Chapter 32 - Physical Activity & Immobility

The basis for safe, effective nursing care is Thinking, Doing, and Caring. You are caring for an older client who needs assistance to ambulate and change positions in bed. When preparing to ambulate, the client refuses to use the prescribed cane. What should you do to support the client's safety and psychosocial needs?

-Some patients consider the use of aids a sign of weakness or inconvenience and resist using them. However, most people dread loss of independence, so you can promote the use of walking aids by stressing their value in helping the person maintain independence 1. Thinking -Theoretical knowledge: A sound knowledge base enables you to teach and respond sensitively to all your clients. You will need theoretical knowledge about the musculoskeletal system, the role of exercise, and the hazards of ambulating without appropriate physical preparation and support. -Critical thinking: To help the client find out why a cane does not want to be used. Is the client embarrassed to use a cane? Does this make the client feel old or dependent? 2. Doing -Practical knowledge: When working with this client, consider discussing the need to have strong muscles and an intact neurological system to walk safely. -Nursing process: To help the client, you will need to assess current knowledge and concerns, clearly identify the issue with safe ambulation, and develop a plan that is acceptable to the client. 3. Caring -Self-knowledge: Be aware of how you react to this client not wanting to use an assistive device to ambulate. How do you feel when you see someone walking with a cane? Do you think that they are disabled and dependent? Think of how your behavior communicates to the person your feelings.

How do the muscles and nerve interact?

-nervous system controls the movement of the musculoskeletal system -when we want to make a conscious decision to move our arm, the thought originates in the motor area of the cerebral cortex -upper motor efferent neurons communication with the lower motor neurons that conduct an impulse to the muscle -when the muscle receives sufficient stimuli it contracts, shortening the biceps brachial and bending the elbow -stimulus to cause a contraction of the biceps generates a stimulus to cause relaxation in the triceps in a process known as reciprocal inner action -movement also occurs through reflex mechanisms -reflexes are protective mechanisms -common reflexes include the knee jerk and corneal reflex

Name suggestions for overcoming objections to exercise.

1. "I hate to exercise" = Pick activities that you enjoy 2. "I burn out on exercise" = Plan ahead and build in rest days and varied activities 3. "I am self-conscious about going to the gym and don't have the motivation to exercise by myself." = Find a friend to exercise with or develop a reward system for yourself if you continue to exercise -an exercise "buddy" can help increase motivation and consistency in the weekly routine 4. "I am too busy with work or family" = Develop and routine that you can do at lunchtime, or exercise with your family 5. "I find exercise boring." = Change your routine more frequently 6. "I can't afford to join a health club, hire a fitness trainer, or buy expensive equipment." = Just get active doing things you enjoy. -go for a brisk walk or play with your grandkids -some of the best core exercises require no equipment at all (e.g. push ups, planks) -you can also use a chair, jump rope, or many things around the house to build into your fitness routine 7. "I'm too tired to exercise." = The hardest part is getting started, but after a few minutes or so, you'll feel better and have more energy after you finish 8. "Exercise hurts" = Make sure you exercise at your target heart rate and plan a rest day after every weight-lifting session 9. "I don't have time." = Schedule your exercise time. -if need be, schedule short 10-15min session throughout the day, and do more as time allows -it all adds up and will benefit you 10. "I have pain all the time." = Take pain medication an hour or so before starting physical activity -if fatigue is the problem, try to arrange schedule to keep balance of rest and activity as well as avoid stimulants (e.g. caffeine or nicotine) that might interfere with the quality of sleep 11. "I have difficulty getting around sometimes." = Stretch adequately before starting exercise, but do not overstretch joints -also, you will need to walk on smooth, even surfaces 12. "I am diabetic and have trouble with my feet. My vision is not very good either." = Be sure shoes fit properly and the area is well lit 13. "I'm too old to exercise." = It's never too late to get active, and any physical activity you do is better than none -exercises that build strength, stamina, flexibility, and balance improve the quality of life and reduce the risk for falls

Identify the most appropriate device for the following activities: 1. Transferring an obese patient from a bed to a stretcher 2. Assisting an immobile patient to a recliner chair 3. Helping a weak patient from bed to chair

1. A transfer board should be used when transferring an obese patient from a bed to a stretcher. 2. A mechanical lift should be used when assisting an immobile patient to a recliner chair. 3. A transfer belt should be used when helping a weak patient from a bed to a chair.

Define the following movements: abduction, abduction, flexion, extension, circumspection, internal rotation, supination, and pronation.

1. Abduction -moving away from the midline 2. Adduction -moving toward the midline 3. Flexion -bending, decreasing the joint angle 4. Extension -straightening, increasing the joint angle 5. Circumspection -moving in a circular fashion 6. Internal rotation -turning toward the midline 7. Supination -turning upward 8. Pronation -turning downward

Name and describe the nursing analysis/diagnosis for physical activity.

1. Activity intolerance -state in which a patient has insufficient physical or psychological energy to carry out daily activities 2. Impaired physical mobility -limitation of independent purposeful movement of the body. 3. Risk for disease syndrome -exists when a patient's prescribed or unavoidable inactivity creates the risk for deterioration of other body systems 4. Sedentary lifestyle -habit of life that is characterized by a low physical activity level.

Identify and describe six position in devices.

1. An adjustable bed, sometimes known as a hospital bed, assumes a variety of positions. The head can be elevated or lowered below the level of the feet, and the foot of the bed can be elevated. Often the bed breaks, or "catches," at the knee to prevent the patient from sliding down when the head is elevated. The height of the bed is also adjustable 2. Pillows expand the weight-bearing area by molding to the body and are the most common device used to assist with positioning. Pillows provide support and elevate body parts. 3. A trapeze bar is a triangular bar that is attached to an overhead bed frame. The patient can use the base of the triangle as a grip bar to move up in bed, turn, pull up in preparation for getting out of bed, or pull up to get on and off the bedpan. 4. A footboard is a device placed at the end of the bed that prevents plantar flexion. 5. A foot cradle is a metal or plastic device that is secured at the foot of the bed to prevent bedding from constricting the movement of the lower extremities 6. Sandbags are small fabric bags filled with sand. They are used in the same manner as pillows, but they provide firm support. 7. Trochanter rolls are made from tightly rolled towels or foam pads. They are usually 12 to 18 inches in length. The rolls are placed adjacent to the hips and thighs to prevent external rotation of the hips. 8. Splints may be premade or fashioned from rolled wash cloths. The purpose of a splint is to hold the wrist and hand in a natural position and prevent claw-hand deformities.

Identify the effects of immobility on the cardiovascular, musculoskeletal, and integumentary systems.

1. Cardiovascular system: -Immobility increases the workload of the heart and promotes venous stasis. When you are active, the skeletal muscles of the legs assist with pumping blood back to the heart. Recall that the veins are thin-walled vessels with valves. Muscular activity propels blood toward the right side of the heart, and the valves prevent backflow of blood. Without muscular activity (immobility), blood pools in the periphery. To compensate, heart rate and stroke volume increase to maintain blood pressure. In addition to venous pooling, immobility leads to compression and injury of the small vessels in the legs and decreased clearance of coagulation factors, causing the blood to clot faster. These three changes—stasis, activation of clotting, and vessel injury—make up what is known as Virchow's triad, a trilogy of symptoms associated with a greater chance of thrombus formation in the effected blood vessels. An immobile person is also more prone to orthostatic hypotension. Bedrest causes inactivation of the baroreceptors involved with constriction and dilation of the vessels. As a result, when a patient who has been immobilized changes position, he is unable to maintain his blood pressure. The patient complains of feeling dizzy and light-headed and may be unable to support his own weight. 2. Musculoskeletal system: -Inactivity causes significant wasting of the gastrocnemius, soleus, and the leg muscles that control flexion and extension of the hip, knee, and ankle. Confinement to bed leads to a 7% to 10% loss of muscle strength (atrophy) per week. Immobility also causes the joints to become stiff. The strongest muscles, usually the flexors, pull the joints in their direction, leading to contractures or joint ankylosis (fusion of the joints). Immobility affects parathyroid function, calcium metabolism, and bone formation. The result of these changes is osteoporosis, calcium depletion in the joints, and renal calculi (stones) due to increased excretion of calcium. These changes place the patient at risk for pathological fractures with minimal trauma. 3. Integumentary system: -External pressure from lying in one position compresses capillaries in the skin, obstructing skin circulation. Poor circulation causes tissue ischemia and possible necrosis (tissue death). Nursing interventions include frequent turning and skin care to prevent the formation of wounds, known as pressure ulcers

Name the US Department of Health and Human Services 2018 Physical Activity Guidelines for Americans.

1. Children and adolescents -pre-school age children (3-5y/o) should be physically active throughout the day to enhance growth and development -children and adolescents (6-17y/o) should engage in at least 1hr of physical activity daily -most activity should be aerobic, either moderate or vigorous intensity -physical activity should be enjoyable. -a variety of activities will improve adherence -at least 3day/week children and teens should participate in vigorous-intensity exercise as well as muscle-and bone-strengthening physical activity 2. Adults -adults should move more and sit less -some physical activity is better than none -for substantial health benefit, get at least 150-300 minutes per week of moderate-intensity or 75-150min a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity -more frequent exercise (throughout the week) is even more beneficial -engage in aerobic activity throughout the week in episodes of at least 10min -longer periods of time provide additional benefits -for additional health benefits, perform muscle-strengthening activities that involve all major muscle group on 2 or more days per week 3. Specific to older adults -older adults unable to perform 150min of moderate-intensity aerobic activity per week should be as physically active as condition allow -includes exercises that maintain or improve balance, tone, and muscle strength 4. Healthy pregnant and postpartum women -consult with the healthcare provider regarding activity level throughout pregnancy -if the pregnancy or postpartum recovery is uncomplicated, women should do at least 150min of moderate-intensity physical activity -aerobic activity throughout the week is the best -if not already engaged in vigorous-intensity activity, get at least 150min of moderate-intensity per week, preferably spread out throughout the week after consulting with healthcare provider. 5. Adults, children and adolescents with chronic conditions or disabilities -avoid inactivity and be as physically active as abilities allow with guidance from their healthcare provider

Name and describe factors affection mobility and activity.

1. Developmental stage -older adults were the least active but were the most likely participate in fitness activities rather than sporting or outdoor activities 2. Nutrition -Obesity often leads to health problems, which indirectly reduces activity and can in turn contribute to further obesity. Movement becomes more difficult as body size increases. Joint and back injuries and osteoarthritis are more prevalent with obesity, which in turn reduces a person's ability to engage in physical activity for weight loss. -Chronic disease may be in negative nitrogen balance—that is, they do not have adequate protein stores available to maintain or repair body tissue. Muscle wasting and fatigue occur, which lead to reduced activity levels, loss of strength and balance. 3. Lifestyle -Personal values about exercise and fitness determine when, or whether, exercise becomes part of a person's routine. Some people enjoy exercise. Others see it as pure drudgery or as "something I have to do." A person's culture and support system define what exercise the person is likely to choose. 4. Environmental factors -Weather - When it is cold, damp or even hot and humid, people tend to avoid strenuous exercise outside, or stay indoors. Encourage patients to choose a variety of activities that they enjoy so they can exercise regardless of the weather. -Pollution - Air quality is poor, suggest indoor activities in order to reduce exposure to allergens and pollutants. -Neighborhood conditions - Crime or lack of parks are examples of conditions that influence attitudes about outside activities. Mall walking is an example of a successful way to incorporate exercise into daily patterns when neighborhood conditions do not encourage activity. -Finances - Joining a fitness center or engaging in sports might be feasible for some budgets. However, many activities, such as walking or playing basketball or tennis in the community park, are options for inexpensive or free. -Support system - Family and friends who are active are likely to promote and support your efforts to exercise. Those who are sedentary may not encourage you to be more active or lose weight.

Discuss factors that affect body alignment and activity.

1. Developmental stage 2. Nutrition -obesity -chronic disease 3. Lifestyle -sedentary lifestyle 4. Environmental factors -weather -pollution -neighborhood conditions -finances -support system 5. Congenital abnormalities of the musculoskeletal -syndactylism -developmental dysplasia of the hip (DDH) -foot deformities -scoliosis 6. Diseases related for bone formation or metabolism -osteogenesis imperfecta -achondroplasia -Paget's disease -vitamin D and calcium 7. Diseases affecting joint mobility -osteoarthritis (OA) -rheumatoid arthritis (RA) -ankylosing spondylitis -gout 8. Problems affecting bone integrity -osteoporosis -osteomyelitis -bone tumors 9. Trauma -fracture -sprains -strains -stretching/tearing 10. Disorders of the CNS -cerebrovascular accident (stroke) -head or spinal cord injury -multiple sclerosis ( a disorder affecting nerve transmission) -myasthenia gravis (a disease caused by antibodies to the acetylcholine receptors at the neuromuscular junction) 11. Diseases of other body systems -respiratory disorders -circulatory disorders -fatigue -bedrest

Name the nursing outcomes/evaluation for physical activity.

1. Energy maintenance 2. Mobility

Identify four principles to be followed when performing PROM.

1. Explain to the patient the purpose of PROM. You should also teach family members and caregivers about the importance of range-of-motion exercises and enlist their help in exercising the patient when they visit 2. Observe the patient as you perform PROM. You may need to perform PROM in several short segments when the patient easily fatigues 3. Support the patient's limb above and below the joint that is to be exercised 4. Move the joint in a slow, smooth rhythmic manner. Avoid fast movements, as they may cause muscle spasm. 5. Never force a joint. Some patients may have limited range of motion. Move each joint until there is resistance, not pain. 6. Perform PROM at least twice daily. Move each joint through its range of motion three to five times with each session. Consider incorporating PROM into care activities—for example, while bathing or turning the patient 7. Return the joint to a neutral position when exercise is complete. 8. Encourage active exercise whenever possible.

Name and describe the different types of exercise programs.

1. Flexibility training -Stretching before exercise helps warm up the muscles and prevents injury during exercise. Stretching after exercise cools the muscles and limits post-exercise stiffness. 2. Resistance training -Movement against resistance increases muscular strength and endurance. Perhaps the most common type of resistance training is weight lifting. -Exercising for strength: Increase the amount of resistance with each exercise (i.e., lift more weight). -Exercising for endurance: Increase the number of repetitions with each exercise 3. Aerobic conditioning -Fitness and body composition are improved by aerobic conditioning. Components of aerobic conditioning include intensity, duration, frequency, and mode. Intensity is how hard one is exercising. -A well-rounded fitness program focuses on flexibility training, resistance training, and aerobic conditioning. The mode of exercise is the type of activity. Aerobic (endurance) and muscle-strengthening (resistance) physical activities both promote better health -Amount of physical activity: Duration is the amount of time one is exercising. Frequency indicates how often one is exercising.

Describe the physical activity recommended for health promotion.

1. Flexibility training -stretching before exercise helps warms up the muscles and prevents injury during exercise 2. Resistance training -movement against resistance increases muscular strength and endurance 3. Aerobic conditioning -improvement of fitness and body composition

Describe the nursing assessment of physical activity.

1. Focused nursing history -nursing history focused on activity and exercise addresses usual activity, fitness goals, mobility problems, underlying health problems, lifestyle, and external factors. 2. Focused physical assessment -Important data to include in a physical assessment related to activity and exercise include vital signs, height, weight, body mass index, body alignment, joint function, gait, muscle strength, and activity tolerance. Before beginning the exam, be fully aware of the patient's mobility status and any restrictions in movement, pain, injury, or otherwise. As you move through the exam, observe for pain, inflammation, and mobility limitations in all areas.

Name the three purposes of the skeletal system.

1. Forms the framework of the body 2. Protects the internal organs 3. Produces red blood cells 4. Serves as a storage site for calcium 5. Works with the muscles to cause movement

Name and describe the different patient positions.

1. Fowler's -semi-sitting position, in which the head of the bed is elevated 45° to 60°. This position promotes respiratory function by lowering the diaphragm and allowing the greatest chest expansion. It is also an ideal position for some patients with cardiac dysfunction. -Semi-Fowler's position, in which the head of the bed is elevated only 30 -High-Fowler's position, in which the head is elevated 90°. -Orthopneic position, the head of the bed is elevated 90° and an overbed table with a pillow on top is positioned in front of the patient. Have the patient lean forward, resting his arms and head on the pillow. This position is helpful for a patient with shortness of breath. 2. Lateral -side-lying position with the top hip and knee flexed and placed in front of the rest of the body. The lateral position creates pressure on the lower scapula, ilium, and trochanter but relieves pressure from the heels and sacrum. -Lateral recumbent position is side-lying with legs in a straight line (see Table 22-1). -Oblique position is an alternative to the lateral position that places less pressure on the trochanter. The patient turns on the side with the top hip and knee flexed; however, the top leg is placed behind the body 3. Prone -patient lies on his abdomen with his head turned to one side. This is the only position that allows full extension of the hips and knees. It also allows secretions to drain freely from the mouth and thus is helpful for an unconscious patient. 4. Sims' -semiprone position where the lower arm is positioned behind the patient, and the upper arm is flexed. The upper leg is more flexed than the lower leg. Sims' position facilitates drainage from the mouth and limits pressure on the trochanter and sacrum. This is an ideal position for administering an enema or a perineal procedure 5. Supine -dorsal recumbent position, the patient lies on his back with head and shoulders elevated on a small pillow. The spine is aligned with the arms and hands comfortably rest at the side.

Describe the following positions: Fowler's, lateral, prone, Sims', and supine.

1. Fowler's position is a semi-sitting position. The head of the bed is elevated 45° to 60° 2. Lateral position is a side-lying position with the top hip and knee flexed and placed in front of the rest of the body 3. Prone position is a position in which the patient lies on his stomach, with his head turned to one side 4. Sims' position is a semiprone position. The lower arm is positioned behind the patient and the upper arm is flexed. The upper leg is more flexed than the lower leg 5. Supine position, also known as the dorsal recumbent position, is a position in which the patient is placed on his back with the head and shoulders elevated on a small pillow. The spine is aligned and the arms and hands comfortably rest at the side.

Name the benefits of exercise.

1. Improves cardiovascular health 2. Increases muscle tone and flexibility 3. Enhances immune system 4. Promotes weight loss 5. Decreases stress/increases overall feeling or well-being -Regular physical activity each week, sustained for months and years, can produce long-term health benefits. Strong evidence links regular physical activity with a lower risk for early death, heart disease, stroke, type 2 diabetes, hypertension, hyperlipidemia, metabolic syndrome, colon and breast cancers, and depression. -Along with a nutritious diet, social engagement, and mentally stimulating activities, physical activity is associated with a reduced risk of cognitive decline and Alzheimer's disease

Identify the assessment methods (inspection, palpation, percussion, and auscultation) used when performing a physical examination focused on mobility concerns.

1. Inspect each joint for swelling, erythema, asymmetry, or obvious deformity. Compare the size of the muscles above and below the joint and on each side of the body. 2. Palpate the joint for temperature and crepitus. Warmth over a joint indicates inflammation or infection. Be sure to compare body temperature over several joints and right to left. As you palpate the joint, move it through its range of motion 3. Auscultation is part of the physical assessment for mobility and range of motion. Listen for crepitus, which is a grating sensation when the joint is moved. It can often be heard as well as felt.

Name and describe the types of exercises.

1. Isometric -involves muscle contraction without motion. These exercises are usually performed against an immovable surface or object; for example, pressing the hand against a wall. Each position is held for 6 to 8 seconds and repeated 5 to 10 times. Isometric training is effective for developing total strength of a muscle or group of muscles. It requires no special equipment and there is little chance of injury. Patients who are bed bound can use isometric exercise to maintain or regain muscle strength. 2. Isotonic -involves movement of the joint during the muscle contraction. A classic example of an isotonic exercise is weight training with free weights. As the weight is moved throughout the range of motion (ROM), the muscle shortens and lengthens. Calisthenics, such as pull-ups, push-ups, and planks, all of which use body weight as the resistance force, are also isotonic exercises. 3. Isokinetic -performed with specialized apparatuses that provide variable resistance to movement. Isokinetic exercise combines the best features of both isometrics and weight training by providing resistance at a constant speed while the muscle moves through the full ROM. Machines available at health clubs and physical therapy departments are used for this form of exercise 4. Aerobic -occurs when the amount of oxygen taken into the body meets or exceeds the amount of oxygen required to perform the activity. Aerobic exercise uses large muscle groups, can be maintained continuously, and is rhythmic in nature. It increases the heart and respiratory rates, thereby providing exercise for the cardiovascular system while simultaneously exercising the skeletal muscles. Jogging, brisk walking, and cycling are common forms of aerobic exercise. 5. Anaerobic -occurs when the amount of oxygen taken into the body does not meet the amount of oxygen required to perform the activity. Therefore, the muscles must obtain energy from metabolic pathways that do not use oxygen. Rapid, intense exercises such as lifting heavy objects and sprinting are examples of anaerobic exercise.

Name and describe the concepts of physical activity and immobility.

1. Mobility -body movement 2. Fitness -ability to carry out activities of daily living with vigor and alertness, without undue fatigue, and with enough energy for leisure pursuits and to respond to emergencies 3. Physical Activity -body movement produced by the contraction of skeletal muscle that increases energy expenditure about a baseline level 4. Exercise -sub concept of physical activity -planned, structured, repetitive, and purposeful for improving or maintaining the physical fitness, physical performance, or health

Name and describe the methods for moving a patient in bed.

1. Moving up in bed -Frail patients slide down in bed because of gravity and their inability to correct their position. Elevating the head of the bed accentuates the slide and places the patient in an awkward position. If the patient is light in weight or able to assist, you will be able to move her independently. 2. Turning in bed -most important intervention to protect a patient's skin and prevent other complications of immobility. For efficient use of time, try to time turning to coincide with moving the patient up in bed. Pillows and other positioning devices help the patient maintain the new position 3. Logrolling -special turning technique used when the patient's spine must be kept in straight alignment. Logrolling moves the patient's body as a unit

Name the methods for assisting wit ambulation.

1. Physical conditioning -Patients who have been confined to bed for more than a week or who have sustained major injury require conditioning before they are able to resume walking. Conditioning exercises include: -Quadriceps and gluteal drills: The quadriceps muscle group and the gluteal muscles are the largest muscles of the body. Patients who are confined to bed can perform isometric exercises to prepare them for walking. -Arm exercises: Patients use the biceps and triceps muscles when getting out of bed and for crutch walking. Be mindful of any cardiac or musculoskeletal precautions that restrict arm movement, weight bearing on the hands and wrists, or other upper body injury. If lymphedema is present in the upper extremities, do not encourage arm exercises or use of the trapeze, unless directed by the primary care provider. -Dangling: Use this position to prepare the patient to get up in a chair, stand, or ambulate. Patients who have been confined to bed frequently become light-headed or develop orthostatic hypotension when first getting up. Dangling allows the patient to experience being upright with limited risk of falling. 2. Assistive devices -Cane, walker, braces, crutches

Name methods for promoting activity.

1. Proper alignment of hospital bed 2. Use of range of motion 3. Incorporation of pillows, wedges, side rails, overhead trapeze, footboard, sandbags/trochanter rolls, splints -Healthy people regularly shift position to maintain comfort. However, many patients are unable to move without assistance. They require a change of position at least every 2 hours to prevent skin breakdown, muscle discomfort, damage to superficial nerves and blood vessels, and contractures. Immobile people are more prone to pressure injury as a result of reduced circulation, impaired oxygen exchange to the tissues, and edema. Devices may be needed to maintain body alignment, prevent contractures, and promote comfort.

What action should you take if a patient begins to fall when ambulating?

1. Protect the patient as you guide him to a seated or lying position 2. Create a wide base of support and project the hip closest to the patient forward 3. Assist the patient to slide down your leg as you call for help 4. Protect the patient's help as his body descends

Describe activities that can promote a patient's readiness for ambulation.

1. Quadriceps and gluteal drills. The quadriceps muscle group and the gluteal muscles are the largest muscles of the body. When practicing good body mechanics, you use these muscles to lift objects to protect your back. Patients who have been confined to bed can perform isometric muscles in bed to increase muscle tone and facilitate the transition to ambulation. Ask the patient to tighten her thigh muscles by pushing downward with her knees and flexing her feet. Hold the position for a count of five and then relax. Repeat this process two to three times per hour during the waking hours. To exercise the gluteal muscles, ask the patient to pinch her buttocks together. Repeat this exercise when the patient exercises the quadriceps muscles. Instruct the patient not to hold her breath as she exercises. 2. Arm exercises. The arm muscles are used when getting out of bed and for crutch walking. To prepare the patient for ambulation, install a trapeze bar. The trapeze bar exercises the biceps muscles. To exercise the triceps muscles, ask the patient to lift his upper body off the mattress by firmly pressing down with the palms. Push-ups can also be done from a seated position at the side of the bed or from a stationary chair or wheelchair. 3. Dangling. Dangling is a seated position at the side of the bed. The patient can rest his feet on the floor or a footstool. This position readies the patient to get up in a chair, to stand, or to ambulate. Patients who have been bedridden frequently become lightheaded or develop orthostatic hypotension when first getting up. Dangling allows the patient to experience being upright with limited risk of falling. As a result, patients should not be moved further unless they are comfortable and stable in the dangling position. 4. Daily activities. Encourage your patient to be active in bed and get out of bed into the chair prior to attempting to walk. Performing ADLs exercises many of the muscle groups used in ambulation. Getting up to the chair readies the patient for an upright posture and is an important predictor of success with ambulation.

Discuss the physiology of movement.

1. Skeletal system -bones -joints -cartilage, ligaments, tendons 2. Muscles -skeletal muscle -smooth muscle -cardiac muscle 3. Motor nervous system -autonomic nervous system -somatic nervous system

Give at least five guidelines for good body mechanics.

1. Stand in good alignment with a wide base of support 2. Minimize bending and twisting -these moments cause an increase in the amount of stress on the back -instead, face the object and bend at the hips or squat -avoid being at the waits 3. Squat or lift heavy objects from the floor -push against the strong hip and thigh muscles to raise yourself to a standing position 4. When lifting or moving an object, the closer it is to the center of gravity, the greater stability -keep object close to your body when you lift, move, or carry items 5. Use both hands and arms when you lift, move, or carry heavy objects 6. Raise the height of the bed and bedside table to waist level when you are working with a patient 7. Face objects or persons you are workin with rather than twisting 8. When possible, keep your elbows bent when carrying an object 9. Use the muscles in your legs as the power for lifting -bend your knees, keep your back straight, and lift smoothly -repeat the same movements for setting the object down 10. If a ladder or step stool is required to reach an object, make sure it is stable and adequate to position your body close to the object -do not stand on tiptoes to reach an object 11. Push, slide, or pull heavy objects whenever possible rather than lift them 12. Make sure you have a good grip on the patient or objects you are moving before attempting to move the patient or object 13. Work with smooth and even movements -avoid sudden or jerky movements 14. Assess the objects or patient you are going to lift -if you have any doubt that you can do it by yourself, get help from a cowoker

Name and describe tests for determining exercise intensity.

1. Target heart rate (THR) method -calculated from an estimate of the maximum heart rate (EMHR) -estimated heart rate is calculated using the following formula: EMHR = maximum heart rate (MHR) - age 2. Talk test -reflects exercise intensity based on the person's ability to talk while exercising -short phrases interspersed with breaths or feelings like you can "just respond" is considered an appropriate level of exercise -if you are too short of breath to answer, the level of intensity is too high -an ability to carry on a conversation indicates that you are not exercising vigorously enough 3. Borg Rate of perceived exertion scale -RPE scale is easy to use -a person who is exercising selects the rating based on how difficult the exercise feels at the time -exerciser selects one of eight categories that best describes the intensity of activity -RPE ratings range from No Exertion at All to Extremely Hard

What are the signs and symptoms of a fracture?

1. Tenderness at the site 2. Loss of function 3. Deformity of the area 4. Swelling of the surrounding tissues 5. Linear bruising -Diagnosis is confirmed by x-ray. Treatment of a fracture is stabilization until the body can create enough new bone to support function. The type and severity of fracture determine whether casting or surgical repair is necessary.

Identify five crutch gaits.

1. Two-point gait 2. Three-point gait 3. Four-point gait 4. Swing-to gait 5. Swing-through gait -Two-point and four-point gaits are used for partial weight-bearing. -Three-point gait is used for non-weight-bearing. -Swing-to and swing-through are used when weight-bearing is permitted.

Name and describe the methods for helping a client out of bed.

1. Use of transfer board -reduces your risk of injury and promotes a smooth transfer. Place the board under the patient on the side to which he will be moved. It is best to use a drawsheet to slide the patient across the board. Transfer boards are also used by patients with long-standing mobility problems to increase their independence. 2. Mechanical lift -hydraulic device used to transfer patients. Place a fabric sling under the patient; and attach chains or straps from the sling to the lifting device. -A mechanical lift is especially useful when providing care for obese and immobile patients. -Lifts are often used in home care because they allow one person to transfer the patient safely. -Most lifts position patients in a seated position and thus are ideal for assisting the patient into a chair. -Others suspend the patient in a supine position; they may be used to transfer the patient from bed to stretcher or to suspend the patient while the bed is made. -Many include scales that weigh the patient while he is suspended in the sling. -Some mechanical lifts are mounted on the ceiling to reduce caregiver back injuries and increase patient safety 3. Transfer belt -heavy belt that is used to facilitate transfer or provide a secure mechanism to hold the patient for ambulation. 4. Standing assist devices -mechanical lifts that help the patient move from a sitting to a standing position or support a patient in the standing position. A sling is positioned around the back and under the arms of the patient. Specialized chairs and wheelchairs are also available. Each has a mechanical lift in the seat that rises to assist the patient to a standing position. Mechanical lift devices reduce the risk of back and musculoskeletal injury.

Name the body mechanics for avoiding injury.

1. Use proper alignment 2. Have a wide base of support 3. Avoid bending and twisting 4. Squatting lift 5. Keep objects close when lifting 6. Raise beds 7. Push versus lift 8. Get help

Describe a focused assessment for patient experiencing mobility concerns.

A nursing history focused on activity and exercise assesses past and current activity, as well as future plans. The history addresses the following topics: • Usual activity • Fitness goals • Mobility concerns • Underlying health concerns • Lifestyle • External factors A physical examination focused on activity and exercise assesses the musculoskeletal system and activity tolerance. Important data include vital signs, pain assessment, height, weight, body mass index, body alignment, joint function, gait, and activity tolerance

Describe the benefits and risks of exercise.

Benefits: -lower risk for early death, heart disease, stroke, diabetes, hypertension, hyperlipidemia, metabolic syndrome, colon/breast cancer, and depression Risks: 1. Cardiac injury -Fear of triggering a cardiac event deters some people from exercising. However, physical activity is rarely life-threatening, especially when compared with health risks related to sedentary lifestyle and a low level of fitness 2. Musculoskeletal injury -High-impact exercises may pose a risk for injury to bones, joints, and muscles. However, you can prevent most such injuries by ensuring proper body alignment as well as gradually increasing the activity level or varying activities. Weight lifting using correct form and appropriate weights markedly reduces the risk for injury. 3. Dehydration -Fluid and electrolyte loss occurs with prolonged exercise, high ambient temperature, certain medications, and underlying health problems. Keep in mind that water is the best choice during and after most exercise. Some sports drinks contain glucose and electrolyte replacement for endurance activities or vigorous activity. 4. Temperature regulation -Hyperthermia can occur when the person exercises in a hot climate. Hyperthermia is often accompanied by dehydration. -Heat exhaustion is a potentially life-threatening event. Signs of heat exhaustion include light-headedness, nausea, headache, fatigue, hyperventilation, loss of concentration, abdominal cramps, elevated temperature, and cold, clammy skin. -Hypothermia can occur when the person does not wear proper clothing or is exposed to cool water for an extended time. It is characterized by fatigue, confusion, and lack of coordination

Define body mechanics. Name and describe the principles of body mechanics.

Body mechanics is a term used to describe the way we move our bodies. It includes four components: body alignment, balance, coordination, and joint mobility. 1. Body alignment -posture, is an important aspect of body mechanics. Proper posture places the spine in a neutral (resting) position. There are four natural curves to the spine (Fig. 32-3). Proper posture maintains these natural curves because it allows movement to occur with less stress and fatigue; the bones are aligned, and the muscles, joints, and ligaments can work at peak efficiency. Good posture contributes to the normal functioning of the nervous system and improves feelings of well-being. 2. Balance -For your body to be balanced, your line of gravity must pass through your center of gravity, and your center of gravity must be close to your base of support. The line of gravity is an imaginary vertical line drawn from the top of the head through the center of gravity. The center of gravity is the point around which mass is distributed. In the human body, the center of gravity is below the umbilicus at the top of the pelvis. The base of support is what holds the body up. The feet provide the base of support. KEY POINT: The broader the base of support, the lower the center of gravity, and the easier it is to maintain balance. 3. Coordination -Smooth movement requires coordination between the nervous system and the musculoskeletal system. Cerebral cortex—Initiates voluntary movement. Cerebellum—Coordinates movements; largely responsible for controlling proprioception, the awareness of posture, movement, and position sense. Basal ganglia—Located deep in the cerebrum, assist with coordination of movement. Damage to the motor cortex, cerebellum, or basal ganglia affects coordination of movement. For example, a stroke affecting the motor cortex alters gait and changes posture. 4. Joint mobility -allows us to sit, stand, bend, walk, and perform other activities. Range of motion (ROM) is the maximum movement possible at a joint. Active range of motion (AROM) is movement of the joint performed by the individual without assistance. Passive ROM (PROM) involves moving joints through their ROM when the patient is unable to do so for himself.

Of the following interventions for the client who is immobile, the nurse will give priority to: A. Encouraging a diet high in fiber and extra fluids B. Administering the prn medication for sleep C. Having the client use the incentive spirometer q 2 hrs D. Massaging the client's legs every hour

C. Having the client use the incentive spirometer q2hr -Use of the incentive spirometer helps to prevent atelectasis, which improves oxygenation—a priority need.

Identify the true statement about devices used when assisting clients to ambulate. A. The client should stand a foot back from the back legs of a walker. B. A cane should be used by the client to support the weakest side of the body. C. A transfer belt should be placed around the client's chest for maximum lift. D. Each crutch-walking gait begins with the client in the tripod position.

D. Each crutch-walking gait begins with the client in the tripod position -The tripod position is the basic crutch standing position from which the client then moves forward.

Describe the physiology of movement.

Depend on the successful interaction among the skeleton, muscles, and nervous system 1. Skeletal system -includes bones, cartilage, ligaments, and tendons -skeleton forms the framework of the body, protects the internal organs, produces blood cells, and stores mineral salts (e.g. calcium) and fat -bones feel strong and tough so it is easy to forget that they are composed of living tissue that is constantly building and remodeling -osteoclasts are specialized cells that function as housekeepers in the bone by breaking down old or damaged tissue -osteoblasts repair damaged bone and build new bone to keep the skeleton strong -delicate balance exists between the actions of the osteoclasts and osteoblasts -when two bones come close together (articulate), a joint is formed -body movement occurs at the joints -joints are classified based on the amount of movement they permit -synarthroses are immovable joints (e.g. structures between the cranial bones. In youth these joints have some flexibility to allow growth, but they gradually become rigid -amphiarthroses allow for limited movement. Examples are the joints between the vertebrae and the pubic bones -diarthroses, or synovial joints are freely movable because of the amount of space between the articulating bones are covered with smooth articulate cartilage (connective tissue found in the joints and skeleton). The synovial fluid and articulate cartilage prevent friction as the bones move 2. Muscles -attach to bone at two points: (1) at the point of origin, to the more stationary bone, and (2) at the point of insertion, to the more movable bone. The "belly" (thickest part) of the muscle lies between these two points. When a skeletal muscle contracts, it shortens, thus causing one bone to move at the joint. Muscles work in pairs. For example, the biceps brachii contracts to flex the forearm (bend the elbow joint). When the biceps contracts, the opposing muscle, the triceps brachii, relaxes. Similarly, contraction of the triceps is associated with relaxation of the biceps 3. Motor nervous system -controls the movement of the musculoskeletal system. Motor nerves are either autonomic or somatic. The autonomic nervous system consists of the sympathetic and parasympathetic nervous systems, which innervate involuntary muscles, such as the heart, blood vessels, and glands. The somatic nervous system innervates the voluntary skeletal muscles. When you make a conscious decision to bend your elbow, the thought originates in the motor area of your cerebral cortex. The upper motor efferent nerves communicate with the lower motor neurons that conduct impulses to the muscles. When the muscle receives sufficient stimuli, it contracts the biceps as the triceps relaxes and moves the elbow. -Movement also occurs through reflex mechanisms. Common reflexes include the knee-jerk reflex and corneal reflex.

Why might immobility be referred to as a stressor?

Immobility might be referred to as a stressor because it triggers the release of epinephrine and norepinephrine, thyroid hormones, adrenocorticotropic hormone from the pituitary gland, and aldosterone from the kidneys. These changes in hormone levels are the same as the stress response, letting us see that immobility can be a stress in itself.

What are three effects of immobility on the GI system?

Immobility slows peristalsis, which often leads to constipation, gas, and difficulty evacuating stool from the rectum. In extreme circumstances, a paralytic ileus (cessation of peristalsis) may occur. With peristalsis slowed, appetite diminishes and food that is consumed is digested slowly. The net effect is usually decreased caloric intake and inability to meet the protein demands of the body. Body muscle is broken down as a fuel source, and further wasting occurs.

What criteria determine whether your patient should be logrolled when he is repositioned?

Logrolling is a special technique used when the patient needs to maintain the spine in straight alignment

Compare the effects of exercise on the body.

Lower risk for early death, heart disease, stroke, type 2 diabetes, hypertension, hyperlipidemia, metabolic syndrome, colon and breast cancers, and depression

What changes in mood might be seen with immobility?

Patients who are in bed (immobile) for long periods of time can suffer depression, anxiety, hostility, sleep disturbances, and changes in their ability to perform self-care activities, as well as disorientation and apathy.

Define paraplegia.

paralysis of the lower portion of the trunk and both legs

Name methods for promoting exercise.

⮞ Choose a variety of exercises that you enjoy and feel comfortable doing, such as walking, biking, dancing, or a team sport. Find an accountability partner. A fitness program is not only more enjoyable when shared with someone else but also is more successful with others for whom you are accountable. Make exercise fun. Find fun things to do, such as taking a walk through the park or watching your favorite show while riding a stationary bike. ⮞ Vary your routine. You may be less likely to get bored or injured. ⮞ Choose a comfortable time of day. ⮞ Don't get discouraged. It can take weeks or months before you notice some of the changes from exercise. ⮞ Forget "no pain, no gain." Although a little soreness is normal after you first start exercising, pain isn't. Stop if you hurt. ⮞ Sign a contract committing yourself to exercise. ⮞ Keep a daily log of your activities. ⮞ Consider joining a health club or community fitness program. The cost gives some people an incentive to exercise regularly. ⮞ Accumulate physical activity throughout the day. For example: -Take the stairs instead of the elevator. -Go for a walk during your coffee break or lunch. -Walk all or part of the way to work. -Park your car at the far end of the parking lot. ⮞ Wear good, shock-absorbing footwear. Shoes that do not support your feet will cause stress on leg bones and the back and, over time, lead to injury. ⮞ Warm up your muscles for 5 to 10 minutes before your main session of aerobic exercise. ⮞ Maintain your exercise intensity for 30 to 45 minutes, if you can. ⮞ Gradually decrease the intensity of your workout (cool down) and then stretch for 5 to 10 minutes at the end of your workout. ⮞ Alternate easy and hard exercise days, or alternate modes of exercise (e.g., alternate running, swimming, and biking). ⮞ Take a day off periodically. The body needs a chance to rest and allow bones, joints, and muscles to rest and repair. ⮞ To avoid becoming dehydrated, drink at least 8 ounces of fluid before the exercise, and then pause regularly during the exercise for more. If you are thirsty after the exercise session, drink until you feel satiated. Water is still the best liquid to drink during and after exercise. However, you can't rely on feeling thirsty as a reminder to replace fluid lost through sweating; one of nature's dirty tricks is that exercise suppresses thirst

Name, describe, and provide examples of the types of synovial joints.

1. Ball-and-socket -a rounded head (ball) fits into a cup-like structure (socket) to allow movement in all plane in addition to rotation -ex: shoulder and hip joints 2. Condyloid -an oval-shaped bone fits into a elliptical cavity to allow movement in two planes at right angles to each other -ex: wrist 3. Gliding -two flat plane surfaces move past each other -ex: intervertebral joints 4. Hinge -a convex surface fits into a cavity, allowing flexion and extension -ex: knee and elbow 5. Pivot -the joint is formed by a ring-like object that turns on a pivot -motion is limited to rotation -ex: atlas and axis of the first vertebrae and base of the skull 6. Saddle -one bone surface is concave in one direction and convex in the other -other surface has the opposite construction so that the bones fit together -movement is possible in two planes at right angles to each other -ex: carpal-metacarpal joint of the thumb

Identify four components of body mechanics.

1. Body alignment 2. Balance 3. Coordination 4. Joint mobility

Discuss the concepts of body mechanics.

1. Body alignment 2. Balance -line of gravity -center of gravity -base of support 3. Coordination -cerebral cortex -cerebellum -basal ganglia 4. Joint mobility -range of motion (ROM) -active range of motion (AROM) -passive ROM (PROM)

Name and describe the benefits of regular exercise.

1. Cardiovascular system: -increase pumping action of the heart -increase circulation by increasing the number of capillaries -increase venous return to the heart -increase blood volume and hematocrit -increase high-density lipoprotein (HDL) -decrease low-density lipoprotein (LDL) and total cholesterol -decrease risk of thrombophlebitis -decrease heart rate, heart rate variability, and blood pressure 2. Respiratory system: -increase pulmonary circulation -increase gas exchange at the alveolar-capillary membrane and overall aerobic capacity -dilates bronchioles to increase ventilation 3. Musculoskeletal system: -increase skeletal development in children -increase muscle mass, strength, power, and endurance -increase flexibility -increase coordination -helps maintain joint structure and function -increase bone mass and mineral density -increase gait speed, stability, and balance -increase bone mass with aging. reduces risk of osteoporosis -decrease risk of falls and helps older adults maintain an independent lifestyle -reduces risk of osteoporosis 4. Nervous system: -increase nerve impulse transmission -increase reaction time -decrease sympathetic response to exercise 5. Endocrine system: -increase sensitivity to insulin at the receptor sites -increase the efficiency of metabolic processes -increase temperature regulation -facilitates weight management -decreased adipose surrounding organs 6. Gastrointestinal system -increase appetite -increase abdominal muscle tone -decrease risk of colon cancer 7. Urinary system: -increase efficiency of kidney function 8. Integumentary system: -increase skin tone as a result of improved circulation 9. Immune system: -decrease susceptibility to minor viral illnesses -decrease systemic inflammation 10. Mental health: -increases energy level -increase endorphins, which assist with pain control and stress management -increase self-esteem and body image -increase nonpharmacological relief of symptoms of anxiety and depression -increase positive outlook and sense of optimism -increase clearer thinking and improved memory in older adults -increase feelings of well-being and diminishes depressive symptoms -increase social interaction -decrease some stress 11. Overall health -increase caloric expenditure to achieve and maintain healthy body weight -increase overall stamina -increase sleep time and sleep quality -decrease abdominal obesity -decrease fatigue

What types of disorders limit activity to mobility?

1. Congenital abnormalities of the musculoskeletal system 2. Disorders of bone formation, integrity, metabolism, or joint mobility 3. Disorders of the central nervous system or other body systems that produce fatigue, shortness of breath, or impaired circulation

Name musculoskeletal system disorders.

1. Congenital anomalies of the musculoskeletal system 2. Diseases related to bone formation or metabolism 3. Diseases affecting joint mobility 4. Problems affecting bone integrity 5. Trauma 6. Disorders of the central nervous system

What are three uses for siderails?

1. Ensure patient safety 2. Provide a grip for the patient who is able to reposition himself in bed 3. Provide a sense of security or the patient in bed

State the components of an exercise program.

1. Flexibility 2. Resistance training 3. Aerobic conditioning

Describe the five types of exercise.

1. Isometric exercises -involve muscle contraction without motion 2. Isotonic exercise -involves movement of the joint during the muscle contraction 3. Isokinetic exercise -performed with specialized apparatus that provide variable resistance to movement 4. Aerobic exercise -acquires energy from metabolic pathways that use oxygen - the amount of oxygen taken into the body meets or exceed the amount of oxygen required to perform the activity 5. Anaerobic exercise -amount of oxygen taken into the body does not meet the amount of oxygen required to perform the activity

Identify and describe the four types of exercise.

1. Isometric exercises: -involve muscle contraction without motion. They are usually performed against an immovable surface or object. For example, when pressing the hand against a wall, the muscles of the arm contract but the wall does not move. Each position is held for 6 to 8 seconds with 5 to 10 repetitions. Isometric training is effective for developing total strength of a particular muscle or group of muscles. It is often used for rehabilitation because the exact area of muscle weakness can be isolated and strengthening can be administered at the proper joint angle. This kind of training requires no special equipment, and there is little chance of injury. Bedridden patients can use this form of exercise to maintain or regain muscle strength. 2. Isotonic exercises: -involves movement of the joint during the muscle contraction. A classic example of an isotonic exercise is weight training with free weights. As the weight is moved throughout the range of motion, the muscle shortens and lengthens. Calisthenics, such as chin-ups, push-ups, and sit-ups, all of which use body weight as the resistance force, are also isotonic exercises. 3. Isokinetic exercise: -utilizes machines that control the speed of contraction within the range of motion. Isokinetic exercise attempts to combine the best features of both isometrics and weight training by providing resistance at a constant preset speed while the muscle moves through the full range of motion. Specialized machines available at health clubs and physical therapy departments are used for this form of exercise. 4. Aerobic exercise: -acquires energy from metabolic pathways that use oxygen—the amount of oxygen taken into the body meets or exceeds the amount of oxygen required to perform the activity. Aerobic exercise uses large muscle groups, can be maintained continuously, and is rhythmic in nature. It increases the heart and respiratory rate, thereby providing exercise for the cardiovascular system while simultaneously exercising the skeletal muscles 5. Anaerobic exercise: -occurs when the amount of oxygen taken into the body does not meet the amount of oxygen required to perform the activity. Therefore, the muscles must obtain energy from metabolic pathways that do not use oxygen. Rapid, intense exercises, such as lifting heavy objects or sprinting, are examples of anaerobic exercise.

Identify three types of muscles.

1. Skeletal muscle -move the skeleton 2. Smooth muscle -found in the digestive tract and other hollow structures, such as the bladder and blood vessels, produces movement of food through eh digestive tract, urine through the urinary tract, and blood through the circulatory system 3. Cardiac muscle -unique form of muscle that possesses the ability to contract spontaneously -responsible for the beating of the heart

What type of cane should a patient with significant balance problems use?

A multipronged cane should be used by a patient with a balance problem

To maintain proper posture, it is important to ___.

Avoid arching shoulders forward when sitting -arching shoulders forward while sitting alters the curvature of the spine and contributes to poor body alignment

In which age-groups are you more likely to see health concerns that affect mobility?

Health concerns that affect mobility may occur throughout the life span. Congenital problems (e.g., hip dysplasia, club foot) are usually identified and treated in infancy. In contrast, degenerative problems (e.g., osteoporosis) are more likely in older adults.

How often should you turn and reposition a patient?

Patients should be turned at least every 2 hours to protect their skin and prevent problems associated with immobility. Turning is often done at the same time the patient is moved up in bed

What is the difference between a strain and a sprain?

Strain: -injury to a muscle caused by excessive stress on the muscle Sprain: -stretch injury of a ligament that causes the ligament to tear

When are forearm support crutches used?

The forearm support crutch is more likely to be used by a patient with permanent limitations.

What is the advantages of the oblique position versus the lateral position?

The oblique position is an alternative to the lateral position that places less pressure on the trochanter. The patient turns on the side with the top hip and knee flexed, but the top leg is placed behind the body

Define atrophy.

decrease in size of muscle tissue due to lack of use or loss of innervation.

Define flaccidity.

decrease or absence of muscle tone

Define hypertrophy.

increase in the size or bulk of a muscle or organ

Define tremor.

involuntary quivering movement of a body part

Define spasticity.

motor disorder characterized by increased muscle tone, exaggerated tendon jerks, and clonus

Define paresthesia.

numbness, tingling, or burning due to injury of the nerve(s) innervating the affected area

Define quadriplegia.

paralysis of all four extremities

Define hemiplegia.

paralysis of one side of the body

Define paresis.

partial or incomplete paralysis

Define clonus.

spasmodic contraction of opposing muscles resulting in tremors