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This final part of a five-part series on early mobilisation provides a series of case scenarios to illustrate how early mobilisation can be achieved in clinical practice

This final part in a five-part series on early mobilisation uses a range of patient scenarios commonly encountered in clinical practice to explore how to encourage mobility after acute illness. The importance of early mobilisation, and the underpinning principles of assessment and equipment selection, are discussed in previous parts of the series.

Citation: Rindsland S (2021) Early mobilisation 5: finding solutions to support patient mobility. Nursing Times [online]; 117: 8, 39-42.

Author: Sharon Rindsland is moving and handling senior coordinator, East Kent Hospitals University NHS Foundation Trust.

This series has outlined the importance of mobilising patients early (part 1), how to carry out a mobility assessment and formulate a care plan (part 2), and principles of transferring a patient from bed to chair both without equipment (part 3) and with it (part 4). The final part of this series uses various patient scenarios to illustrate how assessment of mobility, as discussed in part 2, can help inform the patient care plan and selection of appropriate equipment. The scenarios will focus on a:

Each scenario will outline the assessment of the patient and identified risk factors, and give a suggested plan of care, including appropriate methods of moving and handling, and a selection of appropriate equipment.

Mrs Smith, aged 62, weighs 222kg (35 stone) and is admitted to hospital after having a stroke. She is given a standard hospital bed but, due to her size and width, is unable to roll from side to side without fear of falling out. She is moved to a wider bariatric bed with a dynamic (airflow) mattress to reduce her risk of pressure ulcers.

Before her stroke, Mrs Smith had reduced mobility, but the stroke has left her with one-sided weakness as well as rendering her immobile and unable to move independently (although she can cooperate with staff for manual handling tasks that can be done in bed). The stroke physiotherapy team assesses the equipment Mrs Smith needs to start rehabilitation/mobilisation to improve her condition. The risk factors assessed, using TILE as a risk assessment tool (Box 1), include:

Box 1. TILE risk assessment tool

When carrying out risk assessments, staff need to consider:

This can be remembered using the acronym: TILE.

The following equipment is specified to help ensure safe, effective moving and handling for both patient and handlers, taking into consideration the patient’s pathway and the equipment suitable for each task:

This equipment is rented from a hospital supplier after measuring Mrs Smith to ensure the dimensions are correct for her safety and comfort. For example:

Mrs Smith is being nursed in a side room, but the assessment shows it is too small to accommodate the gantry and chair, so she is given two bed spaces on the ward. The bariatric bed is wide enough to allow her to move freely and, because she can cooperate, it is relatively easy for nurses to insert the sling for the hoist using slide sheets. This enables staff to hoist her into the chair using a seated transfer.

A repositioning sheet (Fig 2) is used for staff to be able to reposition, lift and turn the patient in bed so she can be washed. Leg raisers attached to the hoist are used to start movement and increase leg strength with slow movements up and down.

As Mrs Smith starts to gain strength, staff use lift pants along with a gantry hoist to support her to sit on the edge of the bed. This allows her to practise standing and gait training under the direction of the physiotherapist without the risk of falling (as she is in the hoist). All this equipment reduces the need for manual handling and reduces the risk of injury to staff and patient.

Mrs Smith makes good progress with her rehabilitation programme and is discharged home fully mobile within three weeks.

Mr Brown, aged 74, is admitted to hospital via the emergency department with a hip fracture after falling at home. The patient lives semi-independently at home, with community care support. He reports that he slipped on a wet kitchen floor but was able to call for help relatively quickly.

Mr Brown is assessed for his suitability for surgery and a dynamic hip screw is seen as the best treatment for the hip fracture. After a successful procedure, Mr Brown is transferred to the orthopaedic ward under the care of the orthopaedic geriatric team to start post-operative care.

Mr Brown’s initial neurological assessment shows a Glasgow Coma Scale (GCS) score of 15. His respiratory function is good, cardiovascular assessment shows no signs of concern and lying-to-sitting blood pressure is stable, indicating that orthostatic hypotension (a sudden drop in blood pressure on moving into an upright position) was not a contributory factor in the fall. The patient has no known cognitive and perception impairment (hearing loss, memory, language, thinking or judgement issues) and no history of falling, so a fall alarm is not requested. His pressure ulcer risk is assessed and his skin is healthy and intact.

Mobilising patients in the first few days after hip surgery is shown to improve recovery and National Institute For Health and Care Excellence guidelines recommend mobilising all patients on the same day or within 24 hours of surgery following assessment by a physiotherapist (NICE, 2017).

On the first day after his operation, Mr Brown is assessed by the nursing and physiotherapy team, who put in place an early mobilisation plan. This involves assisting Mr Brown’s transfer from bed to chair with the help of a stand and transfer aid, which enables safe and active sit-to-stand and transfer to or from bed, wheelchair or toilet. Although Mr Brown needs increased pain relief to allow him to mobilise, he is in good spirits and is generally determined to mobilise and get home. By day two, he can transfer from bed to chair and take some steps using a wheeled walking frame with the help of one carer.

Risk factors assessed using the TILE tool include:

Risk reduction measures to reduce the risk of falls include:

Mr Brown is reassessed regularly to check for any changes in his mobility needs; for example, if he had started to show signs of quick onset fatigue or increased fear of falling staff could consider other equipment options, such as powered transfer aids.

Following hip fracture repair, only a minority of older patients will completely regain their previous abilities, and increased dependency and difficulty walking mean a quarter will need long-term care (Royal College of Physicians, 2019). Discharge planning, as part of Mr Brown’s assessment, was started at the point of admission in liaison with rehabilitation and community services. After 10 days in hospital, Mr Brown returns home following modifications to his living accommodation, including moving his bed downstairs.

Mrs White, aged 82, is admitted to hospital after a fall in her care home. Her X-ray shows no sign of fracture, but due to the large hematoma on her leg, doctors decide to keep her in hospital. Mrs White is a frail patient, who is cognitively impaired and has dementia, requiring nurses to liaise with the care home about her care needs, and how best to communicate with her. She can mobilise independently but finds the ward environment disorientating and when the nurses try to help her she becomes aggressive. Staff allow her to walk around, as they feel she is less anxious on her own, however, this puts her at a high risk of falling, because she does not know her surroundings.

After reassessment, Mrs White is transferred to a specialist dementia ward for one-to-one nursing care due to her high risk of falls. Familiarity with her carers means Mrs White is more likely to engage with what the nurses want her to do, but her dementia means she needs regular reassessment to monitor any changes in her cognitive ability that might affect her mobility needs, such as the ability to follow instruction, as this can change quickly in people with cognitive impairment and may increase their falls risk. Patients with dementia have special communication needs and Mrs White’s carers employ the following good practice in assessing and helping her mobilise safely:

Touch is a powerful stimulus and can be another way to communicate with your patient; remember that every patient is different and should be assessed individually. Holding the hand of a patient who is cognitively impaired can help some patients feel safe when walking. Some manual handling techniques advise against this because if patients were to fall, the handler may attempt to catch/support patients by holding on to their limbs, risking a fracture for patients and musculoskeletal injury for staff. However, there are special techniques that allow you to release your grip if your patient falls while still supporting the patient, so ask your manual handling adviser.

Risk factors when moving a frail patient include:

These risk can be addressed by:

Mrs White does well on the dementia ward and is discharged a week later from hospital back to her care home.

Mr Taylor, aged 52, is admitted to hospital for rehabilitation after spending two weeks in a specialist neurological centre following a suspected stroke. Mr Taylor lives at home with his family and has no previous neurological issues. He was at work when he had the stroke and was taken to the emergency department by ambulance. An MRI confirmed a bleed to the brain following stroke, leaving him with a dense hemiparesis. Mr Taylor is transferred to the stroke ward under the care of the neurological medical, nursing and therapy team.

On the day he is admitted, Mr Taylor is assessed by the nursing and physiotherapy team, who put a care plan in place. The patient’s initial neurological assessment shows a Glasgow Coma Scale (GCS) score of 13, respiratory function is good, and the cardiovascular assessment gives no cause for concern, with stable lying-to-sitting blood pressure. Mr Taylor has no known previous cognitive and perception impairment. A pressure ulcer risk assessment is carried out and the patient’s skin condition is intact with no sign of pressure damage, although the assessment indicates that he is at risk of skin breakdown and a preventative plan is put in place. The patient’s nutrition and hydration have been affected post stroke, but he is showing much improvement. The dietitians have made their assessment, with recommendations for the nursing team to follow.

The handover from the specialist neurological centre shows the patient has been hoisted for all transfers, including into a neuro chair during the day – which provides extra support when sitting – and a shower chair with a tilt-in-space function for bathing and toileting.

Following assessment, the nursing and therapy team help Mr Taylor sit on the side of the bed and undertake standing transfers using a transfer aid (or a standing hoist if he experiences the onset of fatigue). Mr Taylor can by now spend short periods of time out of bed, sitting in a standard hospital chair with a pressure-relieving cushion (NICE, 2014).

He makes daily visits to the physiotherapy gym, but although he can take some steps in the parallel bars, he fatigues easily. This increases his feelings of frustration and anxiety, and worsens his fear of falling.

Ward staff have several mobility and transfer aids available. Mr Taylor’s assessment highlights the equipment and method staff should adopt at any given time, including if the patient experiences a sudden onset of fatigue or an increase in pain and/or anxiety. This ensures ward staff have clear instruction on how to meet Mr Taylor’s changing mobility needs.

Length of stay for patients on the stroke ward averages around six weeks, although this varies depending on the density of the stoke and other factors, such as comorbidities. Some patients need a rehabilitation placement, or a nursing home placement if they are in a care home that cannot accommodate their post-stroke needs. Others require a temporary placement pending a home assessment by the community therapy team.

In Mr Taylor’s case, he is discharged after four weeks, with a rehabilitation placement prior to going home, following an assessment by the occupational therapist and some minor modifications to his living accommodation.

Supporting patients to mobilise as soon as possible after an acute illness is a fundamental part of recovery, and a pivotal role of nurses and caregivers as part of a whole team approach. It is also vital to prevent complications associated with prolonged bedrest. This series has provided nurses and other caregivers with the underpinning knowledge to support patients in hospital to get up and moving after acute illness, and to assess and manage their patients’ mobility needs. Points for reflection from the case scenarios used in this final article are shown in Box 2.

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