Download Mr. Indelicato will demonstrate proper use of a walker while

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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
2
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
4
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
5
Nursing Process
Assessment
Diagnosis
Planning
Implementation
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Evaluation
6
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
7
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
8
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
9
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
10
Implementation

Health promotion



Acute care




Teach patients to calculate maximum heart rate.
Body mechanics
Musculoskeletal system
Joint mobility
Walking
Restorative and continuing care
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
11
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
12
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
13
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
14
Controlled Fall
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
15
Assistive Devices for Walking



Walkers
Canes
Crutches



Measuring for crutches
Crutch gait
Sitting in a chair with crutches
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
16
Assistive Devices for Walking
(cont’d)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
17
Measuring for Crutches
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
18
Measuring for Crutches (cont’d)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
19
Crutch Gait
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
20
Ascending Stairs
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
21
Descending Stairs
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
22
Sitting in a Chair
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
23
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
24
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
25
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
26
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
27
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
28
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
29
Metabolic Changes
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
30
Respiratory Changes
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
31
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
32
Cardiovascular Changes



Orthostatic
hypotension
Increased cardiac
workload
Thrombus formation
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
33
Musculoskeletal Changes

Muscle effects



Patient loses lean body
mass.
Muscle weakness/ atrophy
Skeletal effects


Disuse osteoporosis
Joint contracture
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
34
Urinary Elimination Changes



Urinary stasis
Renal calculi
Infection
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
35
Integumentary Changes

Pressure ulcers



Inflammation
Ischemia
Older adults at greater risk
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
36
Psychosocial Effects

Emotional and behavioral responses


Sensory alterations


Hostility, giddiness, fear, anxiety
Altered sleep patterns
Changes in coping

Depression, sadness, dejection
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
37
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
38
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
39
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
40
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
41
Applying Sequential Compression
Devices
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
42
Applying Sequential Compression
Devices (cont’d)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
43
Applying Sequential Compression
Devices (cont’d)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
44
Applying Sequential Compression
Devices (cont’d)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
45
Applying Antiembolitic Elastic
Stockings
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
46
Applying Antiembolitic Elastic
Stockings (cont’d)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
47
Applying Antiembolitic Elastic
Stockings (cont’d)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
48
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
49
Implementation (cont’d)


Psychosocial changes
Developmental changes
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
50
Implementation (cont’d)

Positioning aids
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
51
Implementation (cont’d)

Positioning techniques





Supported Fowler’s
Supine
Prone
Side-lying
Sims’
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
52
Implementation (cont’d)

Transfer techniques

Moving/repositioning patients
• From bed to chair
• From bed to stretcher
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
53
Transferring Patient from Bed to
Chair
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
54
Transferring Patient from Bed to
Chair (cont’d)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
55
Transferring Patient from Bed to
Chair (cont’d)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
56
Transferring Patient from Bed to
Chair (cont’d)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
57
Transferring Patient from Bed to
Stretcher



Determine patient’s ability to assist.
Communicate actions to patient.
Use appropriate resources.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
58
Implementation

Restorative
and
continuing
care



IADLs
ROM
exercise
Walking
IADLs, Instrumental activities of daily living; ROM, range of motion.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
59
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?
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
60
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
61
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
62
Individual Risk Factors

Traumatic injury





Brain
Spinal cord
Bones, joints, muscles
Neurologic conditions
Chronic conditions (and/or treatment
interventions)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
63
Elements of Musculoskeletal
Assessment







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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
64
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
65
Common Diagnostic Tests
Radiographic Tests







X-ray
MRI
CT scans
Bone scan
Bone mineral density
Myelogram
Arthrography
Other Diagnostic Tests



Arthroscopy
Electromyography
General laboratory tests

Multiple
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
66
CLINICAL MANAGEMENT
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
67
Clinical Management:
Primary Prevention




Regular physical activity
Protection against injury
Optimal nutrition
Fall prevention measures
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
68
Clinical Management:
Collaborative Interventions

General care guidelines for immobilized
patient







Frequent turning, positioning, alignment
Skin assessment and skin care
Range of motion
Deep breathing
Weight bearing (if possible)
Measures to optimize elimination
Nutrition
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
69
Clinical Management:
Collaborative Interventions (cont’d)

Exercise therapy





Ambulation
Joint mobility
Stretching
Balance
Pharmacologic agents



Antiinflammatory agents
Analgesics
Nutrition supplementation
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
70
Clinical Management:
Collaborative Interventions (cont’d)

Surgical interventions


Immobilization


Curative versus palliative
Casts and splints, braces, traction, slings,
shoulder immobilizers, pillows, etc.
Assistive devices

Crutches, canes, walkers, wheelchairs,
prostheses
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
71