Bedside mobility assessment tool: Nurses get patients moving

As nurses provide patient care, patient safety is top of mind. Keeping patients from falling is always a concern.

“Sometimes nurses are so vigilant about fall prevention that they are hesitant to get a patient up and moving because they’re afraid the patient is going to fall,” says Barb Pusateri, MSN, RN, Medline Clinical Solutions Manager. “But this is part of patient care. Mobility is medicine.”

In fact, inpatient early mobility initiatives are effective for improving patient outcomes and decreasing use of hospital resources among adult ICU and general medicine patients.¹

So how do you foster a culture of early, progressive patient mobility among nurses at your hospital?

Immobility affects all systems of the body. It can cause a variety of adverse outcomes such as deconditioning, embolization and pulmonary dysfunction.

Why does this happen? Because humans are mobile beings. We change positions unconsciously, like blinking or breathing. Patients in the hospital who are sedated or in critical condition may not be able to unconsciously reposition or mobilize themselves.

“The goal is to help the patient regain mobility to their baseline status,” says Pusateri. “For example, if a patient was able to walk up and down stairs pre-hospital admission, ideally, the patient would be able to do that before being discharged.”

She adds, “It’s a step-by-step process. If you don’t get the patient up and working on balance, strength and endurance, they’re more likely to fall. Then they’ll end up back in ICU or going to a skilled nursing facility instead of being discharged to home.”

What’s that step-by-step process? Progressive mobility.

Progressive mobility includes range-of-motion exercises, elevating the head of bed, dangling at the bedside, taking a few steps and eventually walking. Consistent and continual reassessment is key to helping ensure that the patient returns to their pre-hospitalization state. This can be accomplished passively, with the help of the healthcare provider or equipment, or actively, where the patient independently performs the exercises or movements on their own.

Progressive mobilization helps the patient’s blood and body fluids flow normally, while also relieving pressure points. The benefits of early, progressive mobilization include improved overall patient strength and endurance, decreased length of hospital stay for the patient, decreased likelihood of delirium development and decreased hospital costs.

A nurse-driven mobility assessment tool will enable safe mobility practices. How? It helps the clinician understand the patient’s dependency level and what interventions to use based on those levels, ultimately preventing caregiver and patient injury.

“There are multiple assessment tools available for use,” says Pusateri. “The predominant one is the Banner Health-developed BMAT, which stands for bedside mobility assessment tool.² Johns Hopkins³ has a tool as well, among others.”

Using a mobility assessment tool, nurses can identify a patient’s mobility level and plan accordingly.

Broadly, here’s how to get started with early patient mobility.

1. Identify the patient’s mobility level

Start by asking the patient to complete a series of small movements.

Begin by having the patient elevate their head of bed or slowly sit up in bed. If the patient is able to withstand this first stage of movement, the caregiver should observe the patient’s strength and head control in a seated position. If the patient is able to independently maintain a seated position, have the patient dangle their legs off the bed while holding on to the side rail.

To determine a patient’s lower body strength, have them straighten their legs and complete leg raises. If the patient is able to complete all of these movements, they are ready to get up and moving.

2. Tailor a plan of care based on the patient’s needs

This will be in accordance with their level of dependence:

• Dependent: The patient needs maximum assistance from the caregiver; they do 25% or less of the work required to move or transfer. Mechanical lifting and repositioning sheets should be utilized to prevent patient or caregiver injury. Lateral transfer sheets should be used when transferring these patients from one surface to another.
• Moderately dependent: Moderately dependent patients do 50% of the work required to move or transfer. They can sit unassisted but cannot stand independently. Stand assist lifts and gait belts should be used when ambulating and mobilizing these patients.
• Independent: Independent patients need little to no assistance from the caregiver and do 75% or more of the work required to move or transfer. Gait belts should always be used when ambulating patients.

“We start with passive range of motion,” says Pusateri. “Then we go to active range of motion. Can we elevate the head of the bed and keep that patient hemodynamically stable, where we can get them to sit at the edge of the bed, dangle their legs, maybe stand up.”

She continues, “Then, if they can take a few steps, the goal is to get them onto the commode. They can start sitting in a chair and using the bathroom to start building their endurance. These progressive movements will help them progress in the recovery phase.”