Community-Acquired Pneumonia in an Older Adult: Early Mobilisation Versus Desaturation
An 81-year-old woman is admitted with community-acquired pneumonia. She lives alone, mobilises indoors with a frame, and has mild cognitive impairment. On assessment she is sitting up in bed, drowsy but rousable, with a respiratory rate of 24, oxygen saturation 90% on 2 L/min nasal cannula, heart rate 104 bpm, blood pressure 112/68 mmHg, and temperature 38.3 C. She has a productive cough that she is not clearing effectively, and auscultation reveals reduced breath sounds and crackles at the right base. She has not been out of bed for 3 days. The medical team has asked for respiratory physiotherapy and early mobilisation. She is on intravenous antibiotics and fluids. Her early warning score is elevated.
1. Decide whether she is safe to mobilise now. Justify your decision using the observations and identify what you would do instead.
Read the worked answer
She is not safe to mobilise out of bed now. Her early warning score is elevated, she is febrile at 38.3 C, tachycardic at 104 bpm, tachypnoeic at 24, and saturating only 90% on supplemental oxygen - below the usual target range for a patient on oxygen therapy. She is drowsy with cognitive impairment, which raises the risk of poor co-operation and of aspiration, and she has not been out of bed for 3 days, so she is deconditioned. Mobilising a patient who is desaturating, febrile, and drowsy risks syncope, a fall, and further respiratory compromise.
What to do instead:
- Escalate to the medical team: the oxygen saturation is below target on 2 L/min and she is drowsy and febrile - this needs review of oxygen prescription, sepsis status, and whether she is deteriorating.
- Position her upright and well supported to optimise ventilation and reduce the work of breathing.
- Provide supported huffing and effective cough assistance, with airway clearance positioning (e.g., right side up) if she tolerates it, and assess whether she can clear secretions.
- Recheck observations before and after any intervention; stop if saturation falls further or she becomes more drowsy.
- Defer mobilisation until she is afebrile or improving, oxygen saturation is within the prescribed target on stable oxygen, and she is alert enough to participate. Document the decision and the plan to reassess.
2. Two days later she is afebrile, saturation 94% on 1 L/min, respiratory rate 18, and alert. Describe how you would reintroduce mobilisation and airway clearance, including safety checks.
Read the worked answer
She is now in a better position to participate: afebrile, saturating 94% on low-flow oxygen, respiratory rate normalised, and alert. Confirm with the medical team that mobilisation is appropriate and that her oxygen prescription and target range are clear.
Airway clearance: teach and supervise huffing and supported coughing, with positioning to help clear the right base; assess sputum clearance and breath sounds before and after. Keep sessions short and stop if she becomes fatigued or desaturates.
Mobilisation progression:
- Sit on the edge of the bed with supervision, checking for dizziness and postural drop.
- Stand with a frame and assistance, monitoring saturation and symptoms.
- Walk short distances with a frame and one or two staff, increasing distance as tolerated, with rests.
- Build toward her prior indoor mobility with a frame, with a plan for the ward and discharge.
Safety checks throughout: oxygen saturation within target, respiratory rate, heart rate, blood pressure on standing, and her level of alertness and fatigue. Stop if saturation falls below target, she becomes breathless or dizzy, or she cannot co-operate. Document baseline and post-session observations, and communicate the plan to nursing staff so mobility continues between sessions.