Activity Progression - GCH



Activity Progression

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Mandatory Education for

Nurses & Unlicensed Assistive Personnel

Compiled by

Professional Nursing Development

10/09, rev 3/10, 10/11, 3/13, & 10/13

Assessment of a patient’s activity level, developing an activity plan, implementing the plan, and evaluation is essential to the patient’s recovery and minimization of risks associated with immobility. Hazards of immobility involve the cardiovascular, respiratory, genitourinary, musculoskeletal, gastrointestinal, integumentary, and neurological systems (Markey & Brown, 2002). Assessment of the activity and mobility level prior to the current illness provides a baseline activity level to progress to. Appropriate mobilization and activity progression can reduce complications of immobility and prepare the patient for effective discharge from the hospital.

Some Hazards of Immobility

Adapted from Markey & Brown, 2002

Increased risk of DVT and PE

Exercise intolerance/impaired ambulation

Orthostatic Hypotension

Decreased Cardiac Output

Pneumonia

UTI

Incontinence

Dysuria

Renal calculi

Decreased muscle strength/Muscle atrophy

Loss of bone mineral density

Contractures

Osteoarthritis

Distention, constipation, impaction

Ischemia, necrosis, skin shearing, ulcers

Sensory deprivation

Depression

Activity Progression Protocol

1. The nurse will implement the Activity Progression Protocol unless the physician writes otherwise.

• If the physician order is for absolute bed rest (ABR), the Registered Nurse will assess the patient for potential activity progression and contact the physician with their findings.

• If an order for Physical Therapy (PT) to evaluate is written, the therapist will evaluate and follow-up with an order that reads Implement Activity Progression based on PT evaluation.

• If the status is determined ABR after Physical therapy evaluation they will document on the PT evaluation that a follow-up order will not be processed for activity progression.

• Communication between Ordering Physician and Physical Therapist will be recorded in PT evaluation.

• PT will place the order for the Physician approval.

• PT will indicate date of Activity Progression on Patient Communication Board at bedside and communicate it to Registered Nurse.

2. The Registered Nurse plans the level of activity and provides report to the unlicensed assistive personnel.

3. The activity plan should be visible on the communication board at the patient’s bedside.

4. Activity Progression should be advanced as tolerated.

5. Depending on the patients level of mobility upon admission the patient may progress to ambulation within the first one to two days by following the activity progression protocol.

6. Vital Signs and symptoms of distress will be monitored by care providers during activity and reported to the Registered Nurse.

Progression of Patient Activity:

1. Range of Motion (ROM - Passive or Active) with Turn every 2 hours:

• Passive ROM: Caregiver moves joints through ROM 5 times each, 2 – 4 times a day.

• Active ROM: Patient independently moves all joints through full ROM 5 times each at least 2 times a day as directed by caregiver.

• Utilize waffle boots if bedridden, if foot drop possible

• Utilize off-loading boots if patient is on a ventilator

• Place patient in proper bed positioning in good alignment with correct support.

• Use pillows or wedges.

• Do not use doughnut shaped cushions.

• Turn patient at least every 2 hours & more often if skin condition or other physical problems warrant.

• Use appropriate pressure relieving devices as required (such as Soft Care Mattress).

2. Transfers (Dangle and Transfer to Chair):

• Bed mobility and "dangling" must occur before sitting or standing.

• Transferring to chair can be done with a mechanical lift device, partially dependently, or independently.

• The patient should progress to more independence with transfers.

• If Physical Therapy is consulted, Physical Therapy should document the patient activity level on their respective evaluation.

3. Mobilization:

• Ambulate in room with assistance

i. Initiate ambulation. If the patient appears unsteady with standing, or the patient used an assistive device prior to admission use a walker initially.

ii. When a patient exhibits an inability to tolerate assisted mobility for short distances the RN should obtain an order for a Physical Therapy consult from the Physician.

• Ambulate in room without assistance.

• Ambulate in hallway with assistance.

• Ambulate in hallway without assistance.

Documentation of Activity Progression:

1. Utilizing the Electronic Medical Record, select the Daily Flowsheet option from the assessment list in Clin Doc.

2. Document activity progression at the time of activity under the Activity/General Tab (PCA/TP and/or RN may document activity in the EMR)

3. Activity 1 and/or Activity 2: Activity Progression is indicated by selecting from the drop down, the activity/demonstration of progression of the patient at the time of activity. Document at a minimum of every 4 hours or more frequently (such as instances where a patient is on bed rest and requires turning/repositioning every 2 hours).

• Independent

• Ambulate (In comments section, indicate in room or hallway & distance traveled).

• Ambulate with assistance

• Ambulate with cane

• Ambulate with walker

• Up in chair

• Up in wheelchair

• Dangle

• Dangle with 1 assist

• Dangle with 2 assist

• Reposition left

• Reposition right

• Reposition supine

• Range of motion/ROM

• Sleep

• Bedrest

4. A comments section is available for additional documentation pertaining to activity. Always indicate if activity is independent or with assistance (1 or 2 person and/or assistive devices), number of feet the patient ambulated, and tolerance as applicable.

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Documentation During Downtime:

1. Utilizing the key on the Clinical Management Record, the Registered Nurse or Unlicensed Assistive Personnel will document the activity / demonstration of progression of the patient in the appropriate area of the medical record at the time of activity.

• Sleep/SL

• Turn/T

• Range of Motion/ROM

• Dangle/D

• Chair Sit (length on time)/CS

• Ambulate in room/AR

• Ambulate in hallway/AH

2. Documentation of activity progression is done at a minimum of every four hours or more frequently if the patient is bed bound and is to be turned every two hours.

REFERENCES:

GCH Activity Progression, Patient Care Services Protocol, 2012

Markey, D. & Brown, R. (2002). An interdisciplinary approach to addressing patient activity and mobility in the medical-surgical patient. Journal of Nursing Quarterly, 16 (4), 1-12.

Silberstein, N. (2008). Foot drop: trends in assessment and treatment. Nursing and Allied Health Collection. Retrieved from

Smith, S., Duell, D., and Martin, B. (2012). Clinical nursing skills: Basic to advanced skills (8th ed). Upper Saddle River, N.J.: Pearson.

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