A nurse is caring for a client who has limited mobility. which of the following actions

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Incidental activity
Retraining ADLs
Ensuring appropriate supervision during mobility and self-care tasks
Environmental modifications

We need to understand our patient’s prior level of mobility, independence in self-care and usual living situation if we are to implement appropriate and effective mobility and self-care interventions. For example, if a patient's mobility restrictions affected their ability to remain socially connected and manage their own affairs, we should develop a plan with them to rectify this.

Consider five areas of mobility and self-care interventions as part of an interdisciplinary strategy: incidental activity, exercise, retraining activities of daily living (ADLs), ensuring appropriate supervision, and environmental modifications.

Interventions should be discussed and implemented in partnership with the older person and their family and carer, as appropriate.

Incidental activity

Incidental activities are those where physical activity occurs as part of regular daily activities, for example, walking to the toilet, transferring and dressing. Performing regular daily activities, including self-care, is the easiest exercise for our patients to undertake in hospital. Self-care can be beneficial to your patient’s mobility.

Encourage your patients to:

dress (consider the possibility of wearing their normal day clothes and footwear)
get out of bed and move around the ward, with supervision or assistance and an appropriate gait aid if required
sit out of bed as soon as it is considered safe to do so, as much as possible as appropriate to their condition
walk to the toilet, with supervision or assistance if required
eat meals out of bed, preferably in a communal dining room where available and appropriate
undertake or participate in showering and other grooming and self-care activities.

As staff, we can:

supervise or assist older people during walking, transfers and ADLs if required
create a continence and mobility plan that fits with patients sitting out of bed for meals
adjust bed height to allow for safe, independent transfers
orient our patients to the ward, showing them where the toilet is
provide a culture that encourages incidental exercise
provide aids to assist with optimal transfers and mobility
avoid using bed rails, which may limit mobility and be a hazard
improve our understanding of the risks of restricting mobility and provide strategies to prevent de-conditioning.

Exercise

As part of an interdisciplinary intervention, an exercise program may benefit your patient.

Exercise programs can be administered in both individual and group settings and may include strength, balance, functional retraining and aerobic (or endurance) exercises. Group classes also provide an opportunity for social interaction and may help prevent loneliness.

We can refer older patients to physiotherapy for prescription of individual or group exercise.

Retraining ADLs

Our patients’ abilities to live independently may depend on retraining their skills in ADLs. We can:

provide the minimal amount of assistance required to encourage optimal participation; assistance should be reduced as the person’s condition improves
encourage and guide our patients to promote independence
assist with alternative strategies for self-care, as necessary
refer our patients to occupational therapy, as appropriate
make sure aids are available to assist with optimal independence
ensure bed and chair heights are optimal for independence
recommend patients for self-care programs, such as cooking groups and self-care education sessions, as appropriate
consider use of everyday clothes and footwear
clear any clutter
ensure obstacles to mobility or self-care are moved
ensure any tools or aids for mobility or self-care are clean and maintained
ensure bed and chair heights are optimal for independence
avoid using bed rails, which may limit mobility and be a hazard.

Ensuring appropriate supervision during mobility and self-care tasks

We can:

supervise patients who are acutely unwell during walking and transfers. It may be appropriate to reduce supervision as medical stabilisation occurs and familiarisation with the environment and equipment is achieved.
consult physiotherapy if we are in doubt about the supervision needs of our patients. Use strategies such as a traffic light colour coding system, a common way to inform all care staff of an individual's mobility supervision needs.

Environmental modifications

The hospital environment is important in promoting mobility and self-care for older people. We should:

clear any clutter
ensure obstacles to mobility or self-care are moved
ensure any tools or aids for mobility or self-care are clean and maintained
ensure bed and chair heights are optimal for independence
avoid using bed rails, which may limit mobility and be a hazard.

Reviewed 05 October 2015

Am Nurse Today. Author manuscript; available in PMC 2018 Jun 1.

Published in final edited form as:

Am Nurse Today. 2017 Jun; 12(6): 42–43.

PMCID: PMC5706660

NIHMSID: NIHMS910400

1University of Michigan School of Nursing, Department of Systems, Populations and Leadership, Ann Arbor Michigan

Find articles by Emily Boltey

1University of Michigan School of Nursing, Department of Systems, Populations and Leadership, Ann Arbor Michigan

2University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor Michigan

3Institute for Healthcare Policy and Innovation, University of Michigan Ann Arbor Michigan

Find articles by Olga Yakusheva

1University of Michigan School of Nursing, Department of Systems, Populations and Leadership, Ann Arbor Michigan

3Institute for Healthcare Policy and Innovation, University of Michigan Ann Arbor Michigan

Find articles by Deena Kelly Costa

Keywords: critical care nursing, evidence-based practice, VAP prevention, mechanical ventilation

Healthcare associated infections (HAI), such as ventilator-associated pneumonia (VAP), are the most common and most preventable complication of a patient’s hospital stay. Their frequency and potential adverse effects increase in critically ill patients because of impaired physiology, including a blunted immune response and multi-organ dysfunction.

Traditionally, VAP rates have been measured as an indicator of quality of care. Despite recent initiatives to measure complications of mechanical ventilation and a decrease in incidence over the past few years, VAP remains an issue for critically ill adults, with mortality estimated as high as 10%.

This article reviews the top five evidence-based nursing practices for reducing VAP risk in critically ill adults.

The most important evidence-based practice for lowering VAP risk is minimizing a patient’s exposure to mechanical ventilation, which can be achieved in two ways.

First, you can encourage and advocate for the use of noninvasive ventilation approaches, such as bilevel positive airway pressure or continuous positive airway pressure. The face masks used with these approaches can be uncomfortable for patients, but data from a small randomized clinical trial suggests that similar benefits can be achieved using a helmet instead. In addition to better patient comfort, helmets resulted in a significantly lower intubation rate compared to face masks.

Second, when mechanical ventilation can’t be avoided, work to minimize its duration. Ventilator weaning protocols or evidence-based care bundles (for example, the Awakening, Breathing Coordination, Delirium, and Early mobility (ABCDE) bundle) can be effective in shortening mechanical ventilation duration. Nurse-led and respiratory therapist-led ventilator-weaning protocols that include daily interruption of sedation and coordination with a spontaneous breathing trial have been effective in removing patients from mechanical ventilation quickly and appropriately. If a ventilator-weaning protocol doesn’t exist on your unit, take the opportunity to design and develop one.

Oral health quickly deteriorates in mechanically ventilated patients. Some patients sustain injuries to the oral mucosa during the intubation procedure, and after intubation, patients are prone to dry mouth. These factors, in addition to a severely compromised immune system, can cause an increase in bacteria colonization in the oral mucosa, with the endotracheal tube serving as a direct route to the lungs.

Adequate oral care can reduce bacterial overgrowth and reduce the risk for infection. In a meta-analysis of more than 18 randomized controlled trials (RCTs), routine oral care with chlorhexidine reduced the incidence of VAP. Currently, no guidelines exist for oral hygiene frequency. A recent systematic review of 38 RCTs showed oral care being performed anywhere from one to four times a day.

Making oral care a routine part of a patient’s assessment in the ICU is one way to enhance its frequency. Consider developing a unit-specific protocol with clear articulation of roles and responsibilities.

Aspiration of secretions that accumulate around the endotracheal tube of mechanically ventilated patients can lead to VAP. Subglottic secretion suctioning can be performed by both the nurse and respiratory therapist and can aid in prevention. A recent meta-analysis of 20 RCTs found that subglottic suctioning reduced the risk for VAP by 45% compared to patients who didn’t receive suctioning. Coordinating subglottic suctioning when conducting oral care may be a good mechanism to cluster care and ensure both of these practices are routinely delivered.

Proper positioning (keeping the head of the bed between 30–45 degrees) and encouraging early mobility of mechanically ventilated patients aid in the prevention of VAP. Gastric reflux and aspiration can also lead to VAP in mechanically ventilated patients. Keeping the head of the bed elevated between 30–45 degrees (semi-recumbent position) is recommended to reduce reflux and subsequent risk for VAP.

Early mobility can be challenging, but it results in more ventilator-free days. Evidence supports the feasibility of early mobilization for critically ill patients, even shortly after intubation, as long as the patient isn’t sedated. Early mobility protocols include a progressive approach that transitions from dangling at the edge of the bed, to standing at the edge of bed, to marching in place and then, for patients who can tolerate a higher level of activity, ambulating. For the best patient outcomes, coordinate exercise and mobilization with physical and occupational therapists.

Adequate nurse staffing in the ICU, especially for mechanically ventilated patients, can help minimize VAP risk. It provides nurses with the time, opportunity, and resources to implement care practices that reduce risk, and it allows them to spend more time with their patients, which may lead to early identification of VAP and prompt treatment.

Healthy work environments and interprofessional collaboration also have been associated with lowering the risk for VAP. Two studies found that better nurse work environments, in conjunction with physician staffing, have implications for VAP risk. For example, in open ICUs where patients are managed by general physicians instead of specially trained critical care physicians, having better nurse work environments can reduce VAP rates for mechanically ventilated patients.

Similarly, prior work identified that when nurses work in environments that support professional nursing practice (i.e. healthy nurse work environments), nurses are significantly less likely to report frequent VAP. These data provide support for you to work with other nurses to ensure your work environment supports professional nursing practice. Ways to do this include developing shared governance models, engaging in quality improvement activities to enhance high quality care and encouraging positive team interactions. Partnering with ICU physician and the rest of the interprofessional team, especially respiratory therapy, are two key ways to continue to encourage positive team interactions and reduce VAP risk.

Nurses are particularly well positioned to lead the healthcare team in VAP prevention. You can help minimize patients’ exposure to mechanical ventilation, work collaboratively to develop a ventilator weaning protocol, and ensure implementation of evidence-based care that minimizes VAP risk.

Key points

Ventilator-associated pneumonia (VAP) is a healthcare associated infection that can complicate care of mechanically ventilated patients in the intensive care unit.
To reduce risk for VAP, the following nurse-led evidence-based practices are recommended: reduce exposure to mechanical ventilation, provide excellent oral care and subglottic suctioning, promote early mobility, and advocate for adequate nurse staffing and a healthy work environment.
Nurses can lead the commitment to reducing VAP and improving quality of care for mechanically ventilated patients by coordinating and implementing these evidence-based practices.

All of the authors work at the University of Michigan in Ann Arbor. Emily Boltey is a doctoral (PhD) student in the Department of Systems, Populations and Leadership at the School of Nursing; Olga Yakusheva is an Associate Professor in the Department of Systems, Populations and Leadership at the School of Nursing and Department of Health Management & Policy in the School of Public Health, a member of the Institute for Healthcare Policy & Innovation; and Deena Kelly Costa is an Assistant Professor in the Department of Systems, Populations and Leadership at the School of Nursing and a member of the Institute for Healthcare Research and Quality. Funding for this work was provided by the Agency for Healthcare Research & Quality (K08 HS024552, PI Costa).

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