Nurs212: week 7
NCPD Nursing Continuing Professional Development Integrating Evidence Into Practice Mobility: A Pathway to Recovery Mary L. Schreiber Assisting patients to achieve safe and effective mobility during hospitalization involves collaboration with patients and the interprofessional team. Early mobility can enhance care environments and patient outcomes greatly. Keywords mobility, immobility, movement, physical activity, recovery, musculoskeletal system, neurologic/nervous system, evidence-based practice, research edical-surgical nurses are challenged with successfully integrating effective care strategies for patients with diverse health conditions. Patient mobility often reflects that diversity. According to the American Heart Association [AHA] (2018), 80% of adults and teens do not get adequate exercise. This percentage is especially relevant when an acute illness leads to hospitalization or a more critical problem occurs, resulting in prolonged or permanent immobility. Mobility deficits negatively impact patients’ recovery time and lead to rising morbidity and mortality rates (Teodoro et al., 2016). Physical activity is a crucial component involved in optimum body system functioning (Dickinson et al., 2018) but can be underappreciated until a person is affected by health issues (Wilkinson et al., 2020). A brief overview is provided of how the musculoskeletal and nervous systems facilitate mobility. Benefits of physical activity, complications of immobility, and common barriers leading to missed care are identified. Nursing implications associated with physical activity and the significance of measuring outcomes are explored. M Instructions for Contact Hours MSN J2116 Nursing Continuing Professional Development (NCPD) contact hours can be earned for completing the evaluation associated with this article. Instructions are available at amsn.org/journalNCPD Deadline for submission: August 31, 2023 1.3 contact hours July-August 2021 • Vol. 30/No. 4 Physiological Influences Symbiotic functioning of the musculoskeletal and nervous systems influences the complexities involved in mobility. Three distinct muscle types (cardiac, smooth [visceral], skeletal) impact movement-related functions in various body areas. Cardiac muscle is located solely in the heart and can contract spontaneously, which results in the heart beating. Visceral muscle in the body’s vasculature, and gastrointestinal and genitourinary organs, produces movement that promotes blood flow and peristalsis. Tendons attach skeletal muscle to the bone, and flexion and relaxation of the skeletal muscle produce joint movement (Wilkinson et al., 2020). Bones of the skeletal system rely on the specific functions of joints, cartilage, ligaments, and tendons (and skeletal muscle) to provide protection and stability for movement and mobility to occur. The nervous system has ultimate control over motor functions of the musculoskeletal system. Two types of motor nerves impact the musculoskeletal system: somatic nerves (regulate voluntary and intentional movements) and autonomic nerves (regulate involuntary responses) (Moulton et al., 2019; Wilkinson et al., 2020). Benefits of Mobility The value of physical activity cannot be overstated. Research has demonstrated numerous benefits of early and frequent movement and mobility of patients, including increased strength in joints and muscles, decreased falls and injuries, and shorter hospitalizations. Fewer nurse injuries and reduced costs overall also have been identified (Boynton et al., 2020; Halpern, 2017). Physical activity can enhance brain function, improve ability to perform tasks, decrease risks for certain health conditions (e.g., heart disease, type 2 diabetes, dementia, certain cancers, some pregnancy problems), and promote better sleep patterns (AHA, 2018). Mobility promotes independence and can enhance quality of life. Complications of Immobility Impaired mobility can have adverse physical and psychological impacts on patients, leading to functional Mary L. Schreiber, MSN, RN, CMSRN®, is Nursing Education Consultant and a MEDSURG Nursing Editorial Board Member. 279 Integrating Evidence into Practice TABLE 1. Common Complications Associated with Immobility • Muscle wasting/atrophy/contractures • Fatigue • Functional mobility loss/increased fall risk/prolonged bedrest • Circulatory compromise/clot formation • Pressure injuries • Hydration/nutrition deficiencies • Pneumonia • Bladder/bowel dysfunction • Psychological stressors Sources: Rindsland, 2021a; Teodoro et al., 2016; Wilkinson et al., 2020 decline of most body systems (Boynton, 2020; Wilkinson et al., 2020). Proactive care is essential for recovery. Numerous complications (not inclusive) associated with immobilization are listed in Table 1. Risk increases for immobility-related complications in older adults and patients with general or orthopedic surgeries (Teodoro, 2016). Effects of general anesthesia can linger, resulting in pain, respiratory issues, circulatory compromise, and alterations in consciousness (Uma et al., 2020). The effects of long-term immobility can produce a downward spiral of changes that depress body functioning. Initially, loss of muscle strength (approximately 10%/week) and limited joint motion occur. Joint contractures also can develop very quickly, as can pressure injuries. Loss of muscle strength and physical energy diminish respiratory function. The cardiovascular system becomes compromised as reserves dwindle, leading to venous stasis, blood pressure changes, and tissue edema. Metabolic needs change, and the stress response triggers release of excess hormones. Bone resorption leads to excess calcium, gastrointestinal and urinary peristalsis decreases, and psychological changes can affect cognition and mood (Wilkinson et al., 2020). Barriers to Nursing Care Nurses are challenged with problems that can hinder or prevent necessary patient care interventions (Jones et al., 2019). Research suggests assisting patients with ambulation and turning and repositioning are mobility interventions frequently missed by nurses (Agency for Healthcare Research and Quality [AHRQ], 2019). Missed nursing care “refers to needed nursing care that is delayed, partially completed, or not completed at all” (AHRQ, 2019, para. 2). Numerous aspects of nursing care have been identified as common barriers resulting in missed care (see Table 2). Inadequate staffing resources relative to workload and acuity have been an ongoing nursing care concern (AHRQ, 2019). Organizational culture and litigation have led some nurses to be apprehensive about patient mobility activities (Growden et al., 2017). Technology 280 TABLE 2. Common Barriers Associated with Missed Nursing Care • • • • • • • • Inadequate staffing (workload) Patient acuity Poor interprofessional communication Accessible resources and supplies Monitoring devices Other nursing and patient prioritizations Patient hesitation or reluctance to participate in care Nursing knowledge and perceptions Sources: AHRQ, 2019; Dickinson, 2018; Halpern, 2017; Jones et al., 2019 has provided devices to monitor various body functions; however, using these devices can cause mobility limitations and safety risks (Halpern, 2017). Various motivations can create patient resistance or apprehension to participate in movement and mobility activities (e.g., knowledge deficit regarding importance of ambulation, fear of falling, ineffective pain management) (Uma et al., 2020). Nursing Implications Implementing effective interventions that support a culture of safety and engage patients in early physical activity are fundamentals of nursing practice (Jones et al., 2019; Kappel et al., 2018). A comprehensive assessment must be performed. Communication must focus effectively on patients’ cognition and physical abilities. Identified deficits, associated risks, and specific needs related to safe mobility must be included in care plans (Wilkinson et al., 2020). Patient and caregiver education is essential, including proper use of positioning and assistive devices. Nurses also must have training (and confidence) to use the equipment competently and safely to perform needed interventions and instruction (Kappel et al., 2018). Patient participation can be promoted further through positive reinforcement techniques (Wilkinson et al., 2020). Immobility produces functional decline, and bedrest does not prevent patient falls (Growden et al., 2017). Effective use of resources and coordinated efforts of the interprofessional team can achieve success. Measuring Outcomes Movement and mobility assessment, interventions, and outcomes are achieved through interprofessional collaboration (Jones et al., 2019). Moulton and coauthors (2019) analyzed mobility and movement as separate concepts used widely by healthcare professionals without differentiation. Mobility refers to the ability of the body to move, and movement is associated with the action of changing the body’s position or moving to an alternate location (Merriam-Webster, n.d.a, n.d.b; July-August 2021 • Vol. 30/No. 4 Mobility: A Pathway to Recovery Nurses have a primary responsibility to incorporate care interventions that enhance patients’ movements and support return of optimal mobility. Moulton et al., 2019). Understanding these two concepts has helped identify more descriptive outcome measures for planning appropriate mobility interventions (Moulton et al., 2019). Accurately assessed and documented outcome data are critical components for planning and implementing appropriate interventions, determining patients’ progress, and identifying ongoing needs (Dickinson et al., 2018). Benefits of collaborative mobility-related interventions are demonstrated through empirical data and quality improvement initiatives. Implementation of a standardized mobility initiative and validated assessment tools can guide consistency and continuity of care among interprofessional team members (Boynton et al., 2020; Rindsland, 2021b). Conclusion Movement precipitates mobility (Moulton et al., 2019). Nurses have a primary responsibility to incorporate care interventions that enhance patients’ movements and support return of optimal mobility. Partnerships through effective communication with patients and interprofessional team members are mutually beneficial and critical for success (Johnson & Howell, 2019). Providing individualized care that emphasizes ongoing support and safety while fostering functional independence can assist patients in creating self-confidence and achieving motivation to overcome mobility obstacles along their path to recovery. Jones, R.A., Merkle, S., Revulcaba, L., Ashton, P., Bailey, C., & Lopez, M. (2019). Nurse-led mobility program. Journal of Nursing Care Quality, 35(1), 20-26. Kappel, S.E., Larsen-Engelkes, T.J., Barnett, R.T., Alexander, J.W., Klinkhammer, N.L., Jones, M.J., … Ye, P. (2018). Creating a culture of mobility: Using real-time assessment to drive outcomes. American Journal of Nursing 118(12), 44-50. Merriam-Webster. (n.d.a). Mobility. https://www.merriam-webster. com/dictionary/mobility Merriam-Webster. (n.d.b). Movement. https://www.merriam-webster. com/dictionary/movement Moulton, E., Wilson, R., & Deluzio, K. (2019). Movement and mobility: A concept analysis. Advances in Nursing Science, 42(40), E 11-E 23. Rindsland, S. (2021a). Early mobilisation 1: Risk factors, complications and costs of immobility. Nursing Times, 117(4), 22–24. https://cdn.ps.emap.com/wp-content/uploads/sites/3/2021/03/ 210317-Early-mobilisation-1-risk-factors-complications-and-costsof-immobility.pdf Rindsland, S. (2021b). Early mobilisation 2: Comprehensive mobility assessment and goal setting. Nursing Times, 117(5), 28-30. https://www.nursingtimes.net/clinical-archive/assessmentskills/early-mobilisation-2-comprehensive-mobility-assessmentand-goal-setting-12-04-2021/ Teodoro, C.R., Breault, K., Garvey, C., Klick, C., O’Brien, J., Purdue, T., … Matney, L. (2016). STEP-UP: Study of the effectiveness of a patient ambulation protocol. MEDSURG Nursing, 25(2), 111-116. Uma, V., Shruthikamal, V., & Jasmine J. (2020). Correlation between attitude and practice regarding early ambulation among post-operative patients at Puducherry. Journal of Evolution of Medical and Dental Sciences, 9(35), 2502-2506. Wilkinson, J.M., Treas, L.S., Barnett, K.L., & Smith, M.H. (2020). Physical activity & immobility. Fundamentals of nursing: Theory, concepts, and applications (4th ed., vol. 1). F.A. Davis. REFERENCES Agency for Healthcare Research and Quality (AHRQ). (2019). Missed nursing care. https://psnet.ahrq.gov/primer/missed-nursing-care American Heart Association (AHA). (2018). American Heart Association recommendations for physical activity in adults and kids. https://www.heart.org/en/healthy-living/fitness/fitness-basics/aharecs-for-physical-activity-inadults Boynton, T., Kumpar, D., & VanGlider, C. (2020). The bedside mobility assessment tool 2.0: Advancing patient mobility. American Nurse Today, 15(7), 18-22. Dickinson, S., Taylor, S., & Anton, P. (2018). Integrating a standardized mobility program and safe patient handling. Critical Care Nursing Quarterly, 1/3, 240-252. Growden, M.E., Shorr, R.I., & Inouye, S.K. (2017). The tension between promoting mobility and preventing falls in the hospital. Journal of the American Medical Association Internal Medicine, 177(6), 759760. https://doi.org/10.1001/jamainternmed.2017.0840 Halpern, L.W. (2017). Early ambulation is crucial for improving patient health. American Journal of Nursing 117(6), 15. https://doi.org/ 10.1097/01.NAJ.0000520240.29643.e2 Johnson, A.M., & Howell, D.M. (2019). Mobility bridges the gap in care: Findings from an early mobilisation quality improvement project in acute care. Journal of Clinical Nursing, 28(21-22), 4044-4052. https://doi.org/10.1111/jocn.14986 July-August 2021 • Vol. 30/No. 4 281 Copyright of MEDSURG Nursing is the property of Jannetti Publications, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.
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