Chapter 16: Activity and Exercise

Introduction:● Research evidence supports role of exercise in improving the health status.

○ can also reverse many chronic diseases. ● Activity-exercise pattern: person’s routine of exercise, activity, leisure, and recreation.

○ ADLS○ type, quality, and quantity of exercise

● Mobility: the ability to move freely, easily, rhythmically, and purposefully in the environment.

○ People often define their health and physical fitness by their activity because mental well-being and effectiveness of body function depend largely on mobility.

Normal Movement● Normal movement and stability are the result of an intact musculoskeletal system, intact

nervous system, and intact inner ear structures responsible for equilibrium. ● Requires coordinated muscle activity and neurologic integration. ● Comprised of four basic elements: posture, joint mobility, balance, and coordinated

movement.

Posture● Lecture notes:

○ Assess head, shoulder, lower back, hip, knees● proper body alignment and posture bring the body parts into position that promotes

optimal balance and maximal body function. ○ Line of gravity: imaginary vertical line drawn through the body’s center of gravity

and the base of support. ■ as long person maintains balance along this line.

● when a person is well aligned: strain on joints, muscles, tendons, and ligaments are minimized and internal structures and organs are properly supported.

● Proper posture enhances lung expansion and promotes efficient circulatory, renal, and GI functions.

● Posture reflects mood, self-esteem, and personality and vice-versa. ● abdominal and skeletal muscles (extensor “antigravity” muscles)

○ functioning continually against the endless downward pull of gravity■ making adjustments to remain erect or seated

Joint Mobility● Lecture notes:

○ Types of Joints

● joints are the functional units of the musculoskeletal system. ● Skeletal muscles are categorized according to the type of joint movement they produce

on contraction. ● Flexor muscles stronger than extensor muscles so when the person is inactive, the joints

are flexed (bent). ● ROM is the maximum movement that is possible for the joint.

○ Joint ROM differs due to several factors:■ genetics, development patterns, disease, and amount of physical activity.

Movement Action

Flexion decreasing the angle of the joint

Extension increasing the angle of the joint

Hyperextension further extension or straightening of a joint

Abduction movement of the bone away from the midline of the body

Adduction movement of the bone toward the midline of the body

Rotation movement of the bone around its central axis

Circumduction movement of the distal part of the bone in a circle while the proximal end remains fixed

Eversion turning the sole of the foot outward from the ankle joint

Inversion turing the sole of the foot inward from the ankle joint

Pronation moving the bones of the forearm so that the palm of the hand faces downward

Supination moving the bones of the forearm so that the palm of the hand faces upward

Balance

● Mechanisms of balance involved maintaining balance and posture involve inputs from: labyrinth (inner ear: vestibule and semicircular canals), vision, and stretch receptors of muscles and tendons.

○ Fluid flow from labyrinth stimulate sensory hair cells that initiate reflexes to change position.

○ Information from balance receptors go directly to the reflex centers rather than the cerebral cortex.

● Proprioception: awareness of posture, movement, and changes in equilibrium and the knowledge of position, weight, and resistance of objects in relation to the body.

Coordinated Movement● Balanced, smooth, purposeful movement is the result of proper functioning of the

cerebral cortex, cerebellum, and basal ganglia. ○ cerebral cortex: operates movements. not muscles.○ cerebellum: coordinates muscles involved in voluntary movement.

■ translates the instructions from cortex into action ○ basal ganglia: helps maintain posture

Exercise● Physical activity: bodily movement that enhances health.● Exercise: type of physical activity defined as a planned, structured, and repetitive bodily

movement performed to improve health and maintain fitness to achieve an optimal state of health.

● Functional strength: ability of the body to perform work.● Activity tolerance: type and amount of exercise or daily living activities an individual is

able to perform without experiencing adverse effects.

Types of Exercise ● Isotonic (dynamic) exercises:

○ muscle shortens to produce muscle contraction and active movement. ■ ex. running, walking, swimming, cycling, ■ ADL’s and active ROM.

● ex. pushing or pulling against a stationary object○ using a trapeze to lift body off the bed, lifting buttocks off

the bed by pushing with the hands, or pushing the body to a sitting position.

● Isometric (static or setting) exercises:○ muscle contraction without moving the joint (therefore muscle length does not

change) ○ useful in strengthening abdominals, gluteal, and quadricep muscles.

■ ex. squeezing a towel or pillow between knees

● Isokinetic (resistive) exercises○ muscle contraction or tension against resistance.

■ ex. resistance training● Aerobic exercise

○ amount of oxygen taken into body is greater than that used to perform the activity.■ ex. CV conditioning and physical fitness.

○ Intensity of exercise can be measured in three ways:■ 1. Target HR■ 2. Talk Test■ 3. Borg scale of perceived exertion (1-20)

● Anaerobic exercise○ muscles cannot draw out enough oxygen from bloodstream, and anaerobic

pathways are used to provide additional energy for a short time. ■ ex. for endurance training of weightlifters and sprinters

Benefits of Exercise● Musculoskeletal system

○ Size, shape, tone, and strength of muscles are maintained with exercise and increased with strenuous exercise.

■ Strenuous exercise causes hypertrophy and increased efficiency of muscular contraction.

○ Exercise increases:■ joint nourishment■ joint flexibility■ stability■ ROM

○ Bone density and strength is maintained through weight-bearing and high-impact movements.

■ maintains balance between osteoblasts and osteoclasts. ○ prevent atrophy

● CV system○ increases strength of heart muscle contraction○ increases blood supply to the heart and muscles○ lowering BP○ improved O2 uptake○ improved HR variability○ improved circulation○ reduces stress

● Respiratory system○ Benefits:

■ improves gas exchange■ increases toxin elimination through deeper breathing■ improves O2 to brain

● enhances problem solving and emotional stability■ prevents pooling of secretions■ decreases breathing effort and risk for infection■ Exercising muscles of respiration:

● enhances oxygenation and stamina● circulation of lymph

○ Special considerations:■ LE exercise forms for treating COPD patients■ yoga breathing and postures with asthma are helpful

● GI system○ Improves appetite○ increases GI tract tone○ facilitates peristalsis○ can help relieve constipation ○ Special Considerations:

■ rowing, swimming, walking, and sit-ups can help relieve constipation.■ abdominal compressive exercise can help improve symptoms of digestive

disorders such as IBS. ● Metabolic/Endocrine system

○ increases metabolic rate therefore increased production of body heat, waste products, and calorie use.

○ increases use of triglycerides and fatty acids■ resulting in lower serum triglycerides, A1C levels, and cholesterol.■ make cells more responsive to insulin

● GU system○ promotes efficient blood flow = excretion of bodily wastes more effectively. ○ prevents stasis of urine and therefore flushes out bacteria = less UTI

● Immune system○ exercise allows for lymph fluid to be more efficiently pumped through the

lymphatic system. ○ moderate exercise enhances immunity, strenuous exercise may reduce immune

function. ● Psychoneurological System

○ exercise can elevate mode and relieve stress and anxiety.○ MoA:

■ exercise increases levels of neurotransmitters ■ exercise increases levels of endorphins■ increases level of O2 to brain inducing euphoria

■ muscular exertion releases stored stress associated with accumulated emotional demands.

○ Relaxation response (RR): physiological state that can be elicited through deep relaxation breathing with emphasis on prolonged exhalation.

■ Emphasis on exhalation recruits PNS “rest and digest” reflex. ■ Progressive contraction and relaxation of muscles throughout body until

feels relaxed. ■ These can be done by anyone at anytime.

● Cognitive function○ Induces cells in brain to strengthen and build neuronal connections. ○ Enhances decision-making, problem-solving, planning, and paying attention. ○ Brain Gym and cross-lateral movements helpful to enhance cognitive functions.

■ Shown to help ADD< ADHD, learning disorders, and mood disorders. ● Spiritual Health

○ Yoga-style exercises improves the mind-body-spirit connection, relationship with God, and physical well-being by establishing balance in the internal and external environment.

○ Emphasis of breathing is thought to soothe the Nervous and Cardiorespiratory systems.

○ Recitation of the a word or prayer can cause muscle relaxation, decrease in HR and RR.

○ Slow breathing enhances heart rate variability and baroreflex sensitivity. ○ Walking labyrinths or doing paper labyrinths can cause a meditative state,

decreasing HR and RR.

Factors Affecting Body Alignment and Activity

Growth & development● Newborns

○ movements are reflexive and random○ all extremities normally flexed, can passively be moved through full range of

motion. ● Toddlers (age 1-5)

○ Gross motor skills precede fine motor skills.■ Gross motor develops head-to-toe (head movement, crawling, walking)

● Age (6-12)○ refinement of motor skills continues and exercise patterns for later life are

determined here.● Age (12-19)

○ growth spurts and behaviors may result in postural changes that often persist into adulthood.

● Age (20-40) ○ Pregnancy ○ Osteoporosis

■ posture changes: leaning forward and stooped● shift center of gravity causing knees to flex to compensate

○ knees flex, support base widens, gait is wide, short stepped, shuffling.

Nutrition

● Undernutrition:○ muscle weakness and fatigue○ Vitamin D deficiency = bone deformity , increases risk of osteoporosis

● Overnutrition:○ obesity = distortion in posture, balance, and joint health

Personal values & attitudes● People’s values concerning physical activity or type of exercise are affected by:

○ family lifestyle and values○ geographic location and cultural role expectations○ personal perception of exercise (recreational vs drudgery)○ motivational states

■ individual exercise prescriptions: exercise mode and dose tailored to a specific individual to ensure greater adherence to the exercise program

■ nurses must be able to assess each client for motivating factors and give appropriate exercise prescriptions to these factors

External factors● Climate

● Availability of recreational facilities○ economic situation

● Community safety

Prescribed limitations● Casts, braces, splints, and traction.● Bed rest

○ meaning may be different per agency, nurses must know the extent of bed rest. ○ within 2 weeks of bedrest (20-40% muscle atrophy)

Effects of Immobility

Musculoskeletal system● disuse osteoporosis

○ without exercise, bones demineralize● Disuse atrophy● Contractures:

○ permanent shortening of the muscle ○ foot drop

● Stiffness and pain in the joints ○ ankylosed: permanently immobile○ excess calcium deposited in joints.

CV system● Diminished cardiac reserve

○ causes ANS imbalance, increases HR, reduces heart’s capacity to respond to any metabolic demands above basal levels.

■ tachycardia with minimal exertion.● Increase use of the Valsalva maneuver

○ Valsalva maneuver: holding breath and straining against a closed glottis. ■ builds up intrathoracic pressure causing interferences with return blood

flow to the heart.■ When client exhales, pressure released and sudden surge of blood flow

back to the heart. ■ may cause arrhythmias

● Orthostatic hypotension● Venous vasodilation and stasis

○ Immobile person: skeletal muscles no longer assist in pumping blood back to heart against gravity.

■ blood pools and causes vasodilation and engorgement. ■ valve incompetence

● Dependent edema ● Thrombus formation

Respiratory system● Decreased respiratory movement

○ intercostal joints become fixed in an expiratory phase of respiration, further limiting the potential for maximal ventilation.

■ produces shallow breathing and reduced vital capacity (additional inhalation passed maximum inhalation)

● Pooling of respiratory secretions● Atelectasis● Hypostatic pneumonia

GI system● constipation due to decreased peristalsis + decreased abdominal and perineal muscles =

impaction ● embarrassment of using a bedpan leads to postponement of defecation leads to weakened

and suppressed defecation reflex ● some clients use Valsalva maneuver excessively which increases intra-abdominal and

thoracic pressure and places stress on heart and circulatory system.

Metabolic system● Decreased metabolic rate● Negative nitrogen balance

○ negative balance between protein anabolism and catabolism■ more catabolism of proteins than intake

● Anorexia○ decreased caloric intake due to decreased metabolic rate (less energy needed)

● Negative calcium balance ○ greater amounts of calcium are extracted from bone than can be replaced

GU system● Urinary stasis

○ urine pools due to gravity ● Renal calculi

○ calcium salts are no longer in balance and form stones. ● Urinary retention

○ bladder distention and occasionally urinary incontinence ○ unable to completely void bladder due to decreased muscle tone

● Urinary infection ○ static urine○ improper perineal care/ indwelling catheter○ urinary reflex (backward flow)

Integumentary system● Reduced skin turgor● Skin breakdown

Psychoneurological ● Decline in mood-elevating substances such as endorphins ● Increased dependence on others

○ may lower person’s self-esteem■ frustration and exaggerated emotional reactions

● Decreased variety of stimuli ○ time perception deteriorates○ problem-solving and decision making deteriorate due to lack of intellectual

stimulation. ● Anxiety

~ Nursing Management ~

Assessing ● Nursing History● Physical Examination (Table 3 pg.600)

○ Body Alignment ■ Nurse must identify

● normal development variations in posture● posture and learning needs to maintain good posture● Factors contributing to poor posture, such as fatigue, pain

compression fractures, or low self-esteem● muscle weakness or other motor impairments

■ Nurse should observe whether:● shoulder and hips are level● toes point forward● spin is straight and not curved to either side.

■ Slumped posture:

● neck is flexed forward, abdomen protrudes, pelvis is thrust forward, and knees are hyperextended.

○ Lordosis: exaggerated anterior/inward curvature of the lumbar spine.

○ Gait■ Stance phase and swing phase. ■ Nurse must assess for the following:

● Chin is level, gaze is straight ahead, sternum is lifted, and shoulders are down and back, relaxed away from the ears.

● Heel strikes the ground before the toe. It is here, where both feet are taking some body weight, that the spine is most rotated.

● Feet are dorsiflexed in the swing phase.● Arm opposite the swing foot moves forward at the same time. ● Gait is smooth, coordinated, and rhythmic, with even weight

distribution on each foot. Hips gently sway with spinal rotation; the body moves forward smoothly, stopping and starting with ease.

● Pace (number of steps/min)○ normal 70-100 steps/min○ older person may be 40 steps/min.

● Need for assistive devices.○ compare gait w/ and w/o devices if possible.

○ Appearance and Movement of Joints

■ Examination of the joints includes: inspection, palpation, assessment of active ROM, and passive ROM.

■ Nurse should assess:● swelling, redness, heat● deformities● muscle development (size and symmetry)● any reported or palpable tenderness● Crepitation: palpable or audible crackling or grating sensation

produced by joint motion.● degree of joint movement

■ ROM shouldn’t be tiring; should be done smoothly, slowly, and rhythmically.

● no joint should be forced. ○ Capabilities and Limitations for Movement

■ Possible hindrances:● client’s illness● obstacles: IV’s, casts, etc. ● ALOC, meds affecting mental status

● balance and coordination● orthostatic hypotension● degree of comfort● visual impairments

■ Capabilities of client ○ Muscle Mass and Strength

■ assess client’s strength and ability to move. ■ Providing appropriate degree of assistance lowers risk of muscle strain and

body injury to both client and nurse. ■ Assessment of UE very important for clients who use assistive devices

such as walkers or crutches. ○ Activity Tolerance

■ Determine appropriate activity level for client and predict whether the client can endure activities that require similar amounts of energy expenditure.

■ Useful in encouraging independence in pt’s with:● CV and respiratory problems● immobilized for a prolonged period● decreased muscle mass or musculoskeletal disorder● inadequate sleep ● pain ● depressed, anxious, or unmotivated

■ Most useful measurements of predicting activity tolerance:● Heart strength, rhythm, and rate● Respiratory depth, rhythm, and rate● BP

○ measure these before, during, immediately after, 3 minutes after activity

■ Activity should be stopped immediately in the event of:● sudden facial pallor● dizziness or weakness● change in LoC● dramatic change in HR or RR from baseline ● dramatic change in heart or respiratory rhythm● weakening of pulse● Dyspnea, SOB, chest pain● DBP change of 10mmHg or more

■ Activity considered safe if client tolerates and vitals return to baseline levels within 5 minutes of activity.

○ Problems Related to Immobility ■ Take/understand assessment findings and lab values

● establish a baseline and compare with later values■ Clients at risk of developing complications of immobility:

● poorly nourished● existing CV, pulmonary, or neuromuscular problems● decreased sensitivity to pain, temperature, or pressure● ALOC

Diagnosing● Activity Intolerance

○ Level I-IV (1 - independent, 4 - dyspnea and fatigue at rest)○ characteristics:

■ abnormal BP response to activity, abnormal HR response, EKG changes (arrhthmias), EKG changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness

■ r/t: bed rest; generalized weakness; O2 supply/demand imbalance; immobility; sedentary lifestyle

● Impaired Physical Mobility○ limitation in independent, purposeful physical movement of the body or of one or

more extremities○ impaired physical mobility can be the etiology (r/t) for:

■ Fear (of falling)■ Ineffective Coping■ Situational Low Self-Esteem■ Powerlessness■ Risk for Falls

○ characteristics: ■ decreased reaction time; difficulty turning; engages in substitutions for movement

(distractions); exertional dyspnea; gait changes; jerky movements; limited ability to perform gross motor skills; limited ability to perform fine motor skills; limited range of motion; movement-induced tremor; postural instability; slowed movement; uncoordinated movements

■ r/t: activity intolerance; contractures; deconditioning; decreased muscle control; decreased muscle mass; decreased muscle strength; deficient knowledge regarding physical activity; discomfort; joint stiffness; limited CV endurance; loss of integrity of bone structures; malnutrition; medications; neuromuscular impairment; pain

■ Classification scale:

● 0 = completely independent● 1 = requires use of assistive device● 2 = requires helps from another person for assistance, supervision, or teaching● 3 = requires help from another person and assistive device● 4 = dependent

● Sedentary Lifestyle○ characteristics: daily routine lacking physical exercise, demonstrates physical deconditioning,

verbalizes preference for low energy activities○ r/t: deficient knowledge; lack of training; lack of resources; lack of motivation; lack of interest

● Self-Care Deficit● Risk for Infection● Risk for Injury● Risk for Disturbed Sleep Pattern

● If immobility is prolonged:○ Ineffective Airway Clearance○ Risk for Infection○ Risk for Injury r/t orthostatic hypotension○ Risk for Disturbed Sleep Pattern ○ Risk for Situational Low Self-Esteem r/t

Planning● Increased tolerance for physical activity● Restored capabilities to ambulate and/or participated in ADL’s

○ self-care● Absence of injury from falling or improper body mechanics

○ fall prevention● Enhanced physical fitness● Absence of any complications associated with immobility● Improved social, emotional, and intellectual well-being

○ focus on positives○ decreased stress levels

● Body positioning● Bowel elimination● Joint movement

○ PROM● Mobility

○ enhance mobility● Respiratory status

○ prevent atelectasis and pneumonia● Sleep

○ 7hrs, limit naps

● Stress level○ therapeutic communication

● Weight control

Implementing● Maintain or promote body alignment & mobility for nurses and patients● Position clients appropriately● Moving & turning clients in bed● Transferring clients● ROM exercises● Ambulating clients● Prevent complications of immobility

Using Body Mechanics ● Body mechanics: efficient, coordinated, and safe use of the body to move objects and

carry out the ADL’s. ● Back belts have not been shown to be effective in reducing back injury. ● Education alone will NOT prevent job-related injuries. ● Nurses who are physically fit are at NO less risk of injury● A nurse should not lift weights exceeding 35 lbs.

○ if exceeds 35lbs use assistive devices. ● Benefits of using proper equipment (ex. Mechanical lifts) outweigh the costs of staff

injuries.● Balance is maintained when the line of gravity falls close to the base of support. ● The broader the base of support and lower the center of gravity = greater stability and

balance.○ Body balance can be enhanced by widening base of support and lowering center

of gravity.

Lifting● Nurses should not lift more than 35lbs without assistance from proper equipment and/or

other persons. ● Lifted objects must be held close to body’s center of gravity to avoid displacement of the

center of gravity and achieve greater stability. ● Using the bones and joints as levers to lift

Pulling and Pushing ● When pushing or pulling: enlarge the base of support by adjusting foot placement. ● Easier and safer to pull and object than push because more control over object when

pulling.

Pivoting● place one foot ahead, raise heels, turn while keeping body aligned.

Preventing Back Injury● Avoid twisting and stooping

Positioning Clients ● Reposition client q2h

○ when client is completely dependent, preferred two or more nurses to move or turn the client.

○ make sure mattress if firm yet supports natural body curvature■ ensure bed is clean and dry

○ avoid placing one body part on top of another (especially those with bony prominences)

○ always obtain info of client comfort○ Use of supportive devices:

■ Pillows (used for elevation, trochanter rolls)■ Mattresses (standard or egg-crate)■ Suspension or heel guard boot■ Footboard■ Handroll (rolling a washcloth, prevents hand contractures)■ Abduction pillow (triangle-shaped that maintains hip abduction to prevent

dislocation after total hip replacement. ● Fowler’s (45-60)

○ careful not to put pillows behind neck due to risk of neck flexion contractures○ Correct measures for Fowler's:

■ Support pillows at: lower back , head, neck, under forearms, under thighs, trochanter roll, lower legs

● Semi-Fowler’s (15-45)● High Fowler’s (60-90) ● Orthopneic (leaning over bedside table)● Dorsal Recumbent (supine with shoulders and head elevated by small pillows)● Prone Position (on stomach with head turned)

○ Gravity pulls on trunk causing lordosis● Lateral Position● Sims’ Position (half lateral/half prone; lower arm positioned behind client)

○ Used in clients who are: unconscious (facilitates drainage from mouth), paralyzed (reduces pressure on sacrum), enemas, treatments of perineal area, pregnancy

Moving and Turning Clients in Bed● Assess:

○ client need to function independently and the need for assistance to move.

○ Degree of client condition (surgery, pain, etc.)○ Need for assistive devices○ IV’s or catheters to be cautious for ○ Need for assistance

● Implementation:○ Face in direction of movement to prevent spinal twisting.○ Assume broad stance○ Lower center of gravity○ Tighten major muscle groups to prepare for action○ Rock from front to back or vice versa in a smooth motion. ○ Assess client for comfort, body alignment, tolerance, ability to assist.

● Moving a Client Up in Bed:○ Adjust HoB so that it is in flattest position tolerable for client. (moving client

upward against gravity requires more force and can cause back strain)○ Moving a client up in bed is not a one-person task especially if care giver is

required to lift more than 35lbs. ■ for client over 200lbs requires friction-reducing device AND three

assistants..○ Ask client to flex hips and knees and position feet for effective pushing.

■ keeps entire lower leg off bed to prevent friction during movement, and ensures use of large muscle groups in the client’s legs when pushing.

○ Place client’s arms across chest and flex neck to keep head off bed surface. ○ Position yourself appropriately and move client

■ face direction of movement to prevent twisting of spine■ broad stance■ shift weight from back leg to front

● Turning Client to the Lateral or Prone Position○ Adjust bed to both client and caregiver comfort○ Move client closer to side of bed opposite of desired side the client will be facing.

■ Ensures client is in center of bed after turning■ Place client’s arm that is closer to edge across chest.■ Abduct client’s far shoulder slightly away from the side of the body.

● For prone position, keep arm alongside body. ● Help facilitate turning motion and prevents arm from being caught

under client’s body during the roll. ■ Place client’s near ankle over and across far ankle to facilitate turning

motion. ○ Support the client’s hip and shoulder during turn. ○ Position client on side with their arms and legs positioned and supported properly. ○ NEVER pull a client across the bed while in PRONE. (Can injure a client's

breasts or genitals)

● Logrolling● Assisting Client to Dangling

Transferring Clients● Nurse must determine client’s physical and mental capabilities to perform transfer

technique.● Gait belts and transfer boards ● When performing a transfer:

○ Plan what, when, where, and how○ Obtain essential equipment ○ remove obstacles from area○ explain transfer to client other nursing personnel ○ always support or hold the client ○ explain step by step what the client should do. ○ document client tolerance (pain, HR, and RR)

● Transferring OOB to Chair○ Lower bed to lowest position so client's feet will rest flat on floor. ○ Place wheelchair parallel to the bed. Lock wheels. ○ Assist client to dangling position. ○ Assess for orthostatic hypotension. ○ Assist on proper covering and nonskid footwear. ○ Place gait/transfer belt ○ Have client put stronger leg under edge of bed so it can power the movement and

provide a broader base of support. ○ Pivot transfer

Providing ROM Exercises● Active ROM

○ isotonic exercises in which the client moves each joint in the body through its complete range of movement, maximally stretching all muscle groups within each plane over the joint.

■ these exercises maintain or increase muscle strength and endurance and also prevent deterioration of joint capsules, ankylosis, and contractures.

● Passive ROM○ another person moves each of the client’s joints through its complete ROM

maximally stretching all muscle groups within each plane over each joint. ■ useful in maintaining joint flexibility, but no value in maintaining muscle

strength. ■ only performed when client unable to accomplish the movements actively■ PROM should be done systematically and repeated throughout the day.

● Active-assistive ROM○ client uses stronger limb to help support and move weaker limb, while nurses

continues the movement passively to its maximal degree. Ambulating Clients

● Ambulation - act of walking● if immobilized for 1-2 days, a client can feel weak, unsteady, and shaky when getting out

of bed. ● Preambulatory Exercises:

○ Plan of muscle tone exercises to strengthen the muscles used for walking before ambulation.

○ Most important group to exercise is the quadriceps femoris.

Using Mechanical Aids for Walking

Client Teaching Using Canes● Cane is grasped by hand that is opposite the leg that is the weakest● Stand with a firm grip on the cane● At the same time, step forward with the weaker leg & swing the cane the same distance

in front. The tip of the cane & forward foot should be even● Take some of the pressure off of the weaker leg by placing pressure on the cane● Step past the cane with the strong leg● Repeat ● Turn by pivoting on the strong leg

Client Teaching Using Walkers● If one leg is weaker ● Move the walker & the weaker leg ahead together● Weight is borne by the stronger leg● Move the stronger leg ahead ● Weight is borne by the affected leg & both arms● When maximum support is required● Move the walker ahead ● Body weight is borne on both legs● Move the right foot up to the walker● Body weight is borne by left leg & both arms● Move the left foot up the right foot● Body weight is borne by right leg & both arms

Crutches● Crutch Stance (Tripod Position)

○ Crutches placed about 6in in front of feet and 12 inches or more apart depending on height.

■ Taller client’s need a wider base of support. ○ Hips and knees are extended, back is straight, and the head is held straight and

high. ○ No hunching of the shoulders to prevent weight bearing of the axillae. ○ If client unsteady, place gait belt and hold from above.

● Four-Point Alternate Gait○ Easiest and safest because has 3 points of support at all times. ○ Does not require much space. ○ To use this gait, client needs to be able to bear weight on both legs. ○ Figure 69 pg 631

● Three-Point Gait○ Most common seen.○ Both crutches and weaker leg move forward.○ Stronger leg move forward

● Two-Point Alternative Gait○ Faster than four-point, requires more balance and only two points of support at

one time. ○ Requires partial weight bearing on each foot. ○ Move opposite foot and crutch at same time.

● Swing-to Gait○ used in clients with paralysis of legs and hips. ○ prolonged use results in atrophy of unused muscles.○ Easiest of these two gaits.

■ Move both crutches together, Swing body to crutches using arm strength. ● Swing-Through Gait

○ Move both crutches together. Swing body beyond crutches using arm strength. ● Getting in/out of a chair

○ Getting in chair: ■ Stand in front of chair with back of stronger leg against chair.■ Transfer crutches to hand on the affected side and then grasp the arm of

the chair with the unaffected side hand.■ Lean forward, flex knees and hips, and lower into the chair.

○ Getting out of chair:■ reverse of getting in■ assume tripod position before moving

● Going up Stairs○ Tripod position -> unaffected leg -> affected legs (+crutches)

● Going down Stairs○ opposite

Evaluating● Has the client’s physical or mental condition changed motivation to perform required

exercise?● Were appropriate ROM exercises implemented?● Was the client encouraged to participate in self-care activities as much as possible?● Was the client encouraged to make as many decisions as possible when developing a

daily activity plan and to express concerns?● Did the nurse provide appropriate supervision and monitoring?● Was the client’s diet adequate to provide appropriate nourishment for energy

requirements?