard intensive care unit beds on which CLRT could be enough to deal with the underlying cause of the instability.8
implemented would reduce the need for repeated transfers of Evaluation of the patient’s oxygen levels, respiratory rate, ven-
patients from one bed to another and would minimize delays. tilator settings, arterial blood gas levels, and other parameters
When such beds are not already available, having defined crite- may reveal the need for interventions in other areas that
ria for obtaining a bed and set procedures for transferring the would minimize desaturation during rotation. Decreasing the
patient to the bed also can shorten the implementation time. time and depth of rotation to the side where the greatest
Once implemented, CLRT therapy should be delivered

as aggressively as the patient will tolerate.
Nurses have been evaluating and implementing mobility desaturation occurs can improve tolerance as well. Alterations
protocols for hospitalized patients as a routine measure for in blood pressure and other hemodynamic parameters can be
decades. Turning the patient from side to side is a standard of addressed by evaluating adequacy of volume resuscitation,
care in the prevention of skin-related complications. Requiring cardiac performance, and vascular tone and intervening
a new physician’s order to initiate CLRT for suitable patients appropriately. Resolving these issues in a timely manner can
also can delay implementation. If set guidelines and criteria are help to meet the goal of rotating the patient 18 hours a day.
established for identifying patients suited for CLRT and Desaturation and hemodynamic alterations will improve over
patients who are not (eg, patients with unstable spinal injuries time as the patient’s pulmonary function improves.
or elevated intracranial pressure), then nursing and respiratory A misconception has occurred that the rotation of the bed
therapy staff can initiate CLRT on the basis of a written hospi- eliminates the need for the routine 2-hour lung and skin
tal protocol without the need for an additional physician’s assessment and positioning that occurred with manual turn-
order. ing. This idea is far from the truth. The rotation should be
Once implemented, CLRT therapy should be delivered as stopped, the skin and lungs should be assessed, and one
aggressively as the patient will tolerate. The turns delivered by should ensure that the patient is in the correct alignment for
rotational therapies have been evaluated in terms of the degree maximal effect of the therapy; then rotation should be
of rotation as well as the percentage of available turn in a cush- resumed. Newer lateral rotation beds include low air loss ther-
ion-based system. However, best outcomes have been reported apy and therapeutic mattress composition to help protect skin

integrity. However, frequent assessment of the patient’s pres- Guidelines Clearinghouse Web site (www.guideline.gov). A
sure points is still necessary. Maintaining clean and dry skin planned repositioning schedule tailored to each individual
helps to prevent maceration and breakdown of the skin. patient is recommended in all pressure ulcer prevention guide-
Criteria for discontinuing CLRT are not well documented. lines. Recently, the National Pressure Ulcer Advisory Panel, in
Daily evaluation of the patient’s response and continued need collaboration with the European Pressure Ulcer Advisory
for therapy is important. Improving P/F ratios, decreasing Panel, announced updated guidelines for prevention and treat-
requirements for oxygen and positive end-expiratory pressure, ment of pressure ulcers. Each guideline recommendation is
and clearing chest radiographs are just some of the indicators supported by a rigorous review of the literature and a
that CLRT could be discontinued and the patient progressed strength-of-evidence rating.1
to other forms of mobility.8 By individualizing each patient’s The goals in progressive mobility programs, specifically
therapy to match the patient’s response, we will ultimately prevention of complications associated with immobility, are
provide the best outcomes. aligned with recommended interventions for pressure ulcer

prevention. Techniques for progressive mobility can be com-
doi: 10.4037/ccn2010766
bined with repositioning techniques recommended for pre-
vention of pressure ulcers.
Acknowledgments
The author thanks the staff of the medical-surgical, neonatal, surgical trauma, Mobilizing Bedridden Patients
and cardiovascular ICUs at the Medical Center of Central Georgia for their
contributions to our CLRT protocol and their continual commitment to excel- Both progressive mobility programs and pressure ulcer
lence in patient care. prevention programs involve planned movements with vari-
Financial Disclosures ous positioning techniques. With the progressive mobility
The author has received Hill-Rom research grants in the past, but not for this program, changes in position for bedridden patients can
study. include changes in head-of-bed elevation, continuous lateral
References rotation, and prone positioning. The patient is then pro-
1. 5 Million Lives Campaign. Getting Started Kit: Preventing Ventilator- gressed to chair sitting and ambulation. Recommended inter-
Associated Pneumonia How to Guide. Cambridge, MA: Institute for
Healthcare Improvement; 2008. (Available at www.ihi.org.) ventions for preventing pressure ulcers in bedridden patients
2. Ahrens T, Kollef M, Stewart J, Shannon W. Effect of kinetic therapy on taken from guidelines for prevention and treatment of pres-
pulmonary complications. Am J Crit Care. 2004;13:376-383. sure ulcers include maintaining the head of the bed at 30º or
3. Delaney A, Gray H, Laupland KB, Zueger DJ. Kinetic bed therapy to
prevent nosocomial pneumonia in mechanically ventilated patients: a lower2 to prevent shearing injuries, especially to the sacral
systematic review and meta-analysis. Crit Care. 2006;10:R70. Also avail- area, and complete changes in position using supine position-
able at: http://ccforum.com/content/10/3/R70.
4. Washington GT, Macnee CL. Evaluation of outcomes: the effects of con- ing and tilted side-lying 30º positions, alternating right, back,
tinuous lateral rotational therapy. J Nurs Care Qual. 2005;20(3):273-282. and left to ensure that pressure over bony prominences is
5. Choi S, Nelson L. Kinetic therapy in critically ill patients: combined
results based on meta-analysis. J Crit Care. 1992;7:57-62.
avoided. Friction and shearing can be avoided when position-
6. McKay C. Best practices: reducing nosocomial pneumonia. Regis Nurse. ing patients by using transfer aids such as slide sheets and
1999;Feb(suppl):3-8. slings or by using at least 2 staff members and draw sheets to
7. Goldhill DR, Imhoff M, McLean B, Waldmann C. Rotational bed ther-
apy to prevent and treat respiratory complications: a review and meta- lift patients. The frequency of positioning, however, should be
analysis. Am J Crit Care. 2007;16:50-62. tailored to individual patients. According to the guidelines
8. Swadener-Culpepper L, Skaggs RL, VanGilder CA. The impact of contin-
uous lateral rotation therapy in overall clinical and financial outcomes from the National and European pressure ulcer advisory pan-
of critically ill patients. Crit Care Nurs Q. 2008;31(3):270-279. els, patients who are not on pressure redistribution mattresses
9. Offner P, Moore E. Lung injury severity scoring in the era of lung protective require more frequent repositioning. Other considerations
mechanical ventilation: the PaO2/FIO2 ratio. J Trauma. 2003;55:285-289.
when positioning patients include using padding between the
knees when patients are lying on their side and elevating or
“floating” heels off the mattress to avoid pressure on the heels.
Tips for Protecting Critically Ill
Patients From Pressure Ulcers Therapy Beds and Pressure Ulcer Prevention
Irene M. Jankowski, RN, MSN, APRN-BC, CWOCN The idea that all therapy beds prevent pressure ulcers is a
common misconception. Actually, the therapy bed is an
n important focus in critical care units is maintaining circu-
A latory, respiratory, and renal function. Care of critically ill
patients also requires interventions that are designed to prevent
adjunct to repositioning patients and does not decrease the
required frequency of repositioning. The selection of a therapy
bed should be tailored to the specific needs of the patient.
pressure ulcers, an all-too-common complication of immobility, Goals for pressure ulcer prevention require the selection of a
inadequate nutrition, and illnesses or medications that affect bed that has a pressure redistribution surface such as air blad-
blood flow and perfusion. Pressure injuries may be avoidable ders, high-density foam, or alternating pressure surfaces. In
when consistent attention is given to assessment, nutrition, and addition to pressure redistribution, some surfaces also provide
appropriate positioning within appropriate time frames. low air loss for microclimate management. Bed manufacturers
At least 10 published guidelines for the prevention and should be able to provide pressure mapping data to aid in
treatment of pressure ulcers can be found on the National appropriate selection of surfaces.

Certain products may be designed to provide various turn- complications related to pressure ulcer injuries such as sepsis
ing features. Some beds offer only a “turn assist” that tilts the related to wound care, amputations, and countless surgical
patient for a short period, thereby helping the caregiver to turn procedures. Skin over bony prominences can be assessed by
the patient during bathing or incontinence care. Other therapy taking a quick look while measuring vital signs or performing
bed products, usually limited to critical care units or pulmonary incontinence care, making it possible to assess skin even more
care units, may provide turning features that include a preset often than every 2 hours. If the patient has an existing pres-
automatic turn designed to promote improved pulmonary sure ulcer, CLRT can be stopped for a time—for example, up
outcomes. Various beds are available with a combination of to 30 minutes—so that bolsters, pillows, and positioning
Erythema can be an early sign of pressure ulcer poten-

tial and should trigger a change in the patient’s position.
features that can meet the needs of patients requiring both pul- techniques can be used to offload pressure points and relieve
monary support and pressure ulcer prevention. pressure to injured areas. Bolsters and other positioning
DeLaat et al3 described a prospective cohort study conducted devices should be removed when CLRT is resumed. Keep in
in an intensive care unit that demonstrated a sustained reduc- mind that CLRT may be most effective in facilitating optimal
tion in intensive care unit–acquired pressure ulcers as a result pulmonary outcomes when employed for at least 18 hours in a
of the introduction of a pressure ulcer prevention protocol that 24-hour period. It is appropriate to use pillows and other posi-
was supported by certain nurses who acted as “supporting tioning devices during the 6 hours of non-CLRT therapy.5-11
innovators” of the project. The strongest significant interven-
tion associated with the decrease in incidence of pressure ulcers Progression to Chair and Ambulation
was identified as the use of pressure redistribution mattresses.3 Even when the patient has progressed to the full upright
Once an appropriate therapy bed is selected, nurses chair position, important nursing interventions are still required
should avoid layering sheets, pads, diapers, and other items for those patients at risk for pressure ulcers. Clinical guide-
between the patient and the specialty bed surface. Such layer- lines from both the Wound, Ostomy and Continence Nurses
ing will interfere with the effectiveness of the pressure redistri- Society and the national and European pressure ulcer advisory
bution surface.4 panels recommend encouraging the patient to shift weight fre-
quently while in a chair. Some patients will require assistance
Continuous Lateral Rotation Therapy with weight shifting. In addition, assisting a patient to a stand-
Continuous lateral rotation therapy (CLRT) is designed to ing position will help prevent pressure ulcers and meet goals
support pulmonary toileting; however, not all therapy beds for progressive mobility. Pressure redistribution chair cush-
with this feature provide pressure redistribution surfaces such ions can also be provided, and measures to protect skin from
as low airloss surfaces. Even when a CLRT bed provides a pres- incontinence-associated skin breakdown such as moisture bar-
sure redistribution surface, CLRT alone (the right and left rier ointments and other skin protective products still should
rotation of 20º to 40º) may not provide protection from pres- be used. Once the patient is ambulatory, nurses should remain
sure ulcers unless specific interventions for pressure ulcer pre- vigilant. Ambulation may begin with a few tentative steps,
vention also are instituted. Even if the CLRT is set for the with the patient quickly returning to the bed or bedside chair,
maximum rotation, the patient never breaks contact with the until he or she can tolerate an extended period of mobility.
surface. Nurses must be vigilant, assessing patients’ skin fre-
quently, particularly over bony prominences, for early signs of Conclusion
pressure injuries. Heels must be protected from prolonged Careful and frequent skin assessments, frequent reposi-
pressure whether by the specialty therapy surface or by the use tioning, managing moisture, and maximizing nutritional sup-
of positioning devices, unless the CLRT bed surface is equipped port are common interventions for prevention of pressure
with air-only bladders designed to prevent heel ulcers. ulcers. Progressive mobility techniques and repositioning
Frequent skin assessments while the patient is on CLRT techniques used to prevent pressure ulcers are designed to
may enable early detection of potential development of pres- promote the best outcomes while preventing dangerous com-
sure ulcers. CLRT can be stopped for short periods to allow for plications.
skin assessments. Erythema can be an early sign of pressure
doi: 10.4037/ccn2010636
ulcer potential and should trigger a change in the patient’s
position whenever possible. Blanchable erythema, also known
as reactive hyperemia, can be reversed simply by eliminating
Financial Disclosures
pressure for a short period. Such careful vigilance may save The author has received grants from Hill-Rom in the past, but not for this
patients from months to years of wound care treatments and paper.

References candidates include patients who require sedation or who are

1. National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory
Panel Pressure Ulcer Prevention and Treatment Clinical Practice Guideline. hemodynamically unstable.
Washington, DC: National Pressure Ulcer Advisory Panel; 2009.
2. Ratliff CR, Bryant DE. Guideline for Prevention and Management of Pres-
sure Ulcers. Glenview, IL: Wound, Ostomy, and Continence Nurses Soci-
Study
ety; 2003:1-52. An internally funded, nonrandomized study was con-
3. deLaat EH, Pickers P, Schoonhoven L, et al. Guideline implementation ducted by a team of clinicians and faculty (led by author K.C.)
results in a decrease of pressure ulcer incidence in critically ill patients.
Crit Care Med. 2007;35(3):815-820. within the surgical-trauma, medical, and neuroscience ICUs at
4. Williamson R, Sauser FE. Linen Usage Impact on Pressure and Microcli- the Medical University of South Carolina Academic Medical
mate Management [white paper]. http://www.hillrom.com/usa/PDF
/156445.pdf. Accessed January 19, 2010. Center. A total of 200 patients were recruited for the study.
5. Ahrens T, Kollef M, Stewart J, Shannon W. Effect of kinetic therapy on The medical ICU patients were removed because they changed
pulmonary complications. Am J Crit Care. 2004;13:376-383. bed frames after beginning the study and a consistent BCP
6. Delaney A, Gray H, Laupland KB, Zueger DJ. Kinetic bed therapy to
prevent nosocomial pneumonia in mechanically ventilated patients: a was not able to be achieved. Duplicate instances of patients
systematic review and meta-analysis. Crit Care. 2006;10:R70. Also avail- were combined. A total of 152 patients were included in the
able at: http://ccforum.com/content/10/3/R70.
7. Washington GT, Macnee CL. Evaluation of outcomes: the effects of con- final analyses.
tinuous lateral rotational therapy. J Nurs Care Qual. 2005;20(3):273-282. The BCP protocol (Figure 2) was used to identify patients
8. Choi S, Nelson L. Kinetic therapy in critically ill patients: combined receiving mechanical ventilation who, on the basis of certain
results based on meta-analysis. J Crit Care. 1992;7:57-62.
9. McKay C. Best practices: reducing nosocomial pneumonia. Regis Nurse. physiological and pathological data, could be considered can-
1999;Feb(suppl):3-8. didates for the BCP. Each ICU patient was evaluated daily to
10. Goldhill DR, Imhoff M, McLean B, Waldmann C. Rotational bed ther-
apy to prevent and treat respiratory complications: a review and meta- see if the patient was an appropriate BCP candidate, and, if so,
analysis. Am J Crit Care. 2007;16:50-62. the patient was placed in the BCP within 24 hours of meeting
11. Swadener-Culpepper L, Skaggs RL, VanGilder CA. The impact of contin-
uous lateral rotation therapy in overall clinical and financial outcomes
inclusion criteria. Once positioned in the BCP, the patient had
of critically ill patients. Crit Care Nurs Q. 2008;31(3):270-279. these same parameters monitored and the protocol of hemo-
dynamic criteria followed to ensure that the patient was toler-
ating the BCP (Figure 2). If the patient did not tolerate the
BCP, the bed was simply adjusted and returned to the baseline
Using the Beach Chair Position in position.
ICU Patients Pilot testing an intervention for a quality improvement
Kelly Anne Pennington Caraviello, RN, BSN, CCRN project in patient care generally relies on pre-post data collec-
Lynne S. Nemeth, RN, PhD tion. The BCP intervention was conducted from June 2008 to
Bonnie Pleasants Dumas, PhD
mmobile intensive care unit (ICU) patients are at risk for

I many complications. Those patients who require mechani-
cal ventilation and who are unable to get out of bed because of
their underlying condition and sedation requirements are at
risk for ventilator-associated pneumonia (VAP). VAP is due to
the colonization of the oropharynx and tracheal airway with
bacteria and the aspiration of oropharyngeal secretions into
the lower airway.1 The Centers for Disease Control and Preven-
tion2 has established criteria to diagnose VAP that include
gross aspiration by the patient, laboratory and radiological
findings, and signs and symptoms. VAP occurs in up to 25% of
ventilator patients, usually within 3 to 10 days of intubation.
This incidence is a concern because VAP is the most common
hospital-acquired infection.3 Mechanical ventilation alone
costs an average of $1522 per day,4 and VAP can increase a
patient’s hospital bill by $40 000.3
The beach chair position (BCP, Figure 1) was conceptual-
ized as a method of early mobilization to help reduce the inci-
dence of VAP in ICU patients who, because of pathological
reason(s) or physiological instability, are unable to get out of
bed. The BCP is defined as having the patient’s head of bed
elevated to 70º and the foot of bed at a -75º angle, as if the
patient is sitting in a chair. By using the bed frame to place
Figure 1 Patient in beach chair position in the intensive
the patient in the BCP, patients who might not be able to get care unit.
out of bed are able safely to attain a sitting position. BCP

Several positive outcomes were realized in this initial

Beach Chair Position Protocol© study. Chi-square analysis indicated a significant reduction in
GOAL: Beach Chair Position© 1 hr 4 times/day for patients
who are candidates VAP rates (P = .03; Figure 3) in the BCP group. Most patients
(95.2%) were able to tolerate the BCP, with only 4.8% unable
Patients who are candidates:
to sit in the BCP for the full 60 minutes. In this 4.8%, cardio-
Hemodynamically stable patients, as defined by:
• No active bleeding vascular events were the reason for patients’ not tolerating the
full 60 minutes 36% of the time, followed by neurological
• MAP ≥ 60
• HR 60-120
• SpO2 ≥ 90
events 21% of the time. Tachycardia or hypertension and the
• RR ″ 30
rare hypotensive events were easily corrected by the staff.
Patients were removed from the BCP due to respiratory con-
Guidelines indicating Beach Chair Position© is tolerated cerns only 8% of the time. The staff placed the patients in the
• HR ~ change ″ 10% from baseline
by patient: BCP 4 times per day in conjunction with the daily tasks that
• BP ~ change ″ 20% from baseline ICU patients require. At times, placing a patient in the BCP
• EKG ~ no changes or arrhythmias that causes symptoms or was not appropriate; for example, during discussions of pallia-
• SpO2 ~ remains ≥ 90%

hemodynamic compromise tive care or withdrawal of care, if such positioning was not the
physician’s preference, if the bed was the wrong type, or if the
• O2 requirement ~ remains same/weaned patient was on a tracheostomy collar or T-bar trial. The
Patients who are not yet candidates: patient was not placed in the BCP 25.6% of the time because of
• Temporary pacemakers physiological concerns such as heart rate, blood pressure, or
• Intraaortic balloon pump
other factors listed in the BCP protocol.
• Sengstaken-Blakemore/Minnesota tubes
• Vasopressor requirement increase Some outcomes were not reduced in the BCP group; these
• ICP >20 included ventilator days, ICU length of stay, and hospital
• ECMO length of stay. When the severity of illness, which is catego-
• Specialty beds/mattress (eg, RotoProne, RotoRest, or KCI rized independently by the hospital team according to the
First Step)
patient’s diagnosis-related group, was compared in the 2
• Paralytics in use
• Ordered HOB flat/bed rest groups (Figure 4), 77% of the BCP group was in class 4, or the
• Clarify with physician as some are ok: sickest class of patients, in comparison to 57% in class 4 in the
-Recent SSG/flap to lower limbs or trunk historical cohort. This difference could account for the higher
-Recent open abdomen number of ventilator days and the longer ICU and hospital
-Unstable C-spine
lengths of stay in the BCP group.
-Pelvic or spine fractures
-Unstable head bleeds/post craniotomy/deep coma patients
-Require continuous lower extremity elevation
12
Figure 2 Beach chair position protocol.
10
Abbreviations: BP, blood pressure; C-spine, cervical spine; ECMO, extracorpo-
real membrane oxygenation; EKG, electrocardiography; HOB, head of bed;
HR, heart rate; ICP, intracranial pressure; MAP, mean arterial pressure; O2,
8
oxygen; PaO2, partial pressure of oxygen; RR, respiratory rate; SpO2, oxygen
Rate
saturation as shown by pulse oximetry; SSG, split skin graft. 6

Reprinted with permission. ©Caraviello 2007.
4
2
November 2008 in patients admitted to the surgical trauma
and neuroscience ICUs. To compare outcomes of the BCP 0
BCP group Historical cohort
cohort versus patients not in the BCP cohort, a comparison
χ2 = 4.8, P = .03
group of ICU patients during the 6-month period from
VAP case rate
November 2007 to May 2008 (the historical cohort) was retro- Odds ratio = 0.321
spectively constructed. It was difficult to match the character- VAP rate per 1000 VD
istics of the retrospective cohort exactly because the BCP
criteria were not assessed in these patients. The BCP inclusion Figure 3 Comparison of ventilator-associated pneumonia
(VAP) case rate and VAP rate per 1000 ventilator days (VD)
and exclusion criteria were not assessed in the retrospective between the beach chair position (BCP) group and the his-
cohort. In the end, data for patients in the medical ICU were torical cohort. Both rates were significantly lower in the
removed from the study because that unit changed bed frames BCP group. The VAP case rate was defined for this study as
after beginning the study and a consistent BCP could not be the number of patients per cohort who had VAP diagnosed.
For the BCP cohort, the VAP case rate was defined as those
achieved. Also, the duration and consistency of use of the BCP patients who had VAP diagnosed while actively being
varied from patient to patient because of other competing placed in the BCP within the past 48 hours.
demands in the ICUs.

not be related to the patients’ disease but may be due to the

90
position change. Respiratory rate, heart rate, and blood pres-
80 sure did change, but the changes were minimal and well
70 tolerated. Use of the BCP is not a benign treatment option;
60 physiological changes that could harm the patient can occur.
However, in patients who are still too ill to walk or even to be
Percent
50
transferred to a chair, the BCP is a practical method of early
40
mobilization that presents minimal risk to the patient and
30
caregivers until the patient can ambulate. The BCP is better
20 than doing nothing in relation to mobility and is better than
10 getting patients out of bed unsafely in order to increase their
0 pulmonary function.

Historical cohort BCP group
SOI 1 SOI 3 doi: 10.4037/ccn2010425

SOI 2 SOI 4
Acknowledgments
Kelly Ann Pennington Caraviello thanks the staff of the surgical/trauma, neu-
Figure 4 Comparison of severity of illness (SOI) between roscience, and medical ICUs at the Medical University of South Carolina Hos-
the historical cohort and the patients in the Beach Chair pital for their participation. Special thanks to Dr John Welton for his support.
Position (BCP) group. All patients admitted to the hospital
have their SOI calculated on the basis of their diagnosis- Financial Disclosures
related group. Most patients in the BCP group were SOI The Medical University of South Carolina Hospital Authority provided finan-
class 4, or the sickest classification, when compared with cial support for this study.
the historical cohort. It is striking that the rate of ventilator-
associated pneumonia was lower in the BCP group, when References
the patients in the BCP group had a higher SOI, were in the 1. American Thoracic Society and the Infectious Diseases Society of Amer-
ica. Guidelines for the management of adults with hospital-acquired,
intensive care unit longer, and had a longer duration of ventilator-associated, and healthcare-associated pneumonia. Am J Respir
mechanical ventilation. Crit Care Med. 2005;171:388-416.
2. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition
of health care–associated infection and criteria for specific types of infec-
tions in the acute care setting. Am J Infect Control. 2008;36(5):309-332.
3. Rello J, Ollendorf DA, Oster G, et al. Epidemiology and outcomes of ven-
As critical care patients require a collaborative effort tilator-associated pneumonia in a large US database. Chest. 2002;
between nurses, respiratory therapists, and physicians, it is 122:2115-2121.
best to begin with a team effort to implement this change in 4. Vollman KM. Ventilator-associated pneumonia and pressure ulcer pre-
vention as targets for quality improvement in the ICU. Crit Care Nurs
practice. The physicians play a key role in understanding the Clin North Am. 2006;18:453-467.
protocol so that they can clear the patients to participate.
Nurses share a key role in incorporating the BCP into their
daily care and in minimizing any barriers that may occur. Res- Safety and Barriers to Care
piratory therapists offered valuable insights into the pul- Amelia G. Ross, RN, MSN
monary stability and ventilator tolerance of the patient. The Peter E. Morris, MD
multidisciplinary team approach also helped to ensure that
BCP sessions are coordinated within the patient’s daily care ritically ill patients are often immobilized as a direct result
and necessary assessments and procedures. C of their illness or because of the administration of seda-
tives and analgesics or anesthetic agents that allow patients to
Conclusion receive other supportive care such as mechanical ventilation.
Is it beneficial to use the BCP? The BCP was safely used for Complications of critical illness documented in the literature
early mobility of ICU patients enrolled in this study and was include pressure ulcers, delirium,1,2 weakness, critical illness
associated with decreased rates of VAP when compared with polyneuromyopathy,3,4 contractures,5 and decreased quality of
the historical comparison group. The BCP can be considered a life after hospital discharge.6 Moreover, critical illness polyneu-
method of early mobilization to improve pulmonary function. romyopathy has significantly associated morbidity and
An added benefit is that placing patients in the BCP requires increased hospital mortality.4 Several reports1,7-11 have now
fewer personnel than other interventions require, and therefore described the safety of organized early mobility therapy in the
the patient may be mobilized more quickly and easily and with intensive care unit (ICU). These reports also suggest that
less risk of injury to the caregiver. As with any position change improvements in activities of daily living and hospital length
in a critically ill patient, use of the BCP is associated with a slight of stay were associated with the use of early mobility protocols
risk. The tradeoff with increasing mobility in critically ill patients in the ICU.
is that because of the patients’ underlying disease, their normal Questions often arise about the feasibility of early mobility
physiological responses are changed. The side effects of agita- in the ICU given the frequent need for invasive monitoring and
tion or increased intracranial pressure noted in this study may other support apparatus such as endotracheal tubes. When

safety limits (Table 1). Other reports on
Admit to ICU
Level I Level II Level III Level IV
Discharge to general care area

early ICU mobility therapies similarly
Unconscious Conscious Conscious Conscious indicate relatively few adverse events,
Passive Passive Passive Passive such as accidental removal of devices. In
ROM 3x/d ROM 3x/d ROM 3x/d ROM 3x/d an assessment of safety and feasibility of
early mobility in patients with respiratory
q2Hr turning q2Hr turning q2Hr turning q2Hr turning failure, Bailey and colleagues8 reported
Active Active Active
that a trained, dedicated group of nurses,
resistance resistance resistance respiratory therapists, physical thera-
PT PT PT pists, and critical care technicians can
safely deliver early mobility twice a day.
Sitting position Sitting position Sitting position Barriers to early mobility may exist in
Minimum 20 Minimum 20 Minimum 20
minutes 2x/d minutes 2x/d minutes 2x/d multiple categories, from human and
technological resources to costs (Table 2).
Can move Sitting on Sitting on Recent studies1,7-10 have demonstrated
arm against edge of edge of benefit with mobility protocols directed
gravity
bed bed
by physical therapy. In a recent report,13
PT + MT PT + MT
less than 10% of responding hospitals had
Active specific criteria guiding the timing of
Can move transfer tp physical therapy interaction for ICU
leg against chair (OOB) patients. Additionally, of protocols found
gravity PT + MT
Minimum 20
in the literature, all have included the
minutes/d services of a physical therapist.1,7-10 In the
future, a protocol without a physical ther-
Figure Passive range of motion (ROM) therapy started on day 1 of protocol (level I). apy component may need to be tested to
As patients demonstrated consciousness and increased strength (see circles with address those medical centers that lack
arrows), they were moved to the next higher level. Physical therapy (PT) would be the services of a physical therapist in the
first attempted at level II. The protocol’s intervention ceased as a patient was trans-
ferred to a bed in a general care area, and then patients within both “protocol” and ICU. Lack of coordination among respira-
“usual care” groups would receive usual care mobility therapy (MT) as dictated by tory therapists, physical therapists, and
the physician teams in the general care areas. bedside nurses in the ICU in delivery of
Abbreviations: ICU, intensive care unit; OOB, out of bed; q2Hr, every 2 hours; 3x/d, 3 times a day. patient care (eg, attainment of sedation
goals, daily awakenings, spontaneous
breathing trials) may impede the ability
invasive and noninvasive devices are used in the care of ICU to keep early mobilization as a priority. The tendency for
patients, it is not uncommon for health care personnel to con- health care disciplines to operate in isolation lends to frag-
sider these patients “too sick” to be moved. Opportunities to mentation of care and lack of teamwork, collaboration, and
change this perception may emerge through protocolized accountability for shared goals.12
mobility interventions with inherent daily assessments for spe- A lack of adequate equipment that enhances patients’
cific inclusion and exclusion criteria.7,12 Models of care that mobility (eg, availability of bedside chairs or portable ventila-
incorporate research-based strategies to address iatrogenic ICU tors) also may impose barriers. Time constraints, multiplicity
complications also may address staff perceptions.12 The proto- of invasive and noninvasive devices, and obesity are potential
cols for early progressive mobility have been designed with
adjustments for patients’ tolerance and stability. In a recent
study,7 a protocol for early ICU mobility was administered in a Table 1 Criteria to withhold early mobility protocol
stepwise fashion based on daily assessments of the patient’s
ability to follow commands and the patient’s strength. The 4 Hypoxia with frequent desaturations below 88%
levels of the protocol included passive range of motion, active Hypotension (mean arterial pressure < 65 mm Hg)
resistance with physical therapy, physical therapy administered Administration of a new vasopressor agent
with the patient sitting on the edge of the bed, then the patient
New myocardial infarction documented by electrocardiography
standing with step movements (see Figure).
and changes in enzyme levels
In this study,7 patient safety was attained by working
within the mobility protocol’s safety parameters. These safety Dysrhythmia requiring the addition of a new antiarrhythmic
agent
parameters typically describe specific hemodynamic and ven-
tilatory parameter thresholds. The safety thresholds of the Increase in the positive end-expiratory pressure on the venti-
lator or change to assist control mode once in a weaning
early ICU mobility protocol are used to withhold the initiation mode
of mobility or end the mobility session if a patient exceeds the

Summary
Table 2 Barriers to early mobility The detrimental sequelae of immobility associated with
critical illness have a profound effect on patients and the
Lack of specific protocols or policies to address mobility in the
health care system. Reports of beneficial outcomes associated
intensive care unit with early ICU mobility protocols may contribute to improved
patient outcomes and utilization of scarce health care
Fragmented care among multidisciplinary health care providers
resources. Early ICU mobility is feasible and safe when proto-
Adequate equipment colized to include hemodynamic and ventilator thresholds.
Culture of the intensive care unit—mobility not seen as a prior- Changes in environmental culture that support multidiscipli-
ity and staff perceptions of patient as too ill nary collaboration and coordination of activities to ensure
Morbid obesity mobility therapy as a priority can be accomplished.

Lack of education on the complications of immobility
Excessive sedation doi: 10.4037/ccn2010118
Delirium
Financial Disclosures
Multiplicity of invasive devices One of the authors, Amelia G. Ross, has received honoraria from Hill-Rom for
presentations, but not for this study.
Resistance to change
Time constraints References
1. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and
Costs occupational therapy in mechanically ventilated, critically ill patients: a
randomized controlled trial. Lancet. 2009;373:1874-1882.
2. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortal-
ity in mechanically ventilated patients in the intensive care unit. JAMA.
2004;291:1753-1762.
barriers to mobility.14 Staff education on the complications of 3. De Jonghe B, Sharshar T, Lefaucheur JP, et al. Paresis acquired in the
“immobility” may lead to an elevation of ICU mobility within intensive care unit: a prospective multicenter study. JAMA. 2002;288(22):
2859-2867.
daily patient care priorities. With such knowledge about the 4. Ali NA, O’Brien JM, Hoffmann SP, et al. Acquired weakness, handgrip
potential risks of immobility, coordination of sedation may be strength, and mortality in critically ill patients. Am J Respir Crit Care
Med. 2008;178:261-268.
improved through the use of sedation and analgesia scales, daily 5. Clavet H, Hébert PC, Fergusson D, Doucette S, Trudel G. Joint contrac-
interruption of sedative infusions, spontaneous breathing trials, ture following prolonged stays in the intensive care unit. CMAJ.
and accommodation of ICU mobility within the many compet- 2008;178(6):691-697.
6. Herridge MS, Cheung AM, Tansey CM, et al. One year outcomes in sur-
ing ICU priorities. With the safety data now available, an oppor- vivors of the acute respiratory distress syndrome. N Engl J Med.
tunity exists for a reduction of staff perceptions that ICU 2003;348(8):683-693.
7. Morris PE, Goad A, Thompson C, et al. Early intensive care mobility
patients are too sick to receive ICU mobility. therapy in the treatment of acute respiratory failure. Crit Care Med.
Last, hospital administrators may be reluctant to justify expen- 2008;36:2238-2243.
8. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and
ditures for work force and equipment related to ICU mobility. safe in respiratory failure patients. Crit Care Med. 2007;35(1):139-145.
However, a recent publication7 reported that early ICU mobility 9. Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill
administered by a dedicated mobility team following a protocol patients enhances short-term functional recovery. Crit Care Med.
2009;37(9):2499-2505.
was associated with significantly fewer days in bed, and reduced 10. Thomsen GE, Snow GL, Rodriquez L, Hopkins RO. Patients with respi-
ICU and hospital length of stay for survivors without increasing ratory failure increase ambulation after transfer to an intensive care unit
where early activity is a priority. Crit Care Med. 2008;36(4):1119-1124.
hospital costs. Bailey et al8 demonstrated no increase in staffing 11. Stiller K, Phillips A. Safety aspects of mobilizing acutely ill inpatients.
costs in a respiratory ICU where early mobility is seen as a pri- Physiother Theory Pract. 2003;19:239-257.
ority of routine care. Additionally, adverse events such as desat- 12. Hopkins RO, Spuhler VJ. Strategies for promoting early activity in criti-
cally ill mechanically ventilated patients. AACN Adv Crit Care.
urations or an increase or decrease in blood pressure did not 2009;20(3):277-289.
result in additional therapy, increased costs, or longer stays. 13. Hodgin KE, Nordon-Craft A, McFann KK, Mealer ML, Moss M. Physi-
cal therapy utilization in intensive care units: results from a national
An alteration of local ICU culture may be required to opti- survey. Crit Care Med. 2009;37(2):561-568.
mize administration of early ICU mobility. A multidisciplinary 14. Morris PE. Moving our critically ill patients: mobility barriers and bene-
commitment to coordination, collaboration, and daily team fits. Crit Care Clin. 2007;23(1):1-20.
work is often the foundation of successful delivery of care
related to early ICU mobility.1,7-10 Evidence-based practices to
facilitate daily delivery of early ICU mobility include best prac- Staff-Perceived Barriers and
tices for the management of sedatives and analgesics, recogni- Facilitators
tion of delirium, promotion of sleep, and coordination and Chris Winkelman, RN, PhD, CCRN
prioritization of procedures. Further data demonstrating a Karen Peereboom, RN
meaningful financial impact of the use of early ICU mobility will
be helpful to hospital administrators who seek optimal patient atients rely on nurses for positioning and assistance with
outcomes, but must weigh costs for multiple competing pro-
grams throughout the ICU and hospital.
P sitting and walking in the intensive care unit (ICU). Little
information is available about how nurses evaluate patients’

readiness for progression from in-bed activity to out-of-bed

mobilization. Understanding the barriers and facilitators to Table 1 Characteristics of the 49 patients in the study
clinical practice may promote implementation of a protocol Characteristic Value
for progressive mobility when this activity is not common
Age at admission, mean (range), y 63 (27-82)
practice in a setting. Barriers and facilitators are defined as
factors that prevent or enhance behavioral change.1 One bar- APACHE III score,a,b mean (range) 69 (27-108)
rier to adopting early, progressive mobility may be nurses’ per- No. of comorbid diseases, mean (range) 3 (0-6)
ceptions of patients’ readiness for activity.2-4 This report Length of stay in intensive care unit, mean
describes the results of staff interviews collected during an Before protocol 19
investigation into the feasibility of a protocol to implement After protocol 14
early, progressive activity among surgical and medical ICU Days after admission when first out-of-bed
patients who received mechanical ventilation for more than activity, mean
48 hours. Before protocol 9
After protocol 6
Methods Body mass indexc 31 (18.2-42.7)

This descriptive study examined nurses’ perceptions of the Women,b % 55
barriers to and facilitators of use of progressive mobility. Data Race, %
were collected with a semistructured interview that preceded White 69
any activity related to patient mobility. African American 28
Hispanic 3
Sample and Setting Admission diagnosis, %

Pulmonary 40
All nurse-participants provided direct care to a subsample Cardiovascular 20
of patients involved in a larger study that included a mobility Neurological 10
intervention in several ICUs in an academic medical center. Sepsis 20
Both ICUs are closed units, with all admissions receiving care Other: gastrointestinal, genitourinary, 10
from an intensivist. Neither unit has a unit-based physical cancer
therapist or lift team, so most patients are mobilized with the a APACHE III, Acute Physiology and Chronic Health Evaluation, version 3; a
nursing staff or the assistance of 1 or 2 patient care assistants. measure of acuity with a range of 0-299 and high scores indicating high acu-
Characteristics of the 49 chronically critically ill patients who ity.5
b Patients had similar characteristics in both phases of the intervention study,
were the recipients of the interviewees’ care are summarized in with the exception of fewer women and higher APACHE scores during the
Table 1; all patients were physiologically stable at the time of protocol phase (P < .05, data not shown).
c Calculated as the weight in kilograms divided by height in meters squared.
the interview. Before the study, neither unit used a systematic
approach to mobility, and out-of-bed activity among ventilator
patients was uncommon. study were mostly female and had a mean of 5 years of ICU
experience. Ten interviews with 8 unique participants
Procedure occurred before the protocol was implemented, and 39 inter-
The interview form was created by the principal investiga- views with 25 unique nurse participants occurred after the
tor, who used a change framework6 to guide the development protocol phase of the larger study was implemented. Charac-
of a tool along with pilot data from 4 staff nurses who were teristics did not vary significantly between the nurses who
asked to identify all factors that contributed to the decisions participated before and the nurses who participated after the
around making a plan for activity for a chronically critically ill protocol was implemented, so demographic data are aggre-
patient in the ICU. Three content experts provided content gated (Table 2).
validation after tool construction; reliability was not tested. Of the 49 activities planned for patients on the day of
Before the protocol phase of the study, nurses in the units interview, 41 were limited to in-bed activity, including fre-
were shown a diagram of the protocol7 at a staff meeting; how- quent manual turning or passive range of motion exercises.
ever, specific questions about the protocol were not included Only 1 nurse planned active range-of-motion exercises. For
in the interview process. these bedfast patients, unstable vital signs (24/41 or 59% of
interviews) and low respiratory and energy reserve (each
Results 19/41 or 46%) were identified as the most common reasons
A total of 33 nurses participated in 49 interviews. Although for restricting activity. Fourteen nurses (34% of interviews)
some nurses were interviewed more than once, second inter- also cited safety concerns, related to either fear of the patient
views were associated with a unique patient and responses in falling or risk to tubing or catheter integrity. Eleven nurses
the first interview were not related to responses in the second (27% of interviews) reported sedation and an additional 3
interview (r = 0.12, P = .28; data not shown). Nurses in this nurses each reported low level of consciousness or agitation as

activity. Generally, nurses did not cite physician orders as

Table 2 Characteristics of the 33 nurses in the study either a barrier or facilitator; in this setting, 5 of 49 or 10% of
Characteristic Value the patients had an activity/activity restriction order. All of
the interviewees described the plan for activity as moderate-
Age, mean (range), y 32 (22-58)
to-high priority or an average of 3.5 on a scale from 0 (not a
Experience in intensive care unit, mean (range), y 5.5 (0.1-25) priority) to 4 (high priority), and higher prioritization was
Women, No. (%) 29 (83) positively associated with out-of-bed activity.
Race, No. (%)
White 30 (91) Discussion
African American 2 (6) This study had several limitations. The study was done at
Asian 1 (3)
a single institution with a convenience sample. Although this
Work setting, No. (%) setting and sample may be representative of other academic
Surgical intensive care unit 17 (52) medical centers, it may not apply to community hospital set-
Medical intensive care unit 16 (48)
tings or among staff with different attributes. In addition, the
design did not examine whether the protocol caused a change
important barriers to out-of-bed activity. Additional findings in nursing behavior; only associations are reported. However,
are reported in Table 3. this study does provide unique data about nurses’ perceptions
Nine nurses planned out-of-bed activity, with the majority of patients’ readiness for mobility activity and how assessment
(7/9) making those plans during the protocol phase. The most is linked to progression of mobility in the ICU.
common facilitator identified by these nurses was “the patient Clinicians in several ICUs who incorporate early progres-
is cooperative today” (9/9 or 100% of interviews with planned sive mobility suggest that an interdisciplinary team is needed
out-of-bed activity). Both “good oxygen reserve” and “physi- to promote mobility interventions.2,8 Although progression of
cian order” were facilitators of out-of-bed activity in 4/9 (44%) mobility activities is challenging, progressive mobility activi-
interviews. Four nurses volunteered that they were placing the ties are used by ICU nurses and can be implemented inde-
patient in an in-bed chair position to evaluate the patient for pendently as well as interdependently.9 Nurses in this study
standing and walking “because we have new beds that make indicated that in-bed and out-of-bed progressive mobility was
this so easy.” The new bed allowed a true chair position with important to patient care, and neither staff availability nor
backrest, hips, and knees all angled at 90º. equipment contributed to decisions about activity implemen-
Plans to keep a patient in bed or to progress a patient to tation. When a protocol was incorporated into care, patients
out-of-bed activity were not associated with the nurses’ sex, were more likely to experience out-of-bed activity, supporting
age, or experience or to the type of ICU
(Table 3). When the periods before and
after the protocol are compared, an asso-
ciation is apparent between the presence
Table 3a Associations between planned activity and potential barriers and
facilitators
of the protocol and planned out-of-bed Nurse plan for activity
activity. During implementation and eval- Potential barrier or facilitator (in bed vs out of bed)b
uation of the protocol, out-of-bed activity Protocol present 0.285c
increased and occurred on day 6 com- Patient’s acuity on admission -0.164
pared with day 9 among patients with
long ICU stays (Table 1). Another factor Patient’s age 0.024
correlated with out-of-bed activity was a Patient’s body mass index -0.035
score of 10 or greater on the Glasgow Patient’s score on Glasgow Coma Scale on interview day 0.360c
Coma Scale. Type of bed 0.186
Neither the numbers of staff nurses,
nursing assistants, or physical therapists Staff age 0.107
(r = 0.04, P = .9) nor the patient’s admit- Staff sex -0.163
ting diagnosis (χ2 = 0.2, P = .60) were Years of staff experience in intensive care unit 0.039
related to either in-bed or out-of-bed Type of intensive care unit (medical or surgical) -0.128
planning for activity. Five of the 49
patients had a physical therapy consulta- Physician’s order for activity -0.013
tion. Physical therapists typically see ICU Rating of importance of planned activity for this patient 0.379c
patients about 3 days a week in this set- a Nurses identified more than 1 factor as contributing to their decisions about the mobility plan.
ting. No associations were found between b Kendall tau used to correlate plan for activity (in bed vs out of bed) with each variable.
c P ≤ .05.
available equipment and the planned

expert opinion that culture influences mobility interventions with inactivity. Results of this study suggest that ICU nurses
in the ICU.10 can successfully initiate early, progressive mobility with lim-
Similar to other reports,11,12 nurses in our study reported ited resources by using a protocol to guide decisions about
decreased consciousness as the most common barrier to pro- patients’ readiness for activity.

gressive mobility in the ICU. Physical therapy consultations
doi: 10.4037/ccn2010393
were uncommon in this setting, and this finding was not
unusual, according to a report13 of the range of physical ther-
apy in ICUs in the United States. Physician prescription for Acknowledgments
The authors would like to acknowledge Dr Emily Chiou-Fang Liou, project
progressive mobility also was uncommon in this setting, but manager, and Drs Daly, Hejal, and Rowbottom, who were coinvestigators in
when an order for out-of-bed activity was present, the order the portion of their study that examined patient-related data. They also thank
facilitated progressive mobility. the ICU nurses who were interviewed.
Equipment to progress mobility appeared to be somewhat Financial Disclosures
underused. For example, we anticipated that the use of a bed This study was funded by Hill-Rom, although no Hill-Rom staff contributed to
the design of the study, to data collection, or to data analysis.
with a “true” chair position that allows patients to place feet
on the floor to progress to weight-bearing would promote pro- References
gressive mobility, but it did not. Beds that ease egress from the 1. Wensing M, Laurant M, Hulscher M, Grol R. Methods for identifying
bed were newly purchased and being used after in-service barriers and facilitators for implementation. In: Thorsen T, Makela M,
eds. Changing Professional Practice: Theory and Practice of Clinical Guide-
training in 30 of the 49 patients. Caregivers were able to lines. Copenhagen, Denmark: DSI; 1999:119-132.
report the presence of features that facilitated activity, but 2. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and
safe in respiratory failure patients. Crit Care Med. 2007;35(1):139-145.
they may not have acquired a high degree of comfort in using 3. Hopkins RO, Spuhler VJ, Thomsen GE. Transforming ICU culture to
those features. facilitate early mobility. Crit Care Clin. 2007;23(1):81-96.
4. Timmerman RA. A mobility protocol for critically ill adults. Dimens Crit
This study suggests that the presence of a protocol can act Care Nurs. 2007;26(5):175-179.
as a facilitator in implementing progressive mobility and that 5. Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic
a culture of valuing activity for patients is important to activ- system: risk prediction of hospital mortality for critically ill hospitalized
adults. Chest. 1991;100(6):1619-1636.
ity progression.10 Coaching about patient readiness by the 6. Grol R, Wensing M. What drives change? Barriers to and incentives for
research nurse who provided in-bed activity and assisted with achieving evidence-based practice. Med J Aust. 2004;180(6 suppl):S57-
S60.
out-of-bed activity before and after implementation of the pro- 7. Morris PE, Goad A, Thompson C, et al. Early intensive care mobility
tocol also may have influenced adoption of early, progressive therapy in the treatment of acute respiratory failure. Crit Care Med.
2008;36:2238-2243.
mobility in this setting. 8. Perme C, Chandrashekar R. Early mobility and walking program for
patients in intensive care units: creating a standard of care. Am J Crit
Care. 2009;18(3):212-221.
Conclusion 9. Ahrens T, Burns S, Phillips J, Vollman K, Whitman J. Progressive Mobil-
In this sample, nurses were unlikely to plan out-of-bed ity Guidelines for Critically Ill Patients. 2005. http://www.vollman.com
/pdf/SugGdlns.pdf. Accessed January 20, 2010.
activity among chronically critically ill patients receiving 10. Hopkins RO, Spuhler VJ. Strategies for promoting early activity in criti-
mechanical ventilation. Concerns about patients’ condition, cally ill mechanically ventilated patients. AACN Adv Crit Care.
particularly the level of consciousness, stability of vital signs, 2009;20(3):277-289.
11. Morris PE. Moving our critically ill patients: mobility barriers and bene-
and respiratory status, were identified as barriers to patient fits. Crit Care Clin. 2007;23(1):1-20.
readiness for progressive activity. The presence of both a pro- 12. Ferguson J, ed. Activity in critically ill individuals with acute pulmonary
dysfunction receiving narcotic and sedative medications. Paper pre-
tocol and a champion (ie, coaching by the research nurse) sented at: American Association of Critical-Care Nurses National Teach-
facilitated increased frequency of out-of-bed activity and estab- ing Institute; May 2007; Atlanta, GA.
13. Hodgkin KE, Nordon-Craft A, McFann KK, Mealer ML, Moss M. Physi-
lished a trend to earlier out-of-bed activity in patients at high cal therapy utilization in intensive care units: results from a national
risk for prolonged bed rest and the complications associated survey. Crit Care Med. 2009;37(2):561-568.

C3_supplmt.qxp:17_28_Gonzalez2_10 3/11/10 11:12 AM Page 1
CE Test Test ID C102S: Progressive Mobility in the Critically Ill

Learning objectives: 1. Identify the risks associated with bed rest and immobility in intensive care unit patients 2. Describe the process of progressive
mobility 3. Discuss challenges and barriers to making positioning and mobility of patients a priority of practice in the intensive care unit
1. What is the major long-term complication resulting from the physical 7. Patients receiving continuous lateral rotation therapy (CLRT) should have the
deconditioning that takes place during a patient’s stay in the intensive care continuous rotation for how many hours per day?
unit (ICU)? a. 12 c. 16
a. Loss of orthostatic tolerance/disturbed equilibrium b. 14 d. 18
b. Onset of depressive mood disorders
c. Diminished quality of life after discharge 8. Which of the following is a recommendation included in all pressure ulcer
d. Increased susceptibility to autoimmune disorders prevention guidelines?
a. Repositioning of patients at least every 2 hours
2. Which of the following is the result of a patient’s developing “gravitational b. Use of a therapy bed with a low-density foam surface
equilibrium”? c. A planned repositioning schedule tailored to each individual patient
a. Increased orthostatic tolerance d. Use of a sling transfer aid when turning and/or repositioning patients
b. Difficulty adapting to a change in position
c. Stabilization of the plasma volume reduction that occurs during the 9. Which of the following statements regarding the use of CLRT is true?
first few days of bed rest a. CLRT alone—the right and left rotation of 20°-40°—is the only pressure ulcer
d. Improved function of the body’s autonomic feedback loop prevention therapy necessary if the CLRT bed has a pressure distribution mattress.
b. Bolsters, pillows, and other positioning devices may be used during times when
3. Progressive mobility is defined as a series of planned movements in a CLRT is stopped, but they should be removed before use of active CLRT.
sequential manner with what final goal? c. CLRT is designed specifically for supporting pulmonary toileting, and should not be used
a. Returning to the patient’s baseline level of mobility for patients who are at high risk for developing pressure ulcers.
b. Achieving 75% of the patient’s pre-ICU activity level d. Incontinent patients receiving CLRT should have diapers and specially designed pads
c. Prevention of ventilator- and hospital-acquired pneumonia placed between them and the surface of the CLRT bed.
d. Patient’s ability to ambulate for a distance of at least 100 feet by the time
of ICU discharge 10. Which of the following is the definition of the beach chair position?
a. Elevation of the patient’s head of bed to 90° and the foot of bed at a -90° angle
4. What was the main cause of functional limitations occurring in patients b. Elevation of the patient’s head of bed to 75° and the foot of bed at a -75° angle
within 1 year after discharge from the ICU? c. Elevation of the patient’s head of bed to 70° and the foot of bed at a -75° angle
a. Heart muscle deconditioning d. Elevation of the patient’s head of bed to 90° and the foot of bed at a -70° angle
b. Skin breakdown/delayed wound healing
c. Joint contractures 11. Evidence-based practices to facilitate daily delivery of early ICU mobility include
d. Muscle wasting best practices in which of the following areas?
a. Management of sedatives and analgesics; promotion of sleep for ICU patients
5. When do this article’s authors recommend assessing each ICU patient’s b. Using physical therapists to initiate progressive mobility programs; prioritization of
readiness for mobility? procedures by ICU nurses
a. During the initial nursing assessment following admission c. Use of beds that allow for patients to be positioned with backrest, hips, and knees
b. Each time a patient’s condition changes significantly angled at 90° without getting out of bed; protocols that include daily passive range of
c. Daily motion exercises
d. At the time of initiation of a progressive mobility protocol d. Physician-ordered “out-of-bed” activity (early mobility); staff education regarding the
complications associated with immobility and bed rest
6. The decreased muscle mass that occurs in critically ill patients is most
pronounced in what area of the body? 12. The study designed to evaluate staff perceptions of patient readiness for mobility
a. Upper limbs found that the most common facilitator identified by the nurses who planned out-of-
b. Lower limbs bed activity for their patients was which of the following?
c. Diaphragm a. “Adequate staffing today”
d. Abdomen b. “Physician order”
c. “Patient is cooperative”
d. “New beds make getting the patient out of bed easier”
1. K a 2. K a 3. K a 4. K a 5. K a 6. K a 7. K a 8. K a 9. K a 10. K a 11. K a 12. K a

Test answers: Mark only one box for your answer to each question. You may photocopy this form.
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Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc
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Test ID: C102S Form expires: April 1, 2012 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Category: Synergy CERP A
Test writer: Ann Lystrup, RN, BSN, CEN, CFRN, CCRN
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What are the risks associated with bed rest and immobility in ICU patients?

What are the risks associated with bed rest and immobility in ICU patients?

What is progressive mobility and what does it involve?

What is progressive mobility and what does it involve?

Apr 2010 suppl_pgs.

qxp:Editorial8_08 3/11/10 12:15 PM Page 3

Progressive Mobility in the Critically Ill

T he term progressive mobility is defined as a series of

www.ccnonline.org CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement S3

©2010 American Association of Critical-Care Nurses

S4 CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement www.ccnonline.org

medical cardiovascular and pulmonary patients. Crit Care Med.

www.ccnonline.org CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement S5

Once implemented, CLRT therapy should be delivered

S6 CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement www.ccnonline.org

©2010 American Association of Critical-Care Nurses

www.ccnonline.org CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement S7

Erythema can be an early sign of pressure ulcer poten-

S8 CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement www.ccnonline.org

References candidates include patients who require sedation or who are

mmobile intensive care unit (ICU) patients are at risk for

www.ccnonline.org CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement S9

Several positive outcomes were realized in this initial

• SpO2 ~ remains ≥ 90%

saturation as shown by pulse oximetry; SSG, split skin graft. 6

S10 CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement www.ccnonline.org

not be related to the patients’ disease but may be due to the

©2010 American Association of Critical-Care Nurses

SOI 1 SOI 3 doi: 10.4037/ccn2010425

www.ccnonline.org CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement S11

safety limits (Table 1). Other reports on

Discharge to general care area

S12 CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement www.ccnonline.org

©2010 American Association of Critical-Care Nurses

www.ccnonline.org CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement S13

readiness for progression from in-bed activity to out-of-bed

Methods Body mass indexc 31 (18.2-42.7)

Sample and Setting Admission diagnosis, %

S14 CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement www.ccnonline.org

activity. Generally, nurses did not cite physician orders as

www.ccnonline.org CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement S15

©2010 American Association of Critical-Care Nurses

S16 CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement www.ccnonline.org

CE Test Test ID C102S: Progressive Mobility in the Critically Ill

1. K a 2. K a 3. K a 4. K a 5. K a 6. K a 7. K a 8. K a 9. K a 10. K a 11. K a 12. K a

For faster processing, take

this CE test online at

(“CE Articles in this issue”)

or mail this entire page to:

AACN, 101 Columbia

Aliso Viejo, CA 92656.

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