Early Mobilitation for

Critically Ill Patients in

ICU
Kartini
RSUPN. dr. Cipto Mangunkusumo
Pendahuluan
Catheters and monitors,
sedative medication used to
Limit mobilizations
calm agitation or reduce
Patient energy expenditure, impaired Limit
levels of alertness from
admit to ICU Mobilisation
medications, sleep
disturbances, electrolyte
imbalances, and tenous
hemodynamic

Adler, J., & Malone, D. (2012). Early mobilization in the intensive care unit: a systematic
review. Cardiopulmonary physical therapy journal, 23(1), 5.
Prolonged immobility, sedation, and mechanical
ventilation during a critical illness

Joint mobility restrictions, muscle weakness, ↓ quality of life

critical illness neuromyopathies, pressure seen in patients
ulcers, deep vein thrombosis (DVT), years after
prolonged mechanical ventilation, and discharge from
psychological disturbances ICU

Clark, D. E., Lowman, J. D., Griffin, R. L., Matthews, H. M., & Reiff, D. A. (2013). Effectiveness of an Early
Mobilization Protocol in a Trauma and Burns Intensive Care Unit: A Retrospective Cohort Study.
Physical Therapy, 93(2), 186–196.
 Is physical activity of sufficient intensity to
In ICU Text is:
produce physiological benefits
ICU
Mobilisation
N IN

Circulation, Central and peripheral perfusion,

ATIO

To
Ventilation, Muscle metabolism, Alertness,
enhance
Prevent deep vein thrombosis and venous stasis
BULM
LY A

Reduce LOS, Reduce Hospital Cost, use of

To
mechanical ventilation and support quality
EAR

Provide
of life after discharge from ICU

Castro-Avila, A. C., Serón, P., Fan, E., Gaete, M., & Mickan, S. (2015). Effect of early rehabilitation during
intensive care unit stay on functional status: systematic review and meta-analysis. PloS one, 10(7),
e0130722.
Nursing Care Plans
Domain 4
Class 2. Activity/Exercise : Moving Part of the body
(mobility), doing work, or performing actions often (but not
always ) against resistance

Nursing Diagnosis :
1. Risk for Disuse Syndrome
2. Impaired bed mobility
3. Impaired physical mobility
4. Impaired wheelchair mobility
5. Impaired sitting
6. Impaired standing
7. Impaired transfer ability
8. Impaired walking
NANDA 2015-2017
Impaired Physical Mobility
Definition : Limitation in independent, purposeful physical movement of the
body or of one or more extremities

Defining Characteristics
■ Alteration in gait
■ Decrease in fine motor skills
■ Decrease in gross motor skills
■ Decrease in range of motion
■ Decrease in reaction time
■ Difficulty turning
Defining characteristics
■ Discomfort
■ Engages in substitutions for movement (e.g., attention to
other’s activity, controlling behavior, focus on pre-illness
activity)
■ Exertional dyspnea
■ Movement-induced tremor
■ Postural instability
■ Slowed movement
■ Spastic movement
■ Uncoordinated movement
Related factor
■ Activity intolerance
■ Alteration in bone structure
integrity
■ Alteration in cognitive functioning
■ Alteration in metabolism
■ Anxiety
■ Body mass index >75th age-
appropriate percentile
■ Contractures
■ Cultural belief regarding
appropriate activity
■ Decrease in endurance
■ Decrease in muscle control
■ Decrease in muscle mass
■ Decrease in muscle strength
■ Depression
■ Developmental delay
Related factor
■ Disuse
■ Insufficient environmental
support (e.g., physical, social)
■ Insufficient knowledge of value
of physical activity
■ Joint stiffness
■ Malnutrition
■ Musculoskeletal impairment
■ Neuromuscular impairment
■ Pain
■ Pharmaceutical agent
■ Physical deconditioning
■ Prescribed movement
restrictions
■ Reluctance to initiate movement
■ Sedentary lifestyle
■ Sensori perceptual impairment
Mobilization of intensive care patients: a
multidisciplinary practical guide for clinicians
Objectives Methodology Discussion Conclusion
These practical tools
allow ICU clinicians to
A raft of tools the Tools have safely and effectively
and strategies been used for implement early
are described to over 5 years in
Practical tool mobilization in
facilitate tertiary ICU with critically ill patients.
to facilitate mobilization in low incidence of Multidisciplinary
EM in ICU ICU by the adverse outcomes
multidisciplinary approach to safe
(<2%) mobilization in ICU is
team.
key to its success in the
long term.

Green, M., Marzano, V., Leditschke, I. A., Mitchell, I., & Bissett, B. (2016). Mobilization of intensive care
patients: a multidisciplinary practical guide for clinicians. Journal of multidisciplinary healthcare, 9, 247.
10 strategies to optimize
early mobilization and
rehabilitation in ICU

Hodgson, C.L., Schaller, S.J., Nydahl, P. et al. Ten strategies to optimize early mobilization and
rehabilitation in intensive care. Crit Care 25, 324 (2021). https://doi.org/10.1186/s13054-021-03741-
Coordinated efforts between the mobility team
and the patient
Nurse Roles in EM
ABCDE Bundle
A = Awakening
BC = Breathing Coordination
D = Delirium Monitoring and Management
E = Early Mobilization

Balas, M. C., Vasilevskis, E. E., Burke, W. J., Boehm, L., Pun, B. T., Olsen, K.
M., ... & Ely, E. W. (2012). Critical care nurses’ role in implementing the
“ABCDE bundle” into practice. Critical care nurse, 32(2), 35-47.
• The ABCDE bundle is indeed complex, although successful implementation holds
potential for tremendous benefit to our sickest patients.
• Nurses play a unique role in the implementation of ABCDE as they are critical to all
requirements for successful implementation.
• Registered nurses lead protocol-guided sedation efforts that include daily spontaneous
awakening trials and measurement of delirium and sedation/agitation using validated
instruments.
• The nurse is also the communication link between each of the individual specialties.
• Decisions to advance to subsequent steps of the ABCDE bundle with SBT, early mobility,
and extubation are dependent upon the RN’s assessments of level of consciousness,
pain, and other clinical parameters communicated to RTs, PTs, and MDs respectively.
• Finally, and equally important, RNs are well suited to the leadership roles required to
individualize the ABCDE bundle to the institution.
Gap of EM in ICU RSCM
• No MDT , no full timer
Therapist
• Still ‘very traditional’ way
• No hoist lifter, manual
• Limitation of nurse
Mobilisation in Burn Unit
In very ‘minim’ technology…
• All nurse staff do massage and ROM during daily care and personal
Hygiene
• Back rubbing and massage gives very best outcome for skin integrity
• Nursing assessment while changing position
• Low incident of pressure sore, Incident rate (2014-2017 : 1.25%,
Target 0%)
• Chest fisiotheraphy help to minimize the risk of pneumonia
• DVT Pump Prophylaxis to prevent DVT
HOIST
LIFTER
o n’t
M d
RSC it
e
hav

Patient Reposition in ICU

Lifter for
mobilisation
Nursing care :
apply DVT pump to
prevent Deep Vein
thrombosis

P ump
DVT
o n
Flo wtr

Dokumentasi pribadi_@dhiewb, NUH 2008.

Nursing care:
turn right-left, chestfisioteraphy,
back rub and assessment for any
pressore sore and skin integrity
The Nurse assist patient to
cough and handle his
sputum
Head of Bed is important
for lung expantion
Patient was planned for
tracheostomy after three
times re-admissions
Patients with burn and
trauma inhalasi pasca
extubation LOS > 20 days in
the BICU, prolong sedasi.
The nurse performs chest
physiotherapy to help the
patient expel sputum
Summary
• Early progressive mobilization is safe and feasible in critically ill
patients and requires close collaboration of the MDT on a daily basis.
• EM improved functional outcomes, reduced LOS, reduce mortality in
patients with respiration failure.
• Establishment of a standardised rehabilitation program during ICU
stay would provide more benefit.
• The available options for implementation are: physical
therapy/occupational therapy and interruption of sedation, physical
and cognitive therapy, electrical muscle stimulation and programs of
progressive exercise.
Citation
• Adler, J., & Malone, D. (2012). Early mobilization in the intensive care unit: a systematic review.
Cardiopulmonary physical therapy journal, 23(1), 5.
• Balas, M. C., Vasilevskis, E. E., Olsen, K. M., Schmid, K. K., Shostrom, V., Cohen, M. Z., ... & Stothert, J.
C. (2014). Effectiveness and safety of the awakening and breathing coordination, delirium
monitoring/management, and early exercise/mobility (ABCDE) bundle. Critical care medicine, 42(5),
1024.
• Balas, M. C., Vasilevskis, E. E., Burke, W. J., Boehm, L., Pun, B. T., Olsen, K. M., ... & Ely, E. W. (2012).
Critical care nurses’ role in implementing the “ABCDE bundle” into practice. Critical care nurse, 32(2),
35-47.
• Castro-Avila, A. C., Serón, P., Fan, E., Gaete, M., & Mickan, S. (2015). Effect of early rehabilitation
during intensive care unit stay on functional status: systematic review and meta-analysis. PloS one,
10(7), e0130722
• Green, M., Marzano, V., Leditschke, I. A., Mitchell, I., & Bissett, B. (2016). Mobilization of intensive
care patients: a multidisciplinary practical guide for clinicians. Journal of multidisciplinary healthcare,
9, 247.
• Herdman, T. H. (Ed.). (2011). Nursing diagnoses 2012-14: definitions and classification. John Wiley &
Sons.
• St George/Sutherland Hospitals And Health Services (SGSHHS) PHYSICAL ACTIVITY and MOVEMENT/
MOBILISATION FOR THE CRITICAL CARE UNIT ADULT PATIENT. (2013) .New South Wales