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Chapter 38
Activity and Exercise
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Scientific Knowledge Base

Overview of exercise and activity:

Body alignment
• Relationship of one body part to another
 Body balance
• Achieved by low center of gravity; enhanced by posture
 Coordinated body movement
• A result of weight, center of gravity, and balance
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Scientific Knowledge Base (cont’d)

Overview of exercise and activity:


Friction
• Force that occurs in a direction to oppose movement
Exercise and activity
• A patient’s individualized exercise program depends on
the patient’s activity tolerance or the type and amount
of exercise or activity that the patient is able to perform.
• Isotonic exercises
• Isometric exercises
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3
Case Study


Mr. Indelicato is a 72-year-old African
American who is hospitalized for surgery on
his right knee. He relates the problem with his
knee to previous sports injuries. He first
sought medical advice and treatment 6 years
ago.
He has tried various treatments, including
physical therapy, rest, and pain medication.
His only preoperative medication is ibuprofen
600 mg every 6 to 8 hours. He and his wife
are very active.
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Case Study (cont’d)


Marilyn Sweeney is a 40-year-old nursing
student. She has just finished rotating
through a general surgical unit and is
spending the remaining 6 weeks in the
orthopedic/rehabilitation division of the
agency. Her assignment is to follow the
patient through his surgery and rehabilitation.
As Marilyn prepares to assess Mr. Indelicato,
she reviews anatomy and physiology related
to the musculoskeletal system and exercise
physiology.
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Regulation of Movement
Skeletal
system
Muscles
concerned
with
movement
Joints
Ligaments,
tendons,
cartilage
Skeletal
muscle
Muscles
concerned
with posture
Muscle
groups
Nervous
system
Proprioception
Balance
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6
Factors Influencing Activity
and Exercise

Developmental changes





Infants through school-aged children
Adolescence
Young to middle adults
Older adults
Behavioral aspects

Patients are more likely to incorporate an exercise
program if those around them are supportive.
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Factors Influencing Activity
and Exercise (cont’d)

Environmental issues





Work site
Schools
Community
Cultural and ethnic influences
Family and social support
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8
Nursing Process
Assessment
Diagnosis
Planning
Implementation
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Evaluation
9
Assessment: Standing
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Assessment: Sitting

Sitting






Head is erect.
Neck and vertebral column are in straight
alignment.
Body weight is distributed on the buttocks and
thighs.
Thighs are parallel and horizontal.
Feet are supported on the floor.
Forearms are supported on the armrest, in the lap,
or on a table in front of the chair.
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Assessment


Recumbent position
Mobility




Range of motion
Gait
Exercise
Activity tolerance
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Case Study (cont’d)



Mr. Indelicato is hesitant to ambulate or use his
continuous positive motion machine. He rates his
pain as 6 to 7 on a scale of 0 to 10 and is using a
patient-controlled analgesia (PCA) pump.
His degree of knee flexion is now 70 degrees. He is
able to ambulate 10 feet with a walker. He further
describes his muscle strength in his right leg as
feeling weak and tired after walking a short distance.
Marilyn observes Mr. Indelicato using the walker
incorrectly.
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Nursing Diagnosis







Activity intolerance
Ineffective coping
Impaired gas exchange
Risk for injury
Impaired physical mobility
Imbalanced nutrition: more than body
requirements
Acute or chronic pain
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14
Planning

Goals and outcomes





Participates in prescribed physical activity while
maintaining appropriate heart rate, blood
pressure, and breathing rate
Verbalizes an understanding of the need to
gradually increase activity based on tolerance and
symptoms
Expresses understanding of balancing rest and
activity
Setting priorities
Teamwork and collaboration
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Case Study (cont’d)
Mr. Indelicato will attain
a tolerable level of pain
during ambulation.
Mr. Indelicato’s pain will be a 2 to 3
on a scale of 0 to 10 during
ambulation.
Mr. Indelicato will gain
optimal functioning of
the right knee with
independent, purposeful
movement.
Mr. Indelicato will ambulate 50 to
75 feet with the aid of a walker
without reports of increasing
fatigue.
Mr. Indelicato will gain a minimum
of 90-degree flexion in the right
knee by the time of discharge.
Mr. Indelicato will
Mr. Indelicato will perform a return
demonstrate proper use demonstration of proper use of a
of a walker while
walker.
ambulating.
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Implementation

Health promotion



Acute care




Teach patients to calculate maximum heart rate.
Body mechanics
Musculoskeletal system
Joint mobility
Walking
Restorative and continuing care
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Controlled Fall
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Case Study (cont’d)

Marilyn wants to help Mr. Indelicato with
ambulation and strength training. To
implement her plan of care, she:




Encourages Mr. Indelicato to use PCA pump
before ambulation
Explains why he should sit in bed and dangle his
legs before standing to ambulate
Establishes realistic increments for Mr. Indelicato
to increase walking distance during ambulation
Talks with him about exercise tolerance
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Principles of Transfer
and Positioning Techniques


When moving a patient, knowledge of safe
transfer and positioning is crucial.
Pathological influences on body alignment
and mobility:




Congenital defects
Disorders of bones, joints, and muscles
Central nervous system damage
Musculoskeletal trauma
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Case Study (cont’d)

As part of the teaching process, Marilyn
consults with a physical therapist on proper
use of the walker. She and the physical
therapist instruct Mr. Indelicato and family
caregivers on the proper use of a walker, and
Marilyn provides written material that
reinforces these verbal instructions.
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Assistive Devices for Walking



Walkers
Canes
Crutches



Measuring for crutches
Crutch gait
Sitting in a chair with crutches
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Assistive Devices for Walking
(cont’d)
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Measuring for Crutches
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Measuring for Crutches (cont’d)
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Crutch Gait
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Ascending Stairs
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Descending Stairs
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Sitting in a Chair
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Implementation

Restoration of activity and chronic illness




Coronary heart disease
Hypertension
Chronic obstructive pulmonary disease
Diabetes mellitus
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Evaluation

Patient outcomes



Reassess the patient for signs of improved activity
and exercise tolerance.
Ask for the patient’s perception of activity and
exercise status after interventions.
Ask if the patient’s expectations are being met.
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Case Study (cont’d)


Marilyn evaluates how effective her plan of care
has been. She asks Mr. Indelicato to rate the
level of pain from 0 to 10, observes his range of
motion and use of the continuous passive motion
(CPM) machine, and observes his ambulation
with a walker.
Mr. Indelicato rates his pain as a 3 and is able to
perform range of motion (ROM) and use the
CPM machine. He has a steady gait with the aid
of the walker.
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Case Study (cont’d)


It has been 5 weeks since Marilyn began to
care for Mr. Indelicato. Mr Indelicato has
progressed steadily to increase both weight
bearing and range of joint motion on the
affected knee. Mr. Indelicato expected the
pain to be completely resolved on hospital
discharge and not to follow into physical
therapy.
Marilyn and the physical therapist worked
with Mr. Indelicato and his orthopedic
surgeon to identify pain control measures.
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Chapter 47
Mobility and Immobility
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Scientific Knowledge Base:
Nature of Movement
Body mechanics
Coordinated efforts of the
musculoskeletal and
nervous systems
Gravity
Weight force exerted on
the body
Alignment and balance
Also refers to posture
Friction
Force that occurs in a
direction opposite to
movement
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35
Physiology and Regulation of
Movements

Skeletal system




Provides attachments for muscles and ligaments
and protects vital organs
Provides leverage for movement
Bones are long, short, flat, or irregular.
Coordination and regulation of muscle groups
depend on muscle tone; activity of
antagonistic, synergistic, and antigravity
muscles; and neural input to muscles.
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Skeletal System


Joints connect bones.
Four classifications:

Synostotic, cartilaginous, fibrous, synovial
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Skeletal System (cont’d)

Ligaments bind joints
together and connect
bones and cartilage.
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Skeletal System (cont’d)

Tendons connect
muscles to bone.
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Skeletal System (cont’d)

Cartilage is a supportive tissue.


Located in joints, thorax, trachea, larynx, nose,
and ears
Can be temporary or permanent
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Skeletal Muscle

Muscle movement and posture



Leverage
Posture
Muscle regulation of posture and movement

Muscle tone
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41
Nervous System



Regulates movement and posture
Motor fibers from the right motor strip initiate
voluntary movement for the left side of the
body.
Motor fibers from the left motor strip initiate
voluntary movement for the right side of the
body.
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Pathological Influences on Mobility
Postural abnormalities
Impaired muscle
development
Damage to central
Musculoskeletal trauma
nervous system (CNS)
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Nursing Knowledge Base: Safe
Patient Handling







Ergonomics assessment protocol
Patient assessment criteria
Algorithms for patient handling and
movement
Special equipment
Back injury resource nurses
“After-action review”
No-lift policy
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Factors Influencing obility/Immobility

Mobility


Immobility


Ability to move about freely
Inability to move about freely
Bed rest

An intervention that restricts patients for
therapeutic reasons
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45
Systemic Effects
Metabolic
Endocrine, calcium
absorption, and GI function
Respiratory
Atelectasis and hypostatic
pneumonia
Cardiovascular
Orthostatic hypotension
Thrombus
Musculoskeletal changes
Loss of endurance and muscle
mass and decreased stability and
balance
Muscle effects
Loss of muscle mass
Muscle atrophy
Skeletal effects
Impaired calcium absorption
Joint abnormalities
Urinary elimination
Urinary stasis
Renal calculi
Integumentary
Pressure ulcer
Ischemia
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46
Quick Quiz!
1. You notice a respiratory change in your
immobilized postoperative patient. The
change you note is most consistent with
A. Atelectasis.
B. Hypertension.
C. Orthostatic hypotension.
D. Coagulation of blood.
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47
Metabolic Changes
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48
Respiratory Changes
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49
Case Study


Ms. Eileen Thomas, who is 82, is admitted for a
fractured right hip. She is on complete bed rest in
Buck’s traction.
Sergio is the nursing student assigned to Ms.
Thomas.
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50
Cardiovascular Changes



Orthostatic
hypotension
Increased cardiac
workload
Thrombus formation
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51
Musculoskeletal Changes

Muscle effects



Patient loses lean body
mass.
Muscle weakness/ atrophy
Skeletal effects


Disuse osteoporosis
Joint contracture
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Urinary Elimination Changes



Urinary stasis
Renal calculi
Infection
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53
Integumentary Changes

Pressure ulcers



Inflammation
Ischemia
Older adults at greater risk
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54
Psychosocial Effects

Emotional and behavioral responses


Sensory alterations


Hostility, giddiness, fear, anxiety
Altered sleep patterns
Changes in coping

Depression, sadness, dejection
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55
Developmental Changes
Infants, Toddlers,
Adolescents
Preschoolers
Delayed in gaining
Prolonged immobility delays
independence and in
gross motor skills,
accomplishing skills
intellectual development, or Social isolation can occur
musculoskeletal
development
Adults
Older Adults
Physiological systems are at Decreased physical activity
risk
Hormonal changes
Changes in family and social
Bone reabsorption
structures
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56
Case Study (cont’d)


Ms. Thomas’ mitral valve was replaced 2
months ago, and since the time of the
surgery, she has been on anticoagulants.
She has had type 2 diabetes mellitus for the
past 10 years and is a smoker. She weighs
195 lbs and is 5′7″ tall. She lives by herself,
and she attends Mass daily.
Her pain is 6 on a scale of 1 to 10.
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57
Critical Thinking





Knowledge
Experience
Patient data
Attitudes
Intellectual and professional standards
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Nursing Process: Assessment


See through the
patient’s eyes.
Mobility


Range of motion
Planes of the body



Sagittal
Transverse
Frontal
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59
Nursing Process: Assessment
(cont’d)

Mobility



Gait (a particular manner or style of walking)
Exercise (physical activity for conditioning the
body, improving health, and maintaining fitness)
Activity tolerance
• Physiological
• Emotional
• Developmental
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60
Nursing Process: Assessment
(cont’d)

Mobility

Body alignment is used for:
• Determining normal physical changes
• Identifying deviations in body alignment
• Patient awareness of posture
• Identifying postural learning needs of patients
• Identifying trauma, muscle damage, or nerve dysfunction
• Obtaining information on incorrect alignment (i.e., fatigue,
malnutrition, psychological problems)
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61
Nursing Process: Assessment
(cont’d)

Body alignment

Standing
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Nursing Process: Assessment
(cont’d)
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Nursing Process: Assessment
(cont’d)

Body alignment

Sitting
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Nursing Process: Assessment
(cont’d)
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Nursing Process: Assessment
(cont’d)

Body alignment

Lying
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Nursing Process: Assessment
(cont’d)

Immobility








Metabolic
Respiratory
Cardiovascular
Musculoskeletal
Integumentary
Elimination
Psychosocial
Developmental
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67
Nursing Diagnosis and Planning
Impaired physical
mobility
Risk for disuse syndrome
Ineffective airway
clearance
Ineffective coping
Risk for injury
Risk for impaired skin
integrity
Insomnia
Social isolation
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Nursing Diagnosis and Planning
(cont’d)

Planning



Goals and outcomes
Setting priorities
Teamwork and collaboration
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Implementation: Health Promotion



Prevention of work-related musculoskeletal injuries
Exercise
Bone health in patients with osteoporosis
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Implementation: Acute Care

Metabolic


Provide high-protein, high-calorie diet with vitamin
B and C supplements.
Respiratory


Cough and deep breathe every 1 to 2 hours.
Provide chest physiotherapy.
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Case Study (cont’d)

Based on Eileen Thomas’ medical history of
type 2 diabetes mellitus, heart valve
replacement surgery 2 months ago, and
being an active smoker, list three nursing
interventions that you will initiate to prevent
respiratory complications related to her
immobility.
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Implementation

Cardiovascular



Progress from bed to
chair to ambulation.
SCDs, TED hose,
and leg exercises
Musculoskeletal



Passive ROM
CPM
Active ROM
CPM, Continuous passive motion; ROM, range of motion; SCD, sequential compression device;
TED, thromboembolic deterrent.
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Applying Sequential Compression
Devices
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74
Applying Sequential Compression
Devices (cont’d)
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Applying Sequential Compression
Devices (cont’d)
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76
Applying Sequential Compression
Devices (cont’d)
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77
Applying Antiembolitic Elastic
Stockings
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78
Applying Antiembolitic Elastic
Stockings (cont’d)
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Applying Antiembolitic Elastic
Stockings (cont’d)
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Quick Quiz!
2. After completing preoperative teaching for a
surgical patient, you can evaluate the
patient’s understanding of the use of elastic
stockings when the patient states
A. “I can remove them at night.”
B. “I can roll them no lower than my calf
muscle.”
C. “I wear them no longer than 4 hours at a
time.”
D. “I can remove them for 30 minutes every 8
hours.”
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Implementation

Integumentary system



Reposition every 1 to 2 hours.
Provide skin care.
Elimination system


Provide adequate hydration.
Serve a diet rich in fluids, fruits, vegetables, and
fiber.
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Implementation (cont’d)


Psychosocial changes
Developmental changes
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Implementation (cont’d)

Positioning aids
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Implementation (cont’d)

Positioning techniques





Supported Fowler’s
Supine
Prone
Side-lying
Sims’
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Implementation (cont’d)

Transfer techniques

Moving/repositioning patients
• From bed to chair
• From bed to stretcher
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Transferring Patient from Bed to
Chair
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87
Transferring Patient from Bed to
Chair (cont’d)
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88
Transferring Patient from Bed to
Chair (cont’d)
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Transferring Patient from Bed to
Chair (cont’d)
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Transferring Patient from Bed to
Stretcher



Determine patient’s ability to assist.
Communicate actions to patient.
Use appropriate resources.
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Implementation

Restorative
and
continuing
care



IADLs
ROM
exercise
Walking
IADLs, Instrumental activities of daily living; ROM, range of motion.
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Evaluation


Have the patient’s goals been met?
Have outcomes been met? If not, ask questions:





Are there ways we can assist you to increase your activity?
Which activities are you having trouble completing right
now?
How do you feel about not being able to dress yourself and
make your own meals?
Which exercises do you find most helpful?
What goals for your activity would you like to set now?
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Safety Guidelines









Communicate clearly.
Mentally review transfer steps.
Assess patient mobility and strength.
Determine assistance needed.
Raise side rail on opposite side of bed.
Arrange equipment.
Evaluate body alignment.
Understand use of equipment.
Educate patient.
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94
MOBILITY
Concept 23
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Goals for This Concept
Presentation
1. Define and describe the concept.
2. Notice risk factors for impaired mobility.
3. Recognize when an individual has
compromised mobility.
4. Provide appropriate nursing and
collaborative interventions to optimize
mobility and minimize complications of
immobility.
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DEFINE AND DESCRIBE THE
CONCEPT OF MOBILITY
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Definition
Mobility is a state or quality of being mobile or
movable.
Other terms
 Immobility
 Disuse syndrome
 Deconditioned
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Scope of Concept
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Categories of Mobility
Collaborative Learning #1
In your learning group,
discuss the three mobility
categories.
 How they are different
 How they are similar
 In what ways they are
dependent on one another
Musculoskeletal
Neurologic
Neuromuscular
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Consequences of Immobility
Collaborative Learning # 2
In your learning group, analyze one
or more of the consequences of
immobility. Why does each
consequence occur? How does it
link to other consequences?
Consequence
Why It Occurs
Link to Other
Consequences
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NOTICE RISK FACTORS FOR
IMPAIRED MOBILITY
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Risk Factors:
Population at Greatest Risk
Collaborative Learning #3
In your learning group, discuss the following:
As a population group, older adults are at
greatest risk for immobility. What physiologic
factors contribute to this risk?
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Individual Risk Factors

Traumatic injury




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Brain
Spinal cord
Bones, joints, muscles
Neurologic conditions
Chronic conditions (and/or treatment
interventions)
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RECOGNIZE WHEN AN
INDIVIDUAL HAS COMPROMISED
MOBILITY
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Elements of Musculoskeletal
Assessment
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Common Symptoms Associated
History
with Altered Mobility
Past medical history
Family history
 Pain
Current medications
 Reduced joint movement
Lifestyle behaviors
 Reduced sensation or
Occupation
loss of sensation
Social environment
 Falls
Problem-based history
 Fatigue
 Altered gait or imbalance
 Reduced functional ability
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Examination Techniques
Collaborative Learning #4
In your learning group, discuss how to do the listed examination
techniques, and list the expected and abnormal findings.
• How do the examination process and expected findings vary
across the age span (infants, children, older adults)?
Examination
Technique
Expected Finding
Abnormal Finding
Observe balance,
gait, posture
Inspect joints and
muscles
Assess muscle
strength
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Common Diagnostic Tests
Radiographic Tests
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X-ray
MRI
CT scans
Bone scan
Bone mineral density
Myelogram
Arthrography
Other Diagnostic Tests



Arthroscopy
Electromyography
General laboratory tests

Multiple
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CLINICAL MANAGEMENT
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Clinical Management:
Primary Prevention
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Regular physical activity
Protection against injury
Optimal nutrition
Fall prevention measures
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Clinical Management:
Screening
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Osteoporosis screening
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What are the national guidelines for screening?
Fall assessment screening


What are common screening tools?
When should these be used?
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Clinical Management:
Collaborative Interventions
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General care guidelines for immobilized
patient
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Frequent turning, positioning, alignment
Skin assessment and skin care
Range of motion
Deep breathing
Weight bearing (if possible)
Measures to optimize elimination
Nutrition
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Clinical Management:
Collaborative Interventions (cont’d)
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Exercise therapy
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Ambulation
Joint mobility
Stretching
Balance
Pharmacologic agents
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Antiinflammatory agents
Analgesics
Nutrition supplementation
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Clinical Management:
Collaborative Interventions (cont’d)

Surgical interventions
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Immobilization
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Curative versus palliative
Casts and splints, braces, traction, slings,
shoulder immobilizers, pillows, etc.
Assistive devices

Crutches, canes, walkers, wheelchairs,
prostheses
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