THE INFLUENCE OF PROGRESSIVE MOBILITY ON MEAN ARTERIAL

PRESSURE AND HEART RATE STABILIZATION IN PATIENT IN ICU

Nina Indriyawati, Rizky Ernanda, Budiyati, Warijan

Poltekkes Kemenkes Semarang
Email: ninagading@hotmail.com

ABSTRACT

Patients undergoing intensive bedrest in bed cause changes in body systems including the
cardiovascular system. Less than three days the first decline is in the blood plasma volume by
8% - 10%. One way to maintain hemodynamic stability is by providing progressive
mobilization with the aim of maximizing ventilation, diffusion, perfusion, blood flow and
oxygen throughout the body. However, this method have not untapped at the Intensive Care
Unit properly. The purpose of this study identifies the influence of progressive mobilization
against the stability of Mean Arterial Pressure and Heart Rate in patients in the ICU Hospital in
Central Java. This type of research is quasy experiment designs without control group, pre-post
test design, carried out over three days with six measurements in 29 respondents with purposive
sampling technique that met the inclusion criteria. Starting with the Head Of Bed 300, Range Of
Motion, then Lateraly Continuous Rotation Therapy. The research data were analyzed using the
dependent t-test results obtained from the first pre-test and post-test of the last measurement.
Obtained difference value - average MAP and HR after being given treatment. Statistical test
results obtained dependent t test p value of 0.000 (<0.05), so that there is a progressive
mobilization effect on the stability of Mean Arterial Pressure and Heart Rate in patients in the
ICU.

Key words: Heart Rate; ICU; Mean Arterial Pressure; Progresif Mobilisation
INTRODUCTION

Intensive care room is a place or a separate unit within the hospital treating patients - patients with
acute illnesses, trauma or complications another disease (Hendra., et al, 2011). Based on research
conducted Vanesha found data from Hospital Dr. Installation Medical Record Kariadi Semarang,
found 165 patients entered the intensive care department of Dr. Kariadi the period from July to
September 2014, with a range of treatment time 2-10 days 150 patients, while 15 patients were treated
in less than 2 days or more than 10 days (Gunawan., 2014).

Critical patients experiencing a change in the metabolic system, respiratory system, cardiovascular
system, integument system, musculoskeletal system, urinary elimination system (Potter & Perry,
2011). In the cardiovascular system in the first 3 days of bedrest decline in blood plasma by 8% - 10%.
Later in the first 4 weeks of blood plasma decreases until it reaches 15% - 20%. In patients with supine
position continuously lowering the blood circulation of the lower extremities are supposed much to the
heart (Vollman, 2012). His heart has to increase as a result of decreased blood volume that should be
accepted by a sufficient amount so that the patient will experience an increase in power of the heart by
increasing the resting heart rate (Sherwood, 2012).

Patients who experience immobilization are also at risk of orthostatic hypotension due to decreased
ability autonomic nerves in the fulfilment of the blood supply in the body. At the time of venous flow
back to the heart, causing a decrease in cardiac output and a decrease in blood pressure followed by a
pressure drop in the average - average arterial (Potter & Perry, 2011). An American study suggests
that to immobilize patients during 14 days of occurrence of the infection can result. In lung infections
arise from the effects of gas ventilation, cardiac depression due to sedation and anesthesia long term,
impaired gastric emptying, decreased physical ability and impaired cardiac output (Rahmanti et al.,
2016).

Failure or one or multiple organ dysfunction that occurs in patients with disturbances hemodinaik
(Setiyawan, 2016). Hemodynamic status that occurs is controlled by the central nervous system in the
medulla oblongata. Changes in the hemodynamic status is affected by systemic stimulus. Acceptance
of systemic stimulus is strongly influenced by the baroreceptors in determining the hemodynamic
status change Heart Rate, Blood pressure and Mean Arterial Pressure. Stimulus received by
baroreceptors in the form of a change of pressure in the blood vessels that will be delivered to the
heart of the regulatory center in the medulla oblongata. Then the heart center will determine the
frequency and strength of the heartbeat so happen compensation in order to maintain balance (Tori et
al., 2008).

Progressive mobilization is mobilization is achieved in stages that are expected to generate better
hemodynamic response. During the administration of mobilization in an upright sitting position
pulmonary performance becomes more leverage in the process of ventilation, diffusion and perfusion
to the tissue. Blood circulation process is also affected by changes in body position and gravity of the
body so that the perfusion, diffusion, distribution of blood flow and oxygen flow throughout the body
(Vollman, 2010). Rough estimation by measurement of average pressure - artery average can indicate
cardiac output state indirectly that indicates the state of non-invasive hemodynamic monitoring so as
to reduce the risk of complications (Setiyawan, 2016).

Other research conducted by I Anne et all 50% of the patients treated in intensive mobilization
mobilitation be active passive, active passive mobilization proves safe transfer is done in an intensive
care unit (Leditschke, 2012). Another study conducted Olviani, 21 respondents were mobilized in the
form of setting the position of Head Of Bed 30 ° and the provision of the right and left oblique
position seen no change in blood pressure parameter p value = 0.020 and respiration with p value =
0.005 (10). Research conducted by Noviyanto in 2015 obtained the change in mean heart rate of 78.58
x / min into 80.75 x / minutes immediately after being granted early mobilization of patients in ICU
RSUD Sleman (Nofiyanto, 2016). Based on the data obtained it is necessary to study how the
influence of the progressive mobilization of the stability of Heart Rate and Mean Arterial Pressure in
Patients in the Intensive Care unit.

METHOD
This research uses quasi-experimental study without control. The design is one group pretest posttest
design. Observations carried out every day before and after the intervention given the interventions
given for three days to see the stability of each respondent. The population of this study were all
patients treated in intensive care with a sample of 29 respondents based on the criteria inclusion. The
sampling technique was purposive sampling.

RESULT
Based on research result shows that the gender distribution is dominated by female respondents a
number of 18 respondents (62.1%), aged 57-67 years a number of 11 respondents (37.9%), medical
diagnostics neurosurgery as many as 16 respondents (55.2%).

The Mean Arterial Pressure (MAP) before and after the progressive mobilization shows that the first
day prior to the mobilization of progressive on the morning of value - average 84.25 (SD ± 15.48),
after being given treatment value - average on the afternoon of 84.67 (SD ± 17.52). On the morning of
the second value - average before being given treatment 84.72 (SD ± 15.75), after being given
treatment on the afternoon of the average - average 85.80 (SD ± 15.45). On the third morning before
being given treatment value - average 85.12 (SD ± 14.24), in the afternoon after being given treatment
value - average 88.27 (SD ± 15.51).

The distribution of values Heart Rate (HR) before and after mobilization progressive shows that the
first day prior to the mobilization of progressive on the morning of value - average 80.23 (SD ±
12.07), after being given treatment value - average on the afternoon of 82.33 (SD ± 11.97). On the
morning of the second value - average before being given treatment 82.84 (SD ± 10.82), after being
given treatment on the afternoon of the average - average 84.54 (SD ± 11.47). On the third morning
before being given treatment value - average 82.59 (SD ± 10.05), in the afternoon after being given
treatment value - average 85.11 (SD ± 12.08).

Table 1. The score of MAP before and after treatment in the ICU (n = 29)

Mean
Variebel Treatment df Mean P value
Difference
Score Pre 29 83.96 6.03 0.000
MAP Post 29 90.00

The table 1. shows that significant value 0.000 <0.05, which means Ha accepted that there is an
influence before and after administration of the MAP progressive mobilization of patients in ICU.

Table 2. The score of HR before and after treatment in the ICU (n = 29)

Mean P
Variebel Treatment df Mean
Difference value
2
Pre 79.68 6.37 0.000
Score 9
HR 2
Post 86.06
9

The table 2. shows that significant value 0.000 <0.05 then Ha accepted which means there is a before
and after the effect of the progressive mobilization against HR patients in the ICU.

DISCUSSION
Based on data analysis showed that the characteristics of the sexes is the largest group of female
respondents. These results are consistent with studies in 2008 in Iran, which states that congenital
abnormalities in women more than men - male (Abdi et al., 2008). On any normal individual would
produce hormones in the body. Among male hormone production - male and female each - each
different. The endocrine system in the body has a role in helping to maintain and regulate vital
functions such as: response to stress and injury, growth and development, reproduction, ion
homeostasis and energy metabolism. So the response to disease that attacks the body also becomes
different between male - male and female so that the total percentage of male patients - men and
women were not equal.

Characteristics of respondents by age dominated in the age range 57-67 years.This is in line with
research Farid in 2011, found the patient in the ICU Hospital Medical Kariadi have average - average
age of 50 years. Each disease is varied to follow the frequency and severity with age. Patients aged
more than 50 years are more prone to suffer the disease. Age is closely associated with physiological
changes in organ because of the increasing age of a person getting organ function decline in function.
The proportion of elderly patients who died in the ICU more than in other age ranges.

Characteristics of respondents based medical diagnostics dominated by neurosurgical diagnoses. This

is because neurosurgery is one type of major surgery so that after the operation requires more intensive
monitoring in the ICU.

In this study, the average MAP that measured before being given the mobilization of 83.9 mmHg. This
is in line with the theory of Potter and Perry in 2011, in his book states that the normal value of MAP
70-100 mmHg. So based on the results of the analysis, the initial value of MAP obtained before being
given treatment in this study were within the normal range. These values are consistent with the theory
that the inclusion criteria permissibility Vollman progressive mobilization is applied if the value of
MAP> 55 and <140 mmHg, this value is considered as a safe limit for mobilization (Vollman, 2010).
After being given a treatment derived indigo progressive mobilization of the average - average MAP
90.00 mmHg. Value shows the mean arterial pressure within normal range. Average pressure - mean
arterial need to be maintained in the normal range to maintain the level of awareness, especially in
patients who were treated in intensive care. This statement is evidenced by the results of statistical
tests performed Martono et al, R2 Test R square values obtained for 0778, which means that the
critical value of mean artery pressure has contributed to the patient's level of consciousness by 77.8%
(Mortono et al., 2016).

Like the blood pressure needs to be maintained to remain stable, as well as the MAP because MAP is a
compensation mechanism in maintaining cerebral perfusion pressure. This compensation mechanism
is done by increasing the mean arterial pressure. The supply of blood flow to the brain needs to be
maintained its stability in order to avoid permanent damage to the brain. Be a huge risk if there is a
failure to identify and know the signs and symptoms of cerebral perfusion pressure and mean arterial
sufficiency as this may cause Irreversible brain damage to death (Martono et al., 2016).

Based on the research, the average HR of 79.68 mmHg before being given mobilization. This value
corresponds to the theory of Varon Joseph, Heart Rate normal adults is 60-100 bpm (Varon & Pilar,
2010). So based on the results of research on the measurement of HR before the mobilization could be
concluded within the normal range.

Cardiovascular parameters before mobilization respondents indicate values that meet safe limits for
mobilization. This is consistent with the concept that mobilization in critically ill patients immediately
after the patient's physiological condition is stable (Truong, 2009). After being given the mobilization
obtained value - average of 86.06 mmHg. This value is within the normal range.

Mobilization is done in accordance with the correct phase and immediately after a stable condition can
prevent blood flow is inhibited. Barriers to blood flow can cause deep vein thrombosis (deep vein
thrombosis) and causing an infection (Nofiyanto, 2016). Mobilization of vicarious able to improve
blood circulation and therefore `nutrients for healing easily met, prevent trobophlebitis, increase the
smooth functioning of the kidneys (to prevent urinary retention), improve metabolism, restore nitrogen
balance, increases intestinal peristalsis (Rachmawati, 2016).

Based on the results of dependent t-test that conclude there are significant before and after the
progressive mobilization of the value of Mean Arterial Pressure in the ICU. The results of this study
prove that a given progressive mobilization can provide good hemodynamic response, especially in
this case the value of Mean Arterial Pressure. HOB position in the first phase of progressive
mobilization give effect to better blood circulation, so that the distribution of blood flow and oxygen
flow throughout the body (Vollman, 2010). Progressive mobilization is done gradually play a role in
reducing the length of treatment in the ICU and in the hospital (Campbell, 2015).

This study is in line with research conducted by Yurida, which states that the p value of 0.020 (p value
<0.05) so that there is an increase in the blood pressure after being given the progressive mobilization
therapy level one in 20 respondents. If an increase of the blood pressure then the mean arterial
pressure will also increase (Gunawan et al., 2014).

The results of dependent t test that concluded there are significant before and after treatment of
progressive mobilization of the value of Heart Rate in ICU. The results of this study are supported by
research conducted by Noviyanto, there are significant differences between before and during
mobilization with p value 0.000 on a breath frequency value and p value 0.001 at the frequency of the
heartbeat. The condition is the result of a compensation mechanism for the activity that is accepted by
the body, causing sympathetic stimulation to improve cardiorespiratory organ function in order to
meet the needs of oxygenation (cardiac output) and tissue perfusion (Nofiyanto, 2016). Mobilization
causes increased heart rate (HR) and lower stroke volume index (SVI). Ventricular stroke work index
decreased, indicating a decrease in myocardial performance. Myocardial function decreased in the first
morning after CABG, but during the postoperative mobilization insignificant decline of influence in
CI and SvO2 changes so that mobilization is safe to do (Nofiyanto, 2016).

This research was supported by the theory advanced by Sherwood (2012) that there was an increase in
heart rate when the body given activity due to the need increased blood flow to the entire body. This
study is in line with research conducted by Stiller stating that there is a significant improvement on
heart rate, blood pressure, decreased oxygen saturation after being given the mobilization of the 39
respondents (Genc et al., 2012). Mobilization is done immediately after a stable condition capable of
accelerating the patient, increase the speed of the depth of breathing, increased circulation, increased
urination and metabolism, especially in patients with postoperative ICU (Nofiyanto, 2016).

CONCLUSION AND RECOMMENDATION

Mobilization of progressive able to increase value - average MAP of 6.03; Mobilization progressively
able to increase value - average HR of 6.37; There is the influence of MAP before and after given the
progressive mobilization in patients treated in an intensive care unit (p <0.05).; There is the influence
of HR before and after given the progressive mobilization in patients treated in an intensive care unit
(p <0.05).

These results indicate that the cause of progressive mobilization in response to the patient's
hemodynamic status, so expect to pay more attention nurse MAP and HR values when performing a
progressive mobilization. Further research is expected to modify the study by adding a control group
and expand the research area not only in one place. But it certainly adds to the existing inclusion
criteria so as to minimize human error in the study.

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