NSG 300 Topic 3.1 Video Notes

Overview and Goals

• Promoting activity and exercise is a foundational nursing principle across all healthcare settings.
• Goal: promote activity safely and efficiently, especially for functionally impaired clients; ensure client motivation to engage in regular exercise.
• Use critical thinking and clinical judgment to select activity/exercise strategies that match the client’s willingness and maximize physical and psychosocial health.
• Regular physical activity and exercise can enhance all aspects of health, including physical and emotional well-being; knowledge of physiology, body movement regulation, and safe transfer/ positioning is essential to understand how health conditions affect activity.
• American Heart Association (AHA) supports that physical activity positively influences various activities (as indicated on the course slide).

Why activity is routinely needed in care

• Functional decline: loss of the ability to perform self-care or activities of daily living (ADLs) can occur with illness, adverse treatment effects, or deconditioning from inactivity.
• Deconditioning occurs quickly during hospitalization; nurses should actively increase overall activity to minimize risks.
• Movement is a complex process requiring coordination between the musculoskeletal and nervous systems.

Core Concepts: Movement and the Nervous System

• Body mechanics: coordinated efforts of the musculoskeletal and nervous systems.
• Historical lifting techniques in nursing caused injuries; modern practice uses evidence-based principles of body alignment, balance, gravity, and friction for transfers, ambulation, fall risk, and safe movement.
• Body alignment and posture refer to the positioning of joints, tendons, ligaments, and muscles while standing, sitting, and lying.

Body Alignment and Balance

• Body alignment means the center of gravity is stable.
• Correct alignment reduces strain, maintains muscle tone, promotes comfort, supports balance, and conserves energy.
• Imbalance can be caused by disease, injury, pain, aging, pregnancy; medications causing dizziness or prolonged immobility can affect balance.
• Impaired balance is a major threat to mobility and safety; it contributes to fear of falling and activity restrictions.
• Weight is the gravitational force acting downward; unbalanced center of gravity increases fall risk.
• Safe lifting requires understanding object weight and its center of gravity.

Friction, Shear, and Pressure Injuries

• Friction opposes movement; larger surface area increases resistance.
• Shear: force where skin remains stationary while underlying structures move (e.g., bed head elevated >60° causing client to slide down, skin against sheets while bones move).
• Prolonged shear and pressure can damage deep tissue, even if surface tissue looks less affected.
• To prevent skin damage when a client cannot assist with repositioning, use ergonomic assistive devices (e.g., full-body sling) to lift the client off the bed surface, reducing friction, tearing, and shearing; protects staff from injury.

Skeletal System and Joints

• Skeleton provides attachments for muscles/ligaments and levers for mobility; it is the body’s framework.
• Types of bones: long, short, flat, irregular.
• Bones are firm, rigid, and elastic; aging, nutrition, and disease can alter bone components and impact mobility.
• Joints are where two or more bones attach; joints are classified by structure and mobility.
• Supporting structures: ligaments (bind joints), tendons (connect muscle to bone), cartilage.
• Muscles: >600 skeletal muscles; contractions enable movement (walk, talk, breathe) and determine body form/contour.
• Most muscles span at least one joint and attach to articulating bones.

The Nervous System and Movement

• Movement and posture are regulated by the nervous system via electrochemical impulses requiring neurotransmitters (e.g., acetylcholine) at the neuromuscular junction.
• Disruptions in neurotransmitter production, impulse transfer, or muscle activation impair movement.
• Proprioception: muscle sense that provides awareness of body position, movement, spatial orientation, and muscle stretch.
• Proprioceptors monitor muscle activity and body position during ADLs; balance requires coordination of proprioception and balance.
• Proper posture enhances body balance.

Posture and Balance: Dynamic Equilibrium

• Posture: maintaining an optimal body position with minimal muscular effort and least strain on tissues.
• Balance requires coordination of sensory input from the inner ear, cerebellum, and vision; dynamic equilibrium maintains balance during movement.
• Adequate balance is essential for standing, walking, turning, lifting, and performing ADLs.

Physical Activity vs Physical Exercise

• Physical activity: any movement produced by skeletal muscles that results in energy expenditure (occupational, sports, conditioning, household).
• Physical exercise: a subset of physical activity that is planned, structured, and repetitive with a goal (e.g., improving or maintaining fitness); can be therapeutic (e.g., rehab post-surgery).
• Individual exercise programs depend on activity tolerance and the type/amount of activity a client can perform.
• Various factors influence activity tolerance: physiological, emotional, developmental.

Pathology and Mobility

• Musculoskeletal conditions are the leading global cause of disability; low back pain is the single leading cause of disability worldwide.
• Pathologies affecting mobility include congenital defects, bone/joint/muscle disorders, CNS disease or injury, musculoskeletal trauma.
• Table 38.2 (referenced) describes conditions affecting body alignment and mobility; understanding these helps tailor individualized activities.

Case Study: Mister Warren

• 72-year-old African American male hospitalized for right knee surgery; past sports injuries; history of physical therapy, rest, pain meds.
• Preop meds: ibuprofen 600 mg every 6–8 hours; highly active with wife.
• Postop rehab anticipated; questions to assess concerns about rehab.
• Demonstrates how to apply clinical judgment to plan rehabilitation goals.

Clinical Judgment, Knowledge, and Safe Practice

• Sound clinical judgment combines nursing knowledge of activity/exercise with pathophysiology to identify patient needs.
• Nurses’ knowledge base in activity/exercise helps select relevant interventions for those with decreased activity tolerance or mobility limitations.
• Manual patient handling poses risks of work-related musculoskeletal injuries; safe handling reduces injuries via ergonomic principles.
• Many states have Safe Patient Handling and Mobility laws; emphasize improved assessment, mechanical equipment use, and safety procedures.

Influences on Activity and Exercise

• Developmental changes, behavior, lifestyle, environmental factors, family/social support, and culture/ethnicity influence activity/exercise.
• Across the lifespan, body appearance and functioning change, affecting movement; knowledge of growth and development aids anticipatory planning.
• Middle-aged adults should generally have full musculoskeletal function; prevalence of two or more chronic conditions rises in ages 45–64; chronic diseases can hinder exercise.
• Older adults may experience slower gait, reduced coordination, fear of falling, and smaller base of support, altering balance and movement.
• Exercise enhances endurance, coordination, and stability, reducing fall risk.

Motivation, Knowledge, and Barrier Assessment

• Successful programs depend on patient knowledge of exercise benefits vs. drawbacks, values/beliefs about health, perceived barriers, and current exercise habits.
• Daily lifestyle strongly influences exercise adherence; nurses must obtain a comprehensive view of routines, options, and constraints.
• Cultural differences influence exercise engagement; Box 38.3 discusses ethnic variations in physical inactivity.
• When designing fitness plans for diverse populations, consider education, beliefs, resources/access, preferences, and motivators.
• Time is a common barrier; workplaces may offer on-site activity opportunities and incentives to promote engagement.
• Weather affects outdoor activity; schools can influence activity levels in children; community design can promote activity (parks, trails).

Environment, Community, and Social Support

• Creating/modifying environments to facilitate walking/running or biking improves activity and community health.
• Community support (walking trails, fitness classes) promotes population health.
• Social support (companionship in group exercise) increases enjoyment and commitment; family support (praise, transportation to events) facilitates activity.

Nursing Process and Client-Centered Care in Activity/Exercise

• Nurses integrate nursing and other disciplines to understand activity tolerance, movement, and fitness effects on clients.
• During assessment, consider scientific and nursing knowledge about the client’s condition to detect needs and plan care.
• Week-by-week coverage: cues in week 1; diagnoses in week 2; planning next; implementation and evaluation follow.
• Client readiness to exercise influences nursing diagnoses and care plans; ask about enjoyment of exercise and belief in ability to exercise; assess current activity levels.
• Box 38.4 offers questions to assess readiness to exercise; assess cultural/socioeconomic resources and readiness to exercise; baseline vital signs are essential before testing tolerance.
• Review for chronic diseases that affect mobility; assess body alignment in standing, sitting, and lying positions; avoid forcing unnatural postures; assess alignment during various positions.
• Assess five components of mobility: sitting, standing, ROM, gait, and exercise; determine if client can sit on bed edge or chair; verify standing ability beyond self-report.
• Functional test: client should be able to raise buttocks off bed and hold for count of five to indicate good mobility/balance.
• ROM assessment clarifies joint stiffness, swelling, pain, limited movement, unequal movement; limited ROM suggests inflammation, effusion, nerve issues, or contractures; hypermobility may indicate connective tissue issues, ligament tears, or fractures.
• Gait assessment reflects balance and walking ability; informs fall risk and independence in tasks.
• Determine client’s preferred exercise, intensity, and frequency; consider setting, safety, and barriers.
• Planning: prioritize multiple diagnoses and tailor interventions to client abilities and willingness; include client choices about exercise type and timing.

Assessing Readiness to Exercise and Diagnoses

• Case exercise question example: arthritis with knee warmth/sensitivity – assess ROM to determine degree of limitation, not just posture or activity tolerance; answer: D (range of motion).
• Common nursing diagnoses related to activity/exercise:
  • Activity intolerance
  • Fatigue
  • Risk for falls (and related injury)
  • Acute or chronic pain

Implementation: Exercise, Mobility, and Safety

• Isometric exercises: safe for many clients, especially those with mobility limitations; therapist collaborates to select beneficial isometrics; nurse supports correct technique and observes for problems.
• Isotonic exercises: include muscle contraction with joint movement; include ROM exercises.
• ROM: three types
  • Active ROM: client moves joints independently; contraindications include healing fracture/surgical sites, severe acute soft tissue trauma, joint pain, limited ROM, joint instability, deformity, contractures.
  • Active-assisted ROM: client moves with assistance.
  • Passive ROM: nurse moves the client’s joints.
• Gait and ambulation:
  • Walking increases joint mobility; measure by distance walked (hallway length, feet, or yards).
  • Use assistive devices when needed (crutches, canes, walkers).
  • Illness/trauma can reduce activity tolerance; some clients require assistive devices or supervision.
• Assistive devices and gait training:
  • Walker: four legs, hand grips, can be with wheels; provides support for lower-extremity weakness or poor balance; careful technique to lift walker and advance it; do not lean over, otherwise risk of imbalance.
  • Cane: provides less support; straight cane length should equal distance from greater trochanter to floor; place cane on the stronger side; move cane forward 6–10 inches (≈ 15–25 cm) and advance weaker leg to cane; two points of support on the floor at all times.
  • Crutches: multiple gait patterns
  • Four-point gait: alternating movement of opposite crutch and opposite leg for stability; three points of support on floor at all times; weight-bearing on both legs.
  • Three-point gait: weight on crutches and unaffected leg; affected leg does not bear weight in early phase; progression to full weight-bearing on both legs.
  • Two-point gait: partial weight-bearing on both feet; opposite leg moves with opposing crutch.
  • Gait progression should emphasize safety and gradual increase in weight bearing and distance.
• Fall safety guidance:
  • When a client may fall, stand with a broad base of support; position yourself to assist without taking a fall risk yourself; use a guided technique for falling as shown in Figure 38.9 (A–C steps):
  • A: Stand with feet apart to create a broad base; prepare to catch or stabilize.
  • B: If the client slides, extend one leg to allow sliding against it to the floor.
  • C: Bend knees to lower the body as the client slides to the floor.
• Transfer safety and equipment readiness:
  • Before transfers, assess mobility/strength and determine required assistance.
  • For orthopedic issues, stand on the unaffected side; for other clients, stand on the affected side.
  • Check transfer equipment and number of personnel required; ensure side rails are raised on the bed opposite your standing side to prevent falls.
  • Arrange lines/tubes so they do not interfere with the transfer; verify equipment function with all team members prior to use.

Early Mobility, Acute Care, and Community Care

• In acute care, activity often declines on admission; early mobility and stretching/active ROM help prevent deconditioning and related complications (delirium, reduced function, poor nutrition, sleep disturbances).
• Randomized and clinical evidence support that nurse-facilitated early mobility programs reduce delirium, improve muscle strength, enhance independence at discharge, and improve overall quality of life for critically ill patients.
• Isometric and isotonic exercises are generally safe; a physical therapist often collaborates to tailor isometric exercises to client needs.
• The role of the nurse includes instructing correct technique, observing for problems, and coordinating with the care team.

Implementing Exercise Across Settings

• Primary care/community: nurses partner with clients to improve physical activity; examples include improving access to parks/walking paths, health fairs, and community walks.
• Population-focused considerations: adapt plans to client preferences, resources, and cultural beliefs; ensure access to equipment/fees; identify motivators.
• Hospitals/acute settings: implement early mobility to prevent deconditioning; assess and adapt exercise type and intensity to condition; use ROM, stretching, and light ambulation as soon as feasible.

Practical Tools, Boxes, and Tables Referenced

• Box 38.3: Physical inactivity among ethnic groups; considerations for culturally tailored physical activity programs.
• Box 38.4: Questions to assess readiness to exercise; comprehensive questions on readiness, barriers, environment, and resources.
• Table 38.2: Pathological conditions affecting body alignment and mobility; helps tailor activity plans.
• Table 38.4: Measures for preventing lift injuries in healthcare workers; guidance on safe handling and staffing.
• Figure 38.9: How to support a client who is falling (demonstrates steps for safe fall management).

Key Equations and Numerical References (LaTeX)

• Pain scale assessment: $0 \,\le\, \text{pain} \le\, 10$
• Degrees and angles mentioned:
  • Bed head elevation that causes shear: >60^{\circ}
  • Knee flexion example in case study: $70^{\circ}$
• Quantities and measurements:
  • Analgesia: ibuprofen $600\,\text{mg}$ every $6\text{--}8\,\text{hours}$
  • Distance measurements in gait: walk distances in feet or yards (e.g., $10\ \text{feet}$) and cane advancement of $6\text{--}10\,\text{inches}$ (≈ $15\text{--}25\,\text{cm}$)
  • ROM time target for isometrics: typically $10\,\text{seconds}$ contraction followed by relaxation
• Muscle count: >$600$ skeletal muscles

Case: Mister Warren (Summary of Practice Points)

• Pre/postop conditions: knee surgery; active prior to surgery; poor ambulation risk without PT; pain level initially high (example: 6–7/10).
• Interventions used: PCA for pain control; CPM machine; progressive ambulation with a walker; ROM and strengthening exercises; knee flexion improved from initial state to $70^{\circ}$; able to ambulate walking distance of $10\text{ ft}$ with a walker.
• Goals by week 5: progress toward weight bearing, increased ROM, and gradual return to sports; pain control enabled participation in therapy; patient’s expectation to return to sports noted (racquetball/tennis) with therapy.
• Key clinical reasoning: establish plan with realistic increments, monitor pain (0–10 scale), monitor ROM, monitor CPM use, assess gait quality, and ensure patient understanding of ROM and CPM importance.
• Discharge planning implication: pain relief and functional recovery should align with PT/ surgeon recommendations; safe ambulation and activity progression critical for discharge planning.

Ethical, Practical, and Professional Implications

• Ethical responsibility to minimize harm (prevent injury to patient and staff) and maximize patient autonomy and participation in activity planning.
• Practical implications include ensuring safe patient handling, compliance with state Safe Patient Handling laws, and using mechanical aids to reduce risk of injury.
• Professional implications include ongoing assessment, staff training on lifting devices, and collaboration with physical therapy and physicians to optimize activity plans.

Quick Reference: Practical Takeaways for Clinical Practice

• Assess five mobility components: sitting, standing, ROM, gait, exercise; document baseline and progress.
• Use body alignment principles to maintain safe posture and reduce energy expenditure.
• Distinguish between activity and exercise; tailor plans to patient tolerance, preferences, and cultural context.
• Consider environmental and social supports; leverage community resources and workplace programs to promote ongoing activity.
• Implement early mobility in acute care to prevent deconditioning: plan is individualized, realistic, and time-bound (SMART).
• Use ROM (active, active-assisted, passive) appropriately; be mindful of contraindications to active ROM.
• Teach and model safe ambulation with walkers, canes, and crutches; choose appropriate device based on stability and balance needs; monitor technique and progress.
• Prepare for transfer and fall-prevention scenarios with stepwise and team-based approaches; ensure equipment readiness and safety checks before transfers.
• Use evidence-based approaches (isometrics, isotonics, ROM) in collaboration with physical therapy; re-evaluate and adapt plans as patient improves.