Mobility Levels

Level 1: BREATHE 2: TILT 3: SIT 4: STAND 5: MOVE

Patient Assessment RASS -5 to -3; SAS 1-2 RASS >-3; SAS >3 RASS >-1; SAS >3 RASS >-0; SAS >4 RASS >-0; SAS >4

e.g. Cannot participate Opens eyes; may have profound weakness Weak but may move arms/legs independently Weak but may tolerate increased activity Weak but may tolerate increased activity

Activities

Maintain HOB ≥ 30°

q2hr turning
Consider continuos lateral rotation therapy (CLRT), see protocol
Passive ROM 2x/day
Up to 20° Reverse Trendelenburg/Tilt Table with lower extremity exercises/ retracting footboard. Min 15 mins/Max 60 mins, 1x/day

Maintain HOB ≥ 30°
q2hr turning
Passive/active ROM 3x/day
Up to 20° Reverse Trendelenburg/Tilt Table with lower extremity exercises/ retracting footboard. Min 15 mins/Max 60 mins, 3x/day
Legs dependent 15-20 mins, 3x/day
PT consultation 1x/day

Maintain HOB ≥ 30°
q2hr turning (assisted)
Active ROM 3x/day
Encourage ADL’s as tolerated
Full chair position (footboard on) 60 mins, 3x/day
Dangling if pt can move arm against gravity as tolerated
PT/OT actively involved, 1x/day

Maintain HOB ≥ 30°
q2hr turning (self/assisted)
Active ROM 3x/day
Encourage ADL’s as tolerated
Full chair position (footboard off/feet on the floor) 60 mins, 3x/day
Stand attempts, if pt can move leg against gravity (use a sit-to-stand lift) 3x/day
Pivot to chair, if tolerates partial weight bearing, 2x/day
PT/OT actively involved, 1x/day

Maintain HOB ≥ 30°
q2hr turning (self/assisted)
Active ROM 3x/day
Encourage ADL’s as tolerated
Pt stands/bears weight > 1 min 3x/day
Pt marches in place 3x/day
Ambulate to bedside chair to achieve “out-of-bed” (use pt lift) 3x/day
PT/OT actively involved, 1x/day

Move to next level when the patient...

Has acceptable oxygenation/hemodynamics
Tolerates q2hrs turning
Tolerates HOB ≥ 30° or up to 20° Reverse Trendelenburg

Tolerates active assistance exercises 2x/day
Tolerates lower extremity exercises against footboard up to 20° Reverse Trendelenburg
Tolerates legs dependent/HOB 45°

Tolerates increasing active exercise in bed
Actively assists with q2hrs turning or tuns independently
Tolerates full chair position 3x/day

Can successfully comply with all activities
Tolerates trial periods of full chair position (footboard off/ feet on the floor) 3x/day
Tolerates partial weight-bearing stand & pivots to chair
Continue to ambulate progressively longer distances as tolerated until pt consistently participates & moves independently.

Level	1: BREATHE	2: TILT	3: SIT	4: STAND	5: MOVE
Patient Assessment	RASS -5 to -3; SAS 1-2	RASS >-3; SAS >3	RASS >-1; SAS >3	RASS >-0; SAS >4	RASS >-0; SAS >4
e.g.	Cannot participate	Opens eyes; may have profound weakness	Weak but may move arms/legs independently	Weak but may tolerate increased activity	Weak but may tolerate increased activity
Activities	Maintain HOB ≥ 30° q2hr turning Consider continuos lateral rotation therapy (CLRT), see protocol Passive ROM 2x/day Up to 20° Reverse Trendelenburg/Tilt Table with lower extremity exercises/ retracting footboard. Min 15 mins/Max 60 mins, 1x/day	Maintain HOB ≥ 30° q2hr turning Passive/active ROM 3x/day Up to 20° Reverse Trendelenburg/Tilt Table with lower extremity exercises/ retracting footboard. Min 15 mins/Max 60 mins, 3x/day Legs dependent 15-20 mins, 3x/day PT consultation 1x/day	Maintain HOB ≥ 30° q2hr turning (assisted) Active ROM 3x/day Encourage ADL’s as tolerated Full chair position (footboard on) 60 mins, 3x/day Dangling if pt can move arm against gravity as tolerated PT/OT actively involved, 1x/day	Maintain HOB ≥ 30° q2hr turning (self/assisted) Active ROM 3x/day Encourage ADL’s as tolerated Full chair position (footboard off/feet on the floor) 60 mins, 3x/day Stand attempts, if pt can move leg against gravity (use a sit-to-stand lift) 3x/day Pivot to chair, if tolerates partial weight bearing, 2x/day PT/OT actively involved, 1x/day	Maintain HOB ≥ 30° q2hr turning (self/assisted) Active ROM 3x/day Encourage ADL’s as tolerated Pt stands/bears weight > 1 min 3x/day Pt marches in place 3x/day Ambulate to bedside chair to achieve “out-of-bed” (use pt lift) 3x/day PT/OT actively involved, 1x/day
Move to next level when the patient...	Has acceptable oxygenation/hemodynamics Tolerates q2hrs turning Tolerates HOB ≥ 30° or up to 20° Reverse Trendelenburg	Tolerates active assistance exercises 2x/day Tolerates lower extremity exercises against footboard up to 20° Reverse Trendelenburg Tolerates legs dependent/HOB 45°	Tolerates increasing active exercise in bed Actively assists with q2hrs turning or tuns independently Tolerates full chair position 3x/day	Can successfully comply with all activities Tolerates trial periods of full chair position (footboard off/ feet on the floor) 3x/day Tolerates partial weight-bearing stand & pivots to chair	Continue to ambulate progressively longer distances as tolerated until pt consistently participates & moves independently.