Activity, Exercise, Restraints, and Orthopedic Care Flashcards

Restraint Safety and Protocol

Pre-Application Assessment and Environmental Interventions

Prior to placing a client in physical restraints, a thorough assessment must be conducted to identify underlying triggers for specific behaviors. Alternative interventions must be explored and implemented whenever possible:

• Determine if the client is experiencing unmanaged pain, distress, or urgent elimination needs.

• Verify whether the client is confused due to environmental changes. Novel environments and negative sensory stimuli frequently trigger acute agitation or confusion.

• Re-orient the client to their environment.

• Implement environmental modifications, such as relocating the client closer to the nurses' station or into a direct visual line-of-sight room, to prevent unsafe behaviors without physical restraint.

Prescriptions, Consent, and Documentation Rules

• Provider Order Requirement: Physical restraints require a specific, non-PRN order from a licensed healthcare provider. There is no such thing as a PRN restraint order.

• Order Renewal: Prescriptions for restraints must be re-evaluated and reissued every $24\text{ hours}$.

• Written Consent: A WRITTEN and SIGNED consent form must be obtained within $24\text{ hours}$ of restraint application. Consent must be granted by the client's Power of Attorney (POA) or legal next of kin.

• Re-evaluation: The nurse must formally re-evaluate the ongoing clinical need for restraints within $4\text{ hours}$ of initial application.

• Family Education: Educate the client's family regarding the specific clinical indication, purpose, and function of the restraint system.

Monitoring, Care Release, and Attachment Protocols

• Mandatory 2-Hour Interventions: Restraints must be released at least every $2\text{ hours}$ and PRN. During release periods, the nurse must:

  1. Assess skin integrity and check for breakdown.

  2. Conduct incontinence checks and assist with restroom or bedpan usage.

  3. Offer fluids and nutrition.

  4. Perform range-of-motion (ROM) exercises (typically passive ROM).

• Documentation: Restraint status, skin condition, and nursing interventions must be documented in the medical record at least every $2\text{ hours}$.

• Fit Test: The restraint must be applied so that $2\text{ fingers}$ can be easily inserted underneath the strap to prevent neurovascular impairment.

• Securement Location: Restraints must ALWAYS be tied directly to the stationary bed frame using a quick-release knot. Restraints must NEVER be attached to bed side rails.

Restraint Classifications, Prohibitions, and Regulatory Standards

• Side Rails and Lap Trays: Bed side rails may be classified as physical restraints under regulatory guidelines. Many healthcare facilities mandate formal consents for raising $2\text{ side rails}$ per Centers for Medicare & Medicaid Services (CMS) directives. Wheelchair lap trays are considered physical restraints unless the client can remove them independently without assistance.

• Absolute Prohibitions: Restraints must NEVER be utilized as a discipline, threat, or convenience for staff or caregivers.

• Sentinel Events: Any client death occurring while a client is in restraints (or where restraints directly contributed to death) is classified as a sentinel event. This requires an immediate root-cause investigation and formal analysis per Joint Commission mandates.

• Seclusion Standards: Placing a client in seclusion requires continuous, uninterrupted audio and visual monitoring.

Compartment Syndrome and Cast Care

Compartment Syndrome Pathophysiology and Clinical Manifestations

Compartment syndrome is a critical medical emergency characterized by increased pressure within an enclosed muscular compartment. Blood circulation to and from the extremity becomes severely impeded, threatening tissue viability.

• Irreversible Necrosis: Complete tissue necrosis and permanent loss of function occur after $6\text{ hours}$ of unrelieved compartment pressure.

• The Six "P"s of Compartment Syndrome:

  1. Pain: Severe, localized pain out of proportion to the physical injury, unresponsive to analgesics.

  2. Pallor: Pale skin tone; pallor serves as the first clinical sign that a cast or compression bandage is too tight.

  3. Paresthesia: Burning, tingling, or numbness distal to the injury.

  4. Paralyses: Inability to move digits or the extremity.

  5. Poikilothermia: Affected extremity assumes ambient environmental temperature (feels cool/cold to touch).

  6. Pulselessness: Weak or absent distal peripheral pulse (a late, critical sign).

• Emergency Interventions:

  • Position the affected limb at the level of the heart (do not elevate above the heart, as this further compromises arterial inflow).

  • Immediately remove all constricting circumferential casts, splints, or compression bandages to allow surgical decompression.

Cast Materials and Maintenance

• Plaster of Paris Casts:

  • Dries within $10\text{ minutes}$ of application but requires up to $48\text{ hours}$ to dry completely.

  • Must NEVER get wet.

  • While drying, handle the cast exclusively with the pads/palms of the hands, never with the fingertips. Fingertip pressure creates permanent internal indentations that cause localized skin breakdown and tissue necrosis.

• Fiberglass (Synthetic) Casts:

  • Dries rapidly and weighs significantly less than a plaster cast.

  • Is not inherently waterproof unless fitted with a specialized waterproof liner.

• Comprehensive Cast Care Guidelines:

  • Keep casts completely dry.

  • To relieve severe itching under the cast, use a hair dryer set strictly on a cool setting. NEVER insert powders, lotions, oils, or long objects inside the cast, as these introduce high infection risks and damage fragile skin.

  • Pad rough cast edges using moleskin or soft padding.

  • Apply ice bags around the cast site to reduce localized tissue edema.

  • Elevate the casted extremity at heart level to facilitate venous return.

  • Inspect the cast structure routinely for cracks, breaks, or softening.

Clinical Neurovascular Assessment and Emergency Priorities

• Assessment Sequence: Always follow Airway, Breathing, Circulation (ABC). Assessing distal extremity circulation is the first priority when caring for a client in a cast or splint.

• Circulatory Checks: Evaluate capillary refill distal to the cast, skin color, temperature, and distal pulses.

• Infection Sign: If a cast feels hot or warm to the touch, assess the client immediately for underlying localized tissue infection or necrosis.

Sprain/Strain Management and Hip Replacement Care

• Sprain and Strain Protocol: Implement RICE (Rest, Ice, Compression, Elevation).

• Bandaging Technique: Compression bandages must be wrapped in a distal-to-proximal direction (toward the heart) to promote venous circulation. A properly applied compression dressing should prevent edema; edema must not form distal to the bandage edge.

• Total Hip Replacement Alignment: Position an abduction pillow between the legs whenever the client is lying in bed to maintain hip abduction and prevent dislocation.

Fundamentals of Movement, Posture, and Alignment

Four Basic Elements of Normal Movement

Normal physical movement and postural stability require an intact musculoskeletal system, an intact nervous system, and intact inner ear structures responsible for equilibrium. Movement comprises four core elements: body alignment (posture), joint mobility, balance, and coordinated movement.

Body Alignment and Posture Dynamics

• Definitions:

  • Center of Gravity: The specific point at which all of the body's mass is centered.

  • Line of Gravity: An imaginary vertical line drawn directly through the body's center of gravity.

  • Base of Support: The foundational surface on which the body rests.

• Standing Alignment Path: In a well-aligned human, the line of gravity originates at the top of the head, passes between the shoulders, extends through the trunk, falls slightly anterior to the sacrum, and drops directly between the weight-bearing joints and the base of support.

• Physiologic Benefits: Proper alignment minimizes strain on joints, muscles, tendons, and ligaments; enhances full lung expansion; and optimizes circulatory, renal, and gastrointestinal functions.

Mechanisms of Balance and Proprioception

• Sensory Inputs: Postural equilibrium is maintained via complex inputs from:

  1. The inner ear labyrinth system.

  2. Visual input (vestibulo-ocular system).

  3. Muscle and tendon stretch receptors (vestibulospinal system).

• Proprioception: The detailed awareness of posture, movement, changes in equilibrium, and the position, weight, and resistance of objects relative to the body.

Neurologic Control of Coordinated Movement

Smooth, purposeful motor activity relies on integrated cerebral function:

• Cerebral Cortex: Initiates voluntary motor movements.

• Cerebellum: Coordinates smooth muscular activity and spatial movement timing. Injury to the cerebellum results in clumsy, hesitant, and uncoordinated movements.

• Basal Ganglia: Maintains static posture and automatic background movement control.

Comprehensive Joint Movements and Range of Motion

Joint Mechanics and Contracture Development

Joints articulate the skeleton and serve as functional movement units. Flexor muscles are naturally stronger than extensor muscles. Consequently, when a client is inactive, joints are pulled into a flexed (bent) position. Without regular exercise and position changes, muscle fibers undergo permanent shortening, resulting in an irreversible joint deformity called a contracture.

Full Range of Motion (ROM) Specifications

Range of Motion (ROM) refers to the maximum movement achievable by a specific joint.

Specific Joint Motion Ranges and ADL Examples:

• Neck (Pivot Joint):

  • Flexion: Move head forward, chin to chest ($45^\circ$ from midline).

  • Extension: Move head to erect position ($45^\circ$ from midline).

  • Hyperextension: Bend head backward ($45^\circ$ from midline).

  • Lateral Flexion: Tilt head toward right/left shoulders ($40^\circ$ from midline).

  • Rotation: Turn face side to side ($70^\circ$ from midline). ADL Example: Nodding "yes" or shaking head "no".

• Shoulder (Ball-and-Socket Joint):

  • Flexion: Raise arm forward beside head ($180^\circ$).

  • Extension: Return arm to side ($180^\circ$).

  • Hyperextension: Move arm behind body ($50^\circ$).

  • Abduction: Raise arm laterally overhead ($180^\circ$).

  • Adduction (Anterior): Swing arm across front of body ($50^\circ$).

  • Circumduction: Move arm in full circular arc ($360^\circ$).

  • External Rotation: Elbow flexed $90^\circ$, rotate arm up ($90^\circ$).

  • Internal Rotation: Elbow flexed $90^\circ$, rotate arm down ($90^\circ$). ADL Example: Reaching overhead light, scratching lower/upper back.

• Elbow (Hinge Joint):

  • Flexion: Lower arm forward and upward to shoulder ($150^\circ$).

  • Extension: Lower arm downward, straightening elbow ($150^\circ$).

  • Supination: Turn palm upward ($70^\circ\text{ to }90^\circ$).

  • Pronation: Turn palm downward ($70^\circ\text{ to }90^\circ$). ADL Example: Eating, bathing, shaving.

• Wrist (Condyloid Joint):

  • Flexion: Bend fingers toward inner forearm ($80^\circ\text{ to }90^\circ$).

  • Extension: Straighten hand parallel to forearm ($80^\circ\text{ to }90^\circ$).

  • Hyperextension: Bend fingers backward ($70^\circ\text{ to }90^\circ$).

  • Radial Flexion (Abduction): Bend wrist laterally toward thumb ($0^\circ\text{ to }20^\circ$).

  • Ulnar Flexion (Adduction): Bend wrist laterally toward fifth finger ($30^\circ\text{ to }50^\circ$). ADL Example: Writing, eating, shaving.

• Hand and Fingers (Metacarpophalangeal Condyloid & Interphalangeal Hinge):

  • Flexion: Make a tight fist ($90^\circ$).

  • Extension: Straighten fingers ($90^\circ$).

  • Hyperextension: Bend fingers back ($30^\circ$).

  • Abduction: Spread fingers apart ($20^\circ$).

  • Adduction: Bring fingers together ($20^\circ$).

• Thumb (Saddle Joint):

  • Flexion: Move thumb across palm toward fifth finger ($90^\circ$).

  • Extension: Move thumb away from hand ($90^\circ$).

  • Abduction: Extend thumb laterally ($30^\circ$).

  • Adduction: Move thumb back to hand ($30^\circ$).

  • Opposition: Touch thumb tip to each finger tip on the same hand.

• Hip (Ball-and-Socket Joint):

  • Flexion: Move leg forward and up ($90^\circ$ knee extended; $120^\circ$ knee flexed).

  • Extension: Move leg back beside other leg ($90^\circ\text{ to }120^\circ$).

  • Hyperextension: Move leg backward behind trunk ($30^\circ\text{ to }50^\circ$).

  • Abduction: Move leg out to side ($45^\circ\text{ to }50^\circ$).

  • Adduction: Move leg back to midline and across other leg ($20^\circ\text{ to }30^\circ$ beyond midline).

  • Circumduction: Move leg in a full circular path ($360^\circ$).

  • Internal Rotation: Flex hip/knee $90^\circ$, rotate thigh toward midline ($40^\circ$).

  • External Rotation: Flex hip/knee $90^\circ$, rotate thigh away from midline ($45^\circ$).

• Knee (Hinge Joint):

  • Flexion: Bring heel toward back of thigh ($120^\circ\text{ to }130^\circ$).

  • Extension: Return foot to resting standing position ($120^\circ\text{ to }130^\circ$).

• Ankle (Hinge Joint):

  • Plantar Flexion (Extension): Point toes downward ($20^\circ$).

  • Dorsiflexion (Flexion): Point toes upward toward face ($45^\circ\text{ to }50^\circ$).

• Foot (Gliding Joint):

  • Eversion: Turn sole of foot outward ($5^\circ$).

  • Inversion: Turn sole of foot inward ($5^\circ$).

• Toes (Interphalangeal & Metatarsophalangeal Hinge):

  • Flexion: Curl toes downward ($35^\circ\text{ to }60^\circ$).

  • Extension: Straighten toes ($35^\circ\text{ to }60^\circ$).

• Trunk (Gliding Joint):

  • Flexion: Bend upper body toward toes ($70^\circ\text{ to }90^\circ$).

  • Extension: Return trunk to upright position ($20^\circ\text{ to }30^\circ$).

  • Hyperextension: Bend trunk backward ($20^\circ\text{ to }30^\circ$).

  • Lateral Flexion: Bend trunk to left and right ($35^\circ$ each side).

  • Rotation: Twist upper torso from side to side ($30^\circ\text{ to }45^\circ$).

Factors Influencing Mobility Across the Lifespan

Lifespan Developmental Changes

• Infants: Newborn movements are reflexive and flexed. Passive ROM is naturally full. Gross motor control develops in a cephalocaudal (head-to-toe) sequence: head control, crawling, pulling up, standing, and walking. Contralateral crawling movements serve as a vital building block for walking.

• Toddlers (1 to 5 Years): Gait is wide-based and shuffling ("toddler"). Fine and gross motor skills are refined (riding a tricycle, running, jumping, using crayons, zipping, brushing teeth).

• School-Age Children (6 to 12 Years): Motor refinement continues; posture is typically excellent.

• Adolescents: Growth spurts, carrying heavy bookbags over one shoulder, and prolonged computer usage can create enduring postural distortions.

• Young Adults and Pregnancy: Pregnant women experience a dramatic shift in center of gravity. American College of Obstetricians and Gynecologists (ACOG) guidelines recommend healthy pregnant women perform at least $150\text{ minutes}$ of moderate-intensity aerobic physical activity per week.

• Older Adults: Experience progressive loss of muscle tone, bone density depletion (osteoporosis), slowed reaction times, and loss of joint flexibility. Posture becomes stooped and forward-leaning, shifting the center of gravity forward. To compensate, knees flex slightly and the base of support widens, causing a wide-based, short-stepped, shuffling gait.

Nutrition, Personal Values, and External Influences

• Nutritional Factors: Undernutrition leads to muscle wasting and fatigue; Vitamin D deficiency impairs bone growth; calcium/vitamin D deficiencies accelerate osteoporosis; obesity strains weight-bearing joints and alters postural equilibrium.

• Personal Values & Culture: Exercise habits reflect family modeling, cultural role expectations, and personal beliefs regarding physical appearance.

• External Factors: Extreme heat and high humidity suppress physical activity; safe neighborhoods and accessible recreational facilities promote outdoor exercise.

Classifications and Physiology of Exercise

Classifications by Muscle Contraction

1. Isotonic (Dynamic) Exercises: Muscle shortens to produce dynamic muscle contraction and active movement (e.g., running, walking, swimming, cycling, active ROM exercises, pushing against a bedframe, pulling up on a trapeze). Increases muscle tone, mass, strength, joint mobility, heart rate, cardiac output, and peripheral circulation.

2. Isometric (Static or Setting) Exercises: Muscle contraction occurs without changing muscle length or joint angle (e.g., gluteal sets, abdominal tightening, tightening quadriceps by forcing knees down against a rolled towel [quad sets]). Maintains strength in immobilized or casted limbs. Produces a mild increase in heart rate and cardiac output without increasing general peripheral blood flow.

3. Isokinetic (Resistive) Exercises: Muscle contraction against variable resistance provided by specialized physical conditioning equipment.

Classifications by Energy Source

• Aerobic Exercise: Physical activity where oxygen taken into the body exceeds the oxygen required to perform the task. Utilizes large muscle groups in repetitive, sustained motion to build cardiorespiratory endurance.

• Anaerobic Exercise: Intense exertion where muscles cannot draw sufficient oxygen from the bloodstream, relying on anaerobic metabolic pathways for short bursts of energy (e.g., heavy weightlifting, sprinting).

Methods for Measuring Exercise Intensity

• Target Heart Rate: Calculate Maximum Heart Rate: $\text{Maximum HR} = 220 - \text{age in years}$. The exercise target heart rate zone is $60\% \text{ to } 85\%$ of maximum HR.

• Talk Test: Intensity is maintained at $\ge 60\%$ max HR when breathing is labored but the client can still comfortably maintain a conversation.

• Borg Scale of Perceived Exertion: A 1-to-20 scale measuring subjective exertion:

  • $7$ = Very, very light

  • $9$ = Very light ($\approx 40\%$ max HR)

  • $11$ = Fairly light

  • $13$ = Somewhat hard ($\approx 75\%$ max HR; standard target for most individuals)

  • $15$ = Hard

  • $17$ = Very hard

  • $19$ = Very, very hard ($\approx 100\%$ max HR)

Eastern Therapeutic Movement Modalities

• Hatha Yoga: Ancient Hindu discipline combining physical postures, breath control, and meditation to strengthen body, mind, and spirit. Can be fully adapted for bedbound or wheelchair-bound clients.

• Qigong: Chinese discipline utilizing gentle breathwork and subtle torso/arm movements to generate and conserve energy.

• T'ai Chi: Non-combative martial art practiced for health promotion, balance control, and fall prevention.

Physiological System Effects: Exercise vs. Immobility

Musculoskeletal System

• Exercise Benefits: Maintains muscle shape, size, tone, and strength; causes muscle hypertrophy during strenuous exertion; nourishes avascular joint structures; maintains bone density by balancing osteoblast (bone-building) and osteoclast (bone-resorption) activity through weight-bearing stress.

• Hazards of Immobility:

  • Disuse Osteoporosis: Lack of weight-bearing stress causes rapid bone demineralization and calcium depletion. Bones become spongy, deformed, and prone to fractures regardless of dietary calcium intake.

  • Disuse Atrophy: Unused muscles lose mass, tone, and strength.

  • Contractures: Irreversible permanent shortening of muscle fibers, tendons, and ligaments, locking joints in flexed positions (e.g., foot drop, wrist drop, external hip rotation).

  • Ankylosis: Permanent joint immobility due to collagen tissue consolidation and calcification.

Cardiovascular System

• Exercise Benefits: The American Heart Association recommends at least $150\text{ minutes/week}$ of moderate exercise or $75\text{ minutes/week}$ of vigorous activity. Increases stroke volume, cardiac output, and myocardial perfusion.

• Hazards of Immobility:

  • Diminished Cardiac Reserve: Autonomic imbalance leads to sympathetic dominance, raising resting heart rate and causing resting tachycardia with minimal exertion.

  • Valsalva Maneuver Risks: Holding breath against a closed glottis during bed repositioning builds high intrathoracic pressure, impeding venous return to the heart. When released, a sudden surge of blood enters the heart, triggering fatal cardiac arrhythmias in clients with heart disease.

  • Orthostatic (Postural) Hypotension: Inactivation of the sympathetic neurovascular vasoconstriction reflex. When rising vertically, blood pools in the lower extremities, central blood pressure plummets, cerebral perfusion drops, and the client experiences marked dizziness, pallor, diaphoresis, tachycardia, or syncope.

  • Venous Stasis and Dependent Edema: Lack of skeletal muscle pump action leads to incompetent venous valves, engorgement, increased venous pressure, and fluid extravasation into interstitial spaces (sacral edema in bedbound clients; foot/leg edema in seated clients).

  • Thrombus and Embolus Formation: Caused by Virchow's Triad (venous stasis, hypercoagulability, and vessel wall injury). Thrombi can detach to form emboli, causing lethal pulmonary embolism, stroke, or myocardial infarction.

Respiratory System

• Exercise Benefits: Increases ventilation, alveolar gas exchange, bronchial secretion clearance, and respiratory muscle stamina.

• Hazards of Immobility:

  • Decreased Respiratory Effort: Recumbent positioning restricts diaphragmatic movement and lung expansion, causing shallow respirations and reduced vital capacity.

  • Pooling of Secretions: Gravitational pooling of mucus in dependent bronchioles impairs $O_2/CO_2$ diffusion, predisposing the client to respiratory acidosis.

  • Atelectasis: Decreased surfactant production combined with mucous plugs collapses alveoli, lobes, or entire lungs.

  • Hypostatic Pneumonia: Static, pooled secretions serve as an ideal bacterial culture medium, rapidly progressing into severe lower respiratory tract infections.

Metabolic and Endocrine Systems

• Exercise Benefits: Increases metabolic rate up to 20 times baseline during strenuous activity; reduces serum triglycerides, cholesterol, and glycosylated hemoglobin (HbA1c); increases insulin sensitivity.

• Hazards of Immobility:

  • Decreased Basal Metabolic Rate (BMR): Energy demands and metabolic efficiency decline.

  • Negative Nitrogen Balance: Catabolism (protein breakdown) exceeds anabolism (protein synthesis). Muscle degradation releases nitrogen, leading to depletion of protein stores required for tissue repair and wound healing.

  • Anorexia: Loss of appetite secondary to diminished metabolic demands.

  • Negative Calcium Balance: Absence of weight-bearing stress extracts calcium from bones faster than it can be replaced.

Urinary System

• Exercise Benefits: Promotes renal blood flow, efficient waste excretion, and complete bladder emptying.

• Hazards of Immobility:

  • Urinary Stasis: Horizontal positioning prevents gravitational drainage from the renal pelvis into the ureters, causing urine stagnation.

  • Renal Calculi: Hypercalcuria combined with alkaline urine causes calcium salts to precipitate out as crystals, forming bladder and kidney stones.

  • Urinary Retention and Overflow: Loss of bladder detrusor tone creates distention, leading to involuntary dribbling without relieving retention.

  • Urinary Tract Infection (UTI): Static urine promotes bacterial growth (predominantly Escherichia coli). Overdistention creates mucosal micro-tears, while urinary reflux backs contaminated urine into the renal pelvis.

Gastrointestinal System

• Exercise Benefits: Stimulates peristalsis, increases abdominal tone, and prevents constipation.

• Hazards of Immobility: Reduced colon motility and weakened abdominal muscles cause constipation, severe fecal impaction, and dangerous straining via the Valsalva maneuver.

Integumentary System

• Hazards of Immobility: Reduced skin turgor, subcutaneous tissue atrophy, loss of elasticity, localized ischemia, and severe pressure injury formation over bony prominences.

Psychoneurologic and Cognitive Function

• Exercise Benefits: Releases endorphins, serotonin, and norepinephrine; elicits the Relaxation Response (RR) (described by Dr. Herbert Benson); improves executive cognitive function, decision making, and sleep quality.

• Hazards of Immobility: Apathy, withdrawal, regression, aggression, loss of self-esteem, distorted temporal perception, impaired problem solving, and heightened anxiety.

Anatomy & Physiology: The Spinal Engine and Locomotion

The Iliopsoas Muscle Complex

• Anatomical Structure: The iliopsoas is a composite muscle consisting of the psoas (originates on the lumbar vertebrae and inserts onto the femur) and the iliacus (originates on the pelvic crest and inserts onto the femur).

• Function: Primary hip flexors essential for erect posture, spinal stability, and locomotion. Prolonged sitting shortens the iliopsoas muscles, producing back pain and gait distortions.

The Spinal Engine Theory

• Theory Principles: Developed by S. A. Gracovetsky, the "spinal engine" theory asserts that gait originates in the spine rather than the legs. Motion in the spine and surrounding axial tissues precedes leg movement.

• Contralateral Locomotion: The rhythmic, opposing swing of the arms and legs (e.g., right arm swinging forward with left leg) reflects spinal rotation, providing energy efficiency, optimal balance, and smooth gait.

Comprehensive Nursing Assessment of Activity and Mobility

Assessment Components

1. Nursing History: Evaluate baseline ADL independence (eating, dressing, bathing, toileting, ambulating, transferring), activity tolerance, exercise habits, environmental barriers, financial resources, and pain.

2. Physical Examination: Inspect body alignment, standing posture, joint structure/ROM, muscle mass/strength, and specific signs of immobility complications.

Gait Assessment Parameters

• Phases of Gait:

  • Stance Phase: Heel strikes the ground; body weight spreads over the ball of the foot while the opposite heel pushes off.

  • Swing Phase: The trailing leg swings forward through the air.

• Normal Gait Features: Level chin, forward horizontal gaze, lifted sternum, relaxed shoulders, fluid contralateral arm swing, and even weight bearing.

• Walking Pace: Normal walking pace is 70 to 100 steps per minute. Older adult walking pace slows to approximately 40 steps per minute.

Activity Tolerance Evaluation Protocol

• Monitoring Schedule: Measure heart rate, respiratory rate, depth, rhythm, and blood pressure at four specific intervals:

  1. Before activity starts (resting baseline).

  2. During the activity.

  3. Immediately after activity ceases.

  4. Exactly $3\text{ minutes}$ post-activity after resting.

• Immediate Discontinuation Criteria: Stop activity instantly if any of the following occur:

  • Sudden facial pallor.

  • Dizziness, light-headedness, or altered level of consciousness.

  • Excessive acceleration of HR or RR.

  • Rhythm shift from regular to irregular.

  • Weakening of peripheral pulse.

  • Dyspnea, shortness of breath, or chest pain.

  • Diastolic blood pressure change of $\ge 10\,\text{mmHg}$.

• Safety Criterion: Activity is considered safe and appropriate if the client's heart rate returns to baseline within $5\text{ minutes}$ of resting.

Systemic Assessment Findings of Immobility (Table 44.3)

• Musculoskeletal: Decreased extremity circumference (muscle atrophy), joint stiffness/pain, reduced ROM, contractures.

• Cardiovascular: Increased resting HR, orthostatic hypotension, dependent edema, weak peripheral pulses, calf redness/swelling/tenderness (thrombophlebitis).

• Respiratory: Asymmetric chest expansion, dyspnea, diminished breath sounds, crackles, wheezes, tachypnea.

• Metabolic: Weight loss, subcutaneous fat loss, generalized edema (hypoproteinemia), dehydration signs.

• Urinary: Decreased output, dark/cloudy urine, high specific gravity, palpable bladder distention.

• Gastrointestinal: Hard dry stools, hypoactive/absent bowel sounds.

• Integumentary: Breakdown of skin integrity, localized erythema.

• Psychoneurologic: Flat affect, confusion, crying, anxiety, altered sleep patterns.

Safe Patient Handling and Mobility (SPHM) and Ergonomics

Occupational Risks and PHI Factors

Patient Handling Injuries (PHIs) and Musculoskeletal Disorders (MSDs)—such as low back pain, herniated disks, muscle strains, and ligament tears—are primary occupational hazards for nurses. Four major risk factors drive PHIs:

1. Exertion: The force required to lift/move a client.

2. Frequency: The cumulative number of client-handling tasks performed per shift.

3. Posture: Awkward body positions, back twisting, bending, or reaching across beds.

4. Duration of Exposure: Cumulative daily exposure to physical strain.

Mandatory Ergonomic Guidelines

• 35-Pound Lifting Limit: Nurses must NEVER manually lift more than $35\,\text{lbs}$ ($15.9\,\text{kg}$) of a client's body weight without assistive mechanical equipment.

• Principles of Body Mechanics:

  • Stability increases by widening the base of support (spreading feet apart) and lowering the center of gravity (flexing hips and knees into a squatting position).

• Pushing vs. Pulling: Pulling an object toward your center of gravity is safer and requires less effort than pushing.

• Pivoting Technique: Turn 90 degrees without spinal twisting by placing one foot forward, lifting heels slightly, and turning on the balls of both feet.

Therapeutic Positioning Protocols

General Positioning Principles

• Schedule: Reposition immobilized clients systematically every 2 hours around the clock.

• Comfort Assessment: Always evaluate alignment appearance AND obtain subjective comfort feedback from the client.

Specific Bed Positions

• Fowler's Position: Head and trunk elevated $45^\circ\text{ to }60^\circ$. Optimal for respiratory distress and cardiac issues. Avoid placing large pillows under the head to prevent neck flexion contractures.

• Semi-Fowler's Position (Low Fowler's): Head and trunk elevated $15^\circ\text{ to }45^\circ$ (typically $30^\circ$).

• High-Fowler's Position: Head and trunk elevated $60^\circ\text{ to }90^\circ$ (sitting upright).

• Orthopneic Position: Sitting in bed or on the edge of the bed, leaning forward over an overbed table. Facilitates maximal lung expansion during expiratory distress.

• Dorsal Recumbent / Supine Position: Client lies on back with head and shoulders slightly elevated on a small pillow. Facilitates healing post-spinal surgery/anesthesia.

• Prone Position: Client lies on abdomen with head turned to one side. Allows full extension of hip and knee joints, preventing flexion contractures. Promotes oral drainage in unconscious clients. Disadvantages: accentuates lumbar lordosis, causes lateral neck rotation, forces plantar flexion, restricts chest expansion.

• Lateral (Side-Lying) Position: Client lies on one side with top hip and knee flexed in front of the body, creating a wide triangular base of support. Reduces lordosis and relieves pressure on the sacrum and heels.

• Sims' (Semiprone) Position: Posture halfway between lateral and prone; lower arm behind client, upper arm flexed; both legs flexed (upper leg flexed acutely). Ideal for enema administration, unconscious oral drainage, and sacral/trochanteric pressure relief.

Supportive Positioning Devices

• Trochanter Roll: Rolled towel/pillow placed from iliac crest to midthigh to prevent external rotation of the femur in supine clients.

• Footboard / Suspension Boots: Maintains feet in dorsiflexion to prevent plantar flexion contractures (foot drop).

• Hand Roll: Keeps fingers and thumb in a functional open position to prevent flexion contractures.

• Abduction Pillow: Triangular foam device placed between legs post-total hip replacement to maintain hip abduction.

Clinical Procedures for Moving, Turning, and Logrolling

Skill 44.1: Moving a Client Up in Bed

• Preparation: Lower head of bed flat (or reverse Trendelenburg as tolerated); adjust bed to caregiver elbow height; lock bed wheels; place pillow against headboard to protect client's head.

• Weight-Based Assist Protocols:

  • Client <200 lbs: Friction-reducing slide sheet + $2\text{ caregivers}$.

  • Client 201-300 lbs: Friction-reducing slide sheet + $4\text{ caregivers}$ OR Air transfer system + $2\text{ caregivers}$.

  • Client >300 lbs: Air transfer system + $2\text{ caregivers}$ OR Total transfer mechanical floor/ceiling lift.

Skill 44.2: Turning to Lateral or Prone Positions

• Move client to opposite side of bed prior to turning.

• Abduct the client's far shoulder slightly and externally rotate it to prevent the arm from being pinned beneath the body during the turn.

Skill 44.3: Logrolling

• Indication: Used to turn clients who must maintain strict, linear spinal alignment (e.g., spinal surgery, spinal cord trauma).

• Personnel: Requires $2\text{ to }3\text{ nurses}$. If cervical spine injury exists, $1\text{ nurse}$ must stand at the head of the bed holding manual head and neck alignment throughout the move.

• Place pillows between the legs to prevent adduction during turning.

Skill 44.4: Assisting to Sit on Side of Bed (Dangling)

• Raise head of bed to highest position, swing client's lower legs over the edge, pivot on balls of feet while supporting shoulders and thighs. Assess for dizziness and orthostatic hypotension.

Client Transfer Techniques and Safety Guidelines

General Transfer Guidelines

• Lock wheels on bed, wheelchair, and stretcher prior to transfer.

• Transfer toward the client's unaffected (stronger) side.

• Utilize nonskid footwear.

• Ensure safe use of transfer/gait belts.

Gait/Transfer Belts

• Indicated only for clients who can bear weight and require minimal assistance.

• Grasped from underneath at the back.

• NEVER use gait belts to lift fully dependent or bariatric clients, or to lift a client off the floor.

Skill 44.5: Transferring Between Bed and Chair

• Place wheelchair parallel to bed on client's strong side. Lock wheelchair brakes and move footplates out of the way. Place gait belt, instruct client to push down on bed frame and lean forward ("Ready-steady-stand"), brace client's feet with nurse's feet, pivot toward chair, ensure back of legs touch chair seat before lowering down.

Skill 44.6: Transferring Between Bed and Stretcher

• Lower head of bed flat. Position bed slightly higher ($1/2\,\text{inch}$) than stretcher surface. Utilize friction-reducing slide sheet, transfer board, or air transfer mattress. Staff pull in unison on command. Immediately raise stretcher safety rails.

Range of Motion (ROM) Exercise Protocols

ROM Exercise Categories

1. Active ROM: Isotonic exercises performed independently by the client. Maintains muscle mass, strength, joint mobility, and cardiorespiratory function.

2. Passive ROM: Another individual moves joint through full range without muscle contraction by client. Maintains joint flexibility ONLY; does NOT build or maintain muscle strength.

   • Execution: Support limb above and below joint by cupping joint in palm or cradling limb along forearm.

   • Frequency: Repeat each movement 3 to 5 times per session, performed twice daily.

   • Move to point of slight resistance, never to pain.

3. Active-Assistive ROM: Client uses stronger opposite limb to move weak/paralyzed limb, supplemented passively by the nurse. Ideal for stroke rehabilitation.

Ambulation Support and Preambulatory Care

Preambulatory Exercises: Quadriceps Sets ("Quad Drills")

Isometric muscle contraction to strengthen quadriceps femoris (knee extensors/hip flexors):

• Client sits/lies flat, consciously tenses quadriceps, pulls kneecap upward, and forces popliteal space firmly against bed surface.

• Count: tense on 1, hold for counts 2-3-4, relax on 5. Repeat several times hourly to build ambulation stamina.

Skill 44.7: Assisting to Ambulate and Managing Falls

• Allow client to dangle at bedside for at least $1\text{ minute}$ prior to standing.

• High safety risk clients require ambulation lifts or sit-to-stand lifts with ambulation slings.

• Low safety risk clients require a gait belt; nurse walks behind and slightly to client's weak side.

• Fall Management Protocol: If a client begins to fall while ambulating, NEVER attempt to catch or manually lift the client. Rapidly clear surrounding hazards, step behind client, extend nurse's leg, guide client smoothly down the nurse's leg to the floor, and protect the client's head from impact. Utilize SPHM lift technology to lift client off the floor.

Mechanical Walking Aids: Canes, Walkers, and Crutches

Canes

• Types: Standard straight-legged, Tripod (3 feet), Quad cane (4 feet, highest stability).

• Holding Position: Hold cane on the STRONGER side of the body.

• Placement: Position tip $15\,\text{cm}$ ($6\,\text{in}$) to the side and $15\,\text{cm}$ ($6\,\text{in}$) in front of foot; elbow flexed slightly ($\approx 30^\circ$).

• Maximum Support Gait:

  1. Advance cane forward $30\,\text{cm}$ ($1\,\text{ft}$).

  2. Advance weak leg forward to cane.

  3. Advance strong leg forward past cane.

• Less Support Gait: Advance cane and weak leg forward simultaneously, then advance strong leg.

Walkers

• Standard Walker: Must be lifted; requires full arm strength and partial bilateral weight bearing.

• Roller Walker (2-Wheel / 4-Wheel): Pushed smoothly; ideal for weak/unstable clients.

• Gait: Move walker ahead $15\,\text{cm}$ ($6\,\text{in}$) -> step weak foot forward into walker -> step strong foot forward beside weak foot.

Crutches

• Crutch Measurement:

  • Supine: Measure distance from anterior axillary fold to heel and add $2.5\,\text{cm}$ ($1\,\text{inch}$).

  • Standing: Crutch pad must rest $2.5\text{ to }5\,\text{cm}$ ($1\text{ to }2\,\text{inches}$ or 3 fingerwidths) below axilla. Adjust handgrips for $30^\circ$ elbow flexion.

  • Critical Warning: Body weight MUST be borne entirely by arms and hands, NEVER by axillae. Pressure on axillae compresses radial nerves, causing irreversible crutch palsy.

• Tripod Position: Crutches placed $15\,\text{cm}$ ($6\,\text{in}$) in front and $15\,\text{cm}$ ($6\,\text{in}$) lateral to feet.

• Standard Crutch Gaits:

  • Four-Point Alternate Gait: Right crutch -> Left foot -> Left crutch -> Right foot. (Requires bilateral weight bearing).

  • Three-Point Gait: Both crutches + weak leg move forward together -> Strong leg moves forward. (Requires full weight bearing on unaffected leg).

  • Two-Point Alternate Gait: Left crutch + Right foot move together -> Right crutch + Left foot move together.

  • Swing-To Gait: Both crutches forward -> swing body TO crutches.

  • Swing-Through Gait: Both crutches forward -> swing body THROUGH and BEYOND crutches.

• Chair Transfers: Hold both crutches by handgrip in hand on affected side; grasp chair armrest with hand on unaffected side; raise/lower body using unaffected leg.

• Stair Navigation:

  • Going UP Stairs ("Up with the Good"): Step unaffected (strong) leg UP onto step first -> bring crutches and affected (weak) leg UP to step.

  • Going DOWN Stairs ("Down with the Bad"): Lower crutches and affected (weak) leg DOWN onto step first -> bring unaffected (strong) leg DOWN to step.