Atividade Física no Cuidado Agudo Ir para: navegação, pesquisa

Introduction

Hospital-level care doesn’t negate the importance of physical activity. In the past, complete bed rest was thought to be the best treatment for managing patients after physical trauma, surgery, and/or illness.^[1] Although some conditions, such as fractures, require local immobilization to heal, often, physician orders to stay in bed are not based on medical necessity. In these cases, prolonged bed rest leads to unnecessary declines in function. The complications of prolonged bed rest include muscle weakness and atrophy, contractures, disuse osteoporosis, decreased cardiac reserve, orthostatic hypotension, venous thromboembolism, glucose intolerance, pneumonia, constipation, and delirium.^[2][3][4]

Despite evidence showing bed rest treatment to be largely ineffective,^[5] low patient mobility continues to persist in the acute care setting.^{[6][7][8][9][10]} Particularly in older adults and the critically ill, low mobility during hospitalization has been associated with functional decline,^[8][11][12] new institutionalization,^[8] and death.^[8][12] These risks support the need to make physical activity a pillar of acute care management.

Determinants of Physical Activity in Acute Care

During hospitalization, many factors influence physical activity. Common barriers include surgery,^[13] medical treatments,^[13] and the patient’s illness.^[13][14][15] Among health care providers, a culture of immobility often exists. This culture is characterized by a fear of falls,^[15][16] unnecessary bed rest orders,^[8] and a lack of perceived time and staff.^[16][17] Nursing personnel cite fear of self-injury,^[17] insufficient training,^[16] deferral of responsibility,^[14][15] and the expectation of increased workload^[16][18] as added barriers. Moreover, inactivity is reinforced by patient and family beliefs that bed rest is vital to recovery.^[7]

The Role of Healthcare Providers

Removing barriers to physical activity is a multidisciplinary effort. On the part of physicians, it requires a critical examination of activity orders and a commitment to minimizing baseless bed rest prescriptions. Frequent nurse-physician communication and high patient interaction put beside nurses in an ideal position to challenge inappropriate bed rest orders, advocate for the removal of unnecessary lines (ex. foley catheters), and help patients move at their highest, yet safe level of function.

In patients requiring physical rehabilitation, physical and occupational therapists are experts in using therapeutic exercise, self-care activities, and mobilization techniques to maximize functional independence. Moreover, both disciplines possess the professional background to train and support nurses who lack the skills and/or confidence to help patients get out of bed.

Patient Mobility Interventions

More and more hospitals are using mobility programs to keep patients active. General recommendations for promoting physical activity within hospitals include:

• Limiting the use of physical and chemical restraints
• Environmental modifications
• Patient education
• Implementation of activity protocols
• Regular assessment of patient function^[6][19]

The application of these recommendations has taken on various forms. Within physical therapy, therapists are involved in the rehabilitation of patients across a variety of acute specialty services, including neurology, critical care, and [11]^[12]

In addition, many hospitals have successfully implemented therapy and/or nursing driven mobility programs to enhance patient care on wards. ^{[20][21][22][23][24][25][26]} Positive outcomes include improved maintenance of functional status,^[21][24][27] greater likelihood of being discharged home,^[21] and decreased length of stay.^[24][27]

Outcome Measures for the Acute Care Setting

Outcome measures are vital for helping nursing and rehabilitation staff assess and monitor changes in patient function. The following are common measures of physical activity in the acute care setting:

Contraindications to Physical Activity

Safety is the most important consideration for physical activity participation. According to the American Heart Association,^[28] absolute contraindications to exercise testing and training include:

• Acute myocardial infarction
• Unstable angina not previously stabilized by medical therapy
• Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic response
• Symptomatic severe aortic stenosis
• Uncontrolled symptomatic heart failure
• Acute pulmonary embolism or pulmonary infarction
• Acute myocarditis or pericarditis
• Acute aortic dissection

Relative contraindications are also specified:

• Left main coronary stenosis
• Moderate stenotic valvular heart disease
• Electrolyte abnormalities
• Severe arterial hypertension (SBP >200, DBP >100)
• Hypertrophic cardiomyopathy and other forms of outflow tract obstruction
• Mental or physical impairment leading to inability to exercise adequately
• High-degree atrioventricular block

Depending on the patient’s illness or injury complex, and co-morbidities, additional restrictions and/or contraindications to exercise therapy may apply.

The Academy of Acute Care Physical Therapy offers [29]

References

1. ↑ Sprague AE. The evolution of bed Rest as a clinical intervention [abstract]. Journal of Obstetric, J Obstet Gynecol Neonatal Nurs 2004; 33(5): 542-549
2. ↑ Dittmer DK, Teasell R. Complications of immobilization and bed rest, part 1: musculoskeletal and cardiovascular complications. Can Fam Physician. 1993; 39: 1428-32, 1435-37
3. ↑ Dittmer DK, Teasell R. Complications of immobilization and bed rest, part 1: musculoskeletal and cardiovascular complications. Can Fam Physician 1993; 39: 1428-32, 1435-37
4. ↑ Corcoran, P. Use it or lose it—the hazards of bed rest and inactivity. West J Med 1991; 154(5): 536-538
5. ↑ Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999; 354(9186): 1229-1233.
6. ↑ ^6.06.1 Kuys S, Dolecka U, and Guard A. Activity level of hospital medical patients: an observational study. Arch Gerontol Geriatr 2012; 55: 417-421
7. ↑ ^7.07.1 Cattanach N, Sheedy R, Gill S, Hughes A. Physical activity levels and patients’ expectations of physical activity during acute general medical admission. Intern Med J 2014; 501-504
8. ↑ ^{8.08.18.28.38.4} Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older adults. J Am Geriatr Soc 2004; 52(8): 1263-70
9. ↑ Callen BL, Mahoney JE, Grieves CB, Wells TJ, Enloe M. Frequency of hallway ambulation by hospitalized older adults on medical units of an academic hospital. Geriatr Nurs 2004; 25(4): 212-217
10. ↑ Brown CJ, Redden DT, Kellie KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc 2009; 57: 1660-1665
11. ↑ ^11.011.1 Hodgson CL, Berney S, Harrold M, Saxena M, Bellomo. Clinical review: early patient mobilization in the ICU. Crit Care 2013; 17(1): 207
12. ↑ ^12.012.112.2 Adler, J & Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J 2012; 23(1): 5-13
13. ↑ ^13.013.113.2 King, BD. Functional decline in hospitalized elders. Medsurg nurs 2006 Oct; 15(5): 265-271
14. ↑ ^14.014.1 Fisher SR, Graham JE, Brown CJ, Galloway RV, Ottenbacher KJ, Allman RM, Ostir GV. Factors that differentiate level of ambulation in hospitalised older adults Age Ageing 2011; 41(1):107-111
15. ↑ ^15.015.115.2 Fisher SR, Goodwin JS, Protas EJ, Kuo YF, Graham JE, Ottenbacher KJ, Ostir, GV. Ambulatory activity of older adults hospitalized with acute medical illness. J Am Geriatr Soc 2011; 59(1): 91-95
16. ↑ ^{16.016.116.216.3} Hoyer EH, Brotman DJ, Chan K, Needham, D. Barriers to early mobility of hospitalized general medicine patients. Am J Phys Med Rehabil 2014; 94(4): 304-312
17. ↑ ^17.017.1 Doherty-King B, Bowers B. Attributing the responsibility for ambulating patients: A qualitative study. Int J Nurs Stud 2013; 50(9): 1240-1246
18. ↑ Brown CJ, Williams B, Woodbury LL, Davis LL, Allman RM. Barriers to mobility during hospitalization from perspectives of older patients and their nurses and physicians. J Hosp Med 2007; 2(5): 305-313
19. ↑ Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med 1993; 118: 219–23
20. ↑ Resnick, B, Galik, E, Ender, H, et al. Pilot testing of function-focused care for acute care intervention. J Nurs Care Qual 2011; 26(2):169-77
21. ↑ ^21.021.121.2 Boltz M, Resnick B, Capezuti E, Shuluk J. Functional decline in hospitalized older adults: can nursing make a difference? Geriatr Nurs 2012; 33(4): 272-9
22. ↑ Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med 1995; 332: 1338–44
23. ↑ Markey DW. Brown RJ. An interdisciplinary approach to addressing patient activity and mobility in the medical-surgical patient. J Nurs Care Qual 2002; 16(4):1-12
24. ↑ ^24.024.124.2 Padula CA, Hughes C, Baumhover L. Impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults. J Nurs Care Qual 2009; 24(4):325-31
25. ↑ Stolbrink M, McGowan L, Saman H, et al. The Early Mobility Bundle: a simple enhancement of therapy which may reduce incidence of hospital-acquired pneumonia and length of hospital stay. J Hosp Infect 2014; 88(1):34-9
26. ↑ Tucker D, Molsberger SC, Clark A. Walking for wellness: a collaborative program to maintain mobility in hospitalized older adults. Geriatr Nurs 2004; 25: 242–5
27. ↑ ^27.027.1 Pashikanti L & Von Ah D. Impact of early mobilization protocol on the medical-surgical inpatient population: an integrated review of literature. Clin Nurse Spec 2012; 26(2): 87-94
28. ↑ American Heart Association. Exercise Standards for Testing and Training. Circulation 2013: https://doi.org/10.1161/CIR.0b013e31829b5b44 (accessed 21 December 2017)
29. ↑ The Academy of Acute Care Physical Therapy. Laboratory values interpretation resources- 2017 update. http://www.acutept.org/?page=ResourceGuides (accessed 21 December 2017)