Chapter 9- activity

This chapter is heavily focused on patient safety, mobility assessment, positioning, transfers, ROM, ambulation, assistive devices, fall prevention, and safe patient handling and mobility (SPHM). For NCLEX, the biggest theme is:

Assess first → choose the safest level of assistance/device → protect the patient AND nurse → reassess tolerance.

1. Why Activity & Mobility Matter

Mobility affects essentially every body system. Prolonged immobility can lead to complications involving the musculoskeletal, cardiovascular, respiratory, GI, GU, integumentary, and psychosocial systems.

Benefits of mobility/activity

Mobility helps:

• Maintain muscle strength and tone

• Maintain joint mobility

• Prevent contractures

• Improve circulation

• Improve respiratory function

• Improve GI function

• Maintain independence with ADLs

• Reduce complications of immobility

• Improve psychological well-being

• Reduce risk for VTE/DVT

• Maintain functional ability

🔥 NCLEX connection

Early mobility is an important nursing intervention because changes from immobility can occur within only a few days.

2. Important Abbreviations

3. Mobility Assessment — ALWAYS Before Moving the Patient

Before transferring or ambulating a patient, determine what the patient can safely do.

Assess:

• Level of consciousness

• Ability to understand/follow directions

• Cooperation

• Muscle strength

• Balance

• Ability to bear weight

• Ability to stand

• Ability to walk

• Upper-extremity strength

• Ability to grasp

• Pain

• Fatigue

• Dizziness/lightheadedness

• Vital signs when appropriate

• Fall risk

• Previous mobility level

• Prescribed activity restrictions

• Weight-bearing restrictions

• Tubes, drains, IVs, incisions, catheters, equipment

• Need for assistive devices

• Need for additional staff

• Need for bariatric equipment

Before mobility when the patient has pain

If pain will interfere with activity:

Assess pain → administer prescribed analgesic → allow time for it to work → begin mobility.

🔥 NCLEX PRIORITY

Never assume:

“The patient walked yesterday, so one nurse can walk them today.”

Assess the patient’s CURRENT ability.

4. Safe Patient Handling & Mobility — SPHM

Modern nursing practice emphasizes using mechanical/assistive devices rather than manually lifting patients whenever appropriate.

This protects both:

• Patient

• Healthcare worker

General principles

Before moving a patient:

1. Review the care plan.

2. Assess mobility.

3. Assess cognition/cooperation.

4. Determine weight-bearing ability.

5. Check equipment.

6. Determine appropriate assistance.

7. Explain the procedure.

8. Protect tubes/lines/drains.

9. Lock appropriate equipment.

10. Use correct body mechanics.

5. Body Mechanics

Proper body mechanics reduce musculoskeletal injuries.

Remember:

WIDE + LOW + CLOSE

• Wide base of support

• Keep center of gravity low

• Keep patient/object close

• Bend knees rather than bending at the waist

• Use large muscles of the legs

• Avoid twisting

• Pivot with the feet

• Face the direction of movement

• Raise the bed to a comfortable working height

🔥 NCLEX

The safest nurse is not necessarily the nurse who is physically strongest.

The safest nurse is the one who:

Uses appropriate equipment and assistance rather than attempting an unsafe manual lift.

6. Bariatric Patients

Bariatric patients may require:

• Additional caregivers

• Expanded-capacity equipment

• Bariatric lifts

• Bariatric stretchers

• Specialized transfer devices

The chapter identifies bariatric algorithms for patients who:

• Weigh >300 lb

• Are ≥100 lb over ideal body weight

• Have BMI >40

Memorize

300 – 100 – 40

300 lb / 100 lb over ideal / BMI >40

These patients may require specialized SPHM planning.

7. Transferring Bed → Chair

Before transferring:

Assess

Can the patient:

• Cooperate?

• Bear weight?

• Maintain standing balance?

• Use upper extremities?

• Grasp with at least one hand?

These answers determine the safest transfer method.

Fully able to bear weight

The patient may:

• Transfer independently

• Use their normal assistive device

Partially weight bearing

Possible options include:

• Seated transfer aid

• Nonpowered standing aid

• Powered standing-assist device

Transfer toward the stronger side when appropriate.

Cannot bear weight / cannot cooperate

Consider:

• Ceiling lift

• Full-body lifting device

• Mechanical transfer device

🔥 NCLEX

Do NOT attempt a manual transfer simply because it seems faster.

8. Bed-to-Chair Transfer Procedure

Major sequence:

Before standing

• Hand hygiene/PPE

• Identify patient

• Explain procedure

• Clear pathway

• Position chair

• Adjust bed

• Lock bed brakes

• Lock chair brakes if available

• Assist patient to sitting

• Let legs dangle

• Assess dizziness/lightheadedness

• Apply nonskid footwear

• Apply gait belt if indicated

Then

Have the patient:

1. Stand.

2. Regain balance.

3. Pivot toward chair.

4. Back up until the legs touch the chair.

5. Reach for chair arms.

6. Slowly lower into sitting.

🔥 Very important

Before continuing after sitting on the bedside:

Assess for balance problems, dizziness, or lightheadedness.

9. Orthostatic Hypotension

A patient moving from lying → sitting → standing may develop a drop in blood pressure.

Symptoms include:

• Dizziness

• Lightheadedness

• Weakness

• Faintness

Therefore:

Dangle before standing.

Let the patient sit at the bedside for several minutes before continuing.

If dizziness occurs

STOP.

Do not tell the patient to “push through.”

Return them to a safe position and reassess.

10. Gait Belts

A gait belt provides a secure place for the caregiver to hold while assisting with mobility.

Purpose

• Improve caregiver grip

• Increase stability

• Reduce injury risk

• Help steady the patient

🚨 Critical NCLEX rule

A gait belt is used to STEADY—not LIFT.

Avoid gait belts when inappropriate

The chapter specifically notes caution/avoidance with:

• Behavioral aggression

• Suicide/self-harm risk

because the belt could potentially be used as a weapon or for self-harm.

11. Powered Full-Body Sling Lift

A powered full-body sling lift is appropriate for patients who cannot safely participate in manual transfers.

Examples include patients who:

• Cannot bear weight

• Cannot safely stand

• Are uncooperative

• Require extensive assistance

Equipment

• Powered full-body lift

• Sling

• Chair/wheelchair

• Additional caregiver(s)

• PPE as indicated

12. Full-Body Lift — Major Safety Sequence

Before transfer

Assess:

• Mobility

• Consciousness

• Ability to follow directions

• Pain

• Tubes/lines/drains

• Equipment

• Need for bariatric equipment

Sling placement

Position sling beneath the patient.

Ensure:

• Correct placement

• Even distribution

• Patient centered

• No pressure from straps/hooks

Lift positioning

Place the lift under/near the bed.

Center the frame over the patient.

Base

Widen the lift base.

Why?

Wider base = greater stability → less tipping.

13. Lift Straps

Typically:

• Short straps → behind patient’s back

• Long straps → other end of sling

Always:

• Check skin

• Make sure straps aren’t pressing into the patient

• Follow manufacturer instructions

14. Lines & Drains During Lift Transfers

Before lifting:

Check ALL equipment, IV lines, tubes, catheters and drains.

Make sure they are:

• Free

• Not caught

• Not tangled

• Not underneath equipment

This prevents:

• Dislodgement

• Injury

• Accidental removal

15. Moving the Patient With the Lift

With caregivers positioned appropriately:

• Support injured limbs

• Explain what is happening

• Raise patient approximately 6 inches above bed

• Unlock lift wheels

• Move patient straight back and away from bed

• Position over chair

• Lock lift wheels

• Lower patient gently

🔥 NCLEX

When moving the lift:

Move straight back, not sideways.

This improves stability.

16. Sling Safety

Do not leave patients sitting in slings unnecessarily.

Prolonged sling use increases:

Pressure injury risk.

17. Range of Motion — ROM

Range of motion (ROM) = complete extent through which a joint normally moves.

ROM maintains:

• Joint mobility

• Flexibility

• Muscle strength

• Muscle tone

• Circulation

It helps prevent:

• Muscle atrophy

• Contractures

18. Active vs Passive ROM

Active ROM — AROM

The patient performs the movement independently.

Passive ROM — PROM

The nurse/caregiver moves the patient’s joints because the patient cannot perform the movement independently.

🔥 Memorize

A = Alone
P = Provider moves it

When possible, encourage the patient to perform as much activity independently as possible.

19. ROM Procedure

Before ROM:

• Review orders/care plan

• Assess limitations

• Assess pain

• Medicate if necessary

• Inspect joints

• Assess redness

• Assess tenderness

• Assess swelling

• Assess deformity

Perform ROM:

Slowly and gently.

Support the extremity above and below the joint.

Perform each movement approximately:

2–5 times

Work:

Head → toe

Encourage independent movement whenever possible.

20. THE BIG ROM SAFETY RULE

🚨 Stop ROM if:

• Patient reports pain

• You encounter significant resistance

Do NOT force a joint.

The chapter emphasizes:

Move the joint until resistance—not pain.

Sudden sharp pain during ROM:

STOP → assess → notify healthcare team as appropriate → revise plan if necessary.

21. ROM Movement Terminology

These terms are extremely testable.

Flexion

Decreases the angle between two body parts.

Example:

Bending elbow.

Extension

Increases the angle.

Example:

Straightening elbow.

Hyperextension

Extension beyond the normal anatomical position.

Abduction

Movement AWAY from midline.

Adduction

Movement TOWARD midline.

Memory trick

ABduct = Away from Body

Then ADduction = back toward the body.

Internal rotation

Rotation toward the body’s midline.

External rotation

Rotation away from the body’s midline.

Supination

Palm faces UP.

Pronation

Palm faces DOWN.

Memory trick

SUPination = holding SUPper

Dorsiflexion

Toes move UP toward the shin.

Plantar flexion

Toes point DOWN.

Think:

Pressing the gas pedal = plantar flexion.

Inversion

Sole of foot turns IN toward midline.

Eversion

Sole turns OUT away from midline.

22. ROM by Joint

23. ROM Delegation

Initial teaching

Patient teaching about ROM:

Cannot be delegated to AP.

AP may

Perform/reinforce ROM when appropriate after assessment and teaching according to policy and patient needs.

🔥 Delegation principle

RN assesses and teaches. AP can perform routine implementation on stable patients.

24. Ambulation

Walking uses most of the body’s muscles and promotes:

• Joint flexibility

• Respiratory function

• GI function

• Circulation

• Muscle strength

• Independence

• Psychological well-being

Early ambulation also helps prevent:

VTE/DVT

25. Before Ambulating

Assess:

• Ability to bear weight

• Balance

• Leg strength

• Cognition

• Cooperation

• Fall risk

• Dizziness

• Lightheadedness

• Pain

• Vital signs when indicated

• Assistive device needs

Tell patient to report:

• Dizziness

• Weakness

• Shortness of breath

• Pain

26. General Ambulation Sequence

Think:

DANGLE → SHOES → BELT → STAND → BALANCE → WALK

1. Sit patient at bedside.

2. Dangle legs.

3. Assess dizziness.

4. Apply nonskid footwear.

5. Apply gait belt if indicated.

6. Assist to stand.

7. Assess balance.

8. Begin ambulation.

27. Nurse Position During Ambulation

When one caregiver assists:

Stand to the side and slightly behind the patient.

Maintain control using the gait belt/appropriate support.

Why slightly behind?

If the patient begins to fall, the nurse is positioned to help control the descent rather than being pulled forward.

28. If a Patient Starts to Fall

🚨 VERY HIGH-YIELD NCLEX

DO NOT attempt to hold the patient upright.

Instead:

1. Widen your stance.

2. Place one foot slightly in front of the other.

3. Bring patient close to your body.

4. Grasp gait belt.

5. Support patient against your thigh/large muscles.

6. Protect the patient’s head.

7. Slowly lower the patient to the floor.

8. Stay with patient.

9. Call for help.

10. Assess patient.

Memorize

Don’t CATCH the fall — CONTROL the fall.

29. Walker Basics

A walker increases:

• Base of support

• Balance

• Stability

Proper walker height allows the elbows to remain slightly flexed—approximately:

15°

30. Getting Up With a Walker

🚨 Patient should NOT pull on the walker to stand.

Instead:

Push from the bed/chair.

Once standing:

• Hold walker handgrips

• Stand upright

• Nurse stays to side/slightly behind

Why?

Pulling on the walker can cause it to:

Tip over.

31. Walking With a Walker

General sequence:

WALKER → WEAK → STRONG

1. Move walker forward.

2. Keep all four feet on floor.

3. Step forward with weak/injured leg.

4. Step forward with strong leg.

Memorize

Walker → Weak → Strong

This is one of the most useful Chapter 9 memory tricks.

32. Walker Safety

Teach patients:

• Keep back upright.

• Don’t hunch over.

• Keep all walker feet on floor.

• Don’t step too far into walker.

• Check rubber tips.

• Don’t pull on walker when standing.

• Use nonskid footwear.

🚨 Never

Use a standard walker:

On stairs or an escalator.

33. Crutches

Crutches allow reduced or absent weight bearing on one/both legs.

Correct fitting is essential.

Proper fit

When standing:

Top of crutch:

2–3 finger widths below axilla

Elbows:

Slightly flexed ≈30°

Body weight should be supported primarily through:

HANDS

NOT the axilla.

34. Why Not Lean on the Axilla?

Prolonged pressure can damage:

Brachial nerves

leading to:

• Nerve palsy

• Loss of sensation

• Upper-extremity weakness/movement problems

🔥 NCLEX

If a patient says:

“I support my weight with my armpits.”

Teaching was NOT effective.

Correct:

“I support my weight through my hands.”

35. Tripod Position

For standing with crutches:

Crutches are approximately:

12 inches in front + 12 inches to the side

This creates a wide base of support.

36. Four-Point Gait

Provides maximum stability.

Sequence:

Right crutch → Left foot → Left crutch → Right foot

Memory:

Crutch → opposite foot → crutch → opposite foot

One point moves at a time.

37. Three-Point Gait

Used when one leg is affected and the patient bears weight on the stronger leg.

Sequence:

1. Both crutches + affected leg forward

2. Strong leg forward

Memory

Bad + crutches → Good

38. Two-Point Gait

Patient bears partial weight on both legs.

Sequence:

1. Left crutch + right foot together

2. Right crutch + left foot together

Think:

Opposites move together.

39. Swing-To Gait

Useful for weakness/paralysis of hips or legs.

1. Move both crutches forward.

2. Lift/swing legs forward to the crutches.

40. Crutch Stair Safety

Important phrase:

UP with the GOOD, DOWN with the BAD.

Going UP

Strong/unaffected leg goes first.

Going DOWN

Affected leg/crutches lead.

This protects the weak leg.

41. Cane Basics

A cane is appropriate when a patient:

• Can bear weight

• Needs additional balance/support

• Has weakness in one leg

A cane should not be used for a patient who cannot bear weight.

42. Which Side Holds the Cane?

🚨 VERY TESTABLE

For weakness in one leg:

Cane is held on the STRONG side.

Example:

Right leg weak → cane in left hand.

Why?

This distributes weight away from the weak side and provides a wider base of support.

Memory

Cane = opposite the pain/weakness.

43. Cane Height

Top of cane should be approximately level with:

Wrist crease

Elbow flexion:

Approximately 15°

44. Cane Walking Sequence

When supporting a weak leg:

Think:

CANE + WEAK → STRONG

Move:

1. Cane

2. Weak leg

3. Strong leg

The cane and affected leg work together to reduce load on the weaker side.

45. Assistive Device Comparison

46. Delegation — Chapter 9

This is an important NCLEX concept.

RN responsibilities

Generally retain:

• Initial assessment

• Clinical judgment

• Initial patient teaching

• Evaluation

• Determining appropriate mobility method

AP can often perform

For stable patients after assessment/instruction:

• Routine transfers

• Ambulation

• ROM

• Reinforcement of previously taught skills

depending on policy and patient condition.

Cannot delegate

Initial teaching about:

• Walker

• Cane

• Crutches

• ROM

Memory

RN = Assess, Teach, Evaluate

47. Unexpected Situation: Dizziness During Transfer

Patient stands and becomes:

• Lightheaded

• Weak

• Knees buckle

Do NOT

Continue transfer.

Instead

Return patient safely to bed/chair.

Assess:

• Vital signs

• Dizziness

• Lightheadedness

Notify healthcare team for significant findings/persistent symptoms.

48. Unexpected Situation: Fatigue During Walker Use

Patient becomes exhausted and says they cannot continue.

Do NOT force them to finish the prescribed distance.

Instead:

• Stop ambulation

• Call for assistance

• Obtain wheelchair if necessary

• Return patient safely

• Reassess

• Plan shorter distances next time

NCLEX principle

Patient tolerance determines progression.

49. Unexpected Situation: Fatigue With Crutches

If patient becomes fatigued and begins bearing weight through the axilla:

STOP.

Why?

Axillary pressure can cause:

Brachial nerve damage.

Return patient safely and reinforce correct technique later.

50. Unexpected Situation: Pain During ROM

Patient reports sudden sharp pain.

Correct action:

STOP the exercise immediately.

Then:

• Assess patient

• Assess other symptoms

• Notify healthcare team as appropriate

• Revise plan if necessary

Never force ROM through pain.

51. Documentation

After mobility activities document:

• Type of activity

• Transfer performed

• Assistive device used

• Number of staff assisting

• Distance walked

• Length of activity

• Patient tolerance

• Dizziness

• Pain

• Fatigue

• Significant observations

• Level of assistance

• Patient response

• Ability to use device correctly

For ROM:

• Exercises performed

• Joints exercised

• Assistance required

• Pain/limitations

• Patient response

52. NCLEX Safety Hierarchy for Chapter 9

When given several possible nursing actions, think:

1. ASSESS

Can they safely move?

↓

2. PREPARE

Pain control, footwear, environment, equipment.

↓

3. PROTECT

Gait belt/assistive device/staff.

↓

4. MOBILIZE

Use safest appropriate technique.

↓

5. REASSESS

Pain, dizziness, balance, fatigue, tolerance.

↓

6. DOCUMENT

🔥 TOP CHAPTER 9 FACTS TO MEMORIZE

If you’re studying the night before the exam, know these cold:

1. Assess mobility BEFORE moving the patient.

2. Dangle before standing to assess for orthostatic symptoms.

3. Never continue mobility when the patient becomes dizzy or unstable.

4. Gait belt = steady, NOT lift.

5. Nurse walks beside and slightly behind an assisted patient.

6. If patient falls: control/lower the fall—don’t try to catch them upright.

7. Walker → Weak → Strong.

8. Patient pushes off chair/bed, NOT walker.

9. Cane goes on the strong side.

10. Cane + weak → strong.

11. Crutch weight goes through hands—not axillae.

12. Crutches approximately 2–3 finger widths below axilla.

13. Crutch elbows ≈ 30° flexion.

14. Tripod = crutches about 12 inches forward and 12 inches outward.

15. Up with good, down with bad.

16. Four-point = R crutch → L foot → L crutch → R foot.

17. Three-point = crutches + affected leg → strong leg.

18. Two-point = opposite crutch + foot move together.

19. Swing-to = both crutches → legs swing to crutches.

20. ROM is performed slowly and gently.

21. ROM generally 2–5 repetitions.

22. Move joints to resistance—not pain.

23. Abduction = away from midline.

24. Adduction = toward midline.

25. Supination = palm up.

26. Pronation = palm down.

27. Dorsiflexion = toes up.

28. Plantar flexion = toes down.

29. Inversion = sole inward.

30. Eversion = sole outward.

31. AROM = patient moves themselves.

32. PROM = caregiver moves the joint.

33. Early ambulation helps prevent VTE/DVT.

34. Widen mechanical-lift base for stability.

35. Check all tubes, drains, IVs and lines before transfers.

36. Never manually lift when safer SPHM equipment is indicated.

37. Initial assistive-device teaching cannot be delegated to AP.

38. Bariatric consideration: remember 300–100–40.

39. Patient safety and staff safety are both priorities.

40. Always evaluate and document tolerance after mobility.

🧠 Chapter 9 Memory Sheet

ROM

AB = Away
ABduction → away
ADduction → toward

SUP = Soup
Supination → palm up holding soup
Pronation → palm down

DORSI = toes to Door/sky
Dorsiflexion → toes up
Plantar → gas pedal/down

INversion = IN
Eversion = Exit/out

ASSISTIVE DEVICES

Walker

Walker → Weak → Strong

Cane

Strong-side cane
Cane + Weak → Strong

Crutches

Hands hold weight — armpits don’t

Stairs

Up with GOOD → Down with BAD

Gait belt

Steady, don’t lift

MOBILITY

Assess → Dangle → Shoes → Belt → Stand → Balance → Walk

FALL

Don’t CATCH → CONTROL

Widen stance → bring patient close → protect head → lower slowly → stay → assess.

🚨 NCLEX “WRONG ANSWER” RED FLAGS

If an answer says any of these, be suspicious:

❌ “Encourage the dizzy patient to continue walking.”

❌ “Lift the patient using the gait belt.”

❌ “Allow the patient to pull themselves up using the walker.”

❌ “Have the patient hold the cane on the weak side.”

❌ “Support body weight through the axillary pads of the crutches.”

❌ “Force the joint through resistance.”

❌ “Continue ROM despite sharp pain.”

❌ “Attempt to hold a falling patient upright.”

❌ “Transfer a non-weight-bearing patient manually when a mechanical lift is available.”

❌ “Teach the AP to provide initial crutch/walker/cane instruction.”

These contradict the major safety principles of the chapter.

⭐ What I Would Expect on a Chapter 9 Exam

The highest-yield question areas from these pages are likely to be application questions rather than simple definitions. Focus especially on:

Patient becomes dizzy → what do you do FIRST?

Patient starts falling → what does the nurse do?

Right leg weak → which hand holds cane?

Which leg moves first with walker?

Where should crutches sit relative to axilla?

Where should weight be supported with crutches?

What is the correct 3-point/4-point/2-point gait sequence?

Pain occurs during ROM → what action?

Patient can’t bear weight → which transfer device?

What can/can’t be delegated to AP?

Which ROM movement is pictured/described?

What should the nurse assess before ambulation?

What complications does early ambulation help prevent?

If you can answer those without hesitating, you’ve covered the most testable safety and clinical-judgment concepts in this portion of Chapter 9.