Chapter 33 - Activity

A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? (A) Carefully assessing the patient care environment (B) Using two nurses to lift a patient who cannot assist (C) Wearing a back belt to perform routine duties (D) Properly documenting the patient lift

(A) Carefully assessing the patient care environment Rationale: Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and movement should be documented but are not the primary focus of interventions related to injury prevention.

A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. (A) Instruct the patient to avoid sudden position changes that may cause dizziness. (B) Recommend that the patient restrict fluid until after exercising is finished. (C) Instruct the patient to push a little further beyond fatigue each session. (D) Instruct the patient to avoid exercising in very cold or very hot temperatures. (E) Encourage the patient to modify exercise if weak or ill. (F) Recommend that the patient consume a high-carb, low-protein diet.

(A) Instruct the patient to avoid sudden position changes that may cause dizziness. (D) Instruct the patient to avoid exercising in very cold or very hot temperatures. Rationale: Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet.

A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. (A) Stop performing the exercises. (B) Decrease the number of repetitions performed. (C) Reevaluate the nursing care plan. (D) Move to the patient's other side to perform exercises. (E) Encourage the patient to finish the exercises and then rest. (F) Assess the patient for other symptoms.

(A) Stop performing the exercises. (C) Reevaluate the nursing care plan. (F) Assess the patient for other symptoms. Rationale: When a patient complains of fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the nursing care plan, and assess the patient for further symptoms. The exercises could then be scheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day.

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? (A) Support weight on stronger leg and cane and advance weaker foot forward. (B) Hold the cane in the same hand of the leg with the most severe deficit. (C) Stand with as much weight distributed on the cane as possible. (D) Do not use the cane to rise from a sitting position, as this is unsafe.

(A) Support weight on stronger leg and cane and advance weaker foot forward. Rationale: The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.

A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? (A) 2 (B) 4 (C) 5 (D) 6

(B) 4 Rationale: The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding.

A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? (A) A 4-month-old infant who is unable to roll over (B) A 6-month-old infant who is unable to hold his head up himself (D) An 11-month-old infant who cannot walk unassisted (E) An 18-month-old toddler who cannot jump

(B) A 6-month-old infant who is unable to hold his head up himself. Rationale: By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. (A) Do full-body pushups in bed six to eight times daily. (B) Breathe in and out smoothly during quadriceps drills. (C) Place the bed in the lowest position or use a footstool for dangling. (D) Dangle on the side of the bed for 30 to 60 minutes. (E) Allow the nurse to bathe the patient completely to prevent fatigue. (F) Perform quadriceps two to three times per hour, four to six times a day.

(B) Breathe in and out smoothly during quadriceps drills. (C) Place the bed in the lowest position or use a footstool for dangling. (F) Perform quadriceps two to three times per hour, four to six times a day. Rationale: Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadriceps two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs.

A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? (A) Supination (B) Dorsiflexion (C) Hyperextension (D) Abduction

(B) Dorsiflexion Rationale: For a patient who has footdrop, the nurse should support the feet in dorsiflexion and use a footboard or high-top sneakers to further support the foot. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions would not be used to prevent footdrop.

A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? (A) Use the axillae to bear body weight. (B) Keep elbows close to the sides of the body. (C) When rising, extend the uninjured leg to prevent weight bearing. (D) To climb stairs, place weight on affected leg first.

(B) Keep elbows close to the sides of the body. Rationale: The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg first when climbing stairs.

A nurse is caring for a patient in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? (A) Improved renal blood supply to the kidneys (B) Urinary stasis (C) Decreased urinary calcium (D) Acidic urine formation

(B) Urinary stasis Rationale: In a nonerect patient, the kidneys and ureters are level. In this position, urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder, resulting in urinary stasis. Urinary stasis favors the growth of bacteria that may cause urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to increased levels of urinary calcium and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.

A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? (A) Dorsal recumbent position (B) Lateral position (C) Fowler's position (D) Sims' position

(C) Fowler's position Rationale: Fowler's position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficulty breathing. Lying flat on the back or side or Sims' position would not facilitate respiration and would be difficult for the patient to maintain.

A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? (A) Have the patient extend his arms outward and cross his legs on top of a pillow. (B) Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. (C) Have the patient cross his arms on his chest and place a pillow between his knees. (D) Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.

(C) Have the patient cross his arms on his chest and place a pillow between his knees. Rationale: The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses.

A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action? (A) Wait a few minutes and then continue the move to the chair. (B) Call for assistance and continue the move with the help of another nurse. (C) Lower the patient back to the side of the bed and pivot her back into bed. (D) Have the patient sit down on the bed and dangle her feet before moving.

(C) Lower the patient back to the side of the bed and pivot her back into bed. Rationale: If a patient becomes faint and knees buckle when moving from bed to a chair, the nurse should not continue the move to the chair. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. Another attempt should be made with the assistance of another staff member if vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position, and avoid hypotension related to a sudden change in position.

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in which position? (A) Side-lying (B) Fowler's (C) Sims' (D) Prone

(D) Prone Rationale: The prone position is contraindicated in patients who have spinal problems because the pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine.

The nursing process - diagnosing

-Activity intolerance related to fatigue, generalized weakness and exertional discomfort -Impaired transfer mobility related to pain and musculoskeletal impairment -Risk for injury related to altered sensation, unsteady gait and confusion -Toileting self-care deficit related to weakness and impaired mobility -Risk for ineffective peripheral tissue perfusion related to sedentary lifestyle, tobacco use, obesity and salt intake

Factors influencing mobility

-Age and neuromuscular development influences body proportions, posture, body mass, movements and reflexes -Acute and chronic health conditions can affect a patient's posture, body proportions, movements and ability to perform self-care activities (activities of daily living [ADLs]) -Conditions such as depression can decrease energy and enthusiasm and ultimately affect mobility -Sedentary lifestyle can affect mobility abilities - this may also be linked to attitude and values -Chronic stress can deplete body energy -External factors such as environment and financial resources can indirectly impact mobility

A note on safe patient handling

-Back injuries affect a high number of nurses! -Results in lost wage and work productivity -May sometimes cause nurses to leave direct patient care -Can have psychological effects, including depression -Call to action by congress -2000 Ergonomic Standard by Occupational Safety & Health Administration (OSHA) -Requires employer to implement ergonomics program

Basic elements of body mechanics

-Body alignment -Posture -Balance -Base of support -Line of gravity -Center of gravity -Coordination

Principles of safe patient handling

-Body mechanics are the coordinated use of body parts to produce and maintain equilibrium -Good body mechanics prevent fatigue, reduce risk for injury and improve appearance -Nursing requires assisting many clients with movement and activity -It is essential that the nurse implement good body mechanics to reduce the risk of muscle strain, while assisting clients with activities

Side-lying or lateral position

-Comfortable alternate to the supine position -Choice position for patients with pressure on bony prominences of the back and sacral pressure sores -NOT used after hip replacement or other orthopedic surgery.

Guidelines for range of motion exercises

-Communicate procedure & purpose of each exercise to patient -Avoid overexertion -Avoid neck hyperextension -Start gradually & work slowly -Move each joint until there is resistance, but not pain -Support the joint during the exercise (i.e. support elbow) -Return the joint to the neutral position -Natural position of alignment -Use passive exercises as necessary, but encourage active participation

Moving the client up in bed

-Communicate procedure to patient -Assess client's body alignment, risk factors and ability to assist -Position bed in Trendelenburg (gravity assists) -Coordinate movements with client and assistance as needed -Use pull sheet/pad or if available to reduce friction and reduce shearing injuries -NEVER a one person task

Turning & repositioning

-Communicate procedure to patient -Assess client's body alignment, risk factors and ability to assist -Position bed to a comfortable working position -Log roll client to one side using hips and shoulders -Use additional pillows or supports while patient is on side -Maintain body alignment -NEVER a one person task

Transferring from bed to chair

-Communicate procedure to patient -Assess client's body alignment, risk factors and ability to help -Place chair next to bed on client's stronger side -Always ensure brakes are locked -Support client and assist with wide base of support -May use transfer belt and pivot -Never twist

Moving a client

-Communicate procedure to patient -Position bed accordingly -Assess client and room prior to moving -VS, tubes, drains, equipment -Brakes are to be locked at all times -Encourage patient participation whenever applicable -Use lift devices whenever possible

Ergonomics slide

-Derives from two Greek words: "ergon"-meaning work & "nomoi"- meaning natural laws -Science of work and a person's relationship to that work -Ergonomics is the practice of designing equipment and work tasks to conform to the capability of the worker and provides a means for adjusting the work environment and work practices to prevent injuries -Patient care ergonomics relates to designing equipment and work tasks in relation to patient care

Positioning patients in bed

-Foam wedges and pillows -Mattresses - special mattresses and pads to prevent pressure injuries -Adjustable beds -Trapeze bar

Anti-embolic stockings & pneumatic compression devices

-Help to prevent blood clots -Venous stasis and the development of venous thrombosis are potential complications of immobility -Stockings: -Improves venous return in lower extremities -Requires MD order (in the hospital; can buy at CVS) -Pneumatic: -Require MD order -Intermittent pump enhances blood flow

Additional considerations

-If patient < 200lbs use friction reduction device & 2-3 caregivers -200lbs or > use at least 3 caregivers & friction reducing device -These rules apply to patients that can offer some assistance in moving -If the patient cannot assist the caregiver at all, lift equipment is necessary

Effects of immobility on the body

-Impaired mobility is when an individual has a limitation in independent, purposeful physical movement of the body or of one or more extremities -May be temporary or chronic -Can lead to: -Increased workload of the heart -Increased risk of blood clots -Poor oxygenation (atelectasis) -Muscle atrophy (decreased muscle size) -Decreased flexibility -Contractures -Poor nutrition -Urinary tract infections -Kidney stones -Skin breakdown -Coping difficulties

Effects of exercise on major body systems

-Increases efficiency of the heart -Decreases heart rate and blood pressure -Improves venous return -Increases coordination -Reduces bone loss -Increases gastric motility -Weight may be controlled -Increases energy -Improves sleep -Improves self-concept

Types of exercise

-Isotonic: muscle shortening and active movement i.e. carrying out ADLs, independently performing range of motion (ROM) activities, swimming, walking, jogging and biking -Isometric: muscle contraction without shortening I.e. holding a yoga pose -Isokinetic: muscle contraction with resistance I.e. rehabilitative exercises for knee and elbow injuries, lifting weights

Supine or dorsal recumbent position

-Laying flat on the back -Allows for correct alignment -NOT used for patients with dyspnea or at risk for aspiration

Prone position

-Laying on abdomen -Helps to prevent flexion contractures of the hips and knees -Contraindicated with patients after abdominal surgery, or those who have respiratory or spinal problems.

Protective positioning

-Patients on bedrest are unaware of the importance of correct body alignment and regular position changes -Need to change position at least every 2 hours -Utilize position change timing to exercise extremities and assess pressure areas -Patients who are unable to change positions independently, use a turn schedule

Risks related to exercise

-Precipitation of a cardiac event pending chronic health conditions -Orthopedic discomfort and disability -Heat exhaustion -Pollution index

Assisting with range of motion exercises

-Range of Motion (ROM): complete extent of movement of which a joint is normally capable -Active exercise: patient independently moves joints through full ROM -Passive exercise: nurse moves each joint through its ROM

What happens if you are walking a patient and they complain of dizziness/fatigue?

-Safely guide them into a chair -In the future, use a two nurse assistance -One assists patient in walking -One follows behind patient with chair

Fowler's position

-Semi sitting (head is elevated 45 to 60 degrees) -Promotes cardiac and respiratory functioning -NOT used after spine or brain surgery

Variables that can lead to back injuries

-Uncoordinated lifts -Manual lifting and transferring patients without assistive devices -Lifting when fatigued -Lifting after recent recovery from a back injury -Repetitive movements such as lifting, transferring and repositioning patients -Standing for long periods of time -Transferring patients from beds to stretchers and chairs -Repetitive tasks (bed baths, changing linens) -Transferring/repositioning uncooperative or confused patients

Trendelenburg's position

-Used for postural drainage and to promote venous return

Lithotomy position

-Used for vaginal and rectal examination. -Difficult for clients with immobilizing arthritis or a joint deformity.

Mechanical aids for walking

-Walker: push walker ahead, step into the walker, one foot at a time; do not lean over walker; do not use on stairs -Cane: hold on strong side and advance one small stride ahead; advance weak foot first parallel with cane; then advance strong leg -Braces: support weakened leg muscles -Crutches

Proper body mechanics:

-Will not eliminate the chance for injury -Helps to reduce risk of injuries (especially lower back injuries)

A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: (A) Grasp the gait belt. (B) Stay with the patient and call for help. (C) Place feet wide apart with one foot in front. (D) Gently slide patient down to the floor, protecting her head. (E) Pull the weight of the patient backward against your body. (F) Rock your pelvis out on the side of the patient.

1. (C) Place feet wide apart with one foot in front. 2. (F) Rock your pelvis out on the side of the patient. 3. (A) Grasp the gait belt. 4. (E) Pull the weight of the patient backward against your body. 5. (D) Gently slide patient down to the floor, protecting her head. 6. (B) Stay with the patient and call for help. Rationale: If a patient being ambulated starts to fall, you should place your feet wide apart with one foot in front, rock your pelvis out on the side nearest the patient, grasp the gait belt, support the patient by pulling her weight backward against your body, gently slide her down your body toward the floor while protecting her head, and stay with the patient and call for help.

Prevention of issues for immobile patients

Encourage patient to: -Complete ADL's -Ambulate, turn, reposition -Complete ROM exercises -Cough and deep breathe -Prophylactic medications (e.g. Heparin) -Occupational Therapy focuses on the promotion of health and well-being through occupation. -Physical Therapy is concerned with providing services, where functions and movements are hampered by injury, disease, or environmental factors.

The nursing process - evaluating

Evaluate (while walking or performing ADLs): -General ease of movement and gait -Body alignment -Joint structure and function -Muscle mass, tone and strength -Endurance

Additional thoughts regarding ROM

Examples are: -Moving neck side to side- pausing in the middle (neutral position) -Touching each finger to thumb -Complete 2X per day; 3-5 repetitions -Do when bathing -Expect increase in HR & RR (respiratory rate) -If they don't return to resting values within 3 minutes, the exercise are too strenuous for the patient

True or false? A person lies on one's abdomen with one's head turned to the side when in the supine position.

False

True or false? Rehabilitative exercises that involve lifting weights are an example of an isometric exercise.

False

True or false? When the rounded head of one bone fits into a cup-like cavity in the other bone, the connection is referred to as a hinge joint.

False

The semi-sitting position, known as _____ position, calls for the head of the bed to be elevated 45 to 60 degrees.

Fowler's

High Fowler's position

Head of bed is elevated to 90 degrees

The nursing process - assessing

Nursing history: -Daily activity level -Endurance -Exercise and fitness goals -Mobility problems -Physical or mental health alterations that affect mobility Physical Assessment: -General ease of movement and gait -Alignment -Joint structure and function -Muscle mass, tone, and strength -Endurance

Do I need assistance?

One Patient Assist -Require minimal support -One individual provides support Two Patient Assist -Safer method to use -Use when uncertainty in patient's strength/ability to walk -Two healthcare providers provide support

The nursing process - implementing

Techniques to ensure safe patient handling and movement: -Plan first: assess patient & situation -Consider use of assistive devices if you are required to lift more than 35 lbs. of a patient's body weight -Communicate with the patient -Lift the bed to a comfortable working height -Face direction of movement: avoid twisting -Maintain balance: take a wide stance -Use large muscle groups (i.e. legs): avoid using your back, keep it straight -Phone a friend!

The nursing process - outcome identification & planning

The patient will: -Identify personal benefits of regular exercise -Demonstrate full range of joint motion (joint mobility) -Demonstrate adequate muscle mass, tone and strength to perform functional ADLs -Be free from alterations in skin integrity -Show signs of adequate venous return -Be free from contractures

True or false? Decreased muscle tone, also known as flaccidity, results from disuse or neurologic impairments and is described as a weakness or paralysis of the involved area.

True

True or false? Manual lifting, transferring and repositioning patients that involves most or all of a patient's weight is a high-risk activity for both nurses and patients

True

True or false? Quadriceps drills is an exercise in which muscle tension occurs without a significant change in the length of the muscle.

True

paralysis

absence of strength secondary to nervous impairment

range of motion

complete extent of movement of which a joint is normally capable

footdrop

complication resulting from extended plantar flexion

atrophy

decrease in the size of a body structure

flaccidity

decreased muscle tone; synonym for hypotonicity

isometric exercise

exercise in which muscle tension occurs without a significant change in muscle length (i.e., there is no movement or only a minimum shortening of muscle fibers); examples include contractions of the quadriceps and gluteal muscles, such as what occurs when holding a Yoga pose.

isokinetic exercise

exercise involving muscle contractions with resistance varying at a constant rate; examples include rehabilitative exercises for knee and elbow injuries and lifting weights

A _____ belt is placed around the patient's waist and secured by Velcro fasteners and can be used to assist a patient with ambulation.

gait

paresis

impaired muscle strength or weakness

spasticity

increased muscle tone

active exercise

joint movement activated by the person

passive exercise

manual or mechanical means of moving the joints

isotonic exercise

movement in which muscles shorten (contract) and move; examples include carrying out ADLs, independently performing range-of-motion exercises, and swimming, walking, jogging, and bicycling.

tonus

normal, partially steady state of muscle contraction

The process of bone demineralization, known as _____, is increased in immobile patients.

osteoporosis

When the patient is unable to move independently, the nurse uses _____ exercise to move each joint through its range of motion.

passive

contractures

permanently contracted state of a muscle

ergonomics

practice of designing equipment and work tasks to conform to the capability of the worker and providing a means for adjusting the work environment and work practices to prevent injuries

patient care ergonomics

practice of designing equipment and work tasks to conform to the capability of the worker in relation to patient care

Strong, flexible, inelastic fibrous bands and flattened sheets of connective tissue known as _____ attach muscle to bone.

tendons

orthopedics

the correction or prevention of disorders of body structures used in locomotion