What is the appropriate management plan for a patient presenting with mobility issues?

Management of Mobility Issues: A Comprehensive Approach

Early assessment and intervention for mobility issues is essential to improve functional outcomes, reduce complications, and enhance quality of life in patients with impaired mobility. The management plan should follow a structured approach based on current evidence-based guidelines.

Initial Assessment

Mobility and Fall Risk Assessment

• Perform standardized assessments to identify fall risk and mobility limitations:
  • Timed Up and Go (TUG) test: Patient rises from chair, walks 3 meters, turns around, returns to chair, and sits down (>12 seconds indicates increased fall risk) 1, 2
  • 4-Stage Balance Test: Patient stands in 4 increasingly challenging positions for 10 seconds each (feet side by side, semitandem stand, tandem stand, single-foot stand) 1, 2
  • Three key screening questions: 1) Have you fallen in the past year? 2) Do you feel unsteady when standing/walking? 3) Are you worried about falling? (A "yes" to any question indicates increased risk) 1

Comprehensive Evaluation

• Assess contributing factors using the P-SCHEME framework 1:
  • Pain (axial or lower extremity)
  • Shoes (suboptimal footwear)
  • Cognitive impairment
  • Hypotension (orthostatic or iatrogenic)
  • Eyesight (vision impairment)
  • Medications (centrally acting)
  • Environmental factors

Intervention Plan

Early Mobilization

• Begin rehabilitation therapy as early as possible once the patient is medically stable 1
• Initiate frequent, brief, out-of-bed activities involving active sitting, standing, and walking within 24 hours if no contraindications exist 1
• For stroke patients, initial assessment by rehabilitation professionals should be conducted within 48 hours of admission 1

Exercise Program

• Implement a multicomponent exercise program including:
  • Balance training
  • Strength training (3 sets of 8-10 repetitions at 50-70% of 1 repetition maximum) 1
  • Gait training
  • Aerobic exercise 2

Positioning and Skin Care

• Reposition immobile patients every 2 hours to prevent pressure ulcers 1
• Ensure skin is kept clean and dry, with special attention to bony prominences 1
• Consider special mattresses and padding for wheelchairs 1

Assistive Devices and Equipment

• Provide appropriate assistive devices based on assessment:
  • Well-fitted walking shoes or athletic shoes for patients with neuropathy or increased plantar pressures 1
  • Extra wide or deep shoes for patients with bony deformities 1
  • Custom-molded shoes for patients with severe deformities 1
  • Appropriate mobility aids (canes, walkers, wheelchairs) based on functional assessment

Specialized Interventions

• For patients unable to perform voluntary muscle contractions, consider:
  • Neuromuscular electrical stimulation (NMES) to prevent disuse muscle atrophy 1
  • Passive range of motion exercises to preserve joint mobility 1
  • Positioning and splinting to maintain skeletal muscle length 1

Venous Thromboembolism Prophylaxis

• For immobile patients:
  • Consider intermittent pneumatic compression (IPC) within first 24 hours of admission 1
  • Assess skin integrity daily when using IPC devices 1
  • Consider low-molecular-weight heparin for high-risk patients 1
  • Note: Anti-embolism stockings alone are not recommended 1

Monitoring and Follow-up

Regular Reassessment

• Monitor temperature every 4 hours for the first 48 hours, then as clinically indicated 1
• Reassess mobility status regularly using standardized tests 2
• Monitor for complications such as pressure ulcers, malnutrition, and aspiration 1

Nutritional Support

• Assess nutritional status, including monitoring intake, outputs, body mass index, and serum protein levels 1
• Implement nutritional interventions for malnourished patients 1

Education and Home Program

• Educate patients and caregivers on:
  • Proper skin care 1
  • Fall prevention strategies 2
  • Home exercise program 2
  • Environmental modifications 2

Special Considerations

Stroke Patients

• Implement specialized balance training approaches considering both voluntary and reactive balance control 2
• Monitor for spasticity, which occurs in approximately 35% of stroke survivors 1
• Treat spasticity if it causes pain or affects mobility, ADLs, or sleep 1
• Assess for dysphagia to prevent aspiration pneumonia 1

Critically Ill Patients

• Consider early implementation of in-bed cycling 1
• Monitor for seizures, particularly in post-stroke patients 1

Common Pitfalls to Avoid

• Providing vague descriptions without specific functional limitations 2
• Failing to document objective measures of mobility and balance 2
• Omitting fall risk assessment information 2
• Not specifying treatment goals or expected outcomes 2
• Neglecting to include relevant medical history that may affect therapy approach 2

By following this comprehensive approach to managing mobility issues, clinicians can help improve functional outcomes, prevent complications, and enhance quality of life for patients with impaired mobility.