The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [223]
The main principles underpinning all interventions regarding patient positioning and mobilization focus on the short- and long-term goals of rehabilitation and management for each specific patient. It is imperative that a thorough assessment is carried out prior to any intervention in order to plan appropriate goals of treatment. It may be necessary to compromise on one principle, depending on the overall goal. For example, for the palliative patient, it may be that the primary aim of any intervention is to facilitate comfort at the cost of reducing function. Regular reassessment is necessary to allow for modification of plans to allow for changes in status.
Effects of bed rest/decreased mobility
Patients with acute medical conditions and decreased mobility are at risk of developing secondary complications of bed rest such as pulmonary embolus (PE) (Riedel 2001), deep vein thrombosis (DVT) or respiratory infection (Convertino et al. 1997). Historically patients complaining of pain, dyspnoea, neurological dysfunction and fatigue were advised to rest. However, inactivity can cause a variety of problems (Creditor 1993, Doyle et al. 2004) including:
deconditioning of many of the body’s systems (particularly in cardiorespiratory and musculoskeletal systems)
deterioration of symptoms
fear of movement
loss of independence
social isolation.
Therefore, patients should be encouraged or assisted to mobilize or change position, at frequent intervals. The use of rehabilitation programmes in the patient with critical illness has the potential to decrease time on the critical care unit, shorten overall hospital stay and prevent readmission (Thomas 2009). Early referral to therapy services is advantageous.
If bed rest is unavoidable then the following factors should be taken into account:
patient comfort and adequate support
avoidance of the complications of prolonged bed rest
the optimum frequency of position change.
Active movements, as advised by the physiotherapist, should be practised where possible in order to (Adam and Forrest 1999):
maintain full joint range
maintain full muscle length and extensibility
assist venous return
maintain sensation of normal movement.
Active ankle movements (Figure 7.3) are to be encouraged to assist the circulation, as failure to exercise the calf muscle for prolonged periods may result in limited or poor blood circulation in the lower leg and increases the risk of DVT (O’Donovan et al. 2006).
Figure 7.3 (a) Ankle in dorsiflexion (DF). (b) Ankle in plantarflexion (PF).
Risk assessment
There is an absolute requirement to assess the risks arising from moving and handling patients that cannot reasonably be avoided. Once the risk of not moving the patient is deemed to be greater than moving the patient (see previous rationale), consider the following (TILE).
T Task/operation: achieving the desired position or movement.
I Individual: this refers to the handler/s. In patient handling, this relates to the skills, competencies and physical capabilities of the handlers. It is also important to consider health status, gender, pregnancy, age and disability.
L Load: in the case of patient handling, the load is the patient.
E Environment: before positioning or moving the patient, think about the space, placement of equipment and removal of any hazards.
There have recently been initiatives looking at specific areas to improve patient care following the publication of High Impact Actions for Nursing and Midwifery in 2009 (www.institute.nhs.uk). One area identified in this report is falls prevention with the aim of demonstrating a reduction in the number of falls in older people within NHS care. Local initiatives and action plans are currently being formulated to address