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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 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