Assessing patient mobility

The right way to move a patient depends on the patient. A woman recovering from pneumonia who can stand and walk with a frame needs supervision and perhaps a gait belt. A man who has just had a stroke and cannot hold himself upright needs a full-body lift. A resident with dementia who could stand yesterday morning may not be able to stand this evening. Choosing the method by habit, or by whatever equipment is nearest, is how the 3 East shoulder injury in Lesson 1 happened.

This lesson explains how to assess a patient's mobility quickly and consistently, how the result is turned into a method and a piece of equipment, how often the assessment is repeated, and how it is communicated to everyone who moves the patient. It connects the patient's needs, which the nursing and therapy staff already think about, with the worker's safety, which they often do not.

What a mobility assessment looks at

A mobility assessment for safe handling is not the same as a full physical therapy assessment. It answers a narrower practical question: what can this patient do for themselves right now, and therefore how much of the work, and which equipment, will staff need? The main factors are:

• Weight-bearing: can the patient take their weight on both legs, one leg, or neither? For how long?
• Upper body strength and trunk control: can the patient sit upright without support, hold on, pull, and lean forward?
• Cognition and cooperation: can the patient understand and follow instructions, and remember them during the move? Are they calm, agitated, sedated or confused?
• Size and shape: weight, height and body shape, which decide whether standard equipment will fit and is strong enough.
• Medical factors: pain, recent surgery, fractures and precautions such as hip precautions, low blood pressure on standing, lines, drains, catheters and oxygen, skin condition, contractures, spasticity and amputations.
• Behavior and history: a history of falls, grabbing or striking out, fear of being moved, and what has worked before.
• The patient's goals and preferences: what the patient wants to do, and whether they agree to the method.

The assessment does not need to take long. For most patients, a trained nurse can do it in two or three minutes at the start of a shift, by talking to the patient and asking them to do a few simple movements. The aim is to see what the patient can do rather than to rely on what the chart said yesterday.

A structured tool: the Bedside Mobility Assessment Tool

Northbridge's new policy uses a structured tool so that every nurse assesses patients the same way and the result points directly to the equipment. Many hospitals in North America use the Bedside Mobility Assessment Tool, known as BMAT, developed by the nurse Teresa Boynton and updated as BMAT 2.0 in 2020. It has four short tests in sequence. The patient moves on to the next test only if they pass the one before, and the level they reach tells staff how to move them.

• Level 1, Sit and shake. From lying with the head of the bed raised to at least 30 degrees, the patient sits up on the edge of the bed and stays sitting without support for up to a minute, then reaches across the middle of their body to shake the nurse's hand, once with each hand. A patient who cannot do this, or who becomes dizzy, sweaty or breathless, stays at level 1.
• Level 2, Stretch. Still sitting, the patient straightens one knee and pumps the ankle at least three times, then does the same with the other leg. This shows leg strength and control.
• Level 3, Stand. The patient moves forward and stands up from the bed or chair and keeps their balance standing for up to a minute, using their usual walking aid if they have one.
• Level 4, Step. The patient marches on the spot three times, then steps forward and back with each foot.

The result is a mobility level from 1 to 4, and each level comes with a recommended method:

The table is a guide, not a substitute for judgment. A level 3 patient who is confused and pulls back unpredictably may be safer in a full-body lift. A level 4 patient who becomes dizzy every time she stands may need a sit-to-stand aid until her blood pressure is controlled. The rule at Northbridge is that the nurse may choose a safer method than the level suggests but may not choose a less safe one without a physical therapist or the safe patient handling coordinator agreeing and the reason being written in the care plan.

Other tools

BMAT is not the only option. The VA's safe patient handling program has its own algorithms for each type of move, and many nursing homes use a simple transfer status assessment that sorts residents into independent, one-person assist, two-person assist with a standing aid, and full mechanical lift. Some rehabilitation units use more detailed functional scales. The important thing is that a unit uses one tool consistently, that the tool leads to a method, and that staff are trained to use it.

Turning the level into a plan

Grace wrote a short script to check the logic of the unit's decision rules before they went into the electronic chart. It takes the level from the bedside test and adds the most common modifiers.

# Choose a transfer method from a bedside mobility level and modifiers
def method(level, kg, confused=False, dizzy_on_standing=False):
    if level == 1:
        plan = "full-body lift"
    elif level == 2:
        plan = "full-body lift (sit-to-stand only if bears weight)"
    elif level == 3:
        plan = "powered sit-to-stand"
    elif level == 4:
        plan = "standing aid or lift with walking vest"
    else:
        plan = "supervision with usual walking aid"
    # modifiers can only add support, never remove it
    if confused and level >= 3:
        plan = "full-body lift (confused: unpredictable standing)"
    if dizzy_on_standing and level >= 4:
        plan = "powered sit-to-stand until blood pressure is stable"
    if kg > 136:
        plan += " + bariatric-rated equipment"
    return plan

patients = [
    ("Room 406", 1, 68),
    ("Room 409", 3, 120),
    ("Room 412", 2, 82),
    ("Room 415", 5, 59),
    ("Room 418", 4, 74, False, True),
    ("Room 421", 4, 150),
    ("Room 424", 3, 66, True),
]
for room, level, kg, *mods in patients:
    print(f"{room}: level {level}, {kg} kg -> {method(level, kg, *mods)}")

Room 406: level 1, 68 kg -> full-body lift
Room 409: level 3, 120 kg -> powered sit-to-stand
Room 412: level 2, 82 kg -> full-body lift (sit-to-stand only if bears weight)
Room 415: level 5, 59 kg -> supervision with usual walking aid
Room 418: level 4, 74 kg -> powered sit-to-stand until blood pressure is stable
Room 421: level 4, 150 kg -> standing aid or lift with walking vest + bariatric-rated equipment
Room 424: level 3, 66 kg -> full-body lift (confused: unpredictable standing)

The rules in the script follow one principle: a modifier can move the plan toward more support, never toward less. Room 424's patient reached level 3, but because he is confused and may not follow instructions while standing, the plan becomes a full-body lift. Room 421's patient can stand but weighs 330 lb (150 kg), so whatever she uses must be rated for her weight. Lesson 9 covers bariatric equipment.

When to assess

Mobility changes, sometimes within hours. A patient who was steady before surgery may faint when first standing after it. A resident with dementia may be able to stand in the morning and not in the evening. Pain medicine, sedation, infection, low blood sugar and fatigue all change what a patient can do. Northbridge's policy sets the minimum times to assess:

• On admission or transfer to a unit, before the first move.
• At least once every shift in acute care, usually at the start.
• Before the first time a patient gets up after surgery, sedation or a procedure.
• Whenever the patient's condition changes, including after a fall, a new medicine that causes drowsiness or a change in behavior.
• In the nursing home, on admission, at least every quarter as part of the care plan review, and whenever a resident's ability changes. Staff also do a quick check before each transfer, because residents with dementia vary from hour to hour.
• In home health, at the first visit and whenever the client's condition, equipment or home changes.

The quick check before each move, part of the bedside check described in Lesson 3 of HSE-390, is the last line of defense. If the patient seems different from what the care plan says (weaker, drowsier, more confused), the worker stops and uses a safer method or asks the nurse to reassess.

Communicating the plan

An assessment helps only if everyone who moves the patient knows the result. At Northbridge, four places carry it:

• The electronic chart, where the nurse records the level, the method, the equipment and the sling size, and any special instructions.
• A sign at the bedside, out of public view inside the wardrobe door or on the room whiteboard, with a simple picture of the method: a lift, a sit-to-stand, a standing aid or a person walking, and the sling size and color. Visitors do not need to see the details, but staff do.
• Shift handover, where the mobility level is part of every patient's report.
• The transfer form, when a patient goes to imaging, the operating room or another unit, so that transporters and receiving staff know how to move the patient before they arrive.

Kevin Tran says the transfer form changed his work more than anything else in the program. Before, he would arrive to take a patient to imaging and find out only at the bedside that she could not stand. Now the request tells him whether to bring a stretcher and an air-assisted transfer mat or a wheelchair, and imaging knows whether to have the ceiling lift ready in the scanning room.

Patients who decline

Some patients do not want to be moved with equipment. They may be frightened of the lift, feel it is undignified, or believe they can manage on their own. Their wishes matter, and many objections disappear with explanation, a demonstration, or a few uses. Staff can explain that the lift is safer for the patient as well as for staff, let the patient touch the sling and see the controls, and start with a gentle, slow move.

A patient's refusal does not, however, oblige a worker to lift them by hand. If a patient who needs a lift declines it, staff do not substitute a manual lift that exceeds safe limits. They explain the risks, offer alternatives (a different sling, a different lift, a different time), involve the nurse in charge, the physical therapist and, where appropriate, the family or substitute decision maker, and record the discussion. A care plan may then be agreed that respects the patient's wishes as far as possible without putting staff at risk, for example by staying in bed until a chosen time, or by using a sit-to-stand aid while the patient builds confidence.