Running head: EARLY MOBILITY
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Early Mobility Improves Patient Outcomes
Morgann Goodling
The Pennsylvania State University, Capital Campus
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Abstract
Introduction: Bed rest times are constantly debated by healthcare providers regarding their
safety and effectiveness on patient outcomes. Healthcare providers have believed that by
shortening bed rest times, patients would be at an in increased risk for complications including
bleeding, hematoma formation, and increased pain. However, in hospitalized cardiovascular
patients would early mobility be more effective than postponing mobility in preventing patient
complications? Methods: The registered nurses on Main/Core 6 of Pinnacle Health Systems,
Harrisburg Hospital were surveyed about bed rest times and the benefits bed rest times have on
patient outcomes. These same nurses were surveyed about certain patient complications that
have been prevalent among their patients and the correlation between the complications and bed
rest times. The nurses were then provided with a pamphlet about the most up to date research on
this topic. Results: Ten out of ten nurses stated that bed rest times were ordered by the provider
and they only know that six hours is around the average time that providers order for cardiac
patients. They also stated that the most common patient complication was pain at the incision
site. Conclusion: Most nurses are not aware of the most recent research on this topic and lack
the knowledge about the benefits early mobility has on patient outcomes.
Key words: early mobility, ambulation, patient outcomes, patient complications, bed rest
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Problem Statement
When determining the proper care and treatment for patients, healthcare providers take
into consideration what will be the most beneficial to this particular patient and what
treatments/interventions will be safe and effective at preventing patient complications. One
patient intervention that seems to be widely used is mobility and ambulation due to the fact that
mobility maintains a patient’s functional status and muscle strength (Pashikanti & Von Ah,
2012). Mobility also allows patients to be more independent in terms of being able to move
about when and how they want ultimately leading to an increase in satisfaction during their
hospital stay (Wilcoxson, 2012). It is widely known among healthcare workers that mobility the
same day of surgery is important in a patient’s recovery because it helps the healing process.
With that being said, there is a range of bed rest times that providers implement according to
their professional opinion, however a traditionally timeframes of five to six hours has been
universally used among cardiovascular patients after a in order to prevent complications
(bleeding, hematoma formation, and pain) (Hoglund, Stenestrand, Todt, & Johansson, 2011).
Pinnacle Health Systems does not currently have protocols in place for healthcare
providers to base their mobility and bed rest orders on, it is left up to their personal and
professional opinion to make these decisions. This results in patients receiving a variety of times
ordered for bed rest and the time that they must wait before they are able to be mobile and
ambulate around their room and hallway. For example, one of Pinnacle’s Cardiovascular
Thoracic providers wrote an order for a patient that underwent a diagnostic cardiac
catheterization through the femoral artery that consisted of keeping the angle of the bed at </= 30
degrees for at least six hours. The order was written this way in order to prevent direct pressure
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to the incision site, which would prevent bleeding at the incision site and rupturing of the
femoral artery.
With varying bed rest times, some patients have a difficult time recovering and some
develop complications due to their immobility. Some of these complications include weakness,
fatigue, muscle atrophy, falls, slow bowel and urinary passage, pressure ulcers, skin breakdown,
and breathing complications. These complications eventually lead to increases in pain and
decreases in patient comfort and satisfaction. By prolonging bed rest times and lengthening the
time before initiating mobility, providers are putting patient comfort and satisfaction at risk
because patients have described that immobility was the most uncomfortable part about having a
cardiac procedure (Hoglund, et al., 2011).
When taking into account patient comfort, satisfaction, and perception of pain, healthcare
providers should consider changing their preferences with bed rest times. Implementing shorter
bed rest times and earlier mobility/ambulation may be more beneficial to these patients. Which
ultimately leads to the question, in hospitalized cardiovascular patients is early mobility more
effective than postponing mobility in improving patient outcomes?
Literature Review
Healthcare providers constantly have to balance whether or not prolonged bed rest and
delayed mobility would be paramount in preventing patient complications such as pain, bleeding,
hematoma formation, weakness, fatigue, and muscle atrophy. For example, the traditional
timeframe for bed rest times after cardiac surgery has been 5-6 hours in order to prevent pressure
on the incision site resulting in hematoma formation and bleeding (Hoglund, Stenestrand, Todt,
& Johansson, 2011). On the other hand, when bed rest times are prolonged, patients are at an
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increased risk of developing other hospital acquired complications such as pressure ulcers,
pneumonia, and falls due to the fact that they are immobile during this time (Pashikanti & Von
Ah, 2012). These unnecessary complications require extended stays at the hospital and increased
hospital bills in order to counteract the complication’s additional resources, such as medications,
nutrition, hydration, and therapy must be used to treat these patients (Pashikanti & Von Ah,
2012). Extended hospital stays result in increased hospital bills not only for the hospital, but also
for the patient with hospital bills increasing anywhere between $17, 483 - $43, 180 per patient
visit (Pashikanti & Von Ah, 2012). Mobility and ambulation, whether active or passive, are key
interventions that are used in order to improve patient outcomes and counteract the effects
associated with extended bed rest times (Pashikanti & Von Ah, 2012). It has also been found
that patients confirm shortened lengths of time on bed rest and early mobility increased their
comfort and satisfaction during their hospital stay (Wilcoxson, 2012).
One of the barriers in implementing a shorter time for bed rest and earlier mobility is a
lack of evidence in research that supports a change to traditional bed rest protocols (Pashikanti &
Von Ah, 2012). This is why many health care providers still use traditional bed rest times and
traditional times for the start of mobility (Hoglund et al., 2011). Due to the lack of evidence,
many researchers are now investigating whether or not there is evidence to prove that early
mobility is a safe and effective intervention for postoperative surgical patients. Determining
what is the best form of care and treatment for hospitalized patients is a major goal of health care
workers. This leads to the question, in hospitalized cardiovascular patients is early mobility
more effective than postponing mobility in improving patient outcomes? A review of literature
indicates that hospitalized cardiovascular patients have enhanced outcomes with early mobility
when compared to postponing mobility.
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Search for Evidence
A computerized search using Pennsylvania State University’s online library and the
CINAHL database were used to develop a working list of research journal articles that have been
published within the last five years, 2010-2015. The search terms that were used to generate
viable journal articles were “bed rest”, “early mobility”, “early ambulation”, “patient outcomes”,
and “patient complications.” The articles that were selected and reviewed focused on early
mobility and ambulation along with the benefits and safety associated with this intervention for
cardiac patients.
Early Mobilization around a Hospital
Early mobility and shortened bed rest times are beneficial to all hospitalized. Patient
immobility and prolonged bed rest are associated with deep vein thrombosis (DVT) formation,
the functional status of patients, and length of hospital stay (Pashikanti & Von Ah, 2012). Using
basic principles of early mobilization, can be associated with improved outcomes for patients at
risk for DVTs, length of stays in the hospital, and the maintenance or improvement of patients’
functional status (muscle strength and flexibility) (Pashikanti & Von Ah, 2012). Overall, lengths
of stays are significantly shorter by 2.4 days in patients who were prescribed early mobility while
admitted to an ICU unit (Clark, Lowman, Griffin, Matthews, Reiff, 2013). Patients are also less
likely to suffer from pulmonary complications when an early mobility program is prescribed to
patients in the ICU (Clark, et al., 2013).
Early Mobility after a Cardiac Procedure
Cardiovascular disease continues to be one of the most prominent health complications
affecting our society with approximately 1 in 3 people being affected each year (Wilcoxson,
2012). Fortunately, for these individuals advances in health care have allowed people to take
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advantage of a vast array of interventions to counteract the effects of cardiovascular disease.
Diagnostic cardiac catheterizations (DCC) are common procedures that are done daily in order to
help better understand what is occurring within the individual’s vasculature, which leads to better
care and treatments for these patients (Wilcoxson, 2012). A percutaneous coronary intervention
(PCI) is another medical intervention that can be performed if an artery(s) is occluded and it
continues to be the most common procedure used for these patients (Augustin, de Quadros,
Sarmento-Leite, 2010). A form of treatment that goes hand-in-hand with a DCC or a PCI,
especially when a femoral access approach is used is strict bed rest, which typically requires the
patient to remain in a supine position, and prolonged bed rest in order to decrease patient
complications (Wilcoxson, 2012). It is said that immobilization of the affected leg is necessary
to prevent bleeding at the femoral puncture site and all other vascular complications (Tongsai &
Thamlikitkul, 2012). Even with recent advances in medical technology, the duration for bed rest
has not shortened (Augustin, et al., 2010). Currently, there are no established universal
guidelines for institutions and physicians to follow regarding bed rest times, but most would
agree that bed rest times between three and six hours are adequate enough to prevent patient
complications (Wilcoxson, 2012). Even with the intervention of prolonged bed rest, patients are
still being affected by pain, vascular complications, and weakness, which have confused many
researchers to the question whether or not a shortened time of bed rest would be more beneficial
to these patients (Pashikanti & Von Ah, 2012).
Shortened times on bed rest and early mobilization have been associated with increased
patient comfort and satisfaction (Wilcoxson, 2012). After a 2011 pilot study titled, “The Effect
of Early Mobilization for Patients Undergoing Coronary Angiography,” with focus on vascular
complications and back pain, it was found that patients would identify bed rest as the most
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uncomfortable part of having a cardiac procedure due to the fact that it interfered with their
ability to move freely and have better pain control (Hoglund, et al., 2011). It has also been found
that patient satisfaction increases when they are able to void on their own terms because patients
have stated that they tend to wait until bed rest times are over to void, which contributes to their
discomfort (Augustin, et al., 2010). Early ambulation can be shown to decrease urinary
discomfort (p=0.03), ultimately leading to increased satisfaction (Chair, Yu, Choi, Wong, Sit, Ip,
2012). Patients also report that the time they are required to spend in bed, without moving, is the
number one contributing factor to their back pain (Hoglund, et al., 2011). Augustin and
colleagues (2010) restate a conclusion from a 2006 study by Lins and colleagues, where they
“affirmed that patients report satisfaction with a decreased bed rest time”. The study goes on
further to discuss the concept of comfort and satisfaction, in which it is described as a sense of
well-being that can only be described by the patient (Augustin, et al., 2010). Early ambulation
increased the general well-being of patients during their hospital stay because it allowed them to
move freely and prevent muscle fatigue and muscle atrophy (p = 0.014) (Chair, et al., 2012).
This is why interviewing patients regarding their experiences with bed rest times and mobility is
an important variable to consider when determining the most beneficial time frame for bed rest
and mobility.
Along with the increased comfort and satisfaction that patients feel when a shortened
version of bed rest is used, patients also present with decreased vascular complications following
a cardiac procedure (Hoglund, et al., 2011). Vascular complications include bleeding, bruising
and hematoma formation at the puncture site (Mohammady, Atoof, Sari, Zolfaghari, 2014). It
isn’t until about 12 hours after a cardiac procedure that bleeding and hematoma formation occur,
which leads some health care providers to postpone mobility and lengthen bed rest times in order
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to reduce the risk of developing these vascular complications (Mohammady, Heidari, Sari,
Zolfaghari, Janani, 2014). However, literature seems to agree that shortened bed rest times can
be safely prescribed to these patients with either no presence of complications or a diminished
presence of complications (Wilcoxson, 2012). Bleeding times are not significantly different (p =
0.31) when early mobility is prescribed compared to postponing mobility (Augustin, et al.,
2010). There is no evidence that early ambulation and mobility are more harmful than late
ambulation and mobility in terms of hematoma formation (p = 0.82) or bleeding events (p =
1.77) (Tongsai & Thamlikitkul, 2012). When comparing four to six hours of bed rest with eight
hours of bed rest, there is a significant difference in the development of hematoma formation (p
= 0.03) and when five to six hours of bed rest is compared with two to four hours of bed rest
there is not a significant difference in hematoma formation (Mohammady, Atoof, Sari, et al.,
2014).
Pain is a common complication associated with cardiovascular procedures that is often
overlooked. Specifically, back pain has been known to be a main source of pain for these
individuals due to the fact that they must remain immobile and in a certain position (supine) for a
number of hours (Mohammady, Heidari, Sari, Zolfaghari, et al., 2014). Patients have reported
that there is a positive relationship between the amount of time spent on bed rest and their
experience with pain (Hoglund, et al., 2011). Twenty-four hours after a cardiac procedure,
assessments of back pain are conducted; when early ambulation groups are compared to late
ambulation groups, there is a lower incidence of back pain reported among those in the early
ambulation/shortened bed rest group (Mohammady, Atoof, Sari, et al., 2014). Early ambulation
significantly reduced back pain eight hours after patients returned to the unit following their
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procedure (p < 0.001) and patient’s back pain was significantly reduced the next morning (p =
0.023) (Chair, et al., 2012).
Catheter sheath size has no effect on the outcomes of early versus delayed mobility times
(Wilcoxson, 2012). Early mobilization after a DCC via access through the femoral artery using
either a 4-French or 6-French sheath can be done safely without any significant vascular
complications (Wilcoxson, 2012). Early ambulation of two to three hours after catheter sheath
removal (catheter sheath size wasn’t taken into consideration) can be done safely and does not
increase the patient’s risk of developing vascular complications nor does it have an effect on the
presence or intensity of pain (Tongsai & Thamlikitkul, 2012).
Limitations
More research is needed to fully understand the benefits of shortened bed rest times and
early mobilization. Due to small sample sizes during many research studies, it is hard for
researchers to determine how significant the impact/statistical differences are among these
patients (Mohammady, Heidari, Sari, Zolfaghari, et al., 2014). Mohammady, Atoof, Sari, et al.
(2014) declares that another limitation to these research studies is the differences among the
length of bed rest times that researchers implemented, which causes flaws in the comparison of
research studies.
Recommendations
Another variable that needs to be taken into consideration with further studies is the
method in which hemostasis is maintained because it may affect the risk of vascular
complications (Mohammady, Atoof, Sari, et al., 2014). For example, it should be taken into
consideration whether or not mechanical compression, either manual compression or FemoStop,
was used or another form of arterial puncture closing device was used in order to conclude more
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specific results about early ambulation (Mohammady, Atoof, Sari, et al., 2014). It should also be
taken into consideration whether or not an ultrasound is available for vascular complication
diagnosis and verification because it is the “superior clinical evaluation of bleeding
complications” (Augustin, et al., 2010). One last variable to take into account would be the
medications that patients are prescribed before, during, and after the procedure because
medications might affect the presence or absence of vascular complications, pain, and the
mobility of patients (Augustin, et al., 2010).
Summary of Research Conclusions
There are no known significant differences between early mobility and postponing
mobility when it comes to preventing patient complications (the incidence of bleeding,
hematoma formation, or pain) after a cardiac procedure (Hoglund, et al., 2011). Nevertheless, it
can be concluded that shortened bed rest times and early mobilization “can be done safely with
positive results” (Wilcoxson, 2012).
Decreased back pain and urinary discomfort, as well as increased patient satisfaction are
shown to be the outcomes of shortened bed rest times and early mobility (Chair, et al., 2012). It
is also concluded that there is a significant correlation between muscle weakness and fatigue due
to the pressure that patients feel when they are lying in the same position while on bed rest,
which is why early mobility should be used because it reduces the stress on a patient’s back
(Hoglund, et al., 2011). Position changes and getting out of bed improves flexibility and reduces
strains on the back without increasing the presence of vascular complications (Hoglund, et al.,
2011).
Conclusion of Literature Review
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Several studies have determined that early mobility and shortened bed rest times are
critical to enhanced patient outcomes, with the two most significant outcomes being increased
patient comfort and increased patient satisfaction. These same research studies have concluded
that patient complications decreased after a cardiac procedure when early mobility was used as
the intervention. Patients have an elevated perception of comfort and satisfaction when early
mobility and shortened bed rest times are used, which begs the question, wouldn’t it be better for
health care providers to prescribe early mobilization for hospitalized cardiovascular patients
when they perceive that early mobilization provides better outcomes?
Draft Plan Part 1
The focus and aim of this research project was to determine if patient complications were
able to be prevented through early ambulation. The research study was implemented between
October 2015 and November 2015 at Pinnacle Health Systems, Harrisburg Hospital on
Main/Core 6, which is a Cardio Thoracic Intermediate ICU. The leader/coordinator (Morgann
Goodling) coordinated the majority of the research construction; however other nurses,
specifically Alexis Leed, RN, helped to construct and develop the research study. The stake
holders of this research are the patients and the hospital.
The project was initiated in order to educate nurses about the current research available
about early mobility and to educate them about the benefits and safety about implementing early
mobility for cardiac patients. The presence of patient complications has been a clinical problem
that has been repeatedly encountered on this unit, which has required patients to stay in the
hospital for an extended length of time. Patient discomfort, pain, and hematoma formation are
patient complications that often occur after a cardiac procedure and they can be positively
correlated with prolonged time on bed rest. It has been long believed that prolonging bed rest
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would in fact decrease patient complications because it keeps pressure off of the incision site as
well as preventing bleeding and pain at the incision site. However, patient testimony clearly
defines prolonged bed rest as the single most related factor to their pain and discomfort because
it requires them to be immobile and dependent on others to care for them. This, without a doubt,
has led to a decrease in patient satisfaction during their hospital stay. These conclusions may
indicate that early ambulation and mobility might be a more suitable intervention for these
patients. This knowledge was gained through nurse testimony, documentation, research articles,
and national standards. Patient testimony and evidence, provided through research articles,
outline that prolonged bed rest is associated with a higher incidence rate of vascular
complications and pain after surgery. Time frames for bed rest are dependent upon provider
preference, however research shows that early mobilization and ambulation following surgery is
safe and can be beneficial to patient outcomes.
The purpose of this research project is to determine whether early ambulation and
mobilization rather than the traditional postponed mobility is more effect in improving patient
outcomes and preventing vascular complications after a cardiovascular procedure. The patient
population was hospitalized cardiovascular patients who have had some type of cardiovascular
procedure. The area of practice was in the CTICU of Pinnacle Health Systems hospital in
Harrisburg, Pennsylvania.
Methods
Registered nurses between the ages of 24 – 56, who had a variety of years of experience
on the unit were surveyed between the months of October 2015 and November 2015. Ten
registered nurses from Main/Core 6 of Pinnacle Health Systems in Harrisburg, Pennsylvania
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were surveyed regarding information about bed rest time protocols and their effects on patient
outcomes (length of time, patient complications, and patient benefits). After the surveys were
concluded, the nurses on the unit were given a pamphlet on the most up to date research and
information about early mobility and patient outcomes because the surveys concluded that there
was a lack of knowledge about the most up to date information on early mobility. The pamphlet
was designed based off of the information gathered through the nurse surveys in which the
information provided on the pamphlets centered around the recent research on early mobility and
the benefits that early mobility has on patient outcomes. The pamphlet also included information
about the safety of prescribing a shorter bed rest time and initiating earlier mobility and
ambulation.
Results
Out of the ten registered nurses that were surveyed, all ten nurses stated that bed rest
times are determined by the patient’s provider. With that being said, it was discussed that bed
rest time orders are based off of provider preference of bed rest times and patient-centered care
was taken into account, which ultimately has led to a variety of bed rest times being used on the
unit. However, the healthcare providers prescribed an average of six hours of bed rest for their
cardiovascular patients who underwent a cardiac procedure.
After determining the average bed rest times that were used among the patients on the
unit, the nurses were then asked about the implications it had on patient complications and
patient benefits. The frequency of the complications was not known and neither was the
association between the bed rest times and the presence of patient complications. Nevertheless,
the nurses were able to describe and list the patient complications that they have seen on the
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floor. The nurses reiterated a comment from multiple patients who reported pain at the incision
site, with 90% of incision sites being the femoral artery(s) and the other 10% of incision sites
being the radial artery(s), was the most common complication that patients experience after their
cardiac procedure. A few patients reported that they developed back pain while on bed rest,
which contributed to their overall discomfort and dissatisfaction. Discomfort came from the fact
that patients wanted to get out of bed earlier than they were allowed and they wished that they
were able to be more mobile while they were on bed rest. Other patient complications,
hematoma formation and bleeding, were discussed, but the nurses mentioned that these were not
common and that they did not consider them as significant complications related to the amount
of time these patients were on bed rest.
Draft Plan Part 2
Implications
If more resources, time, and patients were available, this research study could have been
completed in one of two different ways. One of the possible studies would have been that more
nurses would have been surveyed regarding this topic. The nurses would have been more
detailed and specific about the patient complications, which would include the pain ratings,
where the pain was located, the number of patients experiencing pain or complications, and the
correlation between patient complications and bed rest times. This would provide more accurate
information for whether shortened bed rest times would be more significant at preventing patient
complications.
The other possible research study would be the actual implementation of an earlier
mobility/shortened bed rest time protocol with some of the patients in order to do a comparison
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between this group and the control group, which would be the normal (average of 6 hours of bed
rest) times. By actually implementing this intervention, the researcher would be able to witness
and conclude definitive results of the study and determine whether the results were significant
enough to call for a change to bed rest times. This direct information would be more infinitive
about the benefits, safety, and complications of the intervention that a general survey of nurses
wouldn’t be able to provide.
Limitations/Barriers
There were a few limitations/barriers to this research study. To begin with, time and
resources contributed to significant restrictions to the coordinator of the study because she was
confined to only a short time period to gather information as well as confined to a limited
amount of finances and people (nurses, patients, and physical therapists). Other barriers that can
be attributed to the original study design is the lack of influence over the providers preference on
bed rest times as well as the noncompliance of providers and nurses to follow early mobility
suggestions. Along with a lack of influence over the providers, the nurses were not welcoming
to change because it went against the prescribed orders. This resulted in an inability to compare
differences in bed rest times.
Summary/Conclusion
In conclusion, more research is still needed in order to better understand the substantial
benefits that early mobility provides for cardiac patients. Advancements in research on this topic
would be beneficial for healthcare employees, of all titles and professions, because it would help
them to fully understand the outcomes of early mobility after a cardiovascular procedure. This
means that researchers need to conduct studies that have larger number of participants in order to
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get a better understanding of the outcomes between early mobility and prolonged bed rest when
comparing the two groups because smaller groups of participants do not produce significant
enough results. This lack in significant results does not have an influence over providers’
preferences or opinions about bed rest times or initiating mobility after a cardiac procedure. As a
result, providers are still prescribing the same amount of bed rest to patients. Therefore, the same
outcomes are being produced over and over again even though it has been found that early
mobility is in fact safe and effective at promoting beneficial outcomes for patients, which is the
goal that providers are striving to reach.
It is important to determine what the most adequate time for bed rest is and the initiation
of mobility/ambulation is because healthcare workers need to be supplying the best form of care
for their patients. Without knowing how important early mobility is for a patient’s recovery,
they (patients) are ultimately the ones who are suffering because they are not being treated with
the most appropriate treatments that will promote a speedy recovery and maintain their health.
The longer a patient is in the hospital recovering, the more likely they are to develop secondary
complications, such as pressure ulcers, muscle fatigue, muscle atrophy, and weakness. It is for
that reason that this topic is so monumental in today’s world because this intervention is able to
be adapted to all and any patients who are recovering in the hospital. It is a simple and easy
intervention that will consistently promote the maintenance and increase in muscle strength,
functional status, health and the independence of patients.
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References
Augustin, A., de Quadros, A., & Sarmento-Leite, R. (2010). Early sheath removal and
ambulation in patients submitted to percutaneous coronary intervention: a randomised
clinical trial. International Journal Of Nursing Studies, 47(8), 939-945.
doi:10.1016/j.ijnurstu.2010.01.004
Chair, S. Y., Yu, M., Choi, K. C., Wong, E. L., Sit, J. H., & Ip, W. Y. (2012). Effect of early
ambulation after transfemoral cardiac catheterization in Hong Kong: a single-blinded
randomized controlled trial. Anatolian Journal Of Cardiology / Anadolu Kardiyoloji
Dergisi, 12(3), 222-230. doi:10.5152/akd.2012.065
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.
doi:10.2522/ptj.20110417
Höglund, J., Stenestrand, U., Tödt, T., & Johansson, I. (2011). The effect of early mobilisation
for patient undergoing coronary angiography; A pilot study with focus on vascular
complications and back pain. European Journal Of Cardiovascular Nursing, 10(2), 130136. doi:10.1016/j.ejcnurse.2010.05.005
Mohammady, M., Atoof, F., Sari, A. A., & Zolfaghari, M. (2014). Bed rest duration after sheath
removal following percutaneous coronary interventions: a systematic review and metaanalysis. Journal Of Clinical Nursing, 23(11/12), 1476-1485 10p. doi:10.1111/jocn.1231
EARLY MOBILITY
19
Mohammady, M., Heidari, K., Sari, A. A., Zolfaghari, M., & Janani, L. (2014). Early ambulation
after diagnostic transfemoral catheterisation: A systematic review and meta-analysis.
International Journal Of Nursing Studies, 51(1), 39-50.
doi:10.1016/j.ijnurstu.2012.12.018
Pashikanti, L., & Von Ah, D. (2012). Impact of early mobilization protocol on the medicalsurgical inpatient population: an integrated review of literature. Clinical Nurse Specialist:
The Journal For Advanced Nursing Practice, 26(2), 87-94.
Silva, Y., R., S., K. Li, and M. J. F. X. Rickard. 2013. "Does the addition of deep breathing
exercises to physiotherapy-directed early mobilisation alter patient outcomes following
high-risk open upper abdominal surgery? Cluster randomised controlled trial."
Physiotherapy 99, no. 3: 187-193. CINAHL, EBSCOhost (accessed September 23, 2015).
Stolbrink, M., McGowan, L., Saman, H., Nguyen, T., Knightly, R., Sharpe, J., & ... Turner, A.
M. (2014). The Early Mobility Bundle: a simple enhancement of therapy which may
reduce incidence of hospital-acquired pneumonia and length of hospital stay. Journal Of
Hospital Infection, 88(1), 34-39. doi:10.1016/j.jhin.2014.05.006
Tongsai, S., & Thamlikitkul, V. (2012). The safety of early versus late ambulation in the
management of patients after percutaneous coronary interventions: A meta-analysis.
International Journal Of Nursing Studies, 49(9), 1084-1090.
doi:10.1016/j.ijnurstu.2012.03.012
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Wilcoxson, V. L. (2012). Early Ambulation After Diagnostic Cardiac Catheterization via
Femoral Artery Access. Journal For Nurse Practitioners, 8(10), 810-815.
doi:10.1016/j.nurpra.2012.06.002