Week 6 - activity and exercise

physical activity

• Elevates mood and attitude

• Enables physical fitness

• Helps to quit smoking and stay tobacco-free

• Boosts energy levels

• Helps in the management of stress

• Promotes a better quality of sleep

• Improves self-image and self-confidence

activity and exercise time

150 minutes per week

Pathological influences on body alignment, mobility, and activity

• Congenital defects

• Disorders of bones, joints, and muscles

• Central nervous system disease or injury

• Musculoskeletal trauma

• Obesity > world-wide problem!

isontoic exercise

moving your muscles and joints

1. swim

2. jog

3. walk

Benefits: Improves muscle strength, endurance, and cardiovascular health.

isometric exercise

stationary / no movement

1. plank

2. muscle tension

3. tightening your abdominal muscles without moving

involves tightening your muscles without moving your joints. our muscles contract, but you hold the same position

resistive exercise

involves making your muscles work against a force or resistance (resistance can come from your body weight, exercise bands, or weights)

1. push-ups

2. weightlifting

3. resistance bands

critical thinking

• Sound clinical judgment is at the core of providing safe and relevant interventions for improving a patient’s activity level and tolerance.

• Integrate knowledge from nursing and other disciplines to understand activity tolerance, movement, and physical fitness and their effects on patients.

• Critical thinking attitudes and intellectual standards help guide the problem-solving approach in making clinical judgments during the nursing process

Assessment/Recognize & Analyze Cues

through the patients eyes, to develop a plan together

Readiness to exercise – perceived self efficacy

• Cultural - beliefs and attitudes about the value of exercise

• Socioeconomic factors - access to exercise programs and other resources, accountability to others

• Physical health - affects a patient’s ability to be mobile and active

• Body alignment - standing, sitting, and then lying down

transtheoretical model

(TTM)

incorporates the concept of self-efficacy

• applied for tailoring interventions to patients’ readiness to change

• can enhance patient progress

• help patients use therapeutic resources more effectively

TTM steps

1. Precontemplation – thinking about it, over next 6 months

2. Contemplation – know they need to change, lack commitment

3. Preparation – concrete plan of action, within one month

4. Action – made the change

5. Maintenance – doing it for six months, working to prevent relapse

assessment questions

look at mobility

• Sitting

• Standing

• Range of motion

• Gait – style of walking

• Exercise pattern, if any

• Activity tolerance – ability to do ADL/IADL

• Environmental factors

• Factors influencing mobility

Bedside mobility assessment tool (BMAT)

It is a nursing assessment used to determine how safely a patient can move and how much assistance they need.

• 4 steps

4 steps of BMAT

uses four progressive mobility assessments. The patient must safely complete each step before moving to the next

• Level 1: sit and shake

• Level 2: stretch and point

• Level 3: stand

• Level 4: walk (step)

level 1: sit and shake

Ask the patient to sit upright and reach across their body to shake your hand.

Tests: Sitting balance, upper-body strength, and ability to follow instructions

level 2: stretch and point

Ask the seated patient to straighten one leg and flex and point their toes. Repeat with the other leg as appropriate.

Tests: Leg strength and control.

level 3: stand

Ask the patient to stand up from the bed or chair and demonstrate that they can maintain the position safely.

Tests: Ability to bear weight, stand, and maintain balance.

level 4: walk / step

Ask the patient to march in place and step forward and back with each foot.

Tests: Walking readiness, balance, and coordination

BMAT memory trick

Sit → Stretch → Stand → Step.

A patient who cannot complete a step should not be pushed to attempt the next one.

nursing diagnosis / generate solutions

how nurses identify patient problems (nursing diagnoses) and develop interventions (solutions) to help the patient.

Analysis and nursing diagnosis examples:

• Activity Intolerance - provide rest in between activities, monitor vitals, gradually increase activity as tolerated

• Risk for Fall-related Injury - bed low, call light in reach, nonslip footwear

• Impaired Mobility in Bed (patient has difficulty moving or changing positions) - assist, se pillows to support proper body alignment, monitor for pressure ulcers

• Impaired Mobility - assist with ablation, walkers, PT

• Acute or Chronic Pain - assess with pain scale, pain meds, comfortable positioning

• Readiness for enhanced health management - educate patient

diagnosis and generate solutions

• Analysis: Look at the patient's assessment findings to identify problems.

• Nursing diagnosis: Identify how the patient is responding to a health condition.

• Generate solutions: Decide what nursing interventions can help improve the patient's condition

planning and prioritize hypotheses

decide which patient problems are most important and create a plan to improve the patient's mobility, safety, and independence

• Planning and outcomes identification: deciding what nursing interventions will help the patient and finding the goals nurse wants the patient to achieve after receiving nursing care

  • outcomes

  • setting priorities - safe patient handling

  • teamwork and collaboration - healthcare workers working together

outcomes

• Effects of Exercise

• Knowledge of home environment - Nurses need to understand the patient's home environment to determine whether they can safely return home.

• Improve or maintain a patient’s functional status - means a patient's ability to perform everyday activities independently.

effects of exercise

• Improve muscle strength.

• Improve blood circulation.

• Maintain joint flexibility.

• Improve balance and coordination.

• Prevent complications of immobility, such as muscle weakness.

implementation / generate solutions

• health promotion

  • isotonic exercises

  • isometric exercises

• acute care

  • Early mobility!!! (Isotonic exercises = arm lifts, plantar flexion)

  • Isometric exercises (tighten/contract muscle groups)

  • Range-of-motion exercise

implementation / take action

Restorative and continuing care

• Assistive devices for walking

  • Walkers

  • Canes

  • Crutches

• Activities and exercises that restore and promote optimal functioning for patients with:

  • Coronary artery disease (CAD)

  • Hypertension (HTN)

  • Chronic obstructive pulmonary disease (COPD)

  • Diabetes mellitus (DM

safety guidelines for nursing skills

• Know patient’s level of mobility

• Assess patient’s risks for activity intolerance

• Mentally review transfer steps before beginning

• Stand on unaffected side (good side)

• Determine transfer equipment needed

• Raise bed’s side rail on opposite side

• Arrange equipment

• Evaluate for correct body alignment

• Understand equipment before starting

basic principles of body mechanics

• Align your center of gravity (pelvic area) with what you are moving

• Bend at the hips and knees, not the back

• Widen base of support

• Bring the object close to your center of gravity

• Lift with your legs, not your back

• Avoid twisting or rotating the spine

• Push vs. pull an object

• When lifting above should level, use a step stool or ask for help

evaluation

• Through the patient’s eyes

  • Are the patient’s expectations being met? How does the exercise make them feel?

• Patient outcomes

  • Make comparisons with baseline measures

  • Consider standards for physical activity performance

  • Compare actual outcomes with expected outcomes

timed up and go test

is a mobility assessment nurses use to evaluate a patient's balance, walking ability, and risk of falling.

• Sit: Have the patient sit in a chair with their back against the backrest.

• Stand: Ask the patient to stand up when you say "Go."

• Walk: Have the patient walk 3 meters (approximately 10 feet).

• Turn: Ask the patient to turn around.

• Return: Have the patient walk back to the chair.

• Sit: Ask the patient to sit back down.

under 10-12 seconds is normal mobility in healthy adults anything over 12 suggests increased fall rest, requiring further assessments

effects on movement

• Postural Disorders

• Muscle abnormalities

• Muscle trauma

• Joint disease

• CNS damage

pulmonary system

When a patient stays in bed too long, their lungs may not expand fully, and mucus can accumulate.

Effects include:

• Decreased lung capacity: The lungs cannot expand as effectively.

• Increased secretions: Mucus builds up in the airways.

• Atelectasis: Small air sacs (alveoli) collapse.

• Pneumonia: Infection can develop when secretions accumulate.

• Pulmonary embolism (PE): A blood clot can travel to the lungs, often originating from a DVT.

cardiovascular system

Immobility causes blood to circulate less efficiently, especially in the legs.

Effects include:

• Orthostatic hypotension: Blood pressure drops when the patient stands, causing dizziness.

• Deep vein thrombosis (DVT): A blood clot forms in a deep vein, usually in the leg.

• Decreased cardiac output: The heart may pump less blood with prolonged deconditioning.

• Tachycardia: The heart may beat faster to compensate for reduced cardiovascular fitness.

• Decreased plasma volume: Prolonged bed rest can cause fluid shifts and increased fluid excretion.

GI and GU system

When the body moves less, digestion slows down and urine may not drain as effectively.

Effects include:

• Constipation: Slower intestinal movement makes bowel movements difficult.

• Ileus: Intestinal movement becomes severely reduced or stops.

• Urinary stasis: Urine remains in the bladder or urinary tract.

• Urinary tract infections (UTIs): Stagnant urine can increase infection risk.

• Kidney stones: Increased calcium in the urine can contribute to stone formation.

musculoskeletal system

When muscles and bones are not used regularly, they become weaker.

Effects include:

• Muscle atrophy: Muscles shrink from lack of use.

• Decreased muscle strength: The patient becomes weaker.

• Contractures: Muscles and joints become stiff and may remain in a fixed position.

• Loss of bone density: Bones become weaker.

• Pressure injuries: Prolonged pressure damages skin and underlying tissues

endocrine and metabolic system

Immobility changes how the body uses nutrients, glucose, and minerals.

Effects include:

• Increased calcium excretion: Calcium is released from bones and eliminated in urine.

• Osteoporosis: Bones become weaker and more likely to fracture.

• Increased insulin resistance: The body becomes less responsive to insulin, potentially increasing blood sugar.

• Decreased protein synthesis: The body may lose muscle tissue.

central nervous system / psychological

Being immobile for a long time can affect a patient's mental and emotional health.

Effects include:

• Anxiety

• Depression

• Sleep disturbances

• Decreased attention and concentration

• Changes in mood and behavior

• Reduced coordination and sensory stimulation

pressure points

are areas of the body where bones are close to the skin and can press against a bed, chair, or wheelchair.

When a patient stays in one position too long, pressure can reduce blood flow to the skin and underlying tissues.

This can cause a pressure injury (bedsore)

patient lying on side of bed (lateral position)

• Ear and side of head

• Shoulder

• Elbow

• Hip (greater trochanter)

• Knees

• Ankles

A patient lying on their right side for a prolonged period may develop a pressure injury over the right hip.

patient lying on back (supine position)

Common pressure points include:

• Back of head (occiput)

• Shoulder blades (scapulae)

• Elbows

• Sacrum and coccyx (tailbone)

• Heels

The sacrum and heels are particularly common areas for pressure injuries in bedridden patients.

patient sitting in chair / wheelchair

Common pressure points include:

• Shoulder blades

• Sacrum and coccyx

• Ischial tuberosities (sitting bones)

• Back of thighs

• Feet and heels

A patient sitting in a wheelchair for several hours without repositioning may develop pressure injuries over the sitting bones.

pressure injury

Damage to skin or underlying tissue from prolonged pressure or pressure combined with shear

prevent pressure injuries

1. reposition patient regularly

2. assess the skin

3. keep skin clean and dry

4. use pressure relieving equipment

5. offload the heels

6. encourage mobility

7. maintain adequate nutrition and hydration

do not massage reddened areas over bony prominences because this can worsen tissue damage

some diseases / developments

Atelectasis - Collapse of small air sacs in the lungs

DVT - Blood clot in a deep vein

Orthostatic hypotension - Blood pressure drops when standing

Muscle atrophy - Muscles shrink from lack of use

Contracture - Permanent or persistent tightening that limits joint movement

Pressure injury - Damage to skin or underlying tissue from prolonged pressure or pressure combined with shear

Urinary stasis - Urine does not drain or empty properly

cardiovascular assessment

Measure blood pressure (lying, sitting, standing to detect orthostasis), apical and peripheral pulses, capillary refill, tissue edema, and baseline calf circumference (to detect unilateral leg swelling)

respiratory assessment

• Inspect chest wall movement and auscultate lung fields at least every 2 hours for crackles, wheezes, or diminished breath sounds.

metabolic assessment

Monitor intake and output (I&O), lab values (serum protein, blood glucose, electrolytes, and serum calcium), weight trends, and skin turgor

musculoskeletal assessment

Evaluate muscle tone, voluntary muscle strength, joint mobility, Range of Motion (ROM), and body alignment

integumentary assessment

Continually inspect skin over bony prominences for erythema or pallor, assessing skin integrity using the Braden Scale

braden scale

The Braden Scale evaluates 6 categories that affect a patient's risk of developing pressure injuries.

1. Sensory Perception - Can the patient feel and respond to discomfort or pressure?

2. Moisture - How often is the patient's skin exposed to moisture, such as sweat or urine?

3. Activity - How often does the patient walk or move around?

4. Mobility - Can the patient change positions independently?

5. Nutrition - Is the patient eating enough to maintain healthy skin?

6. Friction and Shear - Is the patient's skin rubbing or sliding against surfaces?

braden scale scoring

the lower the score = more potential for skin problem

• Five categories are scored 1–4.

• Friction and shear are scored 1–3.

• Total score ranges from 6 to 23

Katz ADL scale

feeding, dressing, bathing, toileting, transferring, continence

lawton IADL scale

shopping, preparing meals, banking, taking medications, laundry,

using phone, transportation

elimination assessment

Track daily fluid intake and urinary output, observe urine color and clarity (checking for urinary stasis or UTI), and document bowel movement frequency (checking at least every 3 days for constipation)

psychological assessment

Evaluate mood stability, sleep quality, coping mechanisms, and age-specific developmental milestones

respiratory care

Promote early mobility, instruct on coughing and deep breathing (C&DB) exercises every 1 to 2 hours, encourage incentive spirometry, and ensure adequate hydration (2,000–3,000 mL/day) to keep airway secretions thin

metabolic and GI care

Provide a high-calorie, high-protein diet rich in Vitamin C (for tissue repair) and Vitamin B complex. Encourage high-fiber foods and adequate fluids to stimulate peristalsis

integumentary care

Reposition bedridden patients at least every 2 hours; instruct chair-bound patients to shift weight or move their buttocks every 15 minutes; utilize pressure-relieving devices or low air loss mattresses

elimination care

Position patients in near-upright sitting alignment when using the bedpan to facilitate normal gravity flow of urine and stool; track bowel movements at least every 3 days

cardiovascular focus

Cardiovascular risk is one of the most immediate concerns when a patient is restricted to bed rest

1. orthostatic hypotension

2. DVT prevention

orthostatic hypotension

A drop in systolic blood pressure of greater than equal to 20 mmHg or diastolic blood pressure of greater than or equal to 10 mmHg within 3 minutes of standing.

• Nursing Interventions:

  1. Mobilize the patient as early as tolerated.

  2. Perform "dangling": Have the patient sit on the edge of the bed with legs hanging for 1–2 minutes before attempting to stand.

  3. Monitor for warning cues: dizziness, lightheadedness, pallor, or sudden tachycardia.

DVT

Venous stasis (sluggish blood flow from immobility), hypercoagulability, and vessel wall damage (Virchow's Triad) allow blood clots to form in the deep veins of the lower extremities

Nursing Interventions:

1. Mechanical Prophylaxis: Apply Sequential Compression Devices (SCDs) or anti-embolism stockings (TED hose) as prescribed to promote venous return.

2. Active Leg Exercises: Instruct the patient to perform ankle circles, leg lifts, and foot pumps (plantar flexion) every hour while awake.

3. Pharmacological Prophylaxis: Administer prescribed low-dose anticoagulants (e.g., heparin or low-molecular-weight heparin).

4. Proper Positioning Cues: Avoid placing pillows or knee gatch cushions directly under the knees or crossing the legs, as this compresses popliteal vessels and worsens venous stasis.

active ROM

Patient moves their joints independently.

passive ROM

Nurse or caregiver moves the patient's joints without the patient assisting. (total help moving joints)

active assisted ROM

Patient moves their joints with some assistance. (partial help moving joints)

supported fowlers position

Patient is lying on their back with the head of the bed elevated, often around 30–60 degrees, with pillows for support.

Purpose: Makes breathing easier, promotes comfort, and supports eating.

supine position

Patient lies flat on their back, facing upward.

Purpose: Used for examinations, rest, and certain procedures.

Pressure points: Back of head, shoulder blades, sacrum, and heels.

prone position

Patient lies on their stomach, facing downward.

Purpose: May improve oxygenation in selected patients and relieve pressure from areas normally compressed when lying on the back.

Pressure points: Face, chest, knees, and toes.

side lying / lateral recumbent position

Patient lies on their left or right side, with pillows used to support proper alignment.

Purpose: Helps relieve pressure on the sacrum, supports comfort, and can reduce aspiration risk in certain situations.

Pressure points: Shoulder, hip, knees, and ankles.

ROM exercises

Maintain joint movement and prevent stiffness

hand rolls

Maintain proper hand positioning

trapeze bar

is an overhead device that patients can grab to help reposition themselves in bed.

It helps patients:

• Lift or reposition their upper body.

• Move more independently.

• Reduce the assistance needed for certain movements

HCW

healthcare workers

major source of injury for HCW is musculoskeletal disorders.

• Nursing assistants: 166.3/10,000

• All other workers: 30.5/10,000

• Reason for approximately 20% of nurses who leave bedside care

safe patient handling

means using proper techniques and equipment to safely move, lift, reposition, or transfer patients.

The main goal is to prevent injuries to both the patient and the healthcare worker.

sit to stand lift

Helps patients move from sitting to standing.

Used for: Patients who can participate in standing and meet the device's weight-bearing requirements but need assistance.

mechanical lift

Uses a sling and mechanical system to lift and transfer patients.

Used for: Patients who cannot safely stand or support their own weight.

slide sheet (repositioning sheet)

Helps caregivers move patients across the bed while reducing friction and shear.

Used for: Repositioning patients who cannot move independently.

air assisted transfer device

Uses air to reduce friction between the patient and the bed.

Used for: Moving patients between surfaces, such as from a bed to a stretcher.

transfer board

A sturdy board that bridges two surfaces to help a patient move between them.

Used for: Patients who have limited leg mobility but can assist with transfers using their upper body.

gait belt

A belt placed around the patient's waist to provide a secure handhold during assisted movement.

Used for: Patients who can bear weight but need help with balance or transfers.

• A gait belt is not used to lift a patient's full body weight

safe handling techniques

before moving patient, the nurse should:

1. assess mobility

2. explain the procedure

3. choose appropriate eqipment

4. prepare the environment

5. use safe body mechanics

6. ask for assistance

SPH and take action

Take Action means performing the nursing intervention you planned.

Example: A patient who recently had a stroke cannot stand independently.

• Recognize cues: Patient has significant leg weakness.

• Analyze cues: Patient cannot safely bear weight.

• Prioritize hypotheses: Risk for falls and impaired physical mobility.

• Generate solutions: Plan a safe transfer using a mechanical lift.

• Take action: Use the mechanical lift with trained staff to transfer the patient.

• Evaluate outcomes: Patient was transferred safely without injury.

when to use 2 person lift

When a client:

• Is not willing or able to help in transfer

• Cannot bear weight on one leg or both arms

• Has limited or no trunk control

• Cannot balance while standing

• Cannot move or straighten the hips, knees, shoulders or elbows

• Behaves in an inconsistent, uncooperative or aggressive way

A 2-person assist means two trained healthcare workers help move or transfer a patient (should not manually lift a patients full body weight)

safety guidelines

• Determine the amount and type of assistance required for safe positioning.

• During positioning raise the side rail on the side of the bed opposite of where you are standing.

• Arrange equipment so that it does not interfere with the positioning process.

• Evaluate the patient for correct body alignment and pressure risks after repositioning.