Chapter 34 & 35: Foundations Comprehensive Guide to Mobility, Activity, and Exercise in Nursing

Nursing Objectives for Mobility and Activity

• Define actual and potential health problems and needs using nursing knowledge and the expertise of other professionals regarding sleep, mobility, and activity.

• Implement mobility and activity assessment skills in clinical practice across the entire lifespan.

• Promote self-care management strategies for clients, families, and caregivers that are consistent with evidence-based practice.

• Implement safe practices within care environments that comply with all relevant laws, policies, and regulations.

Physiology of the Musculoskeletal and Nervous Systems

• Skeletal System: Functions via joints and specific points of attachment for muscles.

• Muscular System:

  • Skeletal muscle.

  • Smooth muscle.

  • Cardiac muscle.

• Nervous System: Responsible for stimulating muscles to contract, facilitating movement.

• Relationship of Skeletal Muscles to Bones:

  • Origins: Point where the muscle attaches to a fixed bone.

  • Tendons: Fibrous tissue connecting muscle to bone.

  • Aponeurosis: A sheet of pearly-white fibrous tissue that takes the place of a tendon in sheet-like muscles.

  • Biceps brachii muscle: Example muscle involved in elbow flexion.

  • Bones involved in arm movement: Clavicle, Scapula, Humerus, Radius, and Ulna.

  • Mechanical Components of Movement:

  • Effort: Muscular contraction.

  • Resistance: The weight of the object being moved plus the weight of the limb (e.g., forearm).

  • Fulcrum: The joint where movement occurs.

Classification of Bones and Joints

• Joint Classifications:

  • Ball and socket.

  • Condyloid.

  • Gliding.

  • Hinge.

  • Pivot.

  • Saddle.

• Bone Classifications:

  • Long bones: Typical of limbs (e.g., humerus).

  • Short bones: Providing stability and some movement.

  • Flat bones: Protecting internal organs (e.g., scapula).

  • Irregular bones: Varying shapes (e.g., vertebrae).

Principles of Body Mechanics and Ergonomics

• Core Components of Mobility:

  • Interaction of bones, muscles, and the nervous system.

  • Body mechanics: The specific way people move.

  • Body alignment (posture).

  • Balance.

  • Coordination.

  • Joint mobility.

• Ergonomic Principles for Healthcare Workers:

  • Maintain proper alignment.

  • Establish a wide base of support.

  • Avoid bending and twisting at the waist.

  • Squat to lift rather than bending over.

  • Keep objects close to the body when lifting.

  • Raise hospital beds to a comfortable working height.

  • Opt to push objects rather than lifting them when possible.

  • Always seek help for heavy or complex moves.

Movement Types and Joint Range of Motion

• Types of Muscle Movement:

  • Isotonic: Involves muscle shortening and active movement.

  • Isometric: Involves muscle contraction without a change in muscle length (no shortening).

  • Isokinetic: Involves muscle contraction performed against resistance.

• Joint Movements (List 1):

  • Abduction: Moving a limb away from the midline.

  • Adduction: Moving a limb toward the midline.

  • Circumduction: Circular movement of a limb.

  • Flexion: Bending a joint to decrease the angle.

  • Extension: Straightening a joint to increase the angle.

  • Hyperextension: Extension beyond the normal anatomical position.

  • Dorsiflexion: Bending the foot upward at the ankle.

  • Plantar flexion: Bending the foot downward (pointing toes).

• Joint Movements (List 2):

  • Rotation.

  • Internal rotation.

  • External rotation.

  • Supination: Turning the palm upward.

  • Pronation: Turning the palm downward.

  • Inversion: Turning the sole of the foot inward.

  • Eversion: Turning the sole of the foot outward.

Factors Influencing Mobility Across the Lifespan

• Developmental Considerations: Age and physiological development stages affect movement capacity.

• Physical Health Factors:

  • Problems originating in the Muscular, Skeletal, or Nervous systems.

  • Secondary problems involving other body systems (e.g., cardiovascular or respiratory limitations).

• Mental Health: Emotional state can impact the desire or ability to move.

• Lifestyle: Sedentary vs. active habits.

• Attitudes and Values: Cultural or personal beliefs regarding exercise and activity.

• Fatigue and Stress: High levels of physical or mental exhaustion can decrease mobility.

• External Factors: Environmental constraints or available resources.

Physiological and Psychological Complications of Immobility

• Systemic Complications:

  • Cardiovascular: Decreased cardiac output, increased risk of Deep Vein Thrombosis (DVT). DVT is characterized by a venous clot causing swelling and inflammation below the blockage site, impeding blood flow to the heart and lungs.

  • Respiratory: Reduced lung expansion and increased risk of pneumonia.

  • Gastrointestinal: Decreased peristalsis leading to constipation.

  • Genitourinary: Increased risk of urinary stasis and kidney stones.

  • Metabolic: Altered protein, fat, and carbohydrate metabolism.

  • Psychological: Depression, anxiety, and social isolation.

• Musculoskeletal Specifics:

  • General muscle weakness.

  • Disuse osteoporosis: Bone loss due to lack of weight-bearing activity.

  • Contractures: Permanent shortening of muscles or joints.

  • Foot drop: A condition where the front of the foot cannot be lifted, often due to nerve or muscle damage caused by immobility.

• Integumentary Specifics:

  • Pressure ulcers (decubitus ulcers) caused by prolonged pressure on specific areas.

  • Critical pressure areas include points of contact in the Supine, Lateral, and Prone positions.

Assessment and Clinical Considerations for Patient Mobility

• Pre-Activity Considerations:

  • Review the medical diagnosis.

  • Assess exercise and activity tolerance.

  • Monitor vital signs, looking for Shortness of Breath (SOB), pallor, or diaphoresis.

  • Assess comfort level and psychosocial issues.

  • Identify required special equipment.

  • Encourage mobility as early as possible in the recovery process.

• Client Physical Assessment:

  • General ease of movement.

  • Gait and posture.

  • Body alignment.

  • Joint structure and function.

  • Muscle mass, tone, and strength.

  • Endurance.

• Team Assessment for Safe Handling:

  • Client’s specific information and needs.

  • The task to be accomplished.

  • Physical strengths and weaknesses of the team members.

  • Available equipment.

Safe Patient Handling and Assistive Equipment

• General Safety Guidelines:

  • Communicate clearly with all healthcare team members.

  • Assess and incorporate the patient’s priorities and preferences into the care plan.

  • Utilize the best evidence when making decisions about patient care.

  • Verify all medical orders and restrictions before moving a patient.

• Assistive Devices:

  • Gait belts.

  • Stand-assist and repositioning aids.

  • Lateral-assist devices.

  • Friction-reducing sheets.

  • Mechanical lateral-assist devices.

  • Transfer chairs.

  • Powered stand-assist and repositioning lifts.

  • Powered full-body lifts.

Positioning and Movement Techniques

• Bed Positioning Equipment:

  • Pillows and foam wedges for support.

  • Specialized mattresses.

  • Adjustable beds and overhead trapeze bars.

  • Cradles and footboards.

  • Trochanter rolls: Used to prevent external hip rotation. These should be placed with the top edge at the hips and the lower edge approximately $\frac{1}{3}$ of the way down the thighs. They should not extend to the knees.

  • Splints and hand rolls.

• Specific Techniques:

  • Log Roll: Used to turn a patient while maintaining spinal alignment.

  • Dangling:

  1. Place the patient in a sitting position with feet and legs hanging over the side of the bed.

  2. Assess for signs of orthostatic hypotension.

  3. Remain with the patient for safety.

• Standard Bed Positions:

  • Fowler’s position.

  • Protective supine position.

  • Protective side-lying or lateral position.

  • Protective Sims’ position.

  • Protective prone position.

• Safe Turning and Movement Steps:

  • Lock the wheels of the bed.

  • Remove the pillow.

  • Position the patient's arms and legs correctly for the turn.

  • Assume a wide base of support.

  • Instruct the client on the plan.

  • Use a count to synchronize movement.

  • Flex knees and hips and shift weight while moving.

Assistive Devices for Ambulation

• Walkers: The patient should hold the handgrips on the upper bars, take a step, move the walker forward, and then take another step.

• Canes:

  • Hold the cane on the stronger side of the body.

  • Distribute weight evenly.

  • Advance the weaker foot forward parallel with the cane while supporting weight on the stronger leg and the cane.

  • Bring the stronger leg forward while supporting weight on the weaker leg and the cane.

Evaluation and Practice Guidelines

• Evaluation Components:

  • Assess patient outcomes.

  • Evaluate the effectiveness of specific mobility interventions.

  • Evaluate the understanding of the patient and family regarding all teaching provided.

• Summary of Mobility Principles:

  • Physical mobility affects every aspect of life.

  • Functioning musculoskeletal and neuromuscular systems are essential for activity.

  • Healthcare professionals must assess for potential or actual mobility and tolerance issues.

  • The nursing process allows for anticipation of the needs of immobile patients.

  • Proper body mechanics and safety are fundamental for all healthcare providers.

Questions and Discussion

• Question: Which classification describes the bones located in the wrist?

• Answer: B. Short bones.

• Question: Tell whether the following statement is true or false: The oblique position, a variation of the side-lying position, is recommended as an alternative to the side-lying position because it places significantly less pressure on the trochanter region.

• Answer: A. True.

• Instruction: Practice time is scheduled for Wednesday 8/18 in the Campus Lab.