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Trauma and Life Support (TLC) Progressive Mobility Algorithm

Trauma and Life Support (TLC) Progressive Mobility Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols, Related


TLC PROGRESSIVE MOBILITY ALGORITHM   Last Revision: 01/01/2016
START HERE  Dependent Transfer to 
Chair 
Dangle  Stand, Pivot, Transfer  Ambulate 
FAILS IF ≥ 1 PRESENT 
 Passive ROM QD by
RN/NA
 Q 2 hour turning
 Consider PRAFO
 PT/OT referral not
indicated unless
significant resistance
to PROM
Reassess Criteria
Every Shift 
PASSES IF 0 
PRESENT 
Begin out of bed 
activity 
Recommendations for Assessing  
Tolerance to Each Activity 
 HR > 50 < 130 bpm
 SBP > 90 < 180 mmHg
 MAP > 65 < 110 mmHg
 RR > 6 < 35
 SPO2 > 88%
 No new arrhythmia
 No marked vent asynchrony
 Consider patient trends
 Maintain tolerable pain level
 Vitals signs remain within
ordered parameters  
RN ACTIVITY ASSESSMENT 
 Moderate cooperation
 Able to:
1. Lift arms against gravity
2. Straighten knee against
gravity in supine 
3. Lift shoulders off bed 
4. Initiate rolling
EXCLUSION CRITERIA 
Complete within 24 hours of admission & 
reassess criteria every shift 
 All trauma patients
Neurologic:
 New ICH or SAH
 Uncleared spine
 ICP or IVD, or spinal drains, need provider
order to clamp and advance activity 
 RASS > +3
Respiratory:
 Episodes of desaturation
 NMBA to maintain vent synchrony
 Vent change within 30 min, consider with
caution 
Cardiovascular: 
 Unstable cardiac rhythm
 New cardiac ischemia
 2+ vasopresors/inotropes or frequent
(>hourly) upward titration 
 Active bleeding
 Current or recent (6 hrs) femoral artery
sheath
Other: 
 Withdrawal of life‐sustaining measures
NURSING ACTIVITY  
(when exclusion criteria resolved) 
 PROM
 Progressive upright sitting
in bed 
 Cardiac chair 30 min to > 1
hour BID
NURSING ACTIVITY 
Previous column activity AND: 
 AROM
 Cardiac chair 1‐2 hours BID 
 Dangle at edge of bed 
NURSING ACTIVITY 
Previous column activity  
AND: 
 Active transfer to bedside
chair
 Out of bed to bedside
RN REFERRAL ASSESSMENT 
Pt can do 2 more of the 
following: 
 Open eyes & track upon
command
 Gesture or attempt to
communicate
 Squeeze hand and/or
wiggle toes consistently 3x
REFERRAL TO OT AND/OR PT 
REFERRAL TO OT AND/OR 
No 
THERAPY TREATMENT 
 Strengthening exercises
 Supine/sitting assisted light
ADLs
 Dangle at EOB
THERAPY TREATMENT 
 Strengthening exercises
 Dangle at edge of bed
 Supine/sitting assisted ADLs
 Sit to stand
 Standing activities
RN ACTIVITY ASSESSMENT 
 Close to full cooperation
 Able to:
1. Maintain unassisted
sitting at EOB
2. Able to straighten one leg
at a time and hold for 5
sec
3. Assisted sit to stand 3X 
No 
RN ACTIVITY ASSESSMENT 
 Full cooperation
 Able to:
1. Shift weight side to side
in standing 
2. Maintain unassisted
standing
Yes 
THERAPY TREATMENT 
 Strengthening exercises
 Transfer OOB to chair
 Ambulation
 Commode transfers
 Sitting and/or standing
ADLs
No 
NURSING ACTIVITY 
Previous column activity  
AND: 
 Assisted ambulation
RN ACTIVITY ASSESSMENT 
 Full cooperation
 Able to:
1. Maintain balance during
activities/ADLs
2. Ambulate with stand‐by
assist
THERAPY TREATMENT 
 Strengthening exercises
 Ambulation
 Balance training
 Standing ADLs 
REFERRAL TO OT AND/OR PT 
No 
Yes 
Yes 
REFERRAL TO OT AND/OR 
Yes 
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