mobility program cbl (2).pptfinal

Mobility Program TrialMobility Program Trial

Why Consider Mobility and Why Consider Mobility and Function In Our Older Patients?Function In Our Older Patients?

Immobility can be devastating!Immobility can be devastating!

CardiovascularCardiovascular - stroke volume, cardiac output - stroke volume, cardiac output RespiratoryRespiratory – respiratory excursion, oxygen – respiratory excursion, oxygen

uptake, potential for atelectasisuptake, potential for atelectasis MusclesMuscles - muscle strength, muscle blood flow - muscle strength, muscle blood flow BoneBone – bone loss, bone density – bone loss, bone density GIGI – Malnutrition, anorexia, constipation – Malnutrition, anorexia, constipation GUGU – Incontinence – Incontinence SkinSkin – Sheering force, potential for skin breakdown – Sheering force, potential for skin breakdown

and pressure ulcersand pressure ulcers PsychologicalPsychological – social isolation, anxiety, depression, – social isolation, anxiety, depression,

disorientationdisorientation

Negative Effects of Bed Rest Negative Effects of Bed Rest

Decline Can Happen Quickly!Decline Can Happen Quickly!

Begin a functional Begin a functional assessment on assessment on admission and admission and provide early nursing provide early nursing interventions to interventions to prevent or minimize prevent or minimize deconditioning and deconditioning and functional decline.functional decline.

The Costs of Functional Decline The Costs of Functional Decline Are Both Human and FinancialAre Both Human and Financial

Increased risk of illness and deathIncreased risk of illness and death Often irreversibly diminished quality Often irreversibly diminished quality

of lifeof life Less autonomy and greater Less autonomy and greater

dependencedependence May lead to nursing home placementMay lead to nursing home placement Increased length of hospital stay and Increased length of hospital stay and

readmissionsreadmissions

Positive Effects of MobilityPositive Effects of Mobility

Maintain strengthMaintain strength Maintain daily activitiesMaintain daily activities Promote good circulationPromote good circulation Prevent infectionPrevent infection Prevent skin breakdownPrevent skin breakdown Prevent complicationsPrevent complications

So Let’s Get Moving!!So Let’s Get Moving!!

““Assessment of function and targeting Assessment of function and targeting interventions during hospitalization are interventions during hospitalization are critically important to acute care of critically important to acute care of older adults.”older adults.”

Patient Safety and Quality: An Evidenced-based Handbook for Patient Safety and Quality: An Evidenced-based Handbook for

Nurses. AHRQ, 2008.Nurses. AHRQ, 2008.

Program GoalsProgram Goals

Nurses will assess patient’s prior activity and Nurses will assess patient’s prior activity and functional status.functional status.

Maintain patient’s daily routine.Maintain patient’s daily routine. Promote safe mobility consistent with the medical Promote safe mobility consistent with the medical

plan of care.plan of care. Up for meals. Ambulate in the hall.Up for meals. Ambulate in the hall. ROM for patients on Bed Rest.ROM for patients on Bed Rest. Educate patient and family on importance of Educate patient and family on importance of

activity and ambulation.activity and ambulation. Shift report to include patient’s physical activity.Shift report to include patient’s physical activity.

Target PopulationTarget Population

Our elder patientsOur elder patients All patients age 70 and older will be All patients age 70 and older will be

included in the Mobility Program.included in the Mobility Program.

Prior Functional AssessmentPrior Functional Assessment Complete a prior functional assessment for Complete a prior functional assessment for

all patients age 70 and older on admissionall patients age 70 and older on admission Katz Independence of ADL’s Scoring Katz Independence of ADL’s Scoring

ToolTool (see next slide) (see next slide)

What was the patient’s prior level of What was the patient’s prior level of function?function?

Ask what activities the patient could Ask what activities the patient could perform and what assistance they needed perform and what assistance they needed two weeks prior to this two weeks prior to this hospitalizationhospitalization

Katz Independence of Katz Independence of ADL’s Scoring ToolADL’s Scoring Tool

Katz Index of Independence in Activities of Daily Living

Activities Points (1 or 0)

Independence (1 Point) NO supervision, direction or personal assistance

Dependence (0 Points) WITH supervision, direction, personal assistance or total care

BATHING Points:______

(1 POINT) Bathes self completely or needs help in bathing only a single part of the body such as the back, genital area or disabled extremity.

(0 POINTS) Needs help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing.

DRESSING Points:______

(1 POINT) Get clothes from closet and drawers and puts on clothes and outer garments complete with fasteners. May have help typing shoes.

(0 POINTS) Needs help with dressing self or needs to be completely dressed.

TOILETING Points:______

(1 POINT) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help.

(0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or commode.

TRANSFERRING Points:______

(1 POINT) Moves in and out of bed or chair unassisted. Mechanical transfer aids are acceptable.

(0 POINTS) needs help in moving from bed to chair or requires a complete transfer.

CONTINENCE Points:______

(1 POINT) exercises complete self control over urination and defecation.

(0 POINTS) Is partially or totally incontinent of bowel or bladder.

FEEDING Points:______

(1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person.

(0 POINTS) Needs partial or total help with feeding or requires parenteral feeding.

Total Points: ____________ Score of 6 = High, Patient is independent

Score of 0 = Low, Patient is very dependent

Daily Mobility and Functional Daily Mobility and Functional AssessmentAssessment

Falls Risk Assessment ScoreFalls Risk Assessment Score You are already completing this as part of You are already completing this as part of

the Falls Prevention Programthe Falls Prevention Program Note the patient’s mobility/balance levelNote the patient’s mobility/balance level Note independence/dependence with Note independence/dependence with

activities of daily livingactivities of daily living Note patient’s risk for fallsNote patient’s risk for falls Assess daily for progress or decline in Assess daily for progress or decline in

patient’s mobility levelpatient’s mobility level

Mobility Cards Mobility Cards

Mobility cards are a screening tool and cue Mobility cards are a screening tool and cue for the Mobility Programfor the Mobility Program

All patients age 70 and older will have a All patients age 70 and older will have a Mobility Card posted by their bedMobility Card posted by their bed

3 levels of mobility determined by the Falls 3 levels of mobility determined by the Falls Risk Assessment Score and *activity Risk Assessment Score and *activity medical ordersmedical orders

**Always check the patient’s medical orders for activityAlways check the patient’s medical orders for activity. . Update the patient’s Mobility Card as their status or activity Update the patient’s Mobility Card as their status or activity

orders changeorders change

Mobility Card LevelsMobility Card Levels

Determined by the Falls Risk Assessment Determined by the Falls Risk Assessment ScoreScore

Falls Risk Assessment Score

Mobility

Card

< 1 = 2 1 3 to 4 2 = / > 5 3

Mobility Card – Level IMobility Card – Level I

Mobility Card – Level IIMobility Card – Level II

Mobility Card – Level IIIMobility Card – Level III

Nursing Assessment Key PointsNursing Assessment Key Points

Assess all patients age 70 and olderAssess all patients age 70 and older Katz Independence of ADL’s Scoring Tool Katz Independence of ADL’s Scoring Tool

on admissionon admission Falls Risk Assessment Score dailyFalls Risk Assessment Score daily Determine medical orders for activity levelDetermine medical orders for activity level Assess for impediments to mobility such Assess for impediments to mobility such

as arthritis, neurological disease, as arthritis, neurological disease, cardiopulmonary activity intolerance, cardiopulmonary activity intolerance, pain, medical devices and others.pain, medical devices and others.

Continued…Continued…

Nursing Assessment Key Points Nursing Assessment Key Points Continued…Continued…

Evaluate need for assistive devices.Evaluate need for assistive devices. Safety needsSafety needs Risk for pressure ulcersRisk for pressure ulcers Nutritional statusNutritional status Patient and family Patient and family

concerns and motivationconcerns and motivation

Let’s Get Moving!Let’s Get Moving! CollaborateCollaborate with physician, patient, family and with physician, patient, family and

health care team to develop a plan of care for health care team to develop a plan of care for mobility mobility

Promote safe mobility consistent with medical Promote safe mobility consistent with medical plan of careplan of care

Maintain patient’s daily activitiesMaintain patient’s daily activities Utilize the Mobility Card to communicate Utilize the Mobility Card to communicate

patient’s mobility levelpatient’s mobility level Utilize the SBAR to communicate patient Utilize the SBAR to communicate patient

specific activities and medical ordersspecific activities and medical orders Utilize the Mobility Care Plan Sticker to plan Utilize the Mobility Care Plan Sticker to plan

nursing care.nursing care.

Mobility Nursing Care Plan StickerMobility Nursing Care Plan Sticker

SBARSBAR

Bed RestBed Rest

Patients on Bed Rest:Patients on Bed Rest: Encourage and assist patients to stay as active Encourage and assist patients to stay as active

as possible by turning themselves in bed and as possible by turning themselves in bed and participating in their care as possibleparticipating in their care as possible

Turn patient at least every 2 hours when they Turn patient at least every 2 hours when they cannot participate in their carecannot participate in their care

Perform active/passive range of motion TID as Perform active/passive range of motion TID as neededneeded

Assess daily with physician Assess daily with physician the need for continued bed the need for continued bed restrest

Up To ChairUp To Chair

Patients who are able to get up to the Patients who are able to get up to the chair –chair –

Encourage to get up to chair Encourage to get up to chair independently or with assistance, independently or with assistance, preferably for mealspreferably for meals

Encourage self feeding as able while up in Encourage self feeding as able while up in chair chair

Up to commode for toileting as able. Up to commode for toileting as able. Consider a toileting routine to promote Consider a toileting routine to promote continence.continence.

AmbulationAmbulation

Patients who are able to ambulate –Patients who are able to ambulate – Encourage and/or assist with ambulation 3 Encourage and/or assist with ambulation 3

times a day as toleratedtimes a day as tolerated Encourage walking in the hallway if ableEncourage walking in the hallway if able Promote use of bathroom and activities Promote use of bathroom and activities

outside of the room as appropriateoutside of the room as appropriate

Lift EquipmentLift Equipment

Utilize appropriate lift Utilize appropriate lift equipmentequipment

Have transfer sheet Have transfer sheet and other lift and other lift equipment available equipment available in patient’s roomin patient’s room

Nursing Intervention Key PointsNursing Intervention Key Points

Plan for mobilityPlan for mobility Minimize bed restMinimize bed rest Safety / Falls PreventionSafety / Falls Prevention Pressure Ulcer PreventionPressure Ulcer Prevention Pain managementPain management Judiciously use medications, especially Judiciously use medications, especially

psychoactive medicationspsychoactive medications

Continued….Continued….

Nursing Intervention Key PointsNursing Intervention Key PointsContinued….Continued….

Explore alternatives to physical restraintsExplore alternatives to physical restraints PT/OT referrals for functional declinePT/OT referrals for functional decline Minimize use of foley cathetersMinimize use of foley catheters Toileting schedules to promote continenceToileting schedules to promote continence Nutritional support for energyNutritional support for energy Nutrition consult for intake < 50%Nutrition consult for intake < 50% Education and support for elders and their Education and support for elders and their

familiesfamilies

Tips from PT/OTTips from PT/OT

Encourage all patients to get out of Encourage all patients to get out of bed and walk as ablebed and walk as able

Up in chair for mealsUp in chair for meals Stand or sit at the sink to complete Stand or sit at the sink to complete

light hygienelight hygiene Encourage patients to use the toilet Encourage patients to use the toilet

as soon as possibleas soon as possible Encourage patients to be up with Encourage patients to be up with

their visitorstheir visitors

Tips for ContinenceTips for Continence

Transient IncontinenceTransient Incontinence Hospitalized older adults are at risk for Hospitalized older adults are at risk for

developing transient incontinence.developing transient incontinence. Transient incontinence is characterized by a Transient incontinence is characterized by a

sudden onset.sudden onset. Transient incontinence is often preventable or Transient incontinence is often preventable or

reversible.reversible. Mobility dependency is a risk factor for new on-Mobility dependency is a risk factor for new on-

set, transient urinary incontinence.set, transient urinary incontinence. Transient incontinence may become established Transient incontinence may become established

incontinence if not recognized and resolved.incontinence if not recognized and resolved.


Causes of Transient Urinary IncontinenceCauses of Transient Urinary Incontinence D D - Delirium or confusional state- Delirium or confusional state I I - Infection, UTI- Infection, UTI A A - Atropic urethritis/vaginitis- Atropic urethritis/vaginitis P P - Pharmaceuticals- Pharmaceuticals P P - Psychologic, especially depression- Psychologic, especially depression E E - Endocrine - Endocrine (hypercalcemia, hyperglycemia)(hypercalcemia, hyperglycemia) R R - Restricted mobility- Restricted mobility S S - Stool impaction/constipation- Stool impaction/constipation


Key PointsKey Points Being able to walk, having use of a bedpan or Being able to walk, having use of a bedpan or

commode and nursing assistance with commode and nursing assistance with toileting fosters continence in the geriatric toileting fosters continence in the geriatric patient in the acute care setting.patient in the acute care setting.

Minimize the use of indwelling urinary Minimize the use of indwelling urinary catheters (which may impede mobility).catheters (which may impede mobility).

Set up a toileting schedule Set up a toileting schedule every two hoursevery two hours and provide verbal cues and assistance with and provide verbal cues and assistance with toileting as needed.toileting as needed.

Tips From NutritionistTips From NutritionistThe Importance of Nutrition and Mobility in The Importance of Nutrition and Mobility in

Older PatientsOlder Patients Need for higher nutrient density due to body Need for higher nutrient density due to body

muscle changes.muscle changes. Close link between physical function and nutrition Close link between physical function and nutrition

at old age.at old age. Maintained or increased need for nutrients, such Maintained or increased need for nutrients, such

as protein, calcium and vitamins D, Bas protein, calcium and vitamins D, B66, B, B1212 and C. and C. Improved physical function only when combining Improved physical function only when combining

exercise (resistance training) and nutrition.exercise (resistance training) and nutrition. May need nutritional supplements to reach proper May need nutritional supplements to reach proper

nutrition.nutrition.

Tips From NutritionistTips From Nutritionist

The Importance of Nutrition and The Importance of Nutrition and Mobility Mobility

Document % PO intake.Document % PO intake. Does the patient consume at least 50% of Does the patient consume at least 50% of

food at meals? If not, refer to RD.food at meals? If not, refer to RD. Assist with feeding and supplements as Assist with feeding and supplements as

needed.needed. Patient and family education.Patient and family education.

Working Smarter to Meet the Working Smarter to Meet the Needs of Our Elder PatientsNeeds of Our Elder Patients

Workflow Guidelines for Mobility ProgramWorkflow Guidelines for Mobility Program The Mobility Program will be introduced to patients and The Mobility Program will be introduced to patients and

families on admission along with the Mobility Program families on admission along with the Mobility Program Education flyer.Education flyer.

SBAR report RN to RN to include daily mobility goals (see SBAR report RN to RN to include daily mobility goals (see SBAR Activity section).SBAR Activity section).

RN to CNA report.RN to CNA report. Vital sign times: 0800, 1200, 1600, 2000, 2400, and 0400.Vital sign times: 0800, 1200, 1600, 2000, 2400, and 0400. Day shift RN will do 0800 V/S and CNA will do 1200 & 2000.Day shift RN will do 0800 V/S and CNA will do 1200 & 2000. CNA to perform AM Care and first ambulation.CNA to perform AM Care and first ambulation. Hourly rounding.Hourly rounding.

Working Smarter to Meet the Working Smarter to Meet the Needs of Our Elder PatientsNeeds of Our Elder Patients

Workflow Guidelines for Mobility Program Workflow Guidelines for Mobility Program – cont.– cont. Baths to be given on Tues, Thurs & Sat for ODD numbered Baths to be given on Tues, Thurs & Sat for ODD numbered

rooms and Mon, Wed, Fri for EVEN number rooms. Sunday rooms and Mon, Wed, Fri for EVEN number rooms. Sunday baths given prn. Charge nurse will assign baths.baths given prn. Charge nurse will assign baths.

AM and PM hygiene care will be given to all patients every AM and PM hygiene care will be given to all patients every day.day.

Linen changes will be done with baths and when soiled.Linen changes will be done with baths and when soiled. All patients will be out of bed for at least 2 meals a day as All patients will be out of bed for at least 2 meals a day as

tolerated unless strict bed rest is ordered.tolerated unless strict bed rest is ordered. RN to communicate with Physicians to obtain appropriate RN to communicate with Physicians to obtain appropriate

mobility/activity orders for patient.mobility/activity orders for patient. Utilize Mobility Care Plan Sticker, SBAR report and Mobility Utilize Mobility Care Plan Sticker, SBAR report and Mobility

Cards to communicate mobility plan for patient.Cards to communicate mobility plan for patient.

Scripting – Patient & CaregiverScripting – Patient & Caregiver

Linen and bathing –Linen and bathing – Notifying patient of scheduling on Notifying patient of scheduling on

admission: admission: – ““Personal hygiene care is provided daily and Personal hygiene care is provided daily and

complete baths are encouraged every other complete baths are encouraged every other day. Linens are changed with the bath every day. Linens are changed with the bath every other day. We encourage you to participate in other day. We encourage you to participate in your bath and shower as able. Please let your your bath and shower as able. Please let your nurse know if you need additional care.”nurse know if you need additional care.”


Mobility Program –Mobility Program – Inform patients and caregivers of the Inform patients and caregivers of the

Mobility Program and goals upon Mobility Program and goals upon admission: admission: – ““Staying active with your usual activities such Staying active with your usual activities such

as walking, bathing and sitting up for meals is as walking, bathing and sitting up for meals is important for your health and helps to maintain important for your health and helps to maintain your strength. The Mobility Program is your strength. The Mobility Program is designed to help you with this.”designed to help you with this.”

– Give patient and families the Mobility Program Give patient and families the Mobility Program Flyer.Flyer.


Patient Motivation –Patient Motivation – Provide encouragement about the benefits Provide encouragement about the benefits

of mobility and activity: of mobility and activity: “You will get “You will get stronger, be less likely to fall...”stronger, be less likely to fall...”

Provide encouragement about the Provide encouragement about the patient’s ability to perform the activity. patient’s ability to perform the activity. Reassurance: Reassurance: “You can do it.”“You can do it.”

Practice. Encourage actual performance / Practice. Encourage actual performance / practice doing the activity – walking, practice doing the activity – walking, bathing…acknowledge patient effort and bathing…acknowledge patient effort and successes. successes.

Educate Elders and FamilyEducate Elders and Family

Educate elders and family on the value Educate elders and family on the value of independent functioning and the of independent functioning and the consequences of functional declineconsequences of functional decline

Strategies to prevent functional declineStrategies to prevent functional decline ExerciseExercise NutritionNutrition Pain managementPain management SocializationSocialization

Patient and Family FlyerPatient and Family Flyer

Patient and Family EducationPatient and Family Education

Provide Mobility Program information Provide Mobility Program information and flyer on admissionand flyer on admission

Teach back daily with education Teach back daily with education questionsquestions

Teach Back for Patient EducationTeach Back for Patient Education

Day 1Day 1

““Who will be helping you at home so Who will be helping you at home so that we can include them in your that we can include them in your daily education?”daily education?”

What is:What is:– Our Mobility Program?Our Mobility Program?– Your mobility Goal for today?Your mobility Goal for today?


Day 2Day 2

Why should you:Why should you:– Exercise today?Exercise today?– Exercise every day?Exercise every day?– Know the signs and symptoms of when Know the signs and symptoms of when

to stop exercising?to stop exercising?


Day 3Day 3

How will you:How will you:– Exercise every day when you are at Exercise every day when you are at

home?home?– Change your lifestyle to increase your Change your lifestyle to increase your

activity every day at home?activity every day at home?– Know when to stop exercise?Know when to stop exercise?– Assist us with today’s plan of care?Assist us with today’s plan of care?

DocumentationDocumentation

Katz Index on Mobility Care Plan Katz Index on Mobility Care Plan StickerSticker

Falls Assessment Score in NA&I/FallsFalls Assessment Score in NA&I/Falls Activities NA&I/ADLActivities NA&I/ADL Repositioning NA&I/Pressure Ulcer Repositioning NA&I/Pressure Ulcer

PreventionPrevention Education NA&I/Education/Activity Education NA&I/Education/Activity

and Exerciseand Exercise

Mobility Program SummaryMobility Program Summary

1. Katz Functional Assessment on 1. Katz Functional Assessment on AdmissionAdmission

2. Falls Assessment Score daily2. Falls Assessment Score daily

3. Mobility Card in patient room3. Mobility Card in patient room

4. SBAR Activity Communication4. SBAR Activity Communication

5. Mobility Care Plan Sticker5. Mobility Care Plan Sticker

6. Document in HED6. Document in HED

mobility program cbl (2).pptfinal

Health & Medicine