Hierarchy for Mobilizing Critical Care Patients

If the patient is unconscious and sedated but cleared by the doctor to begin therapy/activity

• Gently bend and straighten the ankle, finger, rest, elbow, and shoulder joints
• If the patient tolerates it well (vitals), you may also gently move the knee and hip (out/in and up/down) joint.
  • The goal is to prevent contractures, which are shortening of connective tissues from inactivity, and can be difficult to reverse. 
• Talk to the patient to tell him what you are doing before you do it as if they can hear and understand. Often enough, people do understand long before they can communicate, and this will ease fear!
• Use folded pillows under the patient’s hip and shoulder to turn from being directly on his back to the right or left side so that he does not develop pressure sores.
  • Pressure sores are breakdowns of the skin from the inside-out that develop from lack of blood flow when the bone is close to the skin (the buttocks region, ankles etc). You can place a pillow under the lower legs to “float” heels off the bed to prevent skin breakdown
    • Red areas that do not disappear in 15-20 minutes are evidence of skin breakdown

If the Patient is conscious but very weak

• Assist the patient with the above motions, but have them “help”. You should encourage them to do gentle motion throughout the day.
  • With you helping, they will keep the range of motion of the joint. When they try themselves or help, even if they are unsuccessful at moving the joint on their own, they will be strengthening
• They can still begin to sit up at the edge of the bed with assistance. A second person would be advised, unless you are experienced. The patients blood pressure, oxygen and heart rate should be recorded beforehand for a baseline. If blood pressure is <99/70 or 140/90, check with the nurse or doctor before completing activity and continue with caution if it is the patient’s norm or they are cleared.
• Log rolling the patient is the best way to keep someone very weak safe and you uninjured, and to facilitate the patient’s independence getting them up to the edge of the bed if they are weak.
  • Assist them with bending a leg
  • Roll to the side (the leg weight will help you roll. If left leg is bent, roll to their right)
  • Once on his or her side, assist the patient with bringing legs over the edge of the bed (this will act as a counterweight to make it easier for them to sit)
• Have the patient push up through their elbow and then hand to sitting. You and and another caregiver can be standing to the sides or in front of the patient
• Take a blood pressure and assess whether the patient is feeling dizzy
  • It is common for people who have been laying down to feel dizzy initially upon sitting. This is due to a drop in blood pressure as gravity pulls the blood down and the body has to adjust to pumping back up to the head against gravity. It is okay to lay down if the patient feels very dizzy. If dizziness clears and blood pressure is stable, you can try sitting again, or stick to arm and leg exercises laying down in the bed. Patient can use weights as able. Encourage the patient to drink fluids, and try again the next time. Pumping the ankles up and down before position changes can also decrease dizziness. If the patient feels slightly/moderately dizzy, you can support them at the edge of the bed and monitor their blood pressure until the dizziness clears
  • Blood loss is another common reason for dizziness. For hemoglobin of 8-9, cease if dizzy. For 9-11, proceed with caution. 

Log Rolling

• If to this point the patient is feeling no dizziness, you can begin working on sitting balance and standing with assistance. 
• If he has trouble sitting unassisted, have him sit with assistance of both arms
• If he can sit with assistance of both arms, have him complete a daily life task, such as brushing teeth, wash his own body, reach for items, arm exercise etc while sitting. You will remain close if he needs help with balance
• If he can sit unassisted, have him complete an activity or exercise with both hands, like eating, exercise, etc. He may get tired quickly the first few times, but will get much stronger each day!